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7 • Diseases of Bone and the Maxillary Sinus
123
levels are typically elevated in hyperparathyroidism and
the test may be used to exclude the hyperparathyroidism
when giant-cell granuloma features are seen. They are,
however, normal in this case.
5. c. Any of these rare malignancies can occur in the
bones of the jaws or surrounding soft tissues. A variety
of histological patterns of osteosarcoma are known and
a large amount of cartilage may be present. Formation
of osteoid by malignant osteoblasts is the defining histological feature. On radiographs the periodontal ligament
may be widened (Garrington sign), teeth may be displaced or resorbed and occasionally “sun-ray spicules”
may be seen.
6. a. All of these conditions present radiographically with
opacification of the antra, but the clinical histories
usually differ.
Case History Answers
CASE HISTORY 1
1. Paget’s disease of bone results in enlargement of cranial
bones and deformation of weight-bearing bones. The
cranium is usually expanded in thickness and symptoms
may arise from cranial nerve compression.
2. Radiographs of the jaws may show hypercementosis,
cemental masses, abnormal trabeculation and a cottonwool appearance in the jaws. The alkaline phosphatase
level is markedly raised.
3. Disordered bone remodelling is seen; larger osteoclasts
are present and the trabeculae show a scalloped outline.
Numerous resting and reversal lines, resulting in a
mosaic pattern, are seen and the vasculature may be
increased. Globular cementum-like masses are seen in
the jaws.
CASE HISTORY 2
1. The features suggest osteoradionecrosis. Recurrent
carcinoma is possible but less likely.
2. Radiotherapy damages tissues by producing free radicals. DNA damage may prevent cell division and repair.
Endoarteritis obliterans results in reduced vascular supply to the tissues. Bone may become necrotic, showing
osteocyte death, sequestration and breakdown of the
matrix. Infection may result in osteomyelitis.
3. Mutations and other genetic damage may lead to neoplasia in irradiated tissues. Osteosarcoma can arise in
this way.
CASE HISTORY 3
1. Osteogenesis imperfecta should be suspected. Increased
joint mobility may also be present.
2. Blue sclera caused by thinness of the connective tissue
may be seen. Some patients have characteristic
‘Madonna facies’.
3. Collagen type I gene mutations have been described.
4. Dentinogenesis imperfecta is a feature of some forms of
osteogenesis imperfecta, but either condition may arise
as a separate disorder.
CASE HISTORY 4
1. The serum calcium level should be measured and radiographs reviewed to exclude hyperparathyroidism.
2. The lesion should be treated by local removal with
curettage.
3. Osteoclast-like giant cells are found in giant-cell granuloma, brown tumour of hyperparathyroidism, Paget’s
disease of bone, aneurysmal bone cyst and some
fibro-osseous lesions, particularly cherubism.
CASE HISTORY 5
1. Carcinoma of the maxillary antrum may be clinically
occult and can present as maxillary swelling, loss of
nasolabial skin crease, facial pain, cervical metastasis
and symptoms similar to those of the temporomandibular disorder. Tumour fungating through premolar and
molar maxillary extraction sockets is a classic sign.
2. Squamous-cell carcinoma is the most common malignancy arising in the maxillary sinus. Infiltrative pleomorphic and mitotically active squamous epithelium
supported by fibrous stroma is seen. Keratin pearls may
be present but some tumours are poorly differentiated.
3. Computed tomography (CT), magnetic resonance and
positron emission tomography are useful modalities for
imaging maxillary sinus carcinoma.
Viva Answers
1. Fibro-osseous lesions are grouped on the basis of their
histology, consisting of cytologically bland fibroblastic
fascicles in which bone trabeculae form. Radiographic
examination is used to distinguish fibrous dysplasia
from cemento-ossifying fibroma, as the former merges
with surrounding bone while the latter has a sharply
defined boundary. Cherubism and aneurysmal bone cyst
have distinct clinical and radiographic features.
2. Dry socket is a local bone infection following tooth extraction. It is treated by irrigation with warm, mild antiseptic solution and placement of an obtudant dressing
with antiseptic properties.
3. Cemento-ossifying fibroma is a solitary, slow-growing,
circumscribed bone tumour; true cementoma is a sclerotic tumour of cementum most often associated with the
roots of a lower first molar; cemento-osseous dysplasia is
a genetic disorder most common in women of African
descent. Periapical, florid and focal forms are described as
part of the spectrum.
4. Acromegaly results from excessive growth hormone secretion, most often from a pituitary adenoma. Condylar
growth is reactivated and the mandible becomes
enlarged and protrusive. The teeth become spaced and
excessive growth of the lips, nose and facial tissues leads
to coarse features. Hands and feet become spade-like.
Diabetes and visual disturbance may also develop.
5. Local features that delay healing in bone include mobility of a fracture, infection, foreign bodies and reduced
local vascular supply. Systemic factors include diabetes
mellitus, steroid therapy, osteoporosis and genetic
disorders.
8
CHAPTER OUTLINE
Overview‚ 124
8.1 Assessment of the Injured Patient‚ 124
8.2 Dental Injuries‚ 127
8.3 Facial Soft Tissue Injuries‚ 129
8.4 Facial Fractures‚ 130
Overview
This chapter is about injuries to the mouth and face and describes those to teeth, soft tissues and the facial bones. Trauma
management has evolved significantly over the last few decades. There has been a focus for patients experiencing major
polytrauma on reducing mortality during the ‘golden hour’.
There has also been an increasing emphasis on the dental
team enquiring about the aetiology of the presenting injury
as there may be a child safeguarding issue or a need for referral of an adult to domestic violence and abuse support agency.
8.1 Assessment of the Injured Patient
LEARNING OBJECTIVES
You should:
• understand the importance of the determining the
aetiology of facial injury.
• understand the principals of assessment of patients
with facial injury that might include other injury.
• know how to document injuries.
PRIMARY SURVEY
Severe facial injury may be accompanied by other injury
and can complicate early management owing to the proximity to the airway, cervical spine and brain.
Guidelines for the management of the injury trauma
patient initially developed by the American College of Surgeons have been widely adopted and disseminated through
Advanced Trauma Life Support (ATLS) courses. These describe treatment priorities to achieve two aims: to save life
and to restore function. A “primary survey” is carried out
simultaneously to identify and to manage life-threatening
conditions and consists of the following:
n
Airway maintenance with cervical spine control.
n
Breathing and ventilation.
8.5 Gunshot Wounds‚ 135
8.6 Dislocation of the Mandible‚ 136
8.7 Complications of Facial Injury, 136
Self-Assessment: Questions‚ 136
Self-Assessment: Answers‚ 138
n
Circulation with control of haemorrhage.
n
Disability owing to neurological deficit.
n
Exposure and environmental control.
These are illustrated in Fig. 8.1. Universal precautions of
cross-infection control are adopted.
Airway
Airway management skills are necessary because the
trauma patient will not be able to maintain his or her own
airway if unconscious or if the airway is compromised by
serious facial soft tissue injury or facial fractures. The situation may be aggravated by diminished consciousness as well
as alcohol and/or drug intoxication, making the patient
vulnerable to aspiration. It is important to understand:
n
how to recognise airway obstruction
n
how to clear and maintain the airway with basic skills
n
the role of advanced airway management including
surgical management.
Airway obstruction may be recognised by the ‘look, listen
and feel’ observations for breathing. Common causes of upper
airway obstruction are the tongue and other soft tissues,
blood, vomit, foreign bodies such as broken teeth or dentures
or oedema. Obstruction may be partial or complete and:
n
silence suggests complete obstruction.
n
gurgling suggests presence of liquid.
n
snoring arises when the pharynx is partially occluded by
the tongue or soft palate.
n
crowing is the sound of laryngeal spasm.
Correction of airway obstruction is as described in
Chapter 3 with the basic manoeuvre of chin lift or jaw
thrust, use of oropharyngeal or nasopharyngeal airways
and suction. The jaw thrust is the method of choice for
the trauma victim as this avoids extension of a potentially
injured neck, and the nasopharyngeal airway should be
avoided if a fracture of the maxilla is suspected as it may
pass into the cranial fossa. Airway compromise resulting
from facial injury will require the early involvement of
the oral and maxillofacial surgeon. Advanced airway
124
8 • Oral and Maxillofacial Injuries
Airway
Disability
125
Endotracheal intubation
Breathing
Intermittent positive
pressure ventilation
Glasgow Coma Scale
Circulation
Plasma expander
infusion via right
and left antecubital
fossae
Chest drain
Exposure
Exclude other injuries
Fig. 8.1 Trauma management primary survey.
management by way of endotracheal intubation is the
“gold standard” of airway maintenance and protection
but is only carried out in the trauma situation after cervical spine radiograph has excluded bony injury.
Surgical airway intervention with emergency tracheostomy may be indicated as a life-saving procedure if it is not
possible to intubate the trachea in the usual way because of
obstruction by facial trauma or foreign body. Cricothyroidotomy may be undertaken in an emergency situation
to provide some minutes to prepare the operating theatre
to undertake a tracheostomy. It is a holding procedure.
Cricothyroidotomy is undertaken by making a transverse
incision with a scalpel through the cricothyroid membrane
to permit placement of a smaller endotracheal tube. Alternatively, a needle cricothyroidotomy may be undertaken in
Urinary
catheterisation
to measure
urine output
which a large-calibre plastic cannula is inserted into the
trachea through the cricothyroid membrane, although this
provides less effective airflow (Fig. 8.2).
The formal tracheostomy is undertaken with a transverse
skin incision which is made midway between the cricoid
cartilage and the suprasternal notch followed by midline dissection of the infrahyoid muscles and division of the thyroid
isthmus. Haemostasis is achieved, and then the trachea is
opened by cutting away part of the second and third rings to
create a circular opening so that a tracheostomy tube may
be placed and secured (Fig. 8.3).
Breathing
Once an airway has been established, then the adequacy of
ventilation must be assessed. Artificial ventilation must be
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Master Dentistry
Fig. 8.2 Needle cricothyroidotomy.
compromise spontaneous ventilation. Early diagnosis of
these potentially life-threatening conditions is essential so
that they can be managed and permit adequate ventilation
of the patient. An orogastric rather than nasogastric tube is
placed when there is suspicion of base of skull fracture to
decompress the stomach. A pulse oximeter monitors atrial
oxygen saturation.
Circulation
Haemorrhage should be controlled by pressure to bleeding
wounds or by applying an artery forcep or ligature to a severed artery as appropriate. Bleeding from a fractured maxilla will not be controlled unless it is manually repositioned,
although this emergency is rare. Severe nasal bleeding may
continue even after adequate anterior and posterior packing but balloon tamponade to provide pressure would need
to be used with caution when there are comminuted fractures in the midface as fragments could be displaced into
the orbits and brain. If all local measures fail to control
haemorrhage from the maxillofacial region, then it may be
necessary to consider ligation of the external carotid artery.
Intravenous fluids should be infused via a large peripheral vein such as in the antecubital fossa. Plasma and
plasma substitutes (“colloids”) contain large molecules that
do not rapidly leave the intravenous space where they exert
osmotic pressure to maintain circulation volume. Urinary
catheterisation is required and adequate fluid replacement
is monitored by documenting urine output, peripheral perfusion and temperature. The prognosis is better when the
patient is warm with full veins and a good urine output.
Electorcardiographic (ECG) monitoring is undertaken.
Fig. 8.3 Insertion of tracheostomy tube.
commenced immediately when spontaneous ventilation is
inadequate or absent using a self-inflating bag and mask
with attached oxygen (see Chapter 3). Whilst ventilation is
clearly essential, it is potentially also hazardous when there
are Le Fort II, III and nasoethmoidal fractures with risk
of forcing material into the brain. Serious chest injuries
such as tension pneumothorax and cardiac tamponade will
Disability
A rapid initial assessment of conscious state can be made
using the AVPU method: Alert, responds to Vocal stimuli,
responds to Painful stimuli or Unresponsive to all stimuli.
Alternatively, the Glasgow Coma Scale, which records the
patient’s motor, verbal and eye movements in response to
stimulation, may be used.
Exposure and Environmental Control
All of the victim’s clothing is removed to permit full assessment and exclude other injuries, taking into account the
environmental conditions and respecting the patient’s dignity. A warming blanket is placed and intravenous (IV) fluids
are warm.
Radiographic Examination
Once immediate life-saving measures have been organised,
essential radiography is undertaken. This is limited to cervical spine, chest and pelvis radiographs. The cervical spine is
immobilised with a collar until any injury has been excluded. The incidence of cervical spine fracture is around
1% to 10% of all maxillofacial trauma.
SECONDARY SURVEY
A secondary survey is carried out once the patient’s general
condition has been stabilised. This consists of a rapid top-totoe detailed patient examination of all body systems and a
more thorough neurological examination, including testing of the cranial nerves. The particular role of the oral
8 • Oral and Maxillofacial Injuries
127
surgeon or oral and maxillofacial surgeon in the secondary
survey is to carry out a detailed examination of the head,
neck and orofacial region. The whole of the scalp should be
examined followed by the neck, face and mouth as described later in this chapter. Appropriate radiographs or
other investigations such as computed tomography (CT)
can then be arranged and definitive care planned.
Documentation
It is vital that there is thorough recording of the history and
examination in all cases of injury. The details may be required by the police service, lawyers, insurers or the Criminal
Injuries Compensation Board at some stage.
CHILDREN
While most injuries are quite innocent, it is important to
consider the possibility of nonaccidental injury (NAI) when
presented with an injured child. Signs suggestive of NAI are:
n
injuries sustained are not consistent with history provided
by parent
n
delayed presentation
n
apparent lack of concern or apparently overanxious
parent
n
clinical or radiological evidence of multiple injuries, especially if of different ages
n
fraenal tears in child less than 1 year old
n
withdrawn or frightened child.
It is good practice to ask the child about the cause of any
injuries and to allow them to talk if they volunteer information about abuse. If the child presents via the accident
and emergency (A&E) department then it may be useful
to arrange admission of the child to hospital and discuss
suspicions with a paediatrician or other professional. The
situation must be dealt with very carefully if there is the
suspicion of NAI, and it is the responsibility of the health
professionals involved in providing care to share concerns
with others. It is also important to remember that the first
duty is to the child and that there is a responsibility for
dealing with any injury or dental needs. No child should be
left untreated or in pain because of underlying concerns
about abuse.
Referral should be made to the local children’s services
via locally agreed protocol. It is important to do this in discussion with appropriate colleagues. It is good practice to
explain the concerns to the child and parents and inform
them of the intention to refer. Being open and honest from
the outset results in better outcomes for children.
ADULT DOMESTIC VIOLENCE AND ABUSE
The face is a common target in assault and consequently
the dentist and dental care professional have a part to play
in identifying domestic violence. Domestic violence is a
term that refers to a wide range of physical, sexual, emotional and financial abuse of people who are, or have been,
intimate partners—whether or not they are married or
cohabiting or between family members. Although domestic
violence can take place in any intimate relationship, including gay and lesbian partnerships, and while abuse of men
by female partners does occur, the great majority of severe
incidents of domestic violence are perpetrated by men
against women. We know that one in four women and one
in six men experience domestic violence and abuse during
their lives.
It is not the role of the dentist or dental care professional
to give advice to someone experiencing domestic violence
on what direct action they should take but rather to identify
violence and abuse and make a referral to an appropriate
support agency. Identification should be with direct questions when enquiring about the aetiology of the injury and
this should be done with the patient is alone.
8.2 Dental Injuries
LEARNING OBJECTIVES
You should:
• know the types of dental injury that are likely to occur.
• understand the management of such injuries.
Dental injures are more common in children than adults.
In children, they are frequently the result of falls, and in
adults, they are commonly the consequence of sport without mouthguard protection. Increased overjet and incompetent lips are predisposing factors.
Definitions of a few basic terms are useful (Fig. 8.4).
Concussion
A traumatic event leads to damage to the periodontium
without loosening or displacement of the tooth.
Subluxation
Damage to the periodontium leads to loosening of the tooth
without overt displacement.
Luxation
This is the term given to dislocation of the tooth within its
socket, leading to loosening and some degree of displacement. Luxation can be intrusive, extrusive or lateral in
direction.
Avulsion
The tooth is completely displaced from its socket.
MANAGEMENT
Table 8.1 gives the management for injuries to primary and
permanent teeth. Reassurance and analgesia are especially
important for children. Patients will require regular review
to assess development of late sequelae.
If there has been any loss of consciousness at the time of
injury and a tooth or part of a tooth has been lost, then a
chest radiograph should be arranged to confirm that this
has not been inhaled.
Splints can be directly constructed in the mouth of the
patient or indirectly constructed on a model in a laboratory. Direct splints may be made from foil adapted over the
teeth and cemented with zinc oxide eugenol or better with
composite that is attached to the teeth over a wire using an
acid-etch technique.
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Master Dentistry
Concussion
Infarction
Root
fracture
Subluxation Extrusion Lateral
Enamel
fracture
Alveolar
fracture
Enamel-dentin
fracture
Fig. 8.4 Examples of some dental injuries.
luxation
Enamel-dentin
pulp fracture
Intrusion Avulsion
Crown-root
fracture without
pulp involvement
Crown-root
fracture with
pulp involvement
Table 8.1 Immediate Treatment for Tooth Injuries
Injury Management
PRIMARY TEETH
Concussion Soft diet advice, no treatment needed
Subluxation Soft diet advice, no treatment needed
Extrusion Extract if more than 3 mm
Intrusion Leave to erupt or extract if radiograph suggests underlying permanent follicle involved
Avulsion Reimplantation not recommended
Enamel-dentine
fracture
Root fracture Reposition then splint for 4 weeks
Alveolar fracture Reposition then splint for 4 weeks
PERMANENT TEETH
Concussion Soft diet advice, no treatment needed
Subluxation No treatment or flexible splint up to 2 weeks
Extrusion Reposition tooth manually under local anaesthesia and flexible splint for 2 weeks followed by root treatment as
Lateral luxation Reposition tooth and flexible splint for 4 weeks
Intrusion Allow eruption or reposition if more than 3 mm, then flexible splint for 4 weeks (or no intervention if incomplete
Avulsion Less than 1 hour since avulsion: irrigate with saline and reimplant (tooth should have been stored in saliva, milk
Infraction Etch and seal with resin if significant or sympoms
Enamel fracture Smooth or restore with composite resin
Smooth or restore (when root canal treatment may be necessary), or extract depending on extent such as pulp
involvement
necessary
root formation)
or water preferably); compress alveolus to reduce any fracture of the socket; suture any gingival lacerations and
flexible splint up to 2 weeks, and prescribe antibiotics and chlorhexidine mouthwash; initiate root canal treatment
7–10 days after replantation and before splint removal or await revascularization if open apex
Reimplant as above if tooth avulsed for more than 60 minutes but has poor long-term prognosis with expected
ankylosis and root resorption. Root canal treatment before replantation or 710 days later
8 • Oral and Maxillofacial Injuries
Table 8.1 Immediate Treatment for Tooth Injuries—cont’d
Injury Management
Fracture involving
dentine
Fracture involving pulp Root canal treatment but pulp cap or partial pulpotomy with calcium hydroxide in developing teeth; then restore
Crown-root fracture without pulp involvement
Crown-root fracture with
pulp involvement
Root fracture Reposition coronal segment of tooth and check radiographically, flexible splint for 4 weeks or up to 4 months if
Alveolar fracture Reposition and suture any gingival lacerations, stabilize for 4 weeks
Protect dentine and restore
tooth
Stabilise fragment or remove, then gingivectomy, tooth extrusion or extraction
Stabilise fragment or remove, root canal treatment or pulp cap or partial pulpotomy with calcium hydroxide in
developing teeth; then gingivectomy, tooth extrusion or extraction
fracture near cervical area, and root canal treatment as necessary later
129
8.3 Facial Soft Tissue Injuries
LEARNING OBJECTIVE
You should:
• understand the presentation and management of facial
soft-tissue injuries.
AETIOLOGY
Soft tissue injury may result from interpersonal violence,
road traffic accidents, falls, sport and industrial accident.
Weapons may or may not be involved. Knife crime has unfortunately increased significantly over the last few years in
the UK. Facial injury may also result from burns either as
an isolated injury or in association with burns of the trunk
or other part of the body.
CLINICAL PRESENTATION
Lacerations and wounds may involve anatomical structures such as the facial nerve, resulting in facial paralysis,
the parotid salivary gland duct, resulting in a salivary fistula, or arteries, resulting in significant blood loss. They
may be “clean” or obviously contaminated. Burns are
described according to their depth and extent. They may be
superficial (first-degree burn), partial thickness (seconddegree burn) or full thickness (third-degree burn). The
“rule of nines” may be used to describe the total body surface area affected by burn: 9% for each arm and the head,
18% for each leg, front and back of trunk, and 1% for the
external genitalia. The rule is modified for children who
have a relatively larger head and face. The estimation is
important for calculating fluid replacement.
RADIOLOGY
Radiographs of the soft tissues may be necessary to locate
glass or other foreign body in a wound or to exclude an
underlying bony injury. Soft tissue radiographs are taken
with reduced exposure to avoid “burn-out” of low-density
debris and using intraoral films wherever possible for
greatest detail.
SURGICAL MANAGEMENT OF LACERATIONS
Small, straightforward lacerations may be managed by A&E
physicians or senior nurses. Lacerations involving the vermilion border of the lip, intraoral lacerations, other more
serious lacerations and gunshot wounds will be referred on
to an oral and maxillofacial surgeon. General dentists may
undertake management of intraoral lacerations in a primary care setting.
Small lacerations can usually be sutured under local anaesthesia unless the patient is a young child, in which case
general anaesthesia is indicated. Thorough cleaning is necessary before wound closure. Skin lacerations are closed
with absorbable material such as polyglactin (Vicryl),
placed deep if necessary and then the overlying skin closed
with fine nonabsorbable material such as 6/0 Prolene or
Ethilon. Intraoral wounds may be closed with Vicryl or silk.
It is important when repairing a lip laceration which involves the vermilion border that it is accurately lined up to
avoid an ugly step on healing.
Alternate skin sutures should ideally be removed at
4 days and the remaining sutures at 5 days to minimise
scarring while maintaining wound support.
Antibiotics are prescribed to reduce the risk of wound
infection: flucloxacillin for skin lacerations and amoxicillin
for intraoral wounds, unless contraindicated. Tetanus prophylaxis should be recommended if immunisation is not up
to date.
SURGICAL MANAGEMENT OF BURNS
Initial management according to ATLS. There could be late
threat to airway due to scar contracture. During the initial
48 hours, the patient is hypovolaemic due to pericapillary tissue exudation and tissue oedema. After 48 hours, the patient
becomes diuretic and fluid replacement demands reduce.
Analgesia is required as well as the prevention of wound
infection with antibiotics and dressings. The area of burn
may require excision. Partial-thickness burns may be best
left exposed to the air when epithelialisation may start at
12 days. Reconstruction may be with skin grafts or microvascular free tissue transfer.
Evidence of carbon deposits in the mouth, pharynx or
sputum are important signs of smoke inhalation that may
lead to respiratory distress.
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Master Dentistry
8.4 Facial Fractures
LEARNING OBJECTIVES
You should:
• know how to identify facial fractures clinically and
radiologically.
• know the principles of management of the different
facial fractures.
• know the techniques used to fix facial fractures.
AETIOLOGY
Facial fractures may result from interpersonal violence,
road traffic accidents, falls, sport and industrial accident or
from pathology resulting in bony weakness such as an extensive cyst. There is a decline in the number of injuries
following road traffic accidents in the developed world,
mainly because of legislation to encourage the wearing
of seat belts, although this has not been as great as hoped
because drivers choose to drive at greater speeds because
they feel safer. Facial injuries incurred through domestic
violence are being increasingly recognised. The commonest
fracture is that of the mandible.
CLINICAL PRESENTATION
Facial trauma is classified into injuries of the lower, middle
and upper thirds of the face. The upper third includes the
frontal bone, the mid-third includes the maxilla, zygomas,
orbits, nose and naso-orbital ethmoidal complex whilst the
lower third includes the mandible.
Examination consists of the palpation of bony margins
of the facial skeleton starting with the supraorbital rims
and progressing down to the lower border of the mandible,
comparing right and left sides. The convexity of the right
and left zygomatic arches should be compared and the malar prominence of the cheek bones (zygomatic bones)
should be compared and is best done by viewing from behind the patient. Any step deformities are noted. Gentle but
firm palpation may be required if there is swelling that
could mask any step or depression in the contour. The eyes
are examined for double vision (diplopia) that may occur
secondary to muscle entrapment causing restriction of
movement and subconjunctival haemorrhage. Enophthalmos is the posterior displacement of the eye (globe) in the
eye socket (orbit) that can occur when there is a fracture
involving the socket allowing fat to escape. The condyles of
the mandible are palpated to check that they move when
the mandible moves and so are not disconnected by fracture, and the movements of the mandible on opening and
lateral excursions are also checked. Swelling, bruising and
lacerations are noted together with any areas of altered
sensation reported by the patient that may have resulted
because of damage to branches of the trigeminal nerve.
Any evidence of cerebrospinal fluid (CSF) leak from the
nose or ears is noted, as this is an important feature of a
fracture of the base of the skull. Glucose and chlorine concentration can be helpful in identifying CSF.
An intraoral examination is then carried out, looking
particularly for alterations to the occlusion (Fig. 8.5), a step
Premature contact
Fig. 8.5 Altered occlusion observed in a fracture of the condyle of the
mandible.
in the occlusion (Fig. 8.6), fractured, displaced or missing
teeth, lacerations and bruises. The stability of the maxilla is
checked by bimanual palpation, one hand attempting to
mobilise the maxilla by grasping it from an intraoral approach, and the other noting any movement at extraoral
sites such as nasal, zygomatic-frontal and infra-orbital. Features that suggest the fracture of a particular part of the
facial skeleton are:
n
mandible:
n
pain and swelling
n
deranged occlusion
Fig. 8.6 A step in the occlusion observed in a fracture of the mandible.
n
paraesthesia in distribution area of inferior alveolar
nerve
n
floor-of-mouth haematoma
n
zygoma:
n
clinical flattening of the cheekbone prominence
n
paraesthesia in distribution area of infraorbital nerve
n
diplopia, restricted eye movements, subconjunctival
haemorrhage (Fig. 8.7)
n
limited lateral excursions of mandibular movements
because of coronoid impaction against the depressed
arch
n
palpable step in infraorbital bony margin
n
orbit:
n
diplopia
n
restricted eye movements
n
subconjunctival haemorrhage
n
enophthalmos
n
maxilla:
n
maxilla mobile
n
deranged occlusion
n
gross swelling if high-level fracture
n
bilateral circumorbital bruising
n
subconjunctival haemorrhage
n
CSF leaking from nose (rhinorrhoea) or ear (otorrhoea)
n
nasal/nasoethmoidal:
n
swelling
n
bilateral circumorbital bruising
n
clinical deviation or depression of nasal bridge
n
nosebleed (epistaxis).
RADIOLOGICAL EXAMINATION
At least two views are usually needed to demonstrate a
fracture adequately.
Teeth
Periapical view is supplemented by another intraoral view
from an oblique angle (e.g., oblique occlusal or bisectingangle periapical).
Dento-Alveolar Fracture
Periapical(s) and oblique occlusal views.
8 • Oral and Maxillofacial Injuries
131
Mandible
Panoramic film and posteroanterior (PA) of mandible are
the basic views. A reverse Towne’s (modified PA) is useful
for suspected condylar fractures. True occlusal views of a
fracture in the body or symphysis are helpful.
Zygoma (or Malar) Fractures
Occipitomental (OM) and OM30° views are required.
Maxillary Fractures
OM, OM30° views of true lateral facial bones, and CT scans
are helpful for complicated and comminuted fractures.
Nasal Fractures
True lateral nasal bones, sometimes with the addition of
superoinferior nasal bones, are both taken using occlusal
films.
Nasoethmoidal Fractures
Views are as for maxillary fractures.
PRINCIPLES OF FACIAL FRACTURE MANAGEMENT
The goals in managing facial trauma are:
n
restoring anatomy and eliminating deformity
n
restoring occlusion and masticatory abilities
n
restoring function including nasal airflow and ocular
function
n
minimising morbidity
n
early return to function.
Good bony healing of fractures requires close apposition
of the fragments and immobility for a period of about
6 weeks. This period may be shorter in children and longer
in elderly patients. Mobility of the fracture site will lead to
fibrous union. The principles of fracture management are,
therefore, those of reduction and fixation.
There are many different techniques for fixation of facial
fractures and these may be described as rigid, semirigid or
nonrigid. The fracture site may be surgically opened and
fixation such as plates applied directly or left closed and
indirect fixation applied. There has been a move in the
developed world towards greater use of direct fixation of
fractures rather than the indirect, but the latter does still
have particular indications.
Fig. 8.7 Subconjunctival haemorrhage associated with a fracture of
the zygomatic complex.
Dento-Alveolar Fractures
Fractures of the tooth-bearing part of the mandible or
maxilla are reduced and then immobilised by one of many
methods. All techniques involve fixing the teeth involved in
the fracture to adjacent teeth, and this may be achieved by
means of wiring, arch bars, acid-etch-retained composite
splinting, orthodontic banding or cement-retained acrylic
splints. Splinting is required for a minimum of 4 weeks.
Mandibular Fractures
Fractures are classified according to their site: dento-alveolar,
symphyseal, parasymphyseal, body, angle, ramus, coronoid
and condyle (Fig. 8.8). They may be compound, involving
the mouth (including via the periodontal membrane of
teeth) or skin, or may be simple or comminuted. It is more
132
Condyle
Coronoid
Angle
Parasymphyseal
Master Dentistry
Symphyseal
Body
Dento-alveolar
Fractures of the condyle not interfering with the occlusion
are frequently managed conservatively, that is with soft diet
and regular review. A 2-week period of IMF rather than ORIF
is a common treatment choice if the occlusion is deranged.
Zygoma (or Malar) Fractures
Zygoma fractures are most commonly reduced by elevation
via a Gillies’ temporal approach. A Rowe’s elevator is placed
beneath the deep temporal fascia, slid under the zygoma
and lifted without levering on the temporal bone (Fig. 8.9).
Alternative methods include an intraoral approach and direct lifting of the zygoma with a hook placed through the
skin of the cheek. The zygoma may or may not need fixation
depending on its stability. When needed, titanium miniplates may be placed at the zygomatic-frontal, infraorbital
and buttress regions as necessary (Fig. 8.10).
unusual to describe fractures as favourable or unfavourable
according to whether they resist the pull of attached muscles. The standard treatment is open reduction and internal
fixation (ORIF) with mini-plates. This approach has revolutionised the management of mandibular fractures and other
facial fractures. A fracture of the mandible in a dentate patient may typically be reduced and fixed with intermaxillary
fixation (IMF) achieved by placement of arch bars (see
p. 134). The fracture site is then surgically opened and fixed
with a mini-plate, the wound closed and the intraoperative
IMF released. The occlusion is, therefore, utilised for accurate
reduction of the fracture but the postoperative disadvantages
of IMF avoided.
If there is a partly erupted or erupted tooth in the line of
a fracture, one should consider whether it ought to be removed to avoid predisposing to later infection of the fracture site or whether it could remain. Most surgeons would
leave the tooth in situ unless it is fractured, grossly carious
or has periapical pathology.
Orbital Fractures
Fractures of the zygomatic complex will necessarily involve
the orbit, but it is also possible to sustain an isolated fracture of the orbit. This may tether the inferior rectus muscle,
causing diplopia, or be large enough to permit herniation
of orbital fat and muscle into the maxillary antrum. Such a
“blow-out” may be repaired with “silastic” or titanium
mesh materials or bone taken from another site, for example iliac crest of the hip or the cranium.
Maxillary Fractures
Fractures of the maxilla are classified as Le Fort I, II or III
(Fig. 8.11). Le Fort I is the lowest level of fracture, in which the
tooth-bearing part of the maxilla is detached. Le Fort II or a
pyramidal fracture of the maxilla involves the nasal bones and
infraorbital rims, while Le Fort III involves the nasal bones and
zygomatic-frontal sutures and the whole of the maxilla is detached from the base of the skull. After reduction of the fracture, fixation may be achieved by a variety of means, including
Fig. 8.9 Gillies’ temporal approach for the elevation of a depressed fracture’s zygomatic complex.