Lecture 1 maxillofacial trauma

Trauma to the facial region frequently results in
injuries to soft tissue , teeth, and major skeletal
components of the face, including the mandible,
maxilla, zygoma, nasoorbital-ethmoid (NOE)
complex, and supraorbital structures. In
addition, these injuries frequently occur in
combination with injuries to other areas of the
body.
2

Participation in the treatment and rehabilitation
of the patient with facial trauma involves a
thorough understanding of the types of,
principles of, evaluation for, and surgical
treatment of facial injuries.
This chapter outlines the fundamental principles
for treatment of the patient with facial trauma.
3

EVALUATION OF PATIENTS
WITH FACIAL TRAUMA
Immediate Assessment
 The first step in evaluating a trauma patient is to assess the patient's
cardiopulmonary stability by ensuring that the patient has a patent
airway and that the lungs are adequately ventilated.
 Vital signs, including respiratory and pulse rates and blood pressure,
should be taken and recorded.
 During this initial assessment (i.e., primary survey), other potentially life
threatening problems, such as excessive bleeding, should also be
addressed.
 Immediate measures, such as pressure dressings, packing, and
clamping of briskly bleeding vessels, should be accomplished as
quickly as possible.
4

An assessment of the patient's neurologic status and
an evaluation of the cervical spine should be
completed next.
Forces severe enough to cause fractures of the facial
skeleton are often transmitted to the cervical spine.
The neck should be temporarily immobilized until
neck injuries have been ruled out.
Careful palpation of the neck to assess possible
areas of tenderness and a cervical spine radiographic
series should be completed as soon as possible.
5

Treatment of head and neck injuries generally should be
deferred until a thorough evaluation, assessment, and
stabilization of the patient has been accomplished.
However, some initial treatment is often necessary to
stabilize the patient.
Management of the patient's airway is of vital importance.
Frequently, fractures of the facial bones severely
compromise the patient's ability to maintain the airway,
particularly when the patient is unconscious or completely
supine.
Severe mandible fractures, especially bilateral or
comminuted fractures, can cause posterior displacement of
the mandible and tongue, which results in obstruction of the
upper airway.
6

Posterior displacement of tongue and occlusion of upper airway
resulting from bilateral mandibular fractures. 7

 Simply grasping, repositioning, and stabilizing the mandible into a more
anterior position may alleviate this obstruction.
 Placement of a nasopharyngeal or an oropharyngeal airway may also
be sufficient to temporarily maintain a patent airway.
 In some cases, endotracheal intubation may be necessary.
 Any prosthetic devices, avulsed teeth, pieces of completely avulsed
bone, or other debris may also contribute to airway occlusion and must
be removed immediately.
 Any areas of bleeding should be quickly examined and managed with
packing, pressure dressings, or clamping.
 All excess saliva and blood must be suctioned from the pharynx to
avoid aspiration and laryngospasm.
8

Injuries to the facial region may involve not only
bones of the face but also soft tissue, such as
the tongue or upper neck areas, or they may be
associated with injuries such as a fractured
larynx.
In some cases an emergency tracheostomy
may be necessary to provide an adequate
airway.
In trauma patients who have complete upper
airway obstruction, a cricothyrotomy is the most
rapid way to access the trachea.
10

Tracheostomy and cricothyrotomy sites with
landmarks for emergency surgical airway
access.
11

HISTORY AND PHYSICAL
EXAMINATION
After the patient has been initially stabilized, as
complete a history as possible should be obtained.
This history should be obtained from the patient;
however, because of loss of consciousness or
impaired neurologic status, information must often be
obtained from witnesses or accompanying family
members.
12

 Five important questions should be considered:
( 1 ) How did the accident occur?
( 2 ) When did the accident occur?
(3) What are the specifics of the injury, including the type of object
contacted, the direction from which contact was made, and similar
logistic considerations?
(4) Was there a loss of consciousness?
(5) What symptoms are now being experienced by the patient, including
pain, altered sensation, visual changes, and malocclusion?
 A complete review of systems, including information about allergies,
medications, and previous tetanus immunization, medical conditions,
and prior surgeries should be obtained.
13

Physical evaluation of the facial structures should be
completed only after an overall physical assessment
that addresses cardiopulmonary and neurologic
functions and other areas of potential trauma,
including the chest, abdomen, and pelvic areas.
Because patients with multiple severe injuries
frequently require evaluation and treatment by
several specialists, trauma teams have become
standard in the emergency departments of major
hospitals.
14

Evaluation of the facial area should be
performed in an organized and sequential
fashion.
The face and cranium should be carefully
inspected for evidence of trauma, including
lacerations, abrasions, contusions, areas of
edema or hematoma formation, and possible
contour defects. Areas of ecchymosis should be
carefully evaluated.
15

Periorbital ecchymosis, especially with
subconjunctival hemorrhage, is often
indicative of orbital rim or zygomatic
complex fractures.
Bruises behind the ear, or Battle's sign,
suggest a basilar skull fracture.
Ecchymosis in the floor of the mouth
usually indicates an anterior mandibular
fracture.
16

Periorbital ecchymosis and lateral
subconjunctival hemorrhage associated with
zygomatic complex fracture. 17

A neurologic examination of the face should include
careful evaluation of all cranial nerves.
Vision, extraocular movements, and pupillary reaction to
light should be carefully evaluated.
Visual acuity or pupillary changes may suggest
intracranial (cranial nerve II or III dysfunction) or direct
orbital trauma.
Uneven pupils (anisocoria) in a lethargic patient suggest
an intracranial bleed (subdural or epidural hematoma or
intraparenchymal bleed) or injury.
 An asymmetric or irregular (not round) pupil is most likely
caused by a globe (eyeball) perforation. 19

Abnormalities of ocular movements may also indicate
central neurologic problems (cranial nerves III, IV, or
VI) or mechanical restriction of the movements of the
eye muscles resulting from fractures of the orbital
complex.
Motor function of the facial muscles (cranial nerve VII)
and muscles of mastication (cranial nerve V) and
sensation over the facial area (cranial nerve V)
should be evaluated. Any lacerations should be
carefully cleaned and evaluated for possible
transection of major nerves or ducts, such as the
facial nerve or Stensen's duct.
20

A, 14-year-old patient
with a left orbital floor
fracture in upward gaze.
B, Entrapment of inferior
rectus muscle is the
result of impingement in
area of linear orbital
floor fracture. In down
gaze, patient is unable to
rotate the left eye
inferiorly, whereas the
right eye is fully rotated
inferiorly.
21

The mandible should be carefully evaluated by
extraorally palpating all areas of the inferior and
lateral borders and the temporomandibular joint,
paying particular attention to areas of point
tenderness.
The occlusion should be examined, and step
deformities along the occlusal plane and lacerations
of gingival areas should be assessed.
22

Irregularity of plane of occlusion and laceration in gingiva and
mucosa between the mandibular central incisors, indicating a
likelihood of mandibular fracture in this area. 23

Bimanual palpation of the suspected fracture area
should be performed by placing firm pressure over
the mandible posterior and anterior to the fracture
area in an attempt to manipulate and elicit mobility in
this area.
The occlusion should be reexamined after this
maneuver. Mobility of the teeth in the area of a
possible fracture should also be noted.
24

The evaluation of the midface begins with an
assessment of the mobility of the maxilla as an
isolated structure or in combination with the zygoma
or nasal bones.
To assess maxillary mobility, the patient's head
should be stabilized by using pressure over the
forehead with one hand. With the thumb and
forefinger of the other hand, one grasps the maxilla;
firm pressure should be used to elicit maxillary
mobility.
25

Examination of maxilla for mobility. A, Firm pressure on forehead is used to
stabilize patient's head. Pressure is placed on maxilla in attempt to elicit
mobility. B, Stabilizing hand can also evaluate mobility in area of nasal
bones. 26

The upper facial and midfacial regions should be
palpated for step deformities in the forehead, orbital rim,
or nasal or zygoma areas.
Firm digital pressure over these areas is used to carefully
evaluate the bony contours and may be difficult when
these areas are grossly edematous.
In checking for a zygomatic complex or arch fracture, an
index finger can be inserted in the maxillary vestibule
adjacent to the molars while palpating and applying
pressure superolaterally. Bony crepitus (the ability to feel
the vibration as fractured bone edges are rubbed against
one another) or extreme tenderness warrants a further
workup.
27

An evaluation of the nose and paranasal structures
includes measurement of the intercanthal distance
between the innermost portions of the left and right
medial canthus.
Frequently, nasoorbital ethmoid injuries cause
spreading of the nasal bones and displacement of the
medial canthal ligaments, resulting in traumatic
telecanthus (widening of the medial intercanthal
distance).
28

Injury to nasoorbital-ethmoid (NOE) complex, which resulted in the displacement
of medial canthal ligaments and a widening of the intercanthal distance (i.e. ,
traumatic telecanthus). A, Diagram of bony fractures and medial canthal ligament
displacement. B , Clinical photograph. (C) Clinical image of traumatic telecanthus
with ruler to demonstrate widening in millimeters. 29

Normally, the medial intercanthal distance should
equal the alar base width.
The nose should also be evaluated for symmetry
The bony anatomy of the nose should be evaluated
by palpation. A nasal speculum is used to visualize
internal aspects of the nose to locate excessive
bleeding or hematoma formation, particularly in the
area of the nasal septum.
30

Intraoral inspection should include an evaluation of
areas of mucosal laceration or ecchymosis in the
buccal vestibule or along the palate and an
examination of the occlusion and areas of loose or
missing teeth.
These areas should be assessed before, during, and
after manual manipulation of the mandible and
midface. Unilateral occlusal prematurities with
contralateral open bites are highly suspicious for
some type of jaw fracture.
31

RADIOGRAPHIC
EVALUATION
After a careful clinical assessment of the facial area,
radiographs should be taken to provide additional information
about facial injuries.
In cases of severe facial trauma, cervical spine injuries
should be ruled out with a complete cervical spine series
(i.e., cross-table, odontoid, and oblique views) before any
manipulation of the neck.
The facial radiographic examination should depend to some
degree on the clinical findings and the suspected injury.
32

Haphazard or excessive radiographic examination is
generally not warranted. In the patient with facial
trauma, the purpose of radiographs should be to
confirm the suspected clinical diagnosis, obtain
information that may not be clear from the clinical
examination, and more accurately determine the
extent of the injury.
Radiographic examination should also document
fractures from different angles or perspectives.
33

Radiographic evaluation of the mandible generally
requires two or more of the following four radiographic
views:
( 1 ) panoramic view,
( 2 ) open-mouth Towne's view,
(3) posteroanterior view, and
(4) lateral oblique views.
Occasionally, even these radiographs do not provide
adequate information; therefore, supplemental
radiographs, including occlusal or periapical views, may
be helpful.
34

A, Posterior-anterior
view demonstrates a
fracture in the angle
area of the mandible
(arrow).
B, Lateral oblique
view shows a
fracture in the angle
area (arrow).
C, Towne's view
shows a
displacement of
condylar fracture
(arrow).
35

Panoramic view shows a displaced fracture of the
left mandibular body and right subcondylar
fracture (arrows).
36

Computed tomography (CT) scans, axial views
without intravenous contrast medium, may provide
information not obtainable from plain radiographs or
when cervical spine precautions or other injuries do
not permit standard facial films.
Because many patients with facial trauma often
receive a CT scan to rule out neurologic injury, this
scan can also be used to supplement the
radiographic evaluation.
37

Evaluation of midface fractures was often
supplemented with radiographic views, including
Waters' view, lateral skull view, posteroanterior skull
view, and submental vertex view.
However, because of the difficulty of interpreting plain
radiographs of the midface, more sophisticated
techniques are generally used. These techniques
often include CT scans done in several planes of
space (e.g., axial and coronal) or, frequently with
three-dimensional reconstruction.
38

A, Water's view shows
fractures of orbital rim
areas (arrows) .
B, Lateral skull view
illustrates a Le Fort III
fracture or craniofacial
separation. The fracture
line (arrow) separates the
midface from the cranium.
C, Submental vertex
demonstrates a zygomatic
arch fracture (arrow).
39

A, Tomographic view demonstrates a disruption of
orbital floor (arrow). B, Computed tomography scan
shows disruptions of the medial wall and floor of
the right orbit. 40

C, Three-dimensional reconstruction of shotgun wound that
resulted in avulsion of the mandible and midface
structures. 41

42
Three-dimensional reconstruction of patient with
multiple facial fractures.

CAUSE AND CLAS SIFICATION
OF FACIAL FRACTURES
Causes of Facial Fractures
The major causes of facial fractures include motor
vehicle accidents and altercations. Other causes of
injuries include falls, sports-related incidents, and
work-related accidents.
Facial fractures resulting from motor vehicle
accidents are far more frequent in persons who were
not wearing restraints at the time of the accident.
43

MANDIBULAR FRACTURES
 Fractures of the mandible are common in patients, who sustain facial
trauma.
 A study conducted by Hang et al in 1983, showed the incidence in the
ratio of 6:2:1 of mandibular, zygomatic, maxillary fractures respectively.
 Approximately two-thirds of all facial fractures are the mandibular
fractures (nearly 70%).
Sex: Most mandibular fractures are seen in male patients. The ratio is
approximately 3:1.
Age: Thirty-five per cent of mandibular fractures occur between the
ages of 20 to 30 years.
44

Applied Surgical Anatomy of
Mandible
Mandible is a long tubular bone bent into a blunt V-
shape. The strength of the mandible lies in the dense
cortical plates.
The cortical bone is thicker anteriorly and at the lower
border of the mandible, whereas posteriorly the lower
border is relatively thin. The central portion consists of
cancellous bone.

Mandible may be compared to an archery bow which
is strongest anteriorly in the midline with
progressively less strength towards the condyles
where fracture is more prone to occur.
The shape of the mandible varies considerably with
age and growth, whereas the tooth plays a major role
in determining the mandibular height.
47

48
Variable mandibular morphology with age.

Alveolar process has a lingual and buccal plate of thin
compact bone. Shape of the alveolar process is dependent
on the presence or absence of teeth. After the extraction of
the teeth, the alveolar process undergoes resorption
continuously and therefore becomes atrophic.
The mandible is unique in its function in the following respect.
Any movement of the mandible results in movement of both
the condyles with respect to the skull base. Though condyles
are the articular surface of the mandible anatomically,
occlusal surface of the mandibular teeth subserves this role
functionally.
49

Bones usually fracture at the site of tensile strength, as
resistance to compressive force is greater in them. In 1961,
Huelke showed that forces applied to symphysis menti,
mandibular body or mental foramen lead to strains at the
condylar neck and also along the lingual plates in the
opposite molar region. The mandible is a strong bone, the
energy required to fracture it ranging from 44.6 to 74.4 kg/m.
Trajectories of force (mandible): A line of stress extends
from one condyle to the other passing along the symphysis.
These lines of orientations of the bony trabeculae correspond
to the pathway of maximal pressure and tension. The major
advantages of these trajectories are that it dissipates the
forces from body of mandible to condyle thus preventing
middle cranial fossa injury.
50

Sometimes an impact which might fail to cause a fracture
may result in capsulitis. Capsulitis refers to an effusion of
the inflammatory synovial fluid into the joint cavity or
bleeding into the cavity resulting in haemarthrosis.
When this occurs in young children, it results in ankylosis of
the TMJ and hinders the normal growth potential of the
condyle. Occasionally condylar head may be driven
backwards which tears the external auditory meatus and
causes bleeding from the external ear.
 Periosteum of the mandible does not significantly influence
the site of mandibular fracture or its displacement. However,
it is of significance in the treatment of edentulous fractures.
 Muscles attached to the mandible considerably influence the
displacement of the fractured segments.
52

Fractures of mandible between mental foramen and
mandibular foramen pose a risk to the inferior alveolar
neurovascular bundle. The mental nerve runs with the inferior
alveolar artery and injury to the canal produces numbness of
the ipsilateral lip and chin.
Blood supply of the mandible is via the inferior alveolar artery
that runs in the inferior alveolar canal. Additionally, blood
supply from surrounding periosteum plays a very important
role in healing, especially in the elderly and in injuries that
include the canal.
 In severely atrophic mandible, there is greater dependency
on the periosteal blood supply; therefore, minimal stripping of
the periosteum to be done in case of open reduction.
53

Area of weakness
Mandible as a single bone has many areas of weakness where the fracture is more likely to
occur. These vulnerable areas become the frequent site of fracture than other areas.
Junction of the alveolar bone and mandibular basal bone:
dentoalveolar fractures tend to occur independently or with other fractures.
Symphysis: fusion of two bony halves of mandible occur in the symphysis at the age of 12
months, making them more vulnerable.
Parasymphysis:presence of incisive fossa and mental foramen creates the natural
susceptibility for fracture to occur lateral to mental prominences.
Angle: junction of thicker mandibular body and comparatively thinner ramus of mandible
naturally creates a line of weakness in angle.
Condyle: slender condyle neck makes more vulnerable for fracture. Direct trauma to chin may
cause the condylar neck fracture as protective mechanism avoiding middle cranial fossa injury.
Teeth: edentulous mandibles are more vulnerable than the dentulous mandible (due to loss of
teeth and resorption of alveolar bone). Presence of long rooted canine and impacted molars
make them vulnerable for fracture.
54

ANATOMICAL CONSIDERATIONS
Attached muscles:
 Masseter
 Temporalis
 Medial and lateral
pterygoid
 Mylohyoid
 Geniohyoid and
genioglosus
 anterior belly of
digastrics
55

Blood supply
Endosteal supply via the ID artery and vein
Periosteal supply, important in aging due to diminishes and
disappearance of alveolar artery
Nerve
Damage of inferior dental nerve
Facial palsy by direct trauma to ramus
Damage of facial nerve in temporal bone fracture
Damage to mandibular division of facial nerve
56

CLASSIFICATION
Simple or closed The linear fracture which does not have
communication with the exterior or the interior. Such a
fracture does not produce a wound open to the external
environment either through the skin, mucosa or periodontal
membrane. It may or may not be displaced.
Examples Fractures in the region of the condyle, coronoid
process, ascending ramus, etc.
1. Kruger’s General Classification
59

Compound or open This fracture has
communication with the external environment through
skin or with the internal environment through mucosa
or periodontal membrane.
All the fractures involving the tooth bearing area of
the mandible or where an external or intraoral wound
is present involving the fracture line.
60

Comminuted A fracture in which the bone is
splintered or crushed into multiple pieces. These
types are generally due to a greater degree of
violence or high velocity impact.
Gunshot wounds, where missiles are travelling at a
high velocity can produce these fractures.
61

Complicated or complex Fractures associated with
the damage to the important vital structures
complicating the treatment as well as prognosis.
Example Fractures with injury to the inferior alveolar
vessels or nerve, facial nerve or its branches, facial
vessels, condylar fractures with associated injuries to
middle cranial fossa, etc.
62

Impacted Rarely seen in mandibular fractures. More
commonly seen in maxilla. This is a fracture in which
one fragment is firmly driven into the other fragment
and clinical movement is not appreciable.
Greenstick A fracture in which one cortex of the bone
is broken with the other cortex being bent. It is an
incomplete fracture seen in young children because
of inherent resilience of the growing bone.
63

Pathological Spontaneous fracture of the mandible
occurring from mild injury or as a result of a normal
degree of muscular contraction. This is because of
weakness caused due to the pre-existing bone
pathological processes.
64

Areas of structural weakness may result from the following:
a. Generalised skeletal disease
i. Endocrinal disorders—hyperparathyroidism or
postmenopausal osteoporosis.
ii. Developmental disorders—osteopetrosis, osteogenesis
imperfecta, etc.
iii. Systemic disorders—reticuloendothelial diseases,
Paget’s disease, osteomalacia and severe anaemia.
b. Localised skeletal disease
various cysts, odontomes, tumours, osteomyelitis,
osteoradionecrosis in the local region, presence of impacted
third molar etc.
65

Types of mandible fractures classified according to extent of injury in
area of fracture site. A, Greenstick. B, Simple. C, Comminuted. D,
Compound. Bone would be exposed through mucosa near teeth.
A B
C D
66

DINGMAN AND NATVIG’S
CLASSIFICATION BY ANATOMIC
REGION
A. Symphysis fracture (midline fracture).
B. Canine region fracture.
C. Body of the mandible between canine and angle.
D. Angle region—triangular region bounded by the anterior border of the masseter to
the posterosuperior attachment of the masseter.
E. Ramus region—bounded by the superior aspect of the angle to two lines forming an
apex at the sigmoid notch.
F. Coronoid region.
G. Condylar fractures.
H. Dentoalveolar region .
67

71
Fracture of body of the mandible.

76
MANDIBULAR DENTOALVEOLAR FRACTURE

FACTORS AFFECTING
DISPLACEMENT OF THE FRACTURE
Muscular pull on the fractured segment
Force of the impact
Site and direction of the fracture line
Presence of teeth in the fracture segments
Favourable or unfavourable fractures
77

FAVOURABLE OR UNFAVOURABLE
Fractures of the mandible are referred to as favorable or
unfavorable, depending on the angulation of the fracture and
the force of the muscle pull proximal and distal to the
fracture.
In a favorable fracture, the fracture line and the muscle pull
resist displacement of the fracture.
In an unfavorable fracture, the muscle pull results in
displacement of the fractured segments.
78

They can be vertically or horizontally in direction
They are influenced by the medial pterygoid-masseter
“sling”
If the vertical direction of the fracture favours the
unopposed action of medial pterygoid muscle, the
posterior fragment will be pulled lingually
If the horizontal direction of the fracture favours the
unopposed action of messeter and pterygoid muscles
in upward direction
Favourable fracture line makes the reduced fragment
easier to stabilize
79

A, Horizontally Unfavorable fractures resulting in displacement at
fracture site caused by pull of masseter muscle.
B, Horizontally Favorable fracture in which direction of fracture and
angulation of muscle pull resists displacement.
80

(1) Vertically favourable line of fracture through the right angle of
the mandible,
(2) Vertically unfavourable line of fracture through the right angle
of the mandible
81

82
(A–B) Horizontally
favourable and
horizontally
unfavourable.
(C–D) Vertically
favourable and
vertically
unfavourable.

84
Parasymphysis favourable and
unfavourable fracture (Vertically).

BILATERAL
PARASYMPHYSIS FRACTURE
85

86
Muscle attachment
to the mandible
(angle and
parasymphysis
fracture).

87
Bilateral mandible body fracture—multiple fractures
displaced anteriorly from digastric muscle pull.

DIAGNOSIS
A thorough history should be obtained.
 What was the mechanism of injury: fist, shod foot, baseball bat, fall,
motor vehicle accident?
 Was the injury witnessed?
 Was there any loss of consciousness?
 Is there a previous history of facial trauma or fractures, either treated or
untreated?
 Were there any pre-existing dental conditions such as deviated or
limited opening of the mouth; a cross-bite, open bite, or other
malocclusion; or the use of partial or complete dentures?
88

The patient’s medical history, allergies, and
medications are important, as well as the patient’s
social situation and habits. Patients with a history of
alcohol or drug abuse have posttreatment compliance
issues, which compromise their treatment outcome.
The age of the fracture upon presentation is important
as well. Compound fractures that present 5–10 days
after injury may be acutely or chronically infected, and
may drastically change the practitioner’s approach to
management.
89

CLINICAL EXAMINATION
 clinical examination should start with an extraoral review of the patient and then move
intraorally.
 Areas of abnormal facial contour or asymmetry should be noted.
 Preauricular swelling is often indicative of a condyle fracture.
 Loss of prominence of the mandibular angle may be a sign of an unfavorable fracture
in this region.
 Chin deviation often indicates a condyle fracture with deviation towards the injured
side.
 Diminished chin prominence with lip incompetence and bilateral preauricular swelling
may indicate bilateral condyle fractures.
 The skin of the face and neck should be examined for areas of redness, ecchymosis,
lacerations, or hematomas. Skin lacerations should be cleaned and inspected for
extension to bone. No wounds should be comprehensively repaired prior to a
definitive diagnosis of bony injury.
90

 The patient should be asked if he or she is experiencing
numbness or paresthesia in the distribution of the inferior alveolar
nerve. While not definitively diagnostic, it can be a clue to
fractures in the mandibular body, angle, and, occasionally, ramus.
 This finding is absent in patients with condyle fractures and
fractures of the mandibular symphysis anterior to mental foramen.
 The external auditory meatus should be checked for the presence
of blood, which is often seen in conjunction with condyle fractures
and blows to the symphysis. Patients may complain of diminished
hearing capacity.
 The patient should also be asked if he or she has difficulty
opening their mouth, or if the bite ‘‘feels’’ different than preinjury.
This should be correlated with an assessment of range of
mandibular motion, any trismus, deviation, or an inability to close
the mouth.
91

A wide range of combinations of mandible fractures can
account for a variety of occlusal discrepancies . However,
dental injuries, dentoalveolar fractures and temporo
mandibular joint (TMJ) arthroses (hemarthrosis, for example)
can confound the diagnosis, accounting for occlusal
discrepancies despite an otherwise negative clinical and
radiographic examination.
The presence of teeth, supported by ligaments within bone,
is the unique factor in these particular orthopedic injuries.
Knowledge of dental anatomy and occlusion, both normal
and abnormal, is critical to the re-establishment of a
functional and harmonious bite. Most patients can generally
indicate if their bite feels different after an injury, but they
cannot always give practitioners an idea of their preinjury
occlusion.
92

As the examination progresses intraorally, the
clinician should examine not only the individual teeth
for injuries but also how the mandibular and maxillary
arches come together.
The practitioner should look for fractured, loose, or
avulsed teeth, obvious step-offs between adjacent
teeth, and flail segments of alveolus or mandible.
The status of the gingiva, including ecchymosis,
bleeding, tears, or hematomas (especially
sublingual), is strongly suggestive of underlying
fractures.
93

If possible, the mandible should be evaluated in a bimanual
fashion for segmental mobility and an attempt to delineate
fracture patterns.
This will generally initiate rebleeding at the fracture sites, so
the patient’s head should be elevated to 45 degrees if
possible with suction and gauze available.
Gentle manual reduction will often control persistent
bleeding.
During the intraoral examination, all dental prostheses
(partial dentures, full dentures, retainers, etc.) should be
retained (broken or not) for possible future use in treatment
of the acute injury.
94

EXTRAORAL EXAMINATION
 Indirect signs: Swelling, ecchymosis, erythaema, abrasion
and lacerations may present as indirect signs of injury or
impact. Laceration or contusion in chin may indicate a
symphyseal injury causing symphysis fracture with or without
bilateral condyle fracture
 Facial deformity: There may be obvious deformity in the
bony contour of the mandible and if considerable
displacement has occurred, the patient is unable to
approximate the anterior teeth together and the mouth
remains in open posture (open bite).
95

96
(A–D) Indirect sign of
fracture—swelling and
laceration in preauricular
region seen in ramus
fracture.

97
(A) Indirect sign of
symphysis fracture—
chin
laceration.
(B) Indirect sign of
symphysis fracture
sutured wound in
chin region.
(C) Indirect sign of
symphysis fracture—
sutured
wound in chin.
(D) Indirect sign of
fracture—sutured
lacerations.

98
Facial deformity from mandible fracture with displacement.

 Inability to occlude teeth : Except angle, ramus and
condyle, all mandibular fractures are compound into
the mouth and bloodstained saliva is frequently
observed dribbling from the corners of the mouth.
 Palpation should begin bilaterally in the condylar
region and then continue downwards and along the
lower border of the mandible. Bone tenderness is
almost pathognomonic of a fracture, even an
undisplaced fracture. Displaced fracture present as
palpable step deformity in lower border and crepitus
from movement of fracture ends.
99

100
Inability to occlude teeth—bilateral condylar fracture

INTRAORAL EXAMINATION
 Buccal or lingual sulci are examined for ecchymosis or clots.
 On the lingual side, mucosa of the floor of the mouth overlies the
periosteum of the mandible, which, if breached following a
fracture, will invariably be the cause of any leakage of blood into
the lingual submucosa causing sublingual haematoma
(Coleman’s sign). Small linear haematomas, particularly in the
third molar region, are reliable indicators of adjacent fracture.
 Step defects in the occlusion or alveolus are noted along with
any obvious lacerations of the overlying mucosa and gingival tear.
101

102
Buccal sulcular ecchymosis in a case of mandibular
angle fracture.

103
Step deformity in occlusion (A) Parasymphysis fracture,
(B) Symphysis fracture.

Change of occlusion is one of the significant sign
which suggests a mandibular fracture. Change of
occlusion might be caused due to a fractured tooth,
fractured alveolar process, fractured mandible or due
to trauma to the TMJ.
 Mobility between the fracture segments can be
elicited by palpation.
 Any pain, tenderness or limitation of movement
during full range of mandibular movements is
indicative of fracture.
104

CLINICAL FEATURES OF
FRACTURE AT VARIOUS SITES
OF MANDIBLE
Fracture of the angle
Swelling at the angle externally and there may be obvious
deformity.
 Laceration of skin or mucosa. Step deformity behind the last
molar tooth may be visible which is more apparent if no teeth
are present in the molar region.
 Undisplaced fractures are usually revealed by the presence
of a small haematoma adjacent to the angle on either the
lingual or buccal side, or both.
105

Anaesthesia or paraesthesia of the lower lip may be present
on the side of the fracture.
 Inability to close the jaw causing premature dental contact.
 Occlusion is often deranged. Movements of the mandible
are painful and range of movements is reduced.
 Trismus to some degree is usually present.
 Anterior open bite is seen in bilateral angle fracture.
 Ipsilateral open bite is seen in unilateral angle fracture.
 Retrognathic occlusion and flattened appearance of the
lateral aspect of the face.
 Movement or crepitus at the fracture site can be felt.
106

FRACTURE OF BODY
 • The physical signs and symptoms like swelling and bone tenderness
similar to that as seen in fracture of angle of mandible.
 • Even slight displacement of the fracture causes derangement of the
occlusion.
 • Premature contact occurs on the distal fragment because of the
displacing action of the muscles attached to the ramus.
 • Fractures between adjacent teeth tend to cause gingival tears.
 • When there is gross displacement, inferior dental artery may be torn
and this can give rise to severe intraoral haemorrhage.
 • Sublingual haematoma or ecchymosis in floor of mouth—COLEMAN
SIGN.
107

 Flattened appearance of lateral aspect of face.
 Inability to open or close the jaw.
 Crepitation on palpation.
 IAN paraesthesia: Fractures of the body of mandible are
often associated with injury to the inferior dental nerve in
which case there will be paraesthesia or anaesthesia on one
or both sides of the lower lip.
 Molar teeth in particular may be split longitudinally in the
fracture line and cause considerable discomfort.
108

FRACTURES OF PARASYMPHYSIS AND
SYMPHYSIS
 • These fractures are commonly associated with fractures of one or
both the condyles.
 • This fracture may be missed if occlusion is undisturbed locally.
 • The presence of bone tenderness and a small lingual haematoma
may be the only physical signs.
 • Sublingual haematoma or ecchymosis in floor of mouth—COLEMAN
SIGN.
 • Posterior open bite or unilateral open bite is seen in parasymphysis
fracture. Posterior crossbite can result from midline symphysis
fractures.
 • Crepitation on palpation is noted in symphyseal fracture.
109

Inability to close the jaw causing premature dental
contact.
 A retruded chin can be caused by bilateral
parasymphyseal fracture.
 Fracture line is often oblique which allows overriding
of the fragments with lingual inversion of the
occlusion on each side.
 These fractures are associated with severe
concussion and may contribute to loss of tongue
control and obstruction of the airway.
110

FRACTURE OF RAMUS
They are uncommon.
 Flattened appearance of the lateral aspect of face.
 Inability to open or close the jaw.
 Swelling and ecchymosis usually noted both extraorally and
intraorally.
Tenderness over the ramus and movements produce pain
over the same area.
 Severe trismus.
111

FRACTURE OF CORONOID PROCESS
 The fracture can be caused by direct trauma to the ramus
but is rarely in isolation. It is usually considered to result from
reflex contracture of the powerful anterior fibres of the
temporalis muscle.
 This fracture is difficult to diagnose clinically.
 Tenderness over anterior part of the ramus.
 Painful limitation of movement, especially during protrusion
of the mandible may be found.
112

Lecture 1 maxillofacial trauma

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Lecture 1 maxillofacial trauma