Facial Fractures & Acute Dental Injuries
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Transcript of Facial Fractures & Acute Dental Injuries
JANINE FERRO, ATC, CSCS
Facial Fractures & Dental Injuries
Occular & Related Maxillofacial Injuries
Injury to External Structures Contusion/periorbital ecchymosis (black eye)
Lacerations of lids
Conjunctivitis
Various Fractures
Occular & Related Maxillofacial Injuries
Anterior Segment Foreign body Corneal abrasion Corneal laceration Subconjunctival
hemorrhage Hyphema Traumatic cataract Dislocated lens Traumatic iritis
Posterior Segment Injury to the
retina/choroid Ruptured globe
Four Cardinal Complaints
Indications for further evaluation/referral: Change in vision
Change in appearance
Pain/discomfort
Trauma
Fractures of the Zygomatic Complex- Tripod Fracture
Etiology & Pathology
Etiology Blunt trauma to the prominence of the zygomatic bone
(cheekbone)
Pathology Fracture of zygomatic arch; fracture dislocation at
zygomaticofrontal & zygomaticomazillary suture lines Inferior, medial, & posterior displacement of
zygomatic bone into maxillary sinus area
Associated Ocular Complications
Retinal detachment
Dislocation of the lens
Injuries to the globe
Orbital floor fractures
Clinical Evaluation
History Blunt trauma to the prominence of the zygomatic bone
Inspection Flattened cheek with periorbital ecchymosis Subconjunctival hemorrhage/ hyphema Lowered lateral palpebral (eyelid) fissure Unilateral nosebleed on affected side Ala (winging) of the nose & lip on affected side
Clinical Evaluation
Palpation Step-off defects of the infraorbital rim & at
zygomaticofrontal suture Point tenderness at fracture site
Functional Tests Trismus (inability to open mouth due to impingement
of zygoma on coronid process) Anesthesia/paraesthesia over cheek, ½ of nose, &
upper lip (infraorbital n. distribution) Diplopia (on outer upward & downward gaze) Restricted eye movement (upward gaze)
Management
Place athlete in comfortable positionCover one/both eyes (unison movement)Cold compress to periorbital regionObserve for nausea/ vomitingAvoid blowing nose!
URGENT EMERGENT REFERRAL!
Orbital Blow-Out Fractures
Etiology & Pathology
Etiology Blunt trauma to the globe of the eye (direct) Results in rapid increase in intraorbital pressure
Pathology Comminuted fractures of the orbital floor/ medial wall Extrusion of inferior orbital soft tissue into maxillary
sinus Entrapment of inferior extraocular ms. in fracture
defect Infraorbital nerve trauma
Associated Occular Complications
Infraorbital nerve trauma
Occular injuries Retinal detachment Dislocation of the lens Injury to the globe Hyphema Bleeding into the orbit causing acute proptosis High intraorbital pressure from intraocular bleeding
Clinical Evaluation
History Direct MOI (blunt trauma to the globe- ball, fist, etc.) Indirect MOI (trauma to surrounding areas)
Inspection Periorbital ecchymosis/edema Lowered globe/sunken eye Retraction of globe Hyphema Subconjunctival hemorrhage
Clinical Evaluation
Palpation Not indicated
Functional Tests Restricted superior/lateral gaze Entrapment of nerve/muscle Vertical diplopia Paresthesia/ hypoesthesia in infraorbital n. distribution
Management Same as zygomatic complex fx. Care- EMERGENCY!!
Nasal Fractures
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Etiology & Pathology
Etiology Blunt trauma to the dorsum of the nose
Force directed anteriorly results in depressed nasal fx Force directed laterally results in lateral fx/ dislocation
Pathology Comminuted fracture of the nasal bones Associated disruption of the septal, lateral, & alar
cartilages
Clinical Evaluation
Complications Septal hematoma Abcess/ septal erosion “Saddle nose” deformity
History Frontal/ lateral blunt trauma to the dorsum of the
nose
Clinical Evaluation
Inspection Lateral deviation of nasal bones/cartilages Flattened nose Edema & ecchymosis over the dorsum of the nose Epistaxis (nosebleed) Septal hematoma & intranasal lacerations
Palpation Bony irregulatities (step-offs) Tenderness over dorsum of nose
Functional Tests Have patient look in a mirror!
Naso-orbital Injuries
Etiology & Pathology
Etiology Blunt trauma to the naso-orbital area
Pathology Comminuted fracture of the nasal bones Disruption of the septal, lateral, and alar cartilages Associated rupture of the medial canthal (palpebral)
ligaments
Clinical Evaluation
History Blunt trauma to the naso-orbital area
Inspection Signs associated with nasal fx. Associated telecanthus (increased intercanthal distance)
& almond shaped medial palpebral fissure (normally elliptical)
Palpation Bony irregularities (step-offs) Tenderness over dorsum of the nose
Clinical Evaluation
Functional Tests None.
Management
Referral
Differential Diagnosis Concussion Blow-out fracture Globe injury
Mandibular Fractures
Etiology & Pathology
Etiology Blunt trauma to the mandibular arch of symphysis
Pathology Fracture through cuspid area (common); multiple
fracture including: Cusid area & 3rd molar area on opposite side Cuspid area & subcondylar area on opposite side Symphysis & angle of the mandible Symphysis & one/ both subcondylar areas
Clinical Evaluation
History Blunt trauma
Inspection Malocclusion Facial asymmetry Ecchymosis in the floor of the mouth Bleeding at base of tooth (3rd molar) External contusion/edema/ecchymosis Otorrhea (condylar fx)
Clinical Evaluation
Palpation Step-offs Point tenderness at fracture site(s) Crepitus/ inability to feel condyle w/ finger in ear
(condylar fx)
Functional Tests Crepitus & instability (passive “rocking” of mandible) Paresthesia/ anesthesia over jaw & lower lip
(mandibular n.) Positive “tongue blade test”
Clinical Evaluation
Complications Mandibular n. trauma Airway obstruction from blood Avulsed teeth Prolapse of tongue (w/ mandibular instability)
Management Immobilize; refer Surgical repair (plate) frequently required Fixation 4-6wks Return to sport 8-12wks
Fractures of the Midface
Etiology & Pathology
Etiology Severe blunt trauma to the midface
Pathology LeFort I, II, or III fractures
Complications
Infraorbital n. injuryOccular injuriesAirway obstruction in soft palate area due to
hemorrhage & edema (LeFort I)Nasal airway obstruction due to bony
displacement/hemorrhage & edema (LeFort II &III)
Cerebrospinal rhinorrhea due to fx in cranial vault (LeFort II & III)
Intracranial injuries
Classification of Midface Fractures
LeFort I Fracture of the maxilla at the level of the nasal floor
LeFort II (pyramidal fx) Fracture in the central portion of the face that
includes both maxillae, medial ½ of both antra, medial ½ of the infraorbital rim, medial portion of the orbit & orbital floor, & nasal bones
LeFort III (craniofacial disjunction) A LeFort fx plus fractures of both zygomatic bones/
separation of facial bones from cranial vault
Clinical Evaluation
History Severe blunt trauma- not usually from sport activity
Inspection Facial asymmetry (elongation, flattened/ “dish
panned” naso-orbital area) Gagged/ open-bite occulusion (impaction of upper &
lower molars) Telecanthus (increased intercanthal distance) Facial edema/ ecchymosis Intraoral ecchymosis in zagomaticomaxillary buttress
areas Cerebrospinal rhinorrhea (LeFort III)
Clinical Evaluation
Palpation “Step-off” defects/ point tenderness at LeFort I, II, III
fracture site
Functional Tests Instability- grab front teeth & try to move Crepitus (passive “rocking” of maxilla) Paresthesia/ anesthesia over cheek, ½ nose, & upper
lip (infraorbital n.)
Dental Injuries/ Inflammatory
Injuries
General Information
Subluxations/Avulsions Partially displaced teeth (intruded, extruded) Avulsed teeth
Fractures Crown fractures Root fractures Alveolar fractures
Inflammatory Conditions Gingivitis Periodontitis Pericoronitis Dental Abscess
Subluxations/Avulsions
Disruption of the supporting structures (periodontal membrane) involving: Sensitivity w/o mobility/ displacement Mobility w/o displacement Intrusion/ partial displacement Extrusion/ partial displacement Complete avulsion
Subluxations/ Avulsions
Handle by crown onlyRinse w/ sterile saline (don’t wipe)ReplaceStabilize (bite on gauze)Re-implant w/in 30min (highest success)If unable to re-implant:
Save a Tooth Cold, whole milk Saline-gauze Under tongue Water
Intruded Tooth Lateral Luxation
Subluxations/Avulsions
Crown Fractures
Direct trauma (hit by object)/ indirect (force through mandible/ contact of mandible & maxillary teeth)
Fractures involving: Enamel with/ without loss of tooth structure (cracked/
chipped) Enamel & dentin or Enamel, dentin, & pulp
Crown Fractures
Enamel Irritating Not sensitive to temperature Can wait
Enamel & Dentin Sensitive to temperature Possibly cover with sugarless gum for temporary relief
Pulp Extremely painful- “hot tooth” Exposed nerve Bloody Save broken portion (Save A Tooth)
Crown Fractures
Root Fractures
Etiology Direct trauma (hip by object) or indirect trauma (force
through mandible/ contact of mandibular & maxillary teeth)
Pathology Vertical crown-root fracture with/without pulp exposure, or Horizontal root fracture of apical (apex) middle, or cervical
third Pain Mobility on finger pressure (primary sign) Pulpal necrosis
If tooth is pushed back, it should not be forced forward (broken below gum line)
Root Fractures
Alveolar Fractures
Etiology Direct trauma (hit by object)
Pathology Fracture of alveolar process of the mandible/ maxilla
with disruption of the tooth socketSigns & Symptoms
Pain Displacement/ simultaneous mobility or two/ more
adjacent teeth (primary sign) Pulpal necrosis
Alveolar Fractures
Protect Your Teeth!!!
Shoulda worn a mouthguard little man! Prom picts
aren’t gonna look so good!