Facial Fractures – Mandible and Frontal Bones Dale Reynolds, MD UT Houston Plastic &...

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Transcript of Facial Fractures – Mandible and Frontal Bones Dale Reynolds, MD UT Houston Plastic &...

  • Facial Fractures Mandible and Frontal BonesDale Reynolds, MDUT HoustonPlastic & Reconstructive Surgery

  • Facial FracturesPhasesEmergency TreatmentAirwayEdemaTeethBloodFBMandible fracture tongue to pharynxStridor, hoarseness, retraction, droolingETTTracheostomyLong term IMFCricothyroidotomy

  • Facial FracturesHemorrhageAnterior cranial fossaMidfaceLacerationsNasalNasal, zygomatic, orbital, frontal, NOE, maxillaryReduction (IMF)Anterior/ posterior packing x 24-48 hrsCompression dressingEmbolizationBilateral external carotid/ superficial temporal ligationBlood factor replacement

  • Facial FracturesAspirationLow threshold for ETTOtherEyeBrainSpine

  • Facial FracturesEarly injury careHistoryPENerves, vision, intraoral, nasopharyngeal, dentitionRadiographsLacerationsIMFImpressions

  • Facial FracturesClassificationAnatomyClosed v. openLe FortRadiographyCT v. x-raysOcclusion/ dentition

  • Facial FracturesMandibleAnatomy

  • Facial FracturesMandibleAnatomy

  • Facial FracturesMandibleAnatomy

  • Facial FracturesMandibleAnatomy

  • Facial FracturesMandibleMost common facial fracture after nasal10-25% of all facial fracturesBody> angle> condyle> parasymphysis> otherM: F = 2: 158% multiple (93% , 3 fx)Preinjury relationshipsStable bony unionFacial proportionsAvoid complications

  • Facial FracturesMandibleHistoryPrevious traumaPrevious baselinePre-injury photo

  • Facial FracturesMandiblePECrepitanceSymmetryTendernessOral/ dental missing teethStep offs

  • Facial FracturesMandibleRadiographyPanorexCTPlain filmsPA, Townes, R and L lateral oblique views (mandibular series)

  • MandibleTreatmentRestore form and functionOcclusion, TMJ function, cosmesisORIFExact anatomic reductionAllows early resumption of mandibular function

  • Mandible

  • MandibleTreatmentClosedDependent on splinting to maxilla to restore centric occlusion (maximal intercusspation)If inadequate number of teeth,Gunning splint may be needed for IMF

  • MandibleTreatmentOpenAccurate reduction Within 2 weeksIf maxilla cannot be used then mandible first or splintsAvoid prolonged IMFTraumitizes gingivaImpairs oral hygiene periodontal diseaseUncomfortableForces can alter tooth position and periodontal attachmentsGreat aspiration riskContraindication in COPD, seizure d/o, impaired MSArticular surfaces under compression cause pressure necrosis

  • MandibleORIFLag screw Anterior

  • MandibleORIFReconstruction plate Comminuted body

  • MandibleORIFTwo plate/ tension band Angle

  • MandibleORIFDynamic compression plate - Condyle

  • MandibleTreatmentContraindications to openNot requiredNot candidateRarely needed in childrenSimpleHeal quicklyOcclusion less established

  • Facial Fractures

  • MandibleTreatment by typeSimpleCR + IMF x 8 weeks if reliable (unreliable avoid IMF and open)

  • MandibleTreatment by typeComplexMultiple or segmentalOften interosseous wires/ reduction clamps/ temporary mini-plates helpInferior butterfly segmentDifficult to reduce

  • MandibleTreatment by typeComplexBilateral fracture each hemi-mandibleSimultaneous reduction may be required to avoid magnification of discrepancyArch bars and IMF may worsenAnterior fracture with one or both condylesConsider reducing one or both condyles first if difficult to control flaring the inferior borderUnilateral segmental fracture in one hemi-mandibleClose fractures two platesSeparated fractures long spanning plate

  • MandibleTreatment by typeComplexComminutedHigh energy GSW, SGW, MVCEasy to devitalize small fragmentsDifficult to accurately reduceLarge reconstruction plate may be requiredTemporary external fixator may be used if condition of patient or soft tissue requiresBone graft for extensive lossPre-treatment infection: Debride small fragmentsPost-treatment infection: FB (bone or screw)

  • MandibleTreatment by typeComplexEdentulousAtrophied and osteopenic poorer healingEarly atherosclerosis (15 years) of inferior alveolar artery 20% non-unionSimple and undisplaced pureed diet and obsUse dentures or splintsFracture with bony defectRigid fixation with spanning reconstruction plateBone graft/ flap within 5 yearsSoft tissue repair and IMF or ex fix until ready

  • MandibleTreatmentInfectionMore common if delayed careAbx, debridementFracture line may resorb and form gaps larger platesExtreme cases may require external fixator with secondary ORIF +/- graft

  • MandibleTreatmentChildren Most need CR + immobilization (single arch bar or lingual splint) x 2 weeksConical shape makes arch bars less usefulIndications for ORIF Unstable fracturesNot amenable to CRBilateral fractures with gross instabilityUse unicortical platesRemove 6-8 weeks later

  • MandibleTreatmentChildren Condyle is growth center of mandibleTrauma can cause hemarthrosis ankylosisIntracapsular fractures that do not alter the centric occlusion should not be immobilized to avoid ankylosis which can occur >12 months later and requires aggressive treatmentUnilateral condylar fractures with altered centric occlusion are treated with arch bars or lingual splints and elasticsDisplaced bilateral condylar fractures with posterior vertical collapse and anterior open bite deformity require CR + IMF x 4 weeks

  • MandibleTreatmentBy LocationAlveolar Process (1%)Remove if devitalized o/w IMF or splintSymphysis (5.8%)Often associated with condylar fracturesSignificant forces cause lateral flaring of posterior segments (often worse with IMF)Parasymphysis (11.6%)Often associated with contralateral fracturesMental nerveBurr/ osteotome may help lessen anterior curvature

  • MandibleTreatmentBy LocationBody (31.9%)May require external approachBi-cortical plates placed beneath mental canalAngle (27.5%)May require external approachOften associated with contralateralHighest complication rate due to third molar teeth and displacing forces

  • MandibleTreatmentBy LocationRamus (2.5%)Usually require extraoral approachOften stable due to splinting effect of masseter-medial pterygoid muscle sling unless displacement causes vertical shortening (telescoping)Coronoid process (1.8%)Soft diet usually enoughSevere pain may require brief IMF

  • MandibleTreatmentBy LocationCondyle (23.8%)Proximal segment can undergo AVNIntra-articular fractures: Very difficult ORIF, OA is common outcome, usually brief IMF for malocclusion o/w early mobilization +/- elasticsCondylar neck: Anteromedial displacement of proximal segment by lateral pterygoid, usually treated with IMF x 6 weeks, ORIF if joint capsule is thought to be involved

  • MandibleTreatmentBy LocationCondyleORIFDisplaced in to middle cranial fossaFB within jointLateral extra-capsular displacement of condyleDisplacement blocking opening or closingPosterior vertical shortening of mandible with open bite after 2 week IMF trialRelativeBilateral associated with unstable midface fracturesBilateral edentulous without splint

  • MandiblePostoperative care+/- Abx, airway control with IMF (wire cutters), HOB (secretions) + ice pack for edemaDietCLD blenderized, 48o IVF, 15 lb wt lossSplints/ IMFOral hygiene (peridex, H2O2, brush), remove waxOral washoutsRelease IMF q 3-5 days if needed

  • MandibleCentric occlusionRemove IMF to assess ORIFTherapeutic rehabilitationRegain strength and mobility, PT if severe (prolonged IMF or condyle fracture)Dental treatment (missing teeth)ComplicationsMalocclusion, malunion, non-union, hardware exposure, infection, non-compliance

  • Mandible Teeth in fracture line

  • Facial FracturesFrontal bone anatomy 7 bones

  • Facial FracturesFrontal bone anatomy

  • Facial FracturesFrontal sinus anatomy Middle meatus

  • Facial FracturesFrontal SinusMVC - Assaults 2-3 x force to fracture lower frontal sinusOther injuries associated (1/4 die in 14d)Rare in children

  • Facial FracturesFrontal Sinus FractureSignsRhinorrheaStep-offSupraorbital anesthesiaSubconjunctival hematomaSubcutaneous crepitance

  • Facial FracturesFrontal Sinus FractureDiagnosisPlain filmsCT

  • Facial FracturesFrontal sinus fracturesAnterior Table (Thick)Displaced ORIFBlockage of nasofrontal duct (methylene blue)Remove mucosaBone graft nasofrontal ducts, fill spaceElevate and fixate bonePosterior Table (Thin)Comminuted CranializeDisplaced greater than one wall thickness ORIF

  • Facial FracturesFrontal Sinus FractureComplications (Posterior > anterior)AcuteEpistaxisCSF leakMeningitisIntracranial injuryHematomaSubacuteMucoceleSinusitisChronicOsteomyelitisAbscesses

  • END