Maxillofacial Trauma

1
Pathognomonic clinical signs of traumatic tissue
maxillofacial area in children. Modern diagnostic
methods. The principles of therapeutic tactics in
injuries of the soft tissues of the face, teeth,
bones. Diagnosis, differential diagnosis and
treatment of TMJ ankilosis. Modern principles of
treatment and rehabilitation of children with
congenital maxillo facial area.
2
Maxillofacial trauma

• Management of traumatized patient

3
Causes

• ? Road traffic accident (RTA)
• 35-60
• Rowe and Killey 1968
• Vincent-Towned and Shepherd 1994
• ? Fight and assault (interpersonal violence)
• Most in economically prosperous countries
• Beek and Merkx 1999
• ? Sport and athletic injuries
• ? Industrial accidents
• ? Domestic injuries and falls

4
Incidence

• Literatures reported different incidence in
  different parts of the WORLD and at different
  TIMES
• v 11 in RTA (Oikarinen and Lindqvist 1975)
• Mandible (61)
• Maxilla (46)
• Zygoma (27)
• Nasal (19.5)

5
Factors affecting the high/low incidence of
maxillofacial trauma

• Geography
• Fight, gunshot and RTA in developed and
  developing countries respectively (Papavassiliou
  1990, Champion et al 1997)
• Social factors
• Violence in urban states (Telfer et al 1991
  Hussain et al 1994 Simpson McLean 1995)
• Alcohol and drugs
• Yong men involved in RTA wile they are under
  alcohol or drug effects (Shepherd 1994)
• Road traffic legislation
• Seat belts have resulted in dramatic decrease
  in injury (Thomas 1990, as reflected in reduction
  in facial injury (Sabey et al 1977)
• Season
• Seasonal variation in temperature zones
  (summer and snow and ice in midwinter) of RTA,
  violence and sporting injuries (Hill et al 1998)

6
Assessment of traumatized patient

• This should not concentrate on the most obvious
  injury but involve a rapid survey of the vital
  function to allow management priorities

5 of all deaths world wide are caused by
trauma This might be much higher in this country
7
Peaks of mortality

• First peak
• Occurs within seconds of injury as a result of
  irreversible brain or major vascular damage
• Second peak
• Occurs between a few minutes after injury and
  about one hour later (golden hour)
• Third peak
• Occurs some days or weeks after injury as a
  result of multi-organ failure

8
Organization of trauma services
triage decisions are crucial in determining
individual patients survival

• Pre-hospital care (field triage)
• Care delivered by fully trained paramedic in
  maintaining airway, controlling cervical spine,
  securing intravenous and initiating fluid
  resuscitation
• Hospital care (inter-hospital triage)
• Senior medical staff organized team to ensure
  that medical resources are deployed to maximum
  overall benefit
• Mass casualty triage

9
Primary survey

• ? Airway maintenance with cervical spine
  control
• ? Breathing and ventilation
• ? Circulation with hemorrhage control
• ? Disability assessment of neurological status
• ? Exposure and complete examination of the patient

10
Airway

• Satisfactory airway signifies the implication of
  breathing and ventilation and cerebral function
• Management of maxillofacial trauma is an integral
  part in securing an unobstructed airway
• Immobilization in a natural position by a
  semi-rigid collar until damaged spine is excluded

11
Sequel of facial injury
Obstruction of airway
asphyxia
Cerebral hypoxia
Brain damage/ death
Is the patient fully conscious? And able to
maintain adequate airway?
Semiconscious or unconscious patient rapidly
suffocate because of inability to cough and adopt
a posture that held tongue forward
12
Immediate treatment of airway obstruction in
facial injured patient

• ?Clearing of blood clot and mucous of the mouth
  and nares and head position that lead to escape
  of secretions (sit-up or side position)
• ? Removal of foreign bodies as a broken denture
  or avulsed teeth which can be inhaled and
  ensuring the patency of the mouth and oropharynex
• ? Controlling the tongue position in case of
  symphesial bilateral fracture of mandible and
  when voluntary control of intrinsic musculature
  is lost
• ? Maintaining airway using artificial airway in
  unconscious patient with maxillary fracture or by
  nasophryngeal tube with periodic aspiration
• ? Lubrication of patients lips and continuous
  supervision

13
Additional methods in preservation of the airway
in patient with severe facial injuries

• Endotracheal intubation
• Needed with multiple injuries, extensive soft
  tissue destruction and for serious injury that
  require artificial ventilation
• Tracheostomy
• Surgical establishment of an opening into the
  trachea
• Indications 1. when prolonged artificial
  ventilation is necessary
• 2. to facilitate
  anesthesia for surgical repair in certain cases
• 3. to ensure a
  safe postoperative recovery after extensive
  surgery
• 4. following
  obstruction of the airway from laryngeal edema
• 5. in case of
  serious hemorrhage in the airway
• Circothyroidectomy
• An old technique associated with the risk of
  subglottic stenosis development particularly in
  children. The use of percutaneous dilational
  treachestomy (PDT) in MFS is advocated by Ward
  Booth et al (1989) but it can be replaced with
  PDT.
• Control of hemorrhage and Soft tissue laceration
• Repair, ligation, reduction of fracture and
  Postnasal pack

14
Cervical spine injury

• Can be deadly if it involved the odontoid
  process of the axis bone of the axis vertebra
• If the injury above the clavicle bone, clavicle
  collar should minimize the risk of any
  deterioration

15
Breathing and ventilation

• Chest injuries
• Pneumothorax, haemopneumothorax, flail
  segments, reputure daiphram, cardiac tamponade
• signs

Clinical Deviated trachea Absence of breath
sounds Dullness to percussion Paradoxical
movements Hyper-response with a large
pneumothorax Muffled heart sounds
Radiographical Loss of lung marking Deviation of
trachea Raised hemi-diaphragm Fluid
levels Fracture of ribs
16
Emergency treatment in case of chest injury

• Occluding of open chest wounds
• Endotreacheal intubation for unstable flail chest
• Intermittent positive pressure ventilation
• Needle decompression of the pericardium
• Decompression of gastric dilation and aspiration
  of stomach content

17
Circulation

• Circulatory collapse leads to low blood
  pressure, increasing pulse rate and diminished
  capillary filling at the periphery

Patient resuscitation Restoration of
cardio-respiratory function Shock
management Replacement of lost fluid
18

• Fluid for resuscitation
• ?Adequate venous access at two points
• ? Hypotension assumed to be due to hypovolaemia
• ? Resuscitation fluid can be crystalloid, colloid
  or blood ringer lactate
• ? Surgical shock requires blood transfusion,
  preferably with cross matching or group O
• ? Urine output must be monitored as an indicator
  of cardiac out put

19

• Reduction and fixation will often arrest bleeding
  of long duration
• Pulse and blood pressure should be monitored and
  appropriate replacement therapy is to be started

20
Neurological deficient

• Rapid assessment of neurological disability is
  made by noting the patient response on four
  points scale
• A Response appropriately, is Aware
• V Response to verbal stimuli
• P Response to painful stimuli
• U Does not responds, Unconscious

21
Glasgow coma scale (GCS)(Teasdale and Jennett,
1974)
Eye opening Eye opening Motor response Motor response Verbal response Verbal response
Spontaneous 4 Move to command 6 Converse 5
To speech 3 Localizes to pain 5 Confused 4
To pain 2 Withdraw from pain 4 Gibberish 3
none 1 flexes 3 grunts 2
none 1 Extends 2 grunts 2
none 1 Extends 2 none 1
none 1 none 1 none 1
Score 8 or less indicates poor prognosis,
moderate head injury between 9-12 and mild
refereed to 13-15
22
Exposure

• All trauma patient must be fully exposed in a
  warm environment to disclose any other hidden
  injuries
• When the airway is adequately secured the
  second survey of the whole body is to be carried
  out for
• Accurate diagnosis
• Maintenance of a stable state
• Determination of priorities in treatment
• Appropriate specialist referral

23
Secondary surveyAlthough maxillofacial injuries
is part of the secondary survey, OMFS might be
involved at early stage if the airway is
compromised by direct facial trauma

• Head injury
• Abdominal injury
• Injury to extremities

24
Head injuryMany of facial injury patients
sustain head injury in particular the mid face
injuries

• Open
• Closed
• it is ranged from Mild concussion to brain death

25
Signs and symptoms of head injury

• Loss of conscious
• OR
• History of loss of conscious
• History of vomiting
• Change in pulse rate, blood pressure and pupil
  reaction to light in association with increased
  intracranial pressure
• Assessment of head injury (behavioral responses
  motor and verbal responses and eye opening)
• Skull fracture
• Skull base fracture (battles sign)
• Temporal/ frontal bone fracture
• Naso-orbital ethmoidal fracture

26

• slow reaction and fixation of dilated pupil
  denotes a rise in intra-cranial pressure
• Rise in intercranial pressure as a result of
  acute subdural or extradural hemorrhage
  deteriorate the patients neurological status
• Apparently stable patient with suspicion of head
  injury must be monitored at intervals up to one
  hour for 24 hour after the trauma

27
Hemorrhage

• Acute bleeding may lead to hemorrhagic shock
  and circulatory collapse
• Abdominal and pelvis injury liver and internal
  organs injury (peritonism)
• Fracture of the extremities (femur)

28
Abdomen and pelvis

• In addition to direct injuries, loss of
  circulating blood into peritoneal cavity or
  retroperitonial space is life threatening,
  indicated by physical signs and palpation,
  percussion and auscultation
• Management
• Diagnostic peritoneal lavage (DPL) to detect
  blood, bowel content, urine
• Emergency laprotomy

29
Extremity trauma

• Fracture of extremities in particular the
  femur can be a significant cause of occult blood
  loss. Straightening and reduction of gross
  deformity is part of circulation control
• Cardinal features of extremities injury
• Impaired distal perfusion (risk of ischemia)
• Compartment syndrome (limb loss)
• Traumatic amputation

30
Patient hospitalization and determination of
prioritiesFacial bone fracture is hardly ever
an urgent procedure,simple and minor injury of
ambulant patient may occasionally mask a serious
injury that eventually ended the patients life

• ? emergency cases require instant admission
• ? conditions that may progress to emergency
• ? cases with no urgency

31
Preliminary treatment in complex facial injury

• Soft tissue laceration (8 hours of injury with no
  delay beyond 24 hours)
• Support of the bone fragments
• Injury to the eye
• As a result of trauma, 1.6 million are blind,
  2.3 million are suffering serious bilateral
  visual impairment and 19 million with unilateral
  loss of sight (Macewen 1999)
• Ocular damage
• Reduction in visual acuity
• Eyelid injury

32
Prevention of infectionFractures of jaw
involving teeth bearing areas are compound in
nature and midface fracture may go high, leading
to CSF leaks (rhinorrhoea, otorrhoea) and risk of
meningitis,and in case of perforation of
cartilaginous auditory canal

• Diagnosis
• Laboratory investigation, CT and MRI scan
• Management
• Dressing of external wounds
• Closure of open wounds
• Reposition and immobilization of the fractures
• Repair of the dura matter
• Antibacterial prophylaxis (as part of the general
  management (Eljamal, 1993)

33
Control of pain Displaced fracture may cause
severe pain but strong analgesic ( Morphine and
its derivatives) must be avoided as they depress
cough reflex, constrict pupils as they may mask
the signs of increasing intracranial pressure

• Management
• ? Non-steroidal anti-inflammatory drugs can be
  prescribed (Diclofenac acid)
• ? Reduction of fracture
• ? sedation

34
In patient care

• Necessary medications
• Diet (fluid, semi-fluid and solid food) intake
  and output (fluid balance chart)
• Hygiene and physiotherapy
• Proper timing for surgical intervention

35
Pathophysiology

• Maxillofacial fractures result from either blunt
  or penetrating trauma.
• Penetrating injuries are more common in city
  hospitals.
• Midfacial and zygomatic injuries.
• Blunt injuries are more frequently seen in
  community hospitals.
• Nose and mandibular injuries.

36
Pathophysiology

• High Impact
• Supraorbital rim 200 G
• Symphysis of the Mandible 100 G
• Frontal 100 G
• Angle of the mandible 70 G
• Low Impact
• Zygoma 50 G
• Nasal bone 30 G

37
Etiology

• _at_60 of patients with severe facial trauma have
  multisystem trauma and the potential for airway
  compromise.
• 20-50 concurrent brain injury.
• 1-4 cervical spine injuries.
• Blindness occurs in 0.5-3

38
Etiology

• 25 of women with facial trauma are victims of
  domestic violence.
• Increases to 30 if an orbital wall fx is
  present.
• 25 of patients with severe facial trauma will
  develop Post Traumatic Stress Disorder

39
Anatomy
40
Anatomy
41
Emergency ManagementAirway Control

• Control airway
• Chin lift.
• Jaw thrust.
• Oropharyngeal suctioning.
• Manually move the tongue forward.
• Maintain cervical immobilization

42
Emergency ManagementIntubation Considerations

• Avoid nasotracheal intubation
• Nasocranial intubation
• Nasal hemorrhage
• Avoid Rapid Sequence Intubation
• Failure to intubate or ventilate.
• Consider an awake intubation.
• Sedate with benzodiazepines.

43
Emergency ManagementIntubation Considerations

• Consider fiberoptic intubation if available.
• Alternatives include percutaneous transtracheal
  ventilation and retrograde intubation.
• Be prepared for cricothyroidotomy.

44
Emergency ManagementHemorrhage Control

• Maxillofacial bleeding
• Direct pressure.
• Avoid blind clamping in wounds.
• Nasal bleeding
• Direct pressure.
• Anterior and posterior packing.
• Pharyngeal bleeding
• Packing of the pharynx around ET tube.

45
History

• Obtain a history from the patient, witnesses and
  or EMS.
• AMPLE history
• Specific Questions
• Was there LOC? If so, how long?
• How is your vision?
• Hearing problems?

46
History

• Specific Questions
• Is there pain with eye movement?
• Are there areas of numbness or tingling on your
  face?
• Is the patient able to bite down without any
  pain?
• Is there pain with moving the jaw?

47
Physical Examination

• Inspection of the face for asymmetry.
• Inspect open wounds for foreign bodies.
• Palpate the entire face.
• Supraorbital and Infraorbital rim
• Zygomatic-frontal suture
• Zygomatic arches

48
Physical Examination

• Inspect the nose for asymmetry, telecanthus,
  widening of the nasal bridge.
• Inspect nasal septum for septal hematoma, CSF or
  blood.
• Palpate nose for crepitus, deformity and
  subcutaneous air.
• Palpate the zygoma along its arch and its
  articulations with the maxilla, frontal and
  temporal bone.

49
Physical Examination

• Check facial stability.
• Inspect the teeth for malocclusions, bleeding and
  step-off.
• Intraoral examination
• Manipulation of each tooth.
• Check for lacerations.
• Stress the mandible.
• Tongue blade test.
• Palpate the mandible for tenderness, swelling and
  step-off.

50
Physical Examination

• Check visual acuity.
• Check pupils for roundness and reactivity.
• Examine the eyelids for lacerations.
• Test extra ocular muscles.
• Palpate around the entire orbits..

51
Physical Examination

• Examine the cornea for abrasions and lacerations.
• Examine the anterior chamber for blood or
  hyphema.
• Perform fundoscopic exam and examine the
  posterior chamber and the retina.

52
Physical Examination

• Examine and palpate the exterior ears.
• Examine the ear canals.
• Check nuero distributions of the supraorbital,
  infraorbital, inferior alveolar and mental
  nerves.

53
Frontal Sinus/ Bone FracturesPathophysiology

• Results from a direct blow to the frontal bone
  with blunt object.
• Associated with
• Intracranial injuries
• Injuries to the orbital roof
• Dural tears

54
Frontal Sinus/ Bone FracturesClinical Findings

• Disruption or crepitance orbital rim
• Subcutaneous emphysema
• Associated with a laceration

55
Frontal Sinus/ Bone FracturesDiagnosis

• Radiographs
• Facial views should include Waters, Caldwell and
  lateral projections.
• Caldwell view best evaluates the anterior wall
  fractures.

56
Frontal Sinus/ Bone FracturesDiagnosis

• CT Head with bone windows
• Frontal sinus fractures.
• Orbital rim and nasoethmoidal fractures.
• R/O brain injuries or intracranial bleeds.

57
Frontal Sinus/ Bone FracturesTreatment

• Patients with depressed skull fractures or with
  posterior wall involvement.
• ENT or nuerosurgery consultation.
• Admission.
• IV antibiotics.
• Tetanus.
• Patients with isolated anterior wall fractures,
  nondisplaced fractures can be treated outpatient
  after consultation with neurosurgery.

58
Frontal Sinus/ Bone FracturesComplications

• Associated with intracranial injuries
• Orbital roof fractures.
• Dural tears.
• Mucopyocoele.
• Epidural empyema.
• CSF leaks.
• Meningitis.

59
Naso-Ethmoidal-Orbital Fracture

• Fractures that extend into the nose through the
  ethmoid bones.
• Associated with lacrimal disruption and dural
  tears.
• Suspect if there is trauma to the nose or medial
  orbit.
• Patients complain of pain on eye movement.

60
Naso-Ethmoidal-Orbital Fracture

• Clinical findings
• Flattened nasal bridge or a saddle-shaped
  deformity of the nose.
• Widening of the nasal bridge (telecanthus)
• CSF rhinorrhea or epistaxis.
• Tenderness, crepitus, and mobility of the nasal
  complex.
• Intranasal palpation reveals movement of the
  medial canthus.

61
Naso-Ethmoidal-Orbital Fracture

• Imaging studies
• Plain radiographs are insensitive.
• CT of the face with coronal cuts through the
  medial orbits.
• Treatment
• Maxillofacial consultation.
• ? Antibiotic

62
Nasal Fractures

• Most common of all facial fractures.
• Injuries may occur to other surrounding bony
  structures.
• 3 types
• Depressed
• Laterally displaced
• Nondisplaced

63
Nasal Fractures

• Ask the patient
• Have you ever broken your nose before?
• How does your nose look to you?
• Are you having trouble breathing?

64
Nasal Fractures

• Clinical findings
• Nasal deformity
• Edema and tenderness
• Epistaxis
• Crepitus and mobility

65
Nasal Fractures

• Diagnosis
• History and physical exam.
• Lateral or Waters view to confirm your diagnosis.

66
Nasal Fractures

• Treatment
• Control epistaxis.
• Drain septal hematomas.
• Refer patients to ENT as outpatient.

67
Orbital Blowout Fractures

• Blow out fractures are the most common.
• Occur when the the globe sustains a direct blunt
  force
• 2 mechanisms of injury
• Blunt trauma to the globe
• Direct blow to the infraorbital rim

68
Orbital Blowout FracturesClinical Findings

• Periorbital tenderness, swelling, ecchymosis.
• Enopthalmus or sunken eyes.
• Impaired ocular motility.
• Infraorbital anesthesia.
• Step off deformity

69
Orbital Blowout FracturesImaging studies

• Radiographs
• Hanging tear drop sign
• Open bomb bay door
• Air fluid levels
• Orbital emphysema

70
Orbital Blowout FracturesImaging studies

• CT of orbits
• Details the orbital fracture
• Excludes retrobulbar hemorrhage.
• CT Head
• R/o intracranial injuries

71
Orbital Blowout FracturesTreatment

• Blow out fractures without eye injury do not
  require admission
• Maxillofacial and ophthalmology consultation
• Tetanus
• Decongestants for 3 days
• Prophylactic antibiotics
• Avoid valsalva or nose blowing
• Patients with serious eye injuries should be
  admitted to ophthalmology service for further
  care.

72
Zygoma Fractures

• The zygoma has 2 major components
• Zygomatic arch
• Zygomatic body
• Blunt trauma most common cause.
• Two types of fractures can occur
• Arch fracture (most common)
• Tripod fracture (most serious)

73
Zygoma Arch Fractures

• Can fracture 2 to 3 places along the arch
• Lateral to each end of the arch
• Fracture in the middle of the arch
• Patients usually present with pain on opening
  their mouth.

74
Zygoma Arch FracturesClinical Findings

• Palpable bony defect over the arch
• Depressed cheek with tenderness
• Pain in cheek and jaw movement
• Limited mandibular movement

75
Zygoma Arch FracturesImaging Studies
Treatment

• Radiographic imaging
• Submental view (bucket handle view)
• Treatment
• Consult maxillofacial surgeon
• Ice and analgesia
• Possible open elevation

76
Zygoma Tripod Fractures

• Tripod fractures consist of fractures through
• Zygomatic arch
• Zygomaticofrontal suture
• Inferior orbital rim and floor

77
Zygoma Tripod FracturesClinical Features

• Clinical features
• Periorbital edema and ecchymosis
• Hypesthesia of the infraorbital nerve
• Palpation may reveal step off
• Concomitant globe injuries are common

78
Zygoma Tripod FracturesImaging Studies

• Radiographic imaging
• Waters, Submental and Caldwell views
• Coronal CT of the facial bones
• 3-D reconstruction

79
Zygoma Tripod FracturesTreatment

• Nondisplaced fractures without eye involvement
• Ice and analgesics
• Delayed operative consideration 5-7 days
• Decongestants
• Broad spectrum antibiotics
• Tetanus
• Displaced tripod fractures usually require
  admission for open reduction and internal
  fixation.

80
Maxillary Fractures

• High energy injuries.
• Impact 100 times the force of gravity is required
  .
• Patients often have significant multisystem
  trauma.
• Classified as LeFort fractures.

81
Maxillary FracturesLeFort I

• Definition
• Horizontal fracture of the maxilla at the level
  of the nasal fossa.
• Allows motion of the maxilla while the nasal
  bridge remains stable.

82
Maxillary FracturesLeFort I

• Clinical findings
• Facial edema
• Malocclusion of the teeth
• Motion of the maxilla while the nasal bridge
  remains stable

83
Maxillary FracturesLeFort I

• Radiographic findings
• Fracture line which involves
• Nasal aperture
• Inferior maxilla
• Lateral wall of maxilla
• CT of the face and head
• coronal cuts
• 3-D reconstruction

84
Maxillary FracturesLeFort II

• Definition
• Pyramidal fracture
• Maxilla
• Nasal bones
• Medial aspect of the orbits

85
Maxillary FracturesLeFort II

• Clinical findings
• Marked facial edema
• Nasal flattening
• Traumatic telecanthus
• Epistaxis or CSF rhinorrhea
• Movement of the upper jaw and the nose.

86
Maxillary FracturesLeFort II

• Radiographic imaging
• Fracture involves
• Nasal bones
• Medial orbit
• Maxillary sinus
• Frontal process of the maxilla
• CT of the face and head

87
Maxillary FracturesLeFort III

• Definition
• Fractures through
• Maxilla
• Zygoma
• Nasal bones
• Ethmoid bones
• Base of the skull

88
Maxillary FracturesLeFort III

• Clinical findings
• Dish faced deformity
• Epistaxis and CSF rhinorrhea
• Motion of the maxilla, nasal bones and zygoma
• Severe airway obstruction

89
Maxillary FracturesLeFort III

• Radiographic imaging
• Fractures through
• Zygomaticfrontal suture
• Zygoma
• Medial orbital wall
• Nasal bone
• CT Face and the Head

90
Maxillary FracturesTreatment

• Secure and airway
• Control Bleeding
• Head elevation 40-60 degrees
• Consult with maxillofacial surgeon
• Consider antibiotics
• Admission

91
Mandible FracturesPathophysiology

• Mandibular fractures are the third most common
  facial fracture.
• Assaults and falls on the chin account for most
  of the injuries.
• Multiple fractures are seen in greater then 50.
• Associated C-spine injuries 0.2-6.

92
Mandible FracturesClinical findings

• Mandibular pain.
• Malocclusion of the teeth
• Separation of teeth with intraoral bleeding
• Inability to fully open mouth.
• Preauricular pain with biting.
• Positive tongue blade test.

93
Mandible Fractures

• Radiographs
• Panoramic view
• Plain view PA, Lateral and a Townes view

94
Mandibular FracturesTreatment

• Nondisplaced fractures
• Analgesics
• Soft diet
• oral surgery referral in 1-2 days
• Displaced fractures, open fractures and fractures
  with associated dental trauma
• Urgent oral surgery consultation
• All fractures should be treated with antibiotics
  and tetanus prophylaxis.

95
Mandibular Dislocation

• Causes of mandibular dislocation are
• Blunt trauma
• Excessive mouth opening
• Risk factors
• Weakness of the temporal mandibular ligament
• Over stretched joint capsule
• Shallow articular eminence
• Neurologic diseases

96
Mandibular Dislocation

• The mandible can be dislocated
• Anterior 70
• Posterior
• Lateral
• Superior
• Dislocations are mostly bilateral.

97
Mandibular Dislocation

• Posterior dislocations
• Direct blow to the chin
• Condylar head is pushed against the mastoid
• Lateral dislocations
• Associated with a jaw fracture
• Condylar head is forced laterally and superiorly
• Superior dislocations
• Blow to a partially open mouth
• Condylar head is force upward

98
Mandibular Dislocation

• Clinical features
• Inability to close mouth
• Pain
• Facial swelling
• Physical exam
• Palpable depression
• Jaw will deviate away
• Jaw displaced anterior

99
Mandibular Dislocation

• Diagnosis
• History Physical exam
• X-rays
• CT

100
Mandibular Dislocation

• Treatment
• Muscle relaxant
• Analgesic
• Closed reduction in the emergency room

101
Mandibular Dislocation

• Treatment
• Oral surgeon consultation
• Open dislocations
• Superior, posterior or lateral dislocations
• Non-reducible dislocations
• Dislocations associated with fractures

102
Mandibular Dislocation

• Disposition
• Avoid excessive mouth opening
• Soft diet
• Analgesics
• Oral surgery follow up

103
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