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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.
Maxillofacial trauma
Management of
traumatized patient
2
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
3
Incidence
Literatures reported different incidence in different
parts of the WORLD and at different TIMES
√ 11% in RTA (Oikarinen and Lindqvist 1975)




Mandible (61%)
Maxilla (46%)
Zygoma (27%)
Nasal (19.5%)
4

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)
5
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
6
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
7
failure
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
8
Primary survey
Ⓐ Airway maintenance with cervical
control
spine
Ⓑ Breathing and ventilation
Ⓒ Circulation with hemorrhage control
Ⓓ Disability assessment of neurological status
Ⓔ Exposure and complete examination of the
patient
9
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 semirigid collar until damaged spine is excluded
10
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
11
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 patient’s lips and continuous supervision
12
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
13
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
14
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
15
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
16
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
17
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
18
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
19
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
20
Glasgow coma scale (GCS)
(Teasdale and Jennett, 1974)
Eye
opening
Motor
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
Extends
2
none
1
none
Score 8 or less indicates poor prognosis, moderate head
injury between 9-12 and mild refereed to 13-15
1
21
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
22
Secondary survey
Although 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
23
Head injury
Many of facial injury patients sustain head injury in
particular the mid face injuries

Open

Closed
it is ranged from Mild concussion to brain death
24
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 (battle’s sign)
Temporal/ frontal bone fracture
Naso-orbital ethmoidal fracture
25
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
patient’s 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
26
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)
27
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
28
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
29
Patient hospitalization and
determination of priorities
Facial 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 patient’s life
△ emergency cases require instant admission
△ conditions that may progress to emergency
△ cases with no urgency
30
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
31
Prevention of infection
Fractures 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)
32
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
33
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
34
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.
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
Etiology

@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%
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
Anatomy
Anatomy
Emergency Management
Airway Control

Control airway:





Chin lift.
Jaw thrust.
Oropharyngeal suctioning.
Manually move the tongue forward.
Maintain cervical immobilization
Emergency Management
Intubation Considerations

Avoid nasotracheal intubation:



Avoid Rapid Sequence Intubation:



Nasocranial intubation
Nasal hemorrhage
Failure to intubate or ventilate.
Consider an awake intubation.
Sedate with benzodiazepines.
Emergency Management
Intubation Considerations



Consider fiberoptic intubation if available.
Alternatives include percutaneous
transtracheal ventilation and retrograde
intubation.
Be prepared for cricothyroidotomy.
Emergency Management
Hemorrhage Control

Maxillofacial bleeding:



Nasal bleeding:



Direct pressure.
Avoid blind clamping in wounds.
Direct pressure.
Anterior and posterior packing.
Pharyngeal bleeding:

Packing of the pharynx around ET tube.
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?
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?
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
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.
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.
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..
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.
Physical Examination



Examine and palpate the exterior ears.
Examine the ear canals.
Check nuero distributions of the supraorbital,
infraorbital, inferior alveolar and mental
nerves.
Frontal Sinus/ Bone Fractures
Pathophysiology


Results from a direct blow to the frontal bone
with blunt object.
Associated with:



Intracranial injuries
Injuries to the orbital roof
Dural tears
Frontal Sinus/ Bone Fractures
Clinical Findings



Disruption or crepitance
orbital rim
Subcutaneous
emphysema
Associated with a
laceration
Frontal Sinus/ Bone Fractures
Diagnosis

Radiographs:


Facial views should
include Waters, Caldwell
and lateral projections.
Caldwell view best
evaluates the anterior
wall fractures.
Frontal Sinus/ Bone Fractures
Diagnosis

CT Head with bone
windows:



Frontal sinus fractures.
Orbital rim and
nasoethmoidal fractures.
R/O brain injuries or
intracranial bleeds.
Frontal Sinus/ Bone Fractures
Treatment

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.
Frontal Sinus/ Bone Fractures
Complications

Associated with intracranial injuries:






Orbital roof fractures.
Dural tears.
Mucopyocoele.
Epidural empyema.
CSF leaks.
Meningitis.
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.
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.
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
Nasal Fractures



Most common of all facial fractures.
Injuries may occur to other surrounding bony
structures.
3 types:



Depressed
Laterally displaced
Nondisplaced
Nasal Fractures

Ask the patient:



“Have you ever broken your nose before?”
“How does your nose look to you?”
“Are you having trouble breathing?”
Nasal Fractures

Clinical findings:




Nasal deformity
Edema and tenderness
Epistaxis
Crepitus and mobility
Nasal Fractures

Diagnosis:


History and physical
exam.
Lateral or Waters view to
confirm your diagnosis.
Nasal Fractures

Treatment:



Control epistaxis.
Drain septal hematomas.
Refer patients to ENT as
outpatient.
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
Orbital Blowout Fractures
Clinical Findings





Periorbital tenderness,
swelling, ecchymosis.
Enopthalmus or sunken
eyes.
Impaired ocular
motility.
Infraorbital anesthesia.
Step off deformity
Orbital Blowout Fractures
Imaging studies

Radiographs:




Hanging tear drop sign
Open bomb bay door
Air fluid levels
Orbital emphysema
Orbital Blowout Fractures
Imaging studies

CT of orbits



Details the orbital
fracture
Excludes retrobulbar
hemorrhage.
CT Head

R/o intracranial injuries
Orbital Blowout Fractures
Treatment

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.
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)
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.
Zygoma Arch Fractures
Clinical Findings




Palpable bony defect
over the arch
Depressed cheek with
tenderness
Pain in cheek and jaw
movement
Limited mandibular
movement
Zygoma Arch Fractures
Imaging Studies & Treatment

Radiographic imaging:


Submental view (bucket
handle view)
Treatment:



Consult maxillofacial
surgeon
Ice and analgesia
Possible open elevation
Zygoma Tripod Fractures

Tripod fractures consist
of fractures through:



Zygomatic arch
Zygomaticofrontal suture
Inferior orbital rim and
floor
Zygoma Tripod Fractures
Clinical Features

Clinical features:




Periorbital edema and
ecchymosis
Hypesthesia of the
infraorbital nerve
Palpation may reveal
step off
Concomitant globe
injuries are common
Zygoma Tripod Fractures
Imaging Studies

Radiographic imaging:


Waters, Submental and
Caldwell views
Coronal CT of the facial
bones:

3-D reconstruction
Zygoma Tripod Fractures
Treatment

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.
Maxillary Fractures




High energy injuries.
Impact 100 times the force of gravity is
required .
Patients often have significant multisystem
trauma.
Classified as LeFort fractures.
Maxillary Fractures
LeFort 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.
Maxillary Fractures
LeFort I

Clinical findings:



Facial edema
Malocclusion of the teeth
Motion of the maxilla
while the nasal bridge
remains stable
Maxillary Fractures
LeFort 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
Maxillary Fractures
LeFort II

Definition:

Pyramidal fracture



Maxilla
Nasal bones
Medial aspect of the orbits
Maxillary Fractures
LeFort II

Clinical findings:





Marked facial edema
Nasal flattening
Traumatic telecanthus
Epistaxis or CSF
rhinorrhea
Movement of the upper
jaw and the nose.
Maxillary Fractures
LeFort II

Radiographic imaging:

Fracture involves:





Nasal bones
Medial orbit
Maxillary sinus
Frontal process of the
maxilla
CT of the face and head
Maxillary Fractures
LeFort III

Definition:

Fractures through:





Maxilla
Zygoma
Nasal bones
Ethmoid bones
Base of the skull
Maxillary Fractures
LeFort III

Clinical findings:




Dish faced deformity
Epistaxis and CSF
rhinorrhea
Motion of the maxilla,
nasal bones and zygoma
Severe airway
obstruction
Maxillary Fractures
LeFort III

Radiographic imaging:

Fractures through:





Zygomaticfrontal suture
Zygoma
Medial orbital wall
Nasal bone
CT Face and the Head
Maxillary Fractures
Treatment
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Secure and airway
Control Bleeding
Head elevation 40-60 degrees
Consult with maxillofacial surgeon
Consider antibiotics
Admission
Mandible Fractures
Pathophysiology
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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%.
Mandible Fractures
Clinical findings
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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.
Mandible Fractures
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Radiographs:
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Panoramic view
Plain view: PA, Lateral and a Townes view
Mandibular Fractures
Treatment
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Nondisplaced fractures:
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Displaced fractures, open fractures and fractures with
associated dental trauma
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Analgesics
Soft diet
oral surgery referral in 1-2 days
Urgent oral surgery consultation
All fractures should be treated with antibiotics and
tetanus prophylaxis.
Mandibular Dislocation
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Causes of mandibular dislocation are:
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Blunt trauma
Excessive mouth opening
Risk factors:
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Weakness of the temporal mandibular ligament
Over stretched joint capsule
Shallow articular eminence
Neurologic diseases
Mandibular Dislocation

The mandible can be
dislocated:
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Anterior 70%
Posterior
Lateral
Superior
Dislocations are mostly
bilateral.
Mandibular Dislocation
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Posterior dislocations:
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Lateral dislocations:
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Direct blow to the chin
Condylar head is pushed against the mastoid
Associated with a jaw fracture
Condylar head is forced laterally and superiorly
Superior dislocations:
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Blow to a partially open mouth
Condylar head is force upward
Mandibular Dislocation
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Clinical features:
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Inability to close mouth
Pain
Facial swelling
Physical exam:
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Palpable depression
Jaw will deviate away
Jaw displaced anterior
Mandibular Dislocation
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Diagnosis:
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History & Physical exam
X-rays
CT
Mandibular Dislocation
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Treatment:
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Muscle relaxant
Analgesic
Closed reduction in the
emergency room
Mandibular Dislocation
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Treatment:
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Oral surgeon consultation:
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Open dislocations
Superior, posterior or lateral dislocations
Non-reducible dislocations
Dislocations associated with fractures
Mandibular Dislocation
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Disposition:
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Avoid excessive mouth opening
Soft diet
Analgesics
Oral surgery follow up