Maxillofacial Trauma

1. Maxillofacial Trauma El-Hawary

3. Maxillofacial Trauma El-Hawary DEFINITION

4. Maxillofacial Trauma El-Hawary Trauma Serious injury or shock to the body as form of violence or accident Bone fracture A medical condition in which there is a break in the continuty of bone

5. Maxillofacial Trauma El-Hawary CLASSIFICATIONS

6. Maxillofacial Trauma El-Hawary • Soft tissue wounds • Soft tissue wounds and fracture bones • Bone fractures only

7. Maxillofacial Trauma El-Hawary WOUNDS • Type of injury in which skin is torn, cut or punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound) • In pathology: it specifically refers to a sharp injury which damages the dermis of the skin

9. Maxillofacial Trauma El-Hawary Classifications of wounds wound According to the exposure to the outer environement According to level of risk of sepsis

10. Maxillofacial Trauma El-Hawary Classification according to the exposure to the outer environment wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury

11. Maxillofacial Trauma El-Hawary Classification according to object causing wound wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury

15. Maxillofacial Trauma El-Hawary wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury Classification according to object causing wound

16. Maxillofacial Trauma El-Hawary Classification according to the exposure to the outer environment wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury http://woundbegone.blogdrive.com/

17. Maxillofacial Trauma El-Hawary Classification according to the exposure to the outer environment wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury http://en.wikipedia.org/wiki/File:Knee_puncture.JPG

18. Maxillofacial Trauma El-Hawary Classification according to object causing wound wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury http://journal.nzma.org.nz/journal/120-1267/2867/

19. Maxillofacial Trauma El-Hawary Classification according to the exposure to the outer environment wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury http://www.podiatrytoday.com/article/6303

21. Maxillofacial Trauma El-Hawary Classification according to the exposure to the outer environment wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury http://en.wikipedia.org/wiki/File:Bruises.jpg

22. Maxillofacial Trauma El-Hawary Classification according to the exposure to the outer environment wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury http://www.buzzle.com/articles/hematoma-treatment.html

23. Maxillofacial Trauma El-Hawary Classification according to object causing wound wound Open Incision Laceration Abrasion Puncture Penetration Gunshot Closed Contusion Hematoma Crush injury http://www.smrteam.com/na1_crushinjury.htm

24. Maxillofacial Trauma El-Hawary Classification According to level of risk of sepsis

25. Maxillofacial Trauma El-Hawary Classification According to level of risk of sepsis wound Clean wound Clean contaminated wounds Contaminated wounds Dirty wounds

26. Maxillofacial Trauma El-Hawary Classification According to level of risk of sepsis wound Clean wound Clean contaminated wounds Contaminated wounds Dirty wounds • No viscus entered • No septic area • No break in aseptic technique • Such wounds should never become infected; infection rates less than 3%

27. Maxillofacial Trauma El-Hawary Classification According to level of risk of sepsis wound Clean wound Clean contaminated wounds Contaminated wounds Dirty wounds • Operation enters a non-infected area but may encounter bacteria • Careful control of the area should result in minimal spillage of organisms • Examples of this include surgery on the upper gastrointestinal tract, biliary tree or respiratory tract • Infection rates for this type of surgery should be less than 10%

28. Maxillofacial Trauma El-Hawary Classification According to level of risk of sepsis wound Clean wound Clean contaminated wounds Contaminated wounds Dirty wounds • Gross spillage of organisms, where there is infection already present but without pus formation • There is a major break in aseptic technique • There is an open wound that has been exposed for less than 4 h (e.g. following major trauma) • In this type of wound, sepsis frequently exceeds 30%

29. Maxillofacial Trauma El-Hawary Classification According to level of risk of sepsis wound Clean wound Clean contaminated wounds Contaminated wounds Dirty wounds • This is an operation through an infected area (e.g. perforated viscus, abscess or traumatic wound) that has been exposed for over 4 h

30. Maxillofacial Trauma El-Hawary Classification of wound healing • Primary Intention • Occurs when: – The edges are clean and held together with ligatures – There is little gap to bridge Healing • Healing properties (When uncomplicated) – Occurs quickly – Rapid ingrowth of wound healing cells (macrophages, fibroblasts, etc.) – Restoration of the gap by a small amount of scar tissue. • soundly united within 2 weeks • Dense scar tissue is laid down within 1 month

31. Maxillofacial Trauma El-Hawary Classification of wound healing • Secondary Intention • Occurs when: – The edges are separated – The gap can not be directly bridged – Extensive epithelial loss – Severe contamination – Significant subepithelial tissue damage • Healing properties – Occurs slowly – Granulation; healing from the bottom towards the surface – Restoration of the gap by a small amount of scar tissue. • Scaring • Wound contracture

32. Maxillofacial Trauma El-Hawary Classification of wound healing • Secondary Intention • Occurs when: – The edges are separated – The gap can not be directly bridged – Extensive epithelial loss – Severe contamination – Significant subepithelial tissue damage • Healing properties – Occurs slowly – Granulation; healing from the bottom towards the surface – Restoration of the gap by a small amount of scar tissue. • Scaring • Wound contracture

33. Maxillofacial Trauma El-Hawary Differences between primary and secondary healing Feature Primary healing Secondary healing Cleanness Clean Unclean Infection Generally uninfected May be infected Margins Surgically clean Irregular Healing Scanty granulation tissue Granulation tissue fill the gap Healing period Short long Healing direction Direct healing From the bottom to the edge Outcome Neat linear scar Contracted irregular wound

34. Maxillofacial Trauma El-Hawary Normal sequence of wound healing

35. Maxillofacial Trauma El-Hawary Normal sequence of wound healing Phases of wound healing Days Weeks Months Hemostasis

36. Maxillofacial Trauma El-Hawary Normal sequence of wound healing Phases of wound healing Days Weeks Months Hemostasis Inflammation

37. Maxillofacial Trauma El-Hawary Normal sequence of wound healing Phases of wound healing Days Weeks Months Hemostasis Inflammation Proliferation

38. Maxillofacial Trauma El-Hawary Normal sequence of wound healing Phases of wound healing Days Weeks Months Hemostasis Inflammation Proliferation Maturation & Remodeling

39. Maxillofacial Trauma El-Hawary http://en.wikipedia.org/wiki/File:Wound_healing_phases.png

40. Maxillofacial Trauma El-Hawary Factors affecting healing Factors Local factors Wound sepsis Blood supply Wound tension Foreign bodies Previous irradiation Poor technique Systemic factors Nutritional deficiencies Systemic diseases Therapeutic agents Age

41. Maxillofacial Trauma El-Hawary Complications of wound healing

42. Maxillofacial Trauma El-Hawary Complications of wound healing complications Infection Dehiscence Incisional Hernia Hypertrophic scaring Keloid scarring Contractures

43. Maxillofacial Trauma El-Hawary Complications of wound healing complications Infection Dehiscence Incisional Hernia Hypertrophic scaring Keloid scarring Contractures • Treatment • Prophylactic antibiotics • Empirical antibiotic • Therapeutic /specific antibiotics • I&D • Antiseptic packs

44. Maxillofacial Trauma El-Hawary Complications of wound healing complications Infection Dehiscence Incisional Hernia Hypertrophic scaring Keloid scarring Contractures • Definition: Total breakdown of all the layers of the surgical repair of a wound • Etiology / causes: • Suture breakage • Knot slippage • Cutting out of sutures • Excess tension on the suture line © 2009 Nucleus Medical Art, Inc. http://www.empowher.com/media/reference/wound-dehiscence

45. Maxillofacial Trauma El-Hawary Complications of wound healing complications Infection Dehiscence Incisional Hernia Hypertrophic scaring Keloid scarring Contractures • Definition: Breakdown of the deeper layers of a wound in which the skin layer remains intact with protrusion of underlying structures through the deeper defect http://www.melbournegallbladder.com.au/patientinfosheets/info_incisional_her nia/info-incisional-hernia-gen-1.htm

46. Maxillofacial Trauma El-Hawary Complications of wound healing complications Infection Dehiscence Incisional Hernia Hypertrophic scaring Keloid scarring Contractures • Treatment: • Difficult • Further surgery should not be attempted for at least 6 months • Excision of the scar and re-suturing often has disappointing results, resulting in the same over healing • Radiotherapy used to be used but has now been abandoned • Some improvement can be achieved with local injection of corticosteroids directly into the scar, a process that might need repeating several times http://www.ehow.com/about_5422431 _natural-herbs-hypertrophic-scars.html

47. Maxillofacial Trauma El-Hawary Complications of wound healing complications Infection Dehiscence Incisional Hernia Hypertrophic scaring Keloid scarring Contractures • Treatment: • Excision generally results in a larger recurrence • Although excision followed by compression bandaging can have slightly better results • Corticosteroid injections give some improvement

48. Maxillofacial Trauma El-Hawary Complications of wound healing complications Infection Dehiscence Incisional Hernia Hypertrophic scaring Keloid scarring Contractures • Wound Contractures can occur with any wounds • More commonly with delayed healing wounds • Contracture of a scar across a joint can result in marked limitation of movement • Surgical treatment include • Skin grafting • local flaps • wound Z-plasty http://www.patient.co.uk/health/D upuytren%27s-Contracture.htm

49. Maxillofacial Trauma El-Hawary SKELETAL TRAUMA

50. Maxillofacial Trauma El-Hawary ETIOLOGY

51. Maxillofacial Trauma El-Hawary • Motor vehicle accidents (MVA) • War injuries • Civilian accidents • Falls, altercations • Animal bites or kicks (dogs, horses, camels) • Pathological • Iatrogenic

52. Maxillofacial Trauma El-Hawary EMERGENCY

53. Maxillofacial Trauma El-Hawary First Aid Treatment • Airway • Breathing • Circulation • Drugs

54. Maxillofacial Trauma El-Hawary First Aid Treatment Airway management

55. Maxillofacial Trauma El-Hawary DIAGNOSIS

56. Maxillofacial Trauma El-Hawary Clinical Examination Radiographic Evaluation Advanced diagnostic History Diagnosis

57. Maxillofacial Trauma El-Hawary Clinical Examination Inspection Palpation Auscultation

58. Maxillofacial Trauma El-Hawary Clinical Examination Inspection Palpation Bimanual Bidigital Auscultation

59. Maxillofacial Trauma El-Hawary Clinical Examination • Systemic examination: - Vital signs - Level of consciousness - CNS - CSF leakage

60. Maxillofacial Trauma El-Hawary Clinical Examination • Signs & Symptoms: - Ecchymosis - Edema - Soft tissue wounds - Malocclusion - Trismus - Segment mobility - Steps or deformities

64. Maxillofacial Trauma El-Hawary Radiographic evaluation Plain Radiography IntraOral Techniques ExtraOral Techniques Advanced Radiographic Techniques

65. Maxillofacial Trauma El-Hawary Techniques Plain Radiography IntraOral Techniques ExtraOral Techniques Advanced Radiographic Techniques 1. Periapical Radiograph 2. Occlusal Radiograph

66. Maxillofacial Trauma El-Hawary Techniques Plain Radiography IntraOral Techniques ExtraOral Techniques Advanced Radiographic Techniques 1. Panoramic Radiograph 2. PA Radiograph 3. Occlusal Radiograph 4. Lateral Radiograph 5. Lateral Oblique

67. Maxillofacial Trauma El-Hawary Techniques Plain Radiography Advanced Radiographic Techniques 1. CT Scanning 2. Dental CT scaning 3. Cone Beam CT Scanning

68. Maxillofacial Trauma El-Hawary Advanced Diagnostic Modalities 1. MRI 2. Ultrasonography 3. SPECT

69. Maxillofacial Trauma El-Hawary II. Radiographic Examination

84. Maxillofacial Trauma El-Hawary TYPES

85. Maxillofacial Trauma El-Hawary Dentoalveolar Fractures

86. Maxillofacial Trauma El-Hawary Dentoalveolar Fractures • Ellis Classification: I. Fx within enamel II. Fx of enamel & dentin III. Fx involving pulp IV. Root fx

87. Maxillofacial Trauma El-Hawary Dentoalveolar Fractures 1. Periodontal Injuries: i. Concussion ii. Displacement (Luxation) a. Subluxation b. Intrusive luxation c. Extrusive luxation d. Lateral luxation e. Avulsion 2. Fx of the Alveolar Process

88. Maxillofacial Trauma El-Hawary Mandibular Fractures

89. Maxillofacial Trauma El-Hawary Mandibular Fractures • Classification: I. According to Site: a. Symphyseal b. Parasymphyseal c. Body d. Angle e. Ramus f. Condyle g. Coronoid

90. Maxillofacial Trauma El-Hawary Mandibular Fractures • Classification: I. According to Site: a. Symphyseal b. Parasymphyseal c. Body d. Angle e. Ramus f. Condyle g. Coronoid

91. Maxillofacial Trauma El-Hawary Anatomical distribution and frequency of mandible fractures (Haug, Parather, Indresano, 1990)

92. Maxillofacial Trauma El-Hawary Mandibular Fractures • Classification: II. According to Side: a. Unilateral b. Bilateral III. According to number of lines: a. Single b. Multiple

93. Maxillofacial Trauma El-Hawary Mandibular Fractures • Classification: IV. According to nature of fracture: a. Green stick b. Simple c. Compound d. Comminuted

94. Maxillofacial Trauma El-Hawary Mandibular Fractures • Classification: V. According to degree of displacement: a. Favorable fractures b. Unfavorable fractures

95. Maxillofacial Trauma El-Hawary Factors affecting the displacement of fracture • Direction of the fracture line (favorable/unfavorable) • Direction of muscle pull (elevators/depressors) • Presence/absence of teeth • Direction and magnitude of the traumatizing force

98. Maxillofacial Trauma El-Hawary Champy’s principles

99. Maxillofacial Trauma El-Hawary Condylar Fractures

100. Maxillofacial Trauma El-Hawary Classification of the TMJ region injury 1. Contusion : - Damage to the capsular ligaments - May be accompanied by : Synovial effusion. (Rowe & Kelly,2nd ed,1970) Haemarthrosis. (Bosanquet et al., 1990, Jones et al., 1991) Tearing of the meniscus &/or displacement of the articular disk. (Faustia et al., 1990) 2. Dislocation : (Sullivan et al., 1995) - Irreducible displacement of the condoyle from the glenoid fossa. - Direction of displacement: Anterior, medial (usually). Lateral, posterior or central (rare). 3. Fracture: - Any fracture above the level of the segmoid notch. - It may be: intracapsular i.e. within the capsule involving the condylar head or neck. extracapsular i.e. outside the capsule in the subcondylar region.

101. Maxillofacial Trauma El-Hawary Classification of Condylar fracture (Lindahl, 1977) A. Classification according to the fracture level: 1. Condylar head (Intracapsular). 2. Condylar Neck. 3. Subcondylar (high or low). B. Classification according to the relation of condyle to Mandible: 1. Non displaced. 2. Deviated or angulated. 3. Displaced ( M or L/A or P overlap). 4. No bony contact. C. Classification according to the relation of condyle to the Glenoid Fossa: 1. Non Displaced. 2. Displaced-still related to fossa. 3. Dislocation-completely out of fossa.

102. Maxillofacial Trauma El-Hawary Mechanism of injury  Provide clues about the magnitude and direction of force delivered to the patient.  The more force delivered, the more severe the fracture.  The direction of force influence the fracture pattern. (Spina & Marciani, 2000) Forces resulting in Trauma to the TMJ: 1. Moving object striking a static individual. 2. Moving individual striking a static object. 3. Combination of forces.

103. Maxillofacial Trauma El-Hawary Maxillary Fractures

104. Maxillofacial Trauma El-Hawary Maxillary Fractures • Classification: – LeForte I (Transverse fracture): Transversely through maxilla above teeth level, lateral antral wall, lower pterygoid plates.

105. Maxillofacial Trauma El-Hawary Maxillary Fractures • Classification: – LeForte II (pyramidal fracture): Nasal bone, maxillary frontal process, lacrimal bone, inf. orbital rim, Zygomaticomaxillary suture, lat. maxillary wall, pterygoid plates, pterygomaxillary fossa.

106. Maxillofacial Trauma El-Hawary Maxillary Fractures • Classification: – LeForte III (craniofacial dysjunction): Zygomaticofrontal, maxillofrontal and nasofrontal sutures

107. Maxillofacial Trauma El-Hawary Zygomatic fractures

109. Maxillofacial Trauma El-Hawary TREATMENT

110. Maxillofacial Trauma El-Hawary • The aim of mandibular fracture treatment is – Reduction • Restoration of anatomical form • Restoration of function • Establish proper occlusion – Fixation Immobilization – Stabilization – Prevention of infection

111. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation

112. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed

113. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigidSemi-rigid

114. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Semi-rigid

115. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Semi-rigid Plates and osteosynthesis Screws osteosynthesis K-wires

116. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Semi-rigid

117. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Semi-rigid Mini-plates osteosynthesis

118. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Open reduction Non-Rigid fixation Semi-rigid Wire osteosynthesis

119. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Open reduction Non-Rigid fixation Semi-rigid Closed reduction Rigid fixation

120. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Open reduction Non-Rigid fixation Semi-rigid Closed reduction Rigid fixation External pin fixation

121. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Open reduction Non-Rigid fixation Closed reduction Semi-rigid fixation Semi-rigid Closed reduction Rigid fixation

122. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Open reduction Non-Rigid fixation Closed reduction Semi-rigid fixation Semi-rigid Closed reduction Rigid fixation Lingual splint

123. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Open reduction Non-Rigid fixation Closed reduction Semi-rigid fixation Semi-rigid Closed reduction Rigid fixation Closed reduction Non-rigid fixation

124. Maxillofacial Trauma El-Hawary Treatment Reduction Fixation Open Closed Rigid Non-rigid Open reduction Rigid fixation Open reduction Semi-Rigid fixation Open reduction Non-Rigid fixation Closed reduction Semi-rigid fixation Semi-rigid Closed reduction Rigid fixation Closed reduction Non-rigid fixation Wiring techniques MMF

126. Maxillofacial Trauma El-Hawary Rigid versus Non-rigid Fixation

127. Maxillofacial Trauma El-Hawary Advantages of Rigid Fixation 1. Pts with poor or inadequate dentition 2. Avoidance of debilitating weight loss 3. No interference with speech 4. Suitable for pts with seizures or alcoholism 5. Immediate return to work and normal life style 6. Risk of infection reduced

128. Maxillofacial Trauma El-Hawary Advantages of Rigid Fixation 7. Avoidance of TMJ disturbance especially in cases with condylar fracture 8. Fewer complications as non- or malunion (1ry rather than 2ry bone healing) 9. Safer airway and decreased risk of aspiration 10. Allows for proper oral hygiene 11. Ability to obtain and maintain precise anatomic reduction of fractured segments

129. Maxillofacial Trauma El-Hawary Effects of Intermaxillary Fixation • On the following tissues – Muscles – TMJ – Bone – Periarticular C.T.

130. Maxillofacial Trauma El-Hawary Factors affecting the selection of the Surgical approaches for open reduction 1. The level of the fracture. 2. The degree of displacement or dislocation. 3. The planned method of the fixation. 4. Langer’s lines

131. Maxillofacial Trauma El-Hawary http://www.beltina.org/health-dictionary/langers-lines-skin.html

132. Maxillofacial Trauma El-Hawary http://hi.baidu.com/hilygogo/blog/item/35cbe8f0db3a7baba50f5271.html

133. Maxillofacial Trauma El-Hawary Factors affecting the selection of the line of treatment 1. Factors related to the patient – Age of the patient. – Well – Systemic condition 2. Factors related to the fracture – Site, type and level of fracture. – Degree of displacement. – Condition of the post injury occlusion. 3. Factors related to the operator 1. Conditions 2. Skill 3. Armamentarium

134. Maxillofacial Trauma El-Hawary TREATMENT MODALITIES

146. Maxillofacial Trauma El-Hawary Fixation of Mandibular Fractures II. Open Reduction Techniques (direct fixation techniques) ORIF: 1. Non-rigid: (needs supplementary fixation, IMF) a. Transosseous (intraosseous) wiring

147. Maxillofacial Trauma El-Hawary Fixation of Mandibular Fractures II. Open Reduction Techniques (direct fixation techniques) ORIF: 2. Rigid: (sole fixation methods) a. Intramedullary Pinning: Kirchner wires, Steinmann pins. b. Metal Mesh plates: Titanium mesh c. Bone plates and screws: mono- or bicortical d. Lag Screws e. Biodegradable (resorbable) bone screws f. Bone Clamps

148. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF:

149. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF:

150. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF: • Bone plates:

156. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF: • Lag screws:

157. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF: • Lag screws:

158. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF: • Biodegradable plates:

159. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF: • Bone clamps:

160. Maxillofacial Trauma El-Hawary Open Reduction Techniques (direct fixation techniques) ORIF: • Bone clamps:

161. Maxillofacial Trauma El-Hawary Treatment of Maxillary Fractures

166. Maxillofacial Trauma El-Hawary Condylar Fx Treatment modalities Treatment modalities Conservative treatment Open reduction Close Observation Closed reduction

167. Maxillofacial Trauma El-Hawary Observation Indications: - Well aligned segments (no displacement). - Repeatable occlusion without pain. - Children under 12 years of age, with minimal fracture displacement and normal occlusion. Technique: - Clinical observation. - Soft diet. - Active function. - Physiotherapy.

168. Maxillofacial Trauma El-Hawary Closed reduction Indications: - Correctable Malocclusion. - Deviation of the mandible with function. - Pain. Technique: - Immobilization (7-21 days) in the form of arch bars, Ivy loops or individual wiring followed by active mobilization and physiotherapy. - Period of immobilization depend on: Age of the patient. Level of fracture. Degree of displacement.

169. Maxillofacial Trauma El-Hawary Indications for open reduction (Zide & Kent, 1983) Absolute indications Relative indications 1. Bilateral condylar fracture with concomitant comminuted midfacial fracture. 2. Bilateral condylar fracture in an edentulous patient when splints are unavilable or imposible because of sever ridge atrophy. 3. Displaced condyle in an medically compromised patient where MMF is contraindicated. 1. Inability to obtain adequate occlusion with closed reduction. 2. Displacement of the condyle into the middle cranial fossa. 3. Lateral extracapsular displacement. 4. Foreign body in the joint capsule.

170. Maxillofacial Trauma El-Hawary Summary of treatment

171. Maxillofacial Trauma El-Hawary Management of condylar fractures in children According to the degree of displacement:  Undisplaced / minimally displaced condylar fractures: Conservative non immobilization with active function.  Severly displaced with malocclusion: 7:10 days immobilization followed up by acyive function and physiotherapy.

172. Maxillofacial Trauma El-Hawary Postoperative instructions /medications • Good oral hygiene – Teeth brushing – Rinse utilizing warm saline and mouth wash • Semi-solid feeding was ordered for the patients on the second postoperative day and until the end of MMF period. • Prophylactic Antibiotics-one week postoperatively • Anti-edemic • Analgesics

173. Maxillofacial Trauma El-Hawary THANK YOUTHANK YOU

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