Controversies in maxillofacial trauma

1. Controversies in
Maxillofacial Trauma
Controversies in
M O D E R A T O R –
D R . R A J A S E K H A R G .
P R E S E N T E D B Y -
D R . S H E E T A L K A P S E

2. INCLUSIONS
• INTRODUCTION
• CURRENT
• CONTROVERSIES
• CONCLUSION
• REFERENCES
1. Management of Fractures Through the Angle of the
Mandible
2. Management of Condylar Process Fractures
3. Management of Comminuted Fractures of the Mandible
4. Management of Atrophic Mandible Fractures
5. Management of Mandibular Fractures in Children
6. Management of Nasal Fractures
7. Management of Orbital Fractures
8. Management of Naso-Orbital-Ethmoidal Fractures
9. Management of Frontal Sinus Fractures
10. Fixation of zygomaticomaxillary complex
11. Sequencing of fixation in case of pan facial trauma
12. Management of Parotid Gland and Duct Injuries
13. Use of Prophylactic Antibiotics in Preventing Infection of
Traumatic Injuries

3. INTRODUCTION
• Controversy can be defined as a dispute, generally with a right and a wrong
side of the argument.
• Controversy can also be defined as a discussion marked by the expression
of opposing
• When there are different approaches to surgical management, it is often not
a matter of right or wrong, but rather what the surgeon believes gives the
best results views.

4. 1. Management of Fractures Through the Angle
of the Mandible
A. Does the angle
fracture have to
extend through the
Goinal Angle of
mandible ??
B. Inclusion of different
type of fractures in
the same series.
• Anatomic region
• Start of fracture line
• Anterior to gonion
• Vertically and posteriorly
• To the gonion
• Slightly above it
• anteriorly
C. Tension & compression zones change
with different biting position and
fracture lines.

5. D. Use of antibiotics
E. Timing of treatment
F. Teeth in the fracture line
 Ellis - 85% contained a third molar.
 Spiessl- lists three undesirable effects of extracting
an unerupted tooth in the line of an angle fracture :
 The possibility of converting a closed fracture to an
open one
 Loss of the bony buttress on the tension side
(superior surface)
 Loss of the possibility for inserting a tension band
plate
Ellis E. Outcomes of patients with teeth in the line of mandibular angle fractures treated
with stable internal fixation. J Oral Maxillofac Surg 2002;60: 863–5.
Soriano E, Kankou V, Morand B, et al. Fractures of the mandibular angle: factors
predictive of infectious complications. Rev Stomatol Chir Maxillofac 2005; 106:146–8.
Spiessl B. Closed fractures. Chapter 5. In: Spiessl B, editor. Internal fixation of the
mandible. Berlin: Springer-Verlag; 1989. p. 199.
No difference in the rate of infection
with closed reduction
Presence of a third molar
associated with a fracture through
the angle of the mandible increases
the risk of infection irrespective of
whether or not the tooth is erupted
or impacted, or whether or not the
tooth is removed during surgery.

6. D. Use of antibiotics
E. Timing of treatment
F. Teeth in the fracture line
G. Close versus open reduction
Even when the fracture is not
displaced, open treatment is usually
provided so that internal fixation
devices can be placed to maintain
the alignment of the fragments and
obviate postoperative MMF.
Only indication of MMF

7. H. Internal fixation schemes Wire fixation + weeks of MMF
Other fixation device without MMF
Bicortical screws & one large and one
small bone plate, or two small plates
Good stability, infection
Bending/ torsional forces
Spiessl B. Closed fractures. Chapter 5. In: Spiessl B, editor. Internal
fixation of the mandible. Berlin: Springer-Verlag; 1989. p. 199.
Champy M, Lodde JH, Must D, et al. Mandibular osteosynthesis by miniature
screwed plates via buccal approach. J Maxillofac Surg 1978;6:14–9.
Levy FE, Smith RW, Odland RM, et al. Monocortical miniplate fixation of
mandibular fractures. Arch Otolaryngol Head Neck Surg 1991;117:149–54.
Alkan A, Celebi N, Ozden B, et al. Biomechanical comparison of different
plating techniques in repair of mandibular angle fractures. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2007;104:752–6.
Ellis E, Walker L. Treatment of mandibular angle fractures using two
noncompression miniplates. J Oral Maxillofac Surg 1994;52:1032–6.

8. H. Internal fixation schemes
I. Postoperative care
• Force distribution through soft tissues explains why a single miniplate
can be very successful in the management of fracture through the angle.
• Association with co-existing fractures of mandible
• Comminuted angle fractures
Rudderman RH, Mullen RL, Phillips JH, et al. The biophysics of mandibular fractures: an evolution toward
understanding. Plast Reconstr Surg 2008; 121:596–607.
requirement
of additional
fixation
Antibiotics
Mouth wash & oral hygiene
Gap at the inferior border
Use of elastics

9. 2. Management of Condylar Process Fractures
Parameters
Closed reduction
(3-6 weeks for adults & 10-
14 days for children)
Open reduction
MIO (maximum
interincisal opening)
Equal or more Faster rate of recovery
Movements Clinically acceptable Faster rate of recovery
Occlusion Chances of malocclusion More satisfactory result
Facial contour No difference No difference
Chin deviation No difference - deviation Less incidences
Post treatment TMJ /
masticatory muscle pain
Frequent pain Less incidences
Procedure related
complications
In particular medical situations Present
Laskin D M. Management of Condylar Process Fractures. Oral Maxillofacial Surg Clin N Am 21 (2009) 193–196.

10. Zide MF, Kent JN (1983) Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:89–98.

11. DEGREE OF DISLOCATION &
ANGLE OF DISPLACEMENTS
Mandibular condyle
fractures evaluation of the
Strasbourg Osteosynthesis
Research Group
classification

13. EDWARD ELLIS III – Symposium
on condylar fractures 2004
• ABSOLUTE INDICATIONS
- Displacement into the middle cranial fossa/external auditory meatus
- Inability to obtain occlusion by non surgical/closed method
- Invasion by foreign body
- Lateral extra capsular displacement
• RELATIVE INDICATIONS
- Bilateral fractures in edentulous jaws
- IMF contraindicated for medical reasons
- Bilateral fractures associated with comminuted midface fractures
- Severe periodontal problems & loss of teeth
- patients desire to avoid IMF

15. Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the
Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction.
Arch Plast Surg. Jul 2012; 39(4): 301–308.

17. • The problem with most comparative studies that have
been reported is that they are generally retrospective
rather than prospective and that there is considerable
variation in the patient selection and outcome criteria
used as well as in the follow-up time.
• Therefore, until better-designed comparative studies
are available that will allow evidence-based decisions to
be made, one can only look at individual case series for
some guidance.

18. 3. Management of Comminuted Fractures of
the Mandible
• 5-7 % of all mandibular fractures, usually compound type.
Joe Hall Morris appliance for
comminuted fracture of the symphysis
Traditional conservative
management
 MMF + external fixator
 Long healing period
 Restricted function
 Morbidity
MMF
Roger Anderson appliance
controlling multiple comminuted
mandibular fractures.
Indications
 Significant head injury
 Necessary equipments
are not available

19. OPEN REDUCTION AND
INTERNAL FIXATION
• Load bearing reconstruction plate
• Decreases healing time
• Post op MMF is not required
• No scarring of skin
• Good functional out come
Technical points
• Stabilize the teeth and alveolus with arch bars
• Intact lingual periosteum
• Simplification of fracture
Technical points
• Reconstruction plate with 3-4 screws on
either side of fractures
• Defect closure with bone graft

20. 4. Management of Atrophic Mandible Fractures
Closed reduction techniques for atrophic edentulous mandible fractures
1. Gunning splints with arch bars
2. Circummandibular wiring of
oblique fractures
3. External fixator
Anterior and posterior
pin connected by a
transverse bar
spanning the fracture
4. No treatment / soft diet

21. A. Indications
B. Approaches (intraoral - vestibular/
extraoral)
Open reduction and internal fixation techniques for atrophic edentulous
mandible fractures

22. C. Fixation with
Reconstruction plate Locking / non-locking
minplates
Titanium or other
mesh crib with
autografts
Lag screw
Alloplastic materials –
• Hydroxyapatite,
• Tricalcium phosphate,
• Glass ceramics,
• Glass carbonate
• Injectable calcium phosphate cements
Future materials –
• Gene therapy
• Tissue engineering

23. 5. Management of Mandibular Fractures in
Children
1. Diagnosis – because of child co-operation
2. Fracture pattern & displacement of segments
3. Open versus closed reduction and closed functional treatment
4. Duration of MMF
5. Role of other treatment modalities
6. Titanium, stainless steel or bioresorbable materials for fixation

24. Hiu GA, Prabhu IS, Morton ME, et al. Acrylated stainless steel basket splint
for mandibular fractures in children. Br JOralMaxillofacSurg 2012;50:577–8.
The occlusion was satisfactory, without
infection or malocclusion. None required
revision, and there was no deviation of the
mandible, ankylosis, or disturbances of growth.
Five children with mandibular
fractures were treated with a
split acrylic splint, which
secured the fracture by wiring
around the mandible.

25. 6. Management of Nasal Fractures
1. TIMING OF NASAL FRACTURE
TREATMENT
• If a patient is seen shortly after trauma,
before significant edema develops
• Lacerations with exposure of the underlying
skeletal or cartilaginous elements
• Presence of a septal hematoma
• Within the first 10 days of injury are less likely to require a revision
septorhinoplasty

26. 2. Local v/s general anesthesia
• In the presence of minor nasal bony deviation and no
associated septal or nasal tip displacement, closed reduction
under local anesthesia has been suggested as the first line of
treatment.
• Complex or severely displaced fractures may require
treatment under general anesthesia.

27. 3. OPEN V/s CLOSED TECHNIQUES
• Closed reductions - most acute isolated nasal fractures with minimal bony and
septal injury (within 10 days).
• Internal packing for 3 days & external for 7 to 10 days.
• 14% to 50% cases - Postreduction deformities - secondary rhinoplasty.
• The final decision - condition of the septum and the need to preserve the
connection between the septum, upper lateral cartilages, and nasal bones.
Denver splint.

28. Outcomes of nasal
fracture treatment may be
compromised by the fact
that late morphologic
changes can occur over 1
or more years because of
scarring.

29. 7. Management of Orbital Fractures
1. INDICATION FOR SURGICAL REPAIR OF ORBIT
Lack of ocular motility
Diplopia : Surgery may increase the risk of diplopia, at
least temporarily.
Enophthalmos : define this as greater than 1 cm3 &
greater than 2.0 mm typically indicates the need for
surgical

30. Ahn HB, Ryu WY, Yoo KW, et al. Prediction of enophthalmos by computer-based volume measurement
of orbital fractures in a Korean population. Ophthal Plast Reconstr Surg 2008;1:36–9.
• There seems to be a direct relationship between the increase of
orbital volume and measured enophthalmos.
a. Volume increase of < 1 mL, enophthalmos ~ 0.9 mm,
b. Volume 2.3 mL ~ 2 mm.
# For every 1 mL increase of volume there is approximately a
0.9 mm increase in enophthalmos.
# However, in normal orbits, there can be a natural volume
difference of up to 8% between the left and right sides.

31. 2. TIMING OF ORBITAL SURGERY
Dortzbach and later Leitch and coworkers : surgery for orbital floor fractures
within 14 and 21 days after trauma.
Cole and coworkers : gave indications for immediate repair
i. Trumatic optic neuropathy (alteration in visual acuity & color desaturation test)
ii. Occulocardiac reflex
iii. Penetrating injuries
iv. Age – younger patients
3. USE OF STEROIDS : Corticosteroids can be used as the only
treatment if the visual acuity is better than 20/400
Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital fractures. Plast Reconstr Surg 2007;120:57–61.
Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures: influence of time of repair and fracture size. Ophthalmology 983;90(9):1066–70.
Leitch RJ, Burke JP, Strachan IM. Orbital blowout fractures: the influence of age on surgical outcome. Acta Ophthalmol 1990;68:118–24.

32. 4. MATERIALS FOR
RECONSTRUCTION
Potter JK, Malmquist M, Ellis E III. Biomaterials for
Reconstruction of the Internal Orbit. Oral Maxillofacial
Surg Clin N Am. 2012; 24 (4):609–627.

34. Abbreviations: FF, very favorable; F, favorable; U, unfavorable; UU, very unfavorable.

35. Abbreviations: BAG, bioactive glass; FF, very favorable; F, favorable; HA, hydroxyapatite;
PDS, polydioxanone; PGA, polyglycolide; PLA/PGA, polylactide/polyglycolide; PLDLA,
poly L/D lactide copolymer; PLLA, poly L lactide; Sil, silicone; Tef, Teflon; Tit, titanium; U,
unfavorable; UU, very unfavorable.

36. 8. Management of Naso-Orbital-Ethmoidal
Fractures
• NOE fractures rarely occur as isolated events.
1. Extent of fracture : NOE fractures
associated with panfacial injuries are
associated with a diffuse facial edema,
whereas isolated NOE fractures are
associated with localized ecchymosis and
edema in the nasal and periorbital regions.
2. Requirement of treatment : examination of
canthus containing fragments and telecantus

37. 3. Early versus late management : waiting no more than 2 weeks.
4. Closed versus open reduction : indications, approaches, fixation
5. Position of reattachment of medial canthus

38. 9. Management of Frontal Sinus Fractures
Repair Obliteration (ablation) Cranialization
Preservation of the sinus
anatomy, including the
nasofrontal duct, sinus
mucosa, and its anterior and
posterior bony walls
Obliteration involves the
elimination of the frontal
sinus cavity while
maintaining the anterior and
posterior tables
similar to frontal sinus
obliteration with the
exception that the
posterior table is
completely removed
No treatment

39. • Volume of material needed is highly variable, averaging
approximately 35 to 40 cm3 to as much as 200 cm3
Endoscopic-
Assisted Repair

41. 10. Fixation of zygomaticomaxillary complex
Rodrigo Otávio Moreira Marinho, Belini
Freire-Maia. Management of Fractures of
the Zygomaticomaxillary Complex. Oral
Maxillofacial Surg Clin N Am 25 (2013)
617–636.
Zingg M et al Classification of ZMC fractures. (A) Type A1: isolated
zygomatic arch fracture. (B) Type A2: lateral orbital wall fracture. (C)
Type A3: infraorbital rim fracture. (D) Type B: complete monofragment
zygomatic fracture. (E) Type C: multifragment zygomatic fracture.
Judgement of fracture reduction
1. Zygomaticosphenoid suture
2. Zygomaticomaxillary buttress
3. Infraorbital rim
4. Frontozygomatic suture

42. Priority of fixation
1. Zygomaticomaxillary buttress
2. Frontozygomatic suture
3. Infraorbital rim
4. Zygomatic arch
Sequence of fixation
1. Frontozygomatic suture
2. Infraorbital rim
3. Zygomaticomaxillary buttress
4. Zygomatic arch

43. 11. Sequencing of fixation in case of pan facial
trauma
Classical approaches
“bottom up and inside out”
“top down and outside in”
Booth PW, Eppley BL, Schmelzeisen R, editors.
Maxillofacial trauma and esthetic facial reconstruction.
Philadelphia: Saunders; 2012.

44. “bottom up and inside out”

45. top down and outside in

46. 12. Management of Parotid Gland and Duct
Injuries
1. DIAGNOSIS :
Use of dye - excessive extravasation from the lacerated duct may
complicate surgery.
Saline can be injected if difficulty is encountered in finding the
proximal end.
No fluid seen in the wound indicates that the duct is intact.
2. TIMING OF REPAIR :
 Done early, preferably in the first 24 hours.
• Late complications, such as a parotid fistula, are difficult to treat.
3. WOUND CLOSURES WITHOUT DUCT REPAIR

47. # MANAGEMENT OF
INJURIES TO THE GLAND
AND DUCT
• Repair of the injury, putting a
stent in the duct, and placing a
pressure dressing, botox in
chronic cases.
• Injury to the duct - repair of the
duct over a stent, ligation of the
duct, or fistulization of the duct
into the oral cavity.

48. • Injury of the duct orifice - insertion of a drain.
4. Leaving the stent in place after duct repair – subsequent swelling can cause
obstruction of duct
5. Use of an autogenous graft for repair of continuity defect of duct

49. 14. Use of Prophylactic Antibiotics in
Preventing Infection of Traumatic Injuries
1. PROPHYLACTIC
ANTIBIOTICS IN PATIENTS
WITH SKIN WOUNDS
• According to the principles of
presurgical prophylaxis, antibiotics, if
they are to be given at all, should be
administered as soon as possible after
the injury, if possible within the first 3
hours and continued for 3 to 5 days.
• Staphylococcus aureus and
streptococci : Cloxacillin and first-
generation cephalosporins
1. Open joints or fractures
2. Human or animal bites
3. Intraoral lacerations
4. Heavily contaminated wounds
(eg, those involving soil, feces,
saliva or other contaminants).
5. Patients who have prosthetic
devices and at risk for developing
endocarditis.
6. Systemic antibiotics also are
recommended when there is a lapse
of more than 3 hours since injury,
7. Lymphedematous tissue
involvement,
8. Host is immunocompromised.
INDICATIONS

50. 2. USE OF PROPHYLACTIC ANTIBIOTICS FOR
PREVENTION OF INFECTION OF INTRAORAL
WOUNDS
• ‘‘through-and-through’’ lacerations - a course of prophylactic
antibiotics to prevent infection after these wounds are repaired.
3. TOPICALANTIBIOTICS FOR TREATMENT OF
TRAUMATIC WOUNDS
• Ointments - bacitracin, neomycin, or polymyxin have been
routinely used.

51. 4. ANTIBIOTIC PROPHYLAXIS IN PATIENTS WITH OPEN
FRACTURES AND JOINT WOUNDS
• Classification Of Open Fractures And Joint
Type of Description
Involved
pathogens
Empirical
antibiotics
I
Is an open fracture with a skin
wound that is clean and less than 1
cm long
S aureus,
streptococci
Spp, and aerobic
gram-negative
bacilli
First- or second-
generation
Cephalosporin
within 6 hours + 24
hours postop
II
An open fracture with a laceration
That is more than 1 cm long, but
without evidence of extensive soft
tissue damage, flaps, or avulsion
III
An open segmental fracture or
An open fracture with extensive
soft tissue damage or a traumatic
amputation
Certain environmental exposures
More no. Of gram
negative
Organisms
Clostridium,
Acinetobacter,
Pseudomonas,
Clostridium, Aeromonas,
Pseudomonas, Aeromonas,
Vibrio
Cephalosporin &
aminoglycoside
Penicillin
within 6 hours + 24
hours postop

52. Why there is controversy ??
i. clinical studies fail to demonstrate a lower infection rate
among patients with uncomplicated wounds treated
with prophylactic antibiotics
ii. studies have assessed their efficacy after suture wound
closure

53. CONCLUSION
• In the treatment of many kinds of traumatic injuries of the
Maxillofacial region, too few randomized, controlled
studies are available to supply strong supporting evidence
for definitely selecting one surgical technique or
procedure over another. Therefore, we have to rely upon
expert opinion, as well as the literature, to guide us in the
decision-making process.

54. REFERENCES
1. Oral Maxillofacial Surg Clin N Am 21 (2009). doi:10.1016/j.coms.2009.01.001
2. Jiewen Dai, Guofang Shen, Hao Yuan, Wenbin Zhang, Shunyao Shen, Jun Shi.
Titanium Mesh Shaping and Fixation for the Treatment of Comminuted
Mandibular Fractures. J Oral Maxillofac Surg 74:337.e1-337.e11, 2016.
3. Booth PW, Eppley BL, Schmelzeisen R, editors. Maxillofacial trauma and
esthetic facial reconstruction. Philadelphia: Saunders; 2012.
4. William Curtis, Bruce B. Horswell. Oral Maxillofacial Surg Clin N Am 25
(2013) 649–660.