This document provides an overview of dental readiness training on fracture diagnosis and initial stabilization. It discusses evaluating and temporarily stabilizing facial fractures in austere environments with limited resources, including using wire ligatures, arch bars, and maxillomandibular fixation to reduce fractures and protect the airway until definitive care. The goals of temporary stabilization are to increase comfort, minimize tissue damage, and stabilize patients for transport to higher levels of care within 7-10 days.

1. DENTAL READINESS TRAINING:
FRACTURE DIAGNOSIS AND
INITIAL STABILIZATION
(Lecture to be used in conjunction with
“Hands-on” fracture stabilization lab)
Thomas W. Beckman, Lt Col, USAF, DC
Oral and Maxillofacial Surgery
Keesler AFB, MS

2. War/Deployment Trauma Care
 Trauma care is often performed in austere,
resource limited, and sometimes dangerous
forward deployed sites
 Care is by echelon- goal oriented
 Forward-deployed care of maxillofacial injuries is
limited to emergency/initial care and stabilization
 Treatment of facial fractures can usually be
deferred for up to 7-10 days after injuries
– definitive care is done after Air Evac out of AOR

3.  “The military surgeon does what must be done,
rather than what could be done to the casualty before
either returning him to his unit or rendering him
transportable to the next higher echelon of medical
care.” Brig General Thomas Bowen

4. Etiology of Fractures
 Motor vehicle
accidents
 Assaults
 Falls/Accidents
 Sports injuries
 Other etiologies

5. Epidemiology of Facial Fractures
 Males > females; 3 to 1
 Most prevalent age range: 16-30 year old
 Concomitant injuries are common
– 1.5 to 1.8 fractures/patient
– Nasal fractures most common
– Mandible/Zygoma/Maxilla : 6/2/1
– Must rule out spinal injuries
– Dental injuries are commonly associated with
other facial fractures

6. Anatomic Region Classification
 Condylar process
 Coronoid
 Ramus
 Angle
 Body
 Symphysis or
Parasymphysis
 Alveolar process

7. Classifications of Fractures
 Simple or closed
fracture
 Compound or open
fracture
 Comminuted fracture
 Greenstick fracture
 Pathologic fracture
 Favorable vs
Unfavorable fracture

8. Favorable/Unfavorable Fractures

9. Favorable/Unfavorable Fractures

10. Diagnosis of Fractures
 Organized systematic evaluation
 Dynamic process-
– Maintain a high index of suspicion
– Frequent re-examination and monitoring
 History
 Physical examination
 Ancillary studies
 Diagnosis/Treatment plan

11. History
 Mechanism of injury
 Previous facial
trauma/TMJ disorders
 Preinjury occlusion
 Past medical history
 Psychiatric history
 Social history
 Special nutritional
requirements

12. Physical Examination
“Look with fingers and eyes”
 Swelling and Ecchymosis
 Tenderness to palpation
 Malocclusion
 Deformity of contour/asymmetry
 Limited motion/loss of function
 Abrasion/Lacerations
 Altered sensation
 Unnatural mobility/crepitus across fx site

13. Physical Examination
“Look with fingers and eyes”

14. Dental Examination
 Loose, fractured, avulsed teeth
 Presence or absence of teeth
– Dentate, partial dentate,
edentulous
 Type of teeth present
– Permanent, deciduous, or mixed
 Relationship of teeth to fracture
 Quality of teeth/periodontium

15. Radiographs
 Panographs
 Mandible series
– Reverse Towne’s
– Posteroanterior
– Right and left lateral
obliques
 Occlusal & periapical
radiographs
 Computer Tomography

16. Objectives of Temporary
Stabilization
 Increase patient comfort
 Minimize further tissue damage
 Protect airway
 Stabilize patient for transport

17. Temporary Stabilization Methods
 Barton’s bandage
 Wire/composite or orthodontic brackets
 Simple “bridle” wire
 Ivy loops/Continuous loops
 Arch bars
 Lingual/occlusal or “Gunning” splints

18. Barton Bandage

19. Simple “Bridle” Wire
 Temporary reduction
and stabilization
 25 or 26 gauge wire
and local anesthesia
 Wrap around two teeth
on either side of
fracture

20. Ivy Loops

21. Continuous Loop

22. Splints for Fixation

23. Maxillomandibular Fixation
(MMF)

24. Goals of Maxillomandibular
Fixation (MMF)
 Restore occlusion
 Reduction of
fracture segments
 Stabilization of
fracture segments

25. Types of Arch Bars
 Erich
– More malleable
 Winters
– Stiffer/less malleable
 Custom
 Others

26. Equipment
 Wire drivers x 2
 Wire cutters
 Minnesota retractors
 Local anesthesia
 Suction
 Orthodontic elastics
– 8 oz.

27. Equipment
 Wires
– 25 or 26 gauge
– Straight wires
» Interdental
– Wire “fishes”
» Interarch for MMF

28. MMF: Key Points
 Interdental wiring
– 25 or 26 gauge wires
 Pass and secure below height of contour of
permanent teeth
 Avoid piercing the gingiva if possible
 Arch bar
– Proper length
– Malleable (reduces orthodontic tooth movement)

29. MMF: Key Points
 Hooks on arch bars placed towards gingiva
 Pre-stretch wires
 Twist wires in a clockwise direction
 Apply forces apically when tightening wires
 Keep wire above arch bar (away from CEJ)
on teeth next to fracture sites and on distal
sides of teeth

30. MMF: Key Points
 Start securing arch bar in premolar region
on one side than work around arch
 Use Minnesota retractor to stabilize arch bar
while tightening wires
 Use wire director (“pickle fork”) to hold
wire below cingulum on lingual of the
anterior teeth
 Lightly tighten all wires then do final
tightening after cutting wires short

31. MMF: Pitfalls
 Overextended arch bars impinge on buccal and
anterior ramus mucosa
 Tails of protruding dental wires impinge on
mucosa of the lips
 Interdental wires become loose and ineffective
because of poor placement
 MMF is ineffective if too few teeth are secured

32. MMF: Case Presentation
 60 y/o male with
cardiogenic syncope
who fell and struck
face on pavement
 Left subcondylar
fracture
 Multiple missing teeth
and #17, 18 requiring
extraction

33. MMF: Case Presentation

34. MMF: Case Presentation

35. MMF: Case Presentation

36. MMF: Case Presentation

37. MMF: Case Presentation

38. Adjunctive treatment
 Hydration and nutrition
 Antibiotics
– All fractures through dentate region/open fx
– Fractures in sinus
– Dirty/old injuries
 Check tetanus status

39. Adjunctive Treatment
 Close all lacerations within 12 hours of
injury, if possible
 Pain management: Avoid over-sedation
 While in Maxillomandibular fixation
– Tooth brushing/chlorhexidine rinse
– Wire cutters on patient at all times
– No alcohol
– High calorie blenderized/non-chew diet

40. Special thanks to the residents/staff of the OMFS Residency Program
at the 59 MDW, Lackland AFB, TX and Col Jeff Armstrong for some
of the photos and cases used in this presentation.