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MAXILLOFACIAL FRACTURE

Ruby Riana A., dr., SpBP


FK UMM
Malang
INTRODUCTION

Maxillofacial trauma (MFT) is a frequent


injury
Injury within the head & neck may present
neurologic, ophthalmologic, aerodigestive,
skeletal, soft tissue or otologic complains
MFT may involve multiple organ system too in
other regions
Surgeons must recognized the extensive
nature & the associated injury
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INITIAL MANAGEMENT
PRIMARY SURVEY
Airway & control of Cx spine : Open &
secure,Jaw thrust & chin lift,remove
foreign bodies,cricothyrotomy if necessary
Breathing : Ass of adequacy of ventilation
Circulation : Control of bleeding, IV fluid
rescuscitation
Disability : Level of consciousness &
pupillary evaluation
Exposure : Complete expose of the px 3
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Maxillofacial Trauma
Life-threatening Emergency Treatment :

1. Maintenance of the airway


2. Prevention of the hemorrhage
3. Identification & prevention of
aspiration
4. Identification of other (occult)
injuries, such as eye, brain and
cervical spine

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SECONDARY SURVEY

Complete Anamnese
Complete head to toe examination
Head, maxilofacial and neck
Thorax
Abdomen, perineum and genital
Musculoskeletal
Neurological Examination
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Anamnesis

History
History and clinical exam. → basis
diagnosis of most facial injury

MOI → help to judge severity of injury


& potential for multiple injury

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Clinical examination : local site

Begin with overall inspection


→ noting asymmetry, hemorrhage
ecchymoses
→ Remove crusted blood
Facial injury:
Soft Tissue Injury
Soft Tissue wound associated with fractures
Fracture without soft tissue wound

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Examination

Scalp : Inspection & Palpate


Frontal
Eye
Raccon eyes, Subconjuctiva Bleeding, Globe
position, Occular ROM, Pupilary respon,
Swinging Flash light test, Visual acuity,
Palpate orbital Rim, Intercantal distance (30-
32mm >35mm), Median Canthal tendon stability

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Otologic Exam
Inspection (Batlle sign)
Otoscopy

Nose:
Inspect + Palpate
Deformities,
Septal dev,
Septal hematomas

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MIDFACE
Inspect: Deformity,
Palpate: Paresthesia
Maxillary Stability
Zygoma

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Mandible
Inspect: Swelling and Bruish
Palpate: Step off
TMJ
Oral: Maloclussion, subluxed,
ecchymoses, numbness.
Lower lip paresthesia
Oral Hygine
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Maxillofacial Trauma :

1. Soft tissue injury


Fractures of frontal sinus
2. Fractures of the zygoma
Fractures of the orbit & nasoethmoidal
bones
3. Fractures of the nose
4. Fractures of the maxilla
5. Fractures of the mandible
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Injury to special region

Facial nerve
Examining facial nerve function
carefully
The nerve should be repaired using 9-
0 or 10-0 nylon

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Parotid gland/duct injury
Duct injury should be repaired over a
stent to allow healing

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Fractures of The Zygoma

Most common injury after Nasal


Fracture
 Prominent position  Susceptible to
traumatic injury
 Changes in facial appearance &
function
 Associated with ocular & periocular
injury
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Signs & Symptoms

- Signs :
- Depression of cheek convexity
- Edema
- Subconjuctival & periorbital ecchymosis
- Limitation of mandibular movement
- Deformity & tenderness along the orbital
rim
- Unilateral epistaxis
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Lateral
Orbitalri
m

Arch Inferior
fractur Orbitalri
e m

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-Symptoms :
- Anesthesia or
hypesthesia
- Diplopia : blow out
fracture!!!
- Limitation of mouth
opening

Fracture of
orbital floor &
medial wall

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Roentgenographic views :

Plain photo :
Water’s View
Submentovertex View
Caldwell view
CT :
Axial & Coronal projections

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Treatment

 Reduction (Gillies Approach)


 Internal Fixation : Wiring
or Plating

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Fractures of the Nose
The most frequent fracture of facial
bone
The most personal & identifiable
feature of human face
Dx , Tx, & follow-up care important to
reduce incidence of unfavourable
sequele

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3.Trauma dari bawah
Menyebabkan fraktur septal dan dislokasi
terutama dislokasi dari kartilag
quadrangularis crest maxilla.
Trauma seperti ini menyebabkan fragmen
yang satu masuk ke dalam fragmen yang lain
menyebabkan pemendekan hidung atau
penyumbatan salah satu sisi jalan napas.

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DIAGNOSIS
I. Pemeriksaan Klinis
1.Anamnesa
- Riwayat trauma yang jelas mengenai hidung
harus dicurigai kemungkinan fraktur nasal.
- Jika epistaksis (+) kemungkinan besar adalah
fraktur terbuka.
- Jika pasien mengeluh adanya perubahan
bentuk hidung/riwayat obstruksi jalan napas ,
fraktur nasal hampir selalu terjadi .

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2. Pemeriksaan Fisik
• Merupakan kunci penegakan diagnosa.
 Inspeksi eksternal/internal :
deformitas, deviasi/ bentuk yang tidak
normal.
Laserasi, robekan mukosa dan hematom
edema pelupuk mata, kemosis sklera,
kemosis periorbital, perdarahan sub
konjungtiva.
 Palpasi
nyeri dan stabilitas, apakah ada depresi
tulang hidung, displacement, false movement,
mobilitas, krepitasi dan angulasi tulang

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II. Pemeriksaan Penunjang

Ro  detil fraktur dapat terlihat, bisa juga terlewat


karena garis sutura, vascular marking atau fraktur
sebelumnya .
penelitian  47 % foto normal  ternyata fraktur.
foto Water’s  tulang septum, piramid dorsal dan
dinding nasal lateral .

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Terapi

• Tujuan akhir dari terapi fraktur nasal:


1. Mengembalikan penampilan sebaik mungkin
2. Mengembalikan patensi napas
3. Mengembalikan septum pada posisinya di
garis tengah.
4. Mempertahankan keutuhan katub nasal
5. Mencegah stenosis dan deformitas

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I. REDUKSI TERTUTUP

Jika fraktur tulang hidung unilateral


/ bilateral.
Fraktur kompleks nasal septal disertai deviasi.
Anaestesi menggunakan cocain 4 %/lidocain
spray 4% diletakkan 4 buah tampon kapas.
Dengan menggunakan elevator Boies atau
Ballenger, forcep Asch atau Walsham.

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Fragmen yang depresi diangkat dengan kuat
dalam arah yang berlawanan dari fraktur,
masukkan masing-masing ujungnya pada masing-
masing lubang.
Stabilisasi septum dengan splints Silastic,
pasang tampon. Splint diangkat pada hari ke-
10, tampon dicabut pada hari ke 3-5.

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II. REDUKSI TERBUKA
Dikerjakan jika:
Fraktur dislokasi luas tulang hidung & septum.
Deviasi piramid lebih dari setengah lebar nasal
bridge.
Dislokasi fraktur septum caudal.
Fraktur septal terbuka.
Deformitas menetap setelah tindakan reduksi
tertutup.

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Fractures of The Maxilla
CLASSIFICATIONS

Simple & isolated fractures


Complex & associated fractures :
Le Fort I, II, III

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Signs & Symptoms

Tenderness,
malocclusion &
nasopharyngeal
bleeding
Facial elongation
Midfacial swelling &
periorbital
hematome
Floating maxilla
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Roentgenographic

Plain Photo : Skull PA /


Lateral & Water’s
CT Scan

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Treatment

Maxillo-mandibular fixation :
Arch Bar
Fracture reduction :
Interosseus wires
Plate & screw stabilization
Primary bone grafting
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Pre op

Post Op

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FRACTURES OF THE MANDIBLE

Prominent position  succeptible


to trauma
Caused by traffic or sport
accidents and pathologic
fractures

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Classification

Alveolar bone alone or involve basal


bone
Single, bilateral & multiple fractures
According to the region of mandible

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Signs & Symptoms

Tenderness, limitation of mouth


opening
Deformity, deviation of midline
Open bite malocclussion
Palpable step defect of the jaw
Pathologic / unnatural mobility of the
mandible
Sublingual hematome
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Roentgenography

Plain photo : Skull PA / Lateral


oblique
Plain photo : Townes view
Panoramic view
CT Scan

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Name tag !!
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Principles of Treatment

Reduced & fixed earlier, the better is


the outcome
Antibiotics should be administered
Fractured & caries teeth must be
extracted
The first measure : Restoring &
securing occlussion

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Treatment

Circumdental wiring : Stability of


mobile fractures
Interdental wiring
Intermaxillary fixation : Fixation of
whole mandible to the maxilla w/ Arch
Bar
Bone wiring : Transosseus wiring
Bone plate
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CONCLUSIONS

Initial rescuscitation : ABCDE


Successful management is by
complete examination
failure often from the inability to
recognised extent of an injury,then
from the inability to treat the
recognized an injury

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Nur Sehat/40 th/ 10654532/ROI

MRS : 17/10/2006
Perawatan hari ke 3
Diagnosis : COR + ICH + IVH + FBC +
Fr. Zygoma D + Observasi TTA +
Observasi TTT + Hematoschezia
Problem : GCS 3-x-5 + Anemia
Plan : transfusi
ORIF Elektif
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Nyam
Nyam
Sudah
penuh...

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