Facial Trauma Surgery in Charlotte
Types of Injuries
Dentoalveolar traumas involve injuries to the teeth and the surrounding bone. Isolated injuries to the teeth are quite common and are usually treated by your general dentist. Sometimes these injuries require the expertise of various dental specialists. Teeth that have been “knocked out” (avulsed) can be saved if replaced and properly splinted in a timely fashion.
In the event of an knocked out tooth one should:
Find the tooth and rinse it gently in cool water. (Do not scrub it or clean it with soap- just use water). If possible, replace the tooth in the socket and hold it there with clean gauze or a washcloth. If you can’t put the tooth back in the socket, place the tooth in a clean container with milk, saliva, or water. Call your dentist immediately to have the tooth replaced and splinted. Time is of the utmost importance, the faster you act, the better chance of saving the tooth. Dentoalveolar fractures involve the teeth and its surrounding bony housing. These injuries usually require the expertise of oral and maxillofacial surgeons. Treatment involves reducing the fracture (placing the involved segment in the proper anatomic position) along with stabilization and immobilization of the bony segments. This requires splinting or wiring the segment to the adjacent uninvolved teeth.
Some dentoaveolar trauma cannot be anticipated or prevented but if you or your child is involved in sports where collisions can occur an athletic mouth guard should be used. The athletic mouth guard is clearly one of the most effective pieces of equipment available with documented effectiveness against dental trauma and concussion. There are several types of mouth guards available but the custom-fitted mouth guard is much more desirable in sports with continuous activity such as basketball and soccer. To learn more about mouth guards visit http://aapd.org/publications/brochures/mouthpro.asp.
Mandible fractures are lower jaw fractures. The specific anatomic location of the fracture is dependent on the mechanism of injury and direction of the traumatic blow. For instance, an impact of the chin region (symphysis) may result in a fracture in that location but the force may also result in a fracture at a distant sight. Patients commonly present with fractures of both the symphysis and subcondylar area (just below the jaw joint) region. Another common sight for fractures to occur is in the angle region of the mandible through impacted wisdom teeth that have not been previously removed.
One of the most important aspects of surgical correction of mandible fractures is restoration of the pre-injury occlusal relationship. The teeth are first aligned and then the upper and lower jaws are temporarily wired together establishing the proper occlusion. The devices used to wire the teeth together are termed arch bars and are similar to braces. Once the occlusion has been established, depending on the nature of the fracture, a bone plate is surgically placed across the fracture site (open reduction) aiding in stabilization of the fracture. At this point, the teeth are unwired, and the occlusion is checked for accuracy. When an open reduction is performed most patients do not have to have their teeth wired together (termed intermaxillary fixation) after the operation. There are some fractures that do not require an open reduction and are best treated with placement of arch bars and a period of post-operative intermaxillary fixation. The surgeon will determine which is the best treatment on a case-by-case basis. Post operative care for mandible fractures is similar to that described in the section on orthognathic surgery.
The diagram in figure 3 demonstrates the location of LeFort I, II and III fractures. All LeFort fractures affect the occlusal relationship. Therefore, a primary goal in the treatment of these fractures is the restoration of the occlusal relationship. Principles of treatment are similar to those in the treatment of mandible fractures. All LeFort II and III level fractures involve the bony orbit and can therefore result damage to the eye. Fractures of this type all require careful ophthalmologic evaluation as well. As a general rule, all midface fractures should have an ophthalmologic evaluation prior to surgical intervention.
LeFort I Fracture, frontal view on the left, lateral view on the right.
Patients with fractures of the zygoma often present with pain, difficulty opening of the eye, visual changes and cosmetic defects. Displaced zygoma fractures can mechanically obstruct the normal movement of the mandible, resulting in limited opening. Zygoma fractures involve the orbit and the bony fracture segments can impinge the muscles responsible for movement of the eye resulting in diplopia (double vision) and other visual changes. It is therefore extremely important to obtain precise realignment of the fractured bone to prevent long-term visual changes. Noticeable flattening of the cheekbone occurs with displaced zygoma fractures and can be prevented with precise reduction and fixation of the fracture. Isolated zygoma fractures do not directly involve the occlusion and patients may resume a normal diet after they have been repaired.
The nasal-orbital-ethmoid area is bordered by the orbital cavities laterally. Anteriorly, the space is demarcated by the frontal process of the maxilla, the nasal bones, and the frontal process of the frontal bone. Posteriorly, the boundary is the anterior aspect of the sphenoid bones and the roof is formed by the cribriform plate of the ethmoid bone. Injuries to this region of the facial skeleton generally occur from a direct frontal force. The diagnosis of fractures in this region is usually made by physical findings aided by a CT scan. Routine films often fail to demonstrate the degree and location of the disruption. Special considerations of fractures in this region involve assessment of the lacrimal apparatus (tear duct system) and injury to the canthal ligaments. Disruption of the canthal ligaments can result in traumatic telecanthus (apparent widening of distance between the eyes). Treatment of nasal-orbital-ethmoid injuries must be directed toward the proper reduction of the nasal fractures, the correction of the medial canthal ligament disruption, and the correction of traumatically induced lacrimal system abnormalities.
(orbital blowout fractures)
The classic orbital blowout fracture, by definition, implies an intact orbital rim and a disruption of one of the walls or floor of the orbit. If the floor or the orbit is fractured and displaced one may experience prolapse of the orbital tissues into the maxillary sinus. Diplopia, entrapment of infraorbital tissues (resulting in inability to move the eye) and enophthalmos (“sunken eye”) can result when these fractures occur. Again, treatment involves reduction of the fractures, which usually requires an open reduction and repair of the defect with a graft material. The reason for repairing a defect with a graft is to support the orbital contents in the correct anatomical position. There have been many different materials used to repair orbital blowout fractures. Alloplasts are frequently used to reconstruct the orbital floor. Among then have been methyl methacrylate, Teflon, Silastic and titanium. Autogenous bone grafts are also used for orbital reconstruction but are generally for more complex reconstructions. There are a variety of graft sites available to obtain autogenous bone. If a large quantity of bone is needed hipbone is often used. Other sites include the cranium, tibia, rib and intraoral sites as well.