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1 Oral and Maxillofacial surgery lec 1

. Sep. 2013

When we talk about trauma , were talking about something that you might face
anywhere even out of the clinic for example in the street so you are the only one
who has medical background to deal with that victim.
Today well talk about trauma patient and management of such case ..

Trauma : is a physical force results in an injury.
Maxillofacial injury results from accidents, falls, interpersonal violence or sport
injury , and it occur with other injuries like abdominal one or extremities because of :
1- Anterior projection of the cranium :
The cranium is flat and anteriorly we have the chin, mandible and the nose which
they can be easily fractured.

2- Function :
Most of special senses in the human being are situated in the face like:
Breathing, sight, smell, eating and talking.

3- Appearance

1- Velocity : can be put under any category such as :
a) Velocity of RTAs ( Road Traffic Accidents ) : if a car was very fast and an
accident happened , the victim consequently will have facial injury. So as
the velocity increase we suspect more trauma and fatality.
Factors affect the injury :
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b) Gun machine : we have types of gun machines according to velocity :
- High velocity gun machine : like AR-15 cause sever trauma.
- Low velocity gun machine .

2- Area of strike : if the patient has facial injury due to blunt sort of instrument in
the cheek so the trauma will be at the same site. But if the blunt injury was a
punch on the right side of the mandible ; the fracture will be on the left side.

3- Resulting movement of the head : if the blunt was anterio-posterior , well be
concerned about the Cervical spine .
The most important vertebrae is C1 because just in front of it the brain stem is
located which is responsible for any type of function of the body like : breathing,
heartbeats . so any injury to the C1 will lead simply to death !

4- Angulation of the strike.

RTAs: higher in developing countries ( like Egypt )compared to developed
ones ( like UK ) because they dont stick to the regulations like seat belt for
example which is a must in the developed countries.

Assaults ( interpersonal violence ) : common in the west because of drinking
habit which is forbidden here due to religious and social reasons.

War injuries

Sport injuries ( the least common )


So RTAs Assaults Falls Sport injuries

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Trimodal distribution :
Triage means that patients have priorities in terms of treatment or management ; so
some types of injuries have to be treated quickly because they might be fatal ,
whereas other types of injuries can wait.
According to a study, they found that theres a specific time ( from few minutes to
hours ) which is called Golden hour . so people in this time are those who can be
People who have sever crushing injuries will die in a short time because they are
likely to have multi-organ failure whereas others who have less severe injuries or
bleeding in peripheries can be rescued.
ATLS : stands for Advanced Trauma Life Support
The story for ATLS is : there was an American orthopedic who had an accident with
his son , he took his son to the hospital where he found that thing are going
haphazardly so he thought that he has to found a way to deal with trauma patients
which ATLS course for all people on medical field like doctors, dentists and nurses ,,
so well have trained personnel and this is applied worldwide.

Its the first thing we have to think of when dealing with a trauma patient , it stands for :
A : Airways and cervical spine
B : Breathing and ventilation
C : Circulation and hemorrhage
D : Disability
Triage and assessment
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E : Exposure : means that you have to remove patients clothes to make sure that
nothing is covered with them.

Airways : The first thing is you have to make sure that the airways is patent i.e , no
foreign bodies in the mouth.
If the patient is unconscious : we use some instruments like Guedel airway or
nasopharyngeal device .
in order to admit these instruments to the airways , we have :
1- Chin lift : ( figure 1 )
By putting one finger on the chin and bring it downward and the rest of the hand
behind the mandible and try to push the mandible anteriorly.

2- Jaw thrust

3- Suctioning the oral cavity

4- Cricothyroidotomy : ( figure 2 )
you can have an open airways for only ( -2 hours ) after that well have
defective airways . how can you do it ?
Between the cricoid cartilage and thyroid we have a cricothyroid membrane which
doesnt have blood vessels, so if you punch it with any sharp instrument youll go
directly to the airways.
A : Airways and cervical spine
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5- Tracheostomy and intubation : ( figure 3 )
patient can live with it for a long time

Cervical spine : we make sure that the cervical spine is secured by a neck collar which
secure the cervical spine by 50% and we can secure it 100% by complete banding
using wooden sort of spatula . when we make sure that theres no fractures using x-
rays , we can remove the neck collar and wooden spatula.

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Always you have to suspect cervical spine injury in these cases until proven
1- Altered level of consciousness
2- Multisystem trauma
3- Blunt trauma above the clavicle

If the patient is conscious : we make sure that the airways is secured by :
Ability to talk : if the patient can talk definitely the airways and to some
extent breathing are fine.

Signs and symptoms of patient who has a problem in breathing and ventilation :

1- Deviated trachea :
If the patient has an injury to the chest and bleeding occur between lungs and the
chest wall ; negative pressure will lead to lung collapse because the air will go to
the other ( non-injured) side.

2- Absence of breath sounds :
If a patient has an injury to the chest wall and you need to hear his breath sounds
using a stethoscope; youll never hear any sound in the affected side while you can
in the other side.

3- Dullness on percussion : ( figure 4 )
Percussion test in one the important tests that we have to know about. How you
can do it ?
By putting the hand on the patient chest and the
middle finger touching the chest, then try to tab it,
if theres resonance then its normal but if its
dull then theres no air ( the chest is empty ).

B : Breathing and Ventilation
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4- Muffled heart sounds :
Sometimes, chest injury and lung shrinkage will lead to pericardial injury. If an
injury occurs between the heart and pericardium; the heart will not be moving as it
should do so youll hear a muffled heart sounds.

Radiographic appearance :

1- Loss of lung markings :
Normally, lungs appear in chest x-ray as a black area ( radiolucent ) but if you take
x-ray for patient with chest injury you will see a white area because the lungs are

2- Deviated trachea :

1- Tension pneumothorax : ( figure 5 )
Here we have an opening in the chest ( injury ) which lead only to entrance of air, so
breathing will lead to lung shrinkage.
- Here we have deviated trachea.

2- Simple pneumothorax :
Here the air enter and exit so its not building in .

Types of pneumothorax:
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3- Massive hemopneumothorax :
Hemopneumothorax means : at the site on injury a sort of bleeding occurred so
theres air + blood.
The risk for this type depend on the size of bleeding ; if its small then no risk and
maybe it will not be noticed. But if its massive then it will lead to symptoms.

Cardiac temponade :
Introduction of air between the cardium ( heart ) and the pericardium .
the management of these cases is chest tube : ( figure 6 )
placed between the chest wall and the lungs which will take the air or
everything between them and then return it back to create a negative pressure
lung will restore its original size

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Suppose that you are extracting a tooth for a patient and suddenly a massive
bleeding start regardless to the cause , the first thing youll do is replacing the lost
blood or fluids ( not necessarily the blood itself ) by volume expander like:
1- blood
2- normal saline
3- ringer lactate
all of them are isotonic.

How can you give them these fluids ?

Using two short, wide bore needles ( cannula )in peripheral veins like in the
anticubital fossa or in feet veins. We dont put them in central vessels like carotids
because this will lead to increase the load on the heart .

Advantages of peripheral insertion of cannulas :
1- Easier for general practitioner to master it
2- Its as effective as the central
3- It will not hinder any further management

Circulation and hemorrhage
You can check breathing and ventilation by :
Look keep eye on chest movement
Listen listen to chest sounds
Feel put your hand in front of the patients mouth and feel if theres air
coming out.

Before checking ABCDE , you have to call the emergency and try to call the
patient by his/her name, and shaking him/her gently from shoulders.
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1- Abrasion ( ) : wound caused by friction between an object and the surface
of soft tissue. Here we dont have a cut in the skin but only the superficial layer
is affected.
- This injury means nothing because the body will restore this layer
easily and will not lead to a scar formation. All what you have to put
is an ointment.

2- Contusion ( ) : subcutaneous or submucosal hemorrhage without break in
the skin.
- Its also called bruise
- It means nothing because the body will reorganize it and itll return
to normal.
- Caused by a blunt injury.
- Lead to bone fractures
- No surgical intervention, conservative approach unless expanding, if
the vessel is small the bruise itself will press on the vessel and
close it but if the vessel is large itll continue bleeding so itll make
risk the airways by pressing them.
- If the bruise was sever and spread all around , it may leads to
infection after days because the blood collection is a good
environment for infection especially if it stays and may leads to
other infection because the patients immunity is low.
give antibiotics

3- Laceration ( ) : tear in the epithelium and subcutaneous tissue. So here
we have a cut in tissues and bleeding all around.
- Need suturing

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Types of closure for soft tissue lacerations :

Suppose that a patient come to you with a laceration in the lip , what you
have to do is :
1- Check ABC ( very important ! )
2- Explore the laceration
3- Irrigation and make sure that theres no foreign body
4- Close it

The Dr. showed us this pictures for abrasions from out textbook! Its not clear at
all ! ( figure 7 )

What are the layers of the lip ?

1- Epidermis
2- Dermis
3- Muscle ( orbicularis oris )
4- Submucosa
5- Mucosal epithelium

Always hard tissue management comes before soft tissue management,
for example if a patient comes to you with fractured mandible and
lacerated lip ,, you can close the lip but this doesnt mean that itll be the
definitive management so you have to start with the mandible then the
next day manage the lacerated lip appropriately.
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. Sep. 2013

If a patient come with a lip laceration, we have to close it in layers from inside to
outside, the other thing you have to care about is that the vermilion border
positioned in its correct position as in ( figure 8 )

- The type of suture that we use in the muscle is buried suture

After adequate anesthesia is provided, the surgical management of lacerations
involves 4 major steps :
1- Cleansing : by irrigation
2- Debridement : by removing foreign bodies and necrotic tissues, but in the face
we dont have to do debridement extensively because this area has rich blood
The Dr. advised us to practice suturing in the
clinic because its a skill and very important !
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3- Hemostasis : by
a- Pressure
b- Local anesthesia ( because it contains vasoconstrictor )
c- Local measure ( surgicell )
d- Ligation

4- Closure :
- Hard palate if its not a deep laceration then you dont have to
close because its very tight and itll heal by secondary intention.
- Tongue if its not deep then dont close but if its deep you have to
close it by layers ( like the lip ) because it has very big muscle in it.

Depends on the environment of the injury :
- If its contaminated you have to give antibiotics
- If it isnt contaminated and the patient is adult dont give
And always remember that the good dentist is the one that doesnt give antibiotics
unless its necessary

Tetanus vaccine : always you have to think about it in any injury and to make
sure that the patient took the booster dose

If Allah can take away something youve never expected losing, He can replace them with something youve
never imagined having