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Al – Iraqia University / college of dentistry

Oral Surgery / Stage V
Dr. Haydar Munir Salih Alnamer
B.D.S., Ph.D. (Board Certified) Lec:8&9&10&11

Maxillofacial Trauma
Review Questions
Q1: Discuss the following statement: (relatively minor mandibular
fractures may be associated with a surprising degree of closed head
injury)
A1:
Because of its position and prominence and blows to the mandible are transmitted
directly to the base of the skull through the temporomandibular articulation

Q2: Enumerate the fundamental mandibular functions that should

be restored after mandibular trauma?
A2:
Restoration of mandibular function, in particular, as part of the stomatognathic
system must include the ability to masticate properly, to speak normally, and to
allow for articular movements as ample as before the trauma.

Q3: Explain direct vs indirect mandibular fracture?

A3: When the force is applied to the mandible, the point of application of the force
is compressed causing direct fracture and the resultant vector travels along the bone
and applies tensile force on the point intersected

By this vector causing indirect fracture. Whenever a direct fracture is seen at the
site of primary impact, one must examine the corresponding indirect fracture site
and rule out the indirect fracture. Common combinations of direct and indirect
fractures are:
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Symphyseal (direct) fracture combined with bilateral subcondylar (indirect)

fractures also called parade ground fracture or guardsman's fracture.
Parasymphyseal (direct) fracture combined with contralateral subcondylar or angle
(indirect) fracture.
Body (direct) fracture combined with contralateral angle or subcondylar (indirect)
fracture.

Q4: Explain the principle of mandibular trauma radiology?

A4: The principle in trauma radiology is to obtain at least two views, each taken at
right angles to the other, in order to assess the degree of displacement and angulation
of the fragments

Q5: What are the principles of treatment of a fracture ?

A5:
1. Debridement
2. Reduction; it is the restoration of functional alignment of the fractured bone
fragments.
3. Fixation.

4. Immobilization.
5. Rehabilitation.

Q6: Discuss the period of immobilization in close treatment of

mandibular fracture?
A6: With early uncomplicated treatment in a healthy young adult union can on
average be achieved after 3 weeks, at which time the fixation can be released. As an
empirical guide a further 1-2 weeks should be added for each and any of the
following circumstances:

1. Where a tooth is retained in the fracture line.

2. Patients aged 40 years and over.

3. Patients who are smokers.

4. Mobile or comminuted fractures.
5. Fractures in alcoholics, particularly those with nutritional problems
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Rules such as these are designed for guidance only, and it must be emphasized that
the IMF should be released and the fracture tested clinically before the fixation is
finally removed.

Q7: Enumerate the absolute indications for removal of a tooth in

fracture line?
A7:
1. Longitudinal fracture involving the root.

2. Dislocation or subluxation of the tooth from its socket.

3. Presence of periapical infection.

4. Advanced periodontal disease.

5. Already infected fracture line.

6. Acute pericoronitis.

7. Where a displaced tooth prevents reduction of the fracture.

Q8: What are the main contributing factors and principles of

management of infection in fracture site?
The main contributing factors are:

1. Compound fractures with gross contamination.


2. Inadequate stabilization of the fracture.

3. Loose fixation devices.

4. Immunocompromised patients, e.g., diabetics and alcoholism

The principles of management are:

1. control the infection (incision and drainage, and antibiotics)


2. Remove any focus of infection (teeth, sequestra, or plates and screws)
3. Optimize the healing environment (patient's health, oral health)

4. Immobilize the fracture.
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Q9: can you accept imperfection in pediatric mandibular fracture?

A9: Slight imperfection in reduction can be accepted when a fracture is treated,

because continuing growth and eruption of teeth will compensate in most cases for
the imperfect alignment the fragments.

Q10: Classify condylar fracture of mandible?

A10:
1. Fracture through the head of the condyle (diacapitular fracture): the fracture line
starts in the articular surface and may extend outside the TMJ capsule.

2. Fracture of the condylar neck: The fracture line starts somewhere above line A
(the perpendicular line through the sigmoid notch to the tangent of the ramus) in
more than half of its length, it runs above the line A in the lateral view.

3. Fracture of the condylar base: The fracture line runs behind the mandibular
foramen and, in more than half of its length, below line A. 


Minimal displacement: displacement of less than 10° or overlap of the bone edges
by less than 2 mm, or both.

Q11: enumerate the absolute and relative indications of ORIF in

condylar fracture?
A11: Absolute Indications:
A. Limitation of function secondary to the following:
1. Displacement of condyle into middle cranial fossa

2. Impossibility of restoring occlusion with closed treatment.
3. Lateral extra-capsular displacement of condylar head
4. Invasion by foreign body within the joint capsule (e.g. missile)
5.

B. Inability to bring the teeth into occlusion for closed reduction

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Relative indications:

1. Bilateral fracture with associated mid-face fracture (particularly where one

condylar fracture is dislocated or angulated)
2. Bilateral fracture with severe open bite deformity

3. Unilateral fracture with dislocation, overlap or significant angulation of the
condylar head

4. When IMF is contraindicated for medical reasons

Q12: In the scope of trauma , enumerate the predisposing factors of

TMJ ankylosis?
A12:
1. Age: the major incidence is below the age of 10 years.

2. Type of injury: intracapsular trauma with crushing of the condyle.
3. Damage to the disc: disruption of the disc is likely to occur in two particular types
of fracture: a severe intracapsular compression injury or a fracture dislocation.

Q13: Explain, the bone ends are more easily displaced in edentulous
mandibular fracture?
A13: Smaller cross-sectional area of bone at the fracture site and the absence of the
stabilizing influence of teeth mean that the bone ends are more easily displaced and
even after reduction the area of contact between them may be insufficient for healing
to occur easily.

Q14: Compare between the traditional and recent methods used in

treatment of comminuted mandibular fracture?

A14: The traditional method of treatment of these fractures used closed techniques,
thereby avoiding periosteal stripping and further devitalizing the bone. However,
these techniques do not guarantee adequate immobilization of all the fragments,
although clinically they work well in selected cases. Recently ORIF has been
advocated to provide a load bearing fixation and stability-across the fracture
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Q15: Enumerate the vertical and horizontal buttresses of midface

A15: The vertical buttresses are the pterygomaxillary, zygomaticomaxillary, and
nasomaxillary buttresses. These vertical pillars are further supported by the
horizontal buttresses;

The horizontal buttresses are supraorbital or frontal bar, infraorbital rims, and
zygomatic arches. Joining these buttresses together is lamellar thin bone. This
framework results in fairly predictable patterns of fracture.

Q16: Enumerate the shared clinical features between lefort I and

lefort II fractures?
A16:
1. malocclusion
2. mobility of upper jaw
3. Hypoesthesia of the infraorbital nerve
4. 'Cracked-pot' sound on tapping teeth.


Q17: Define CSF rhinorrhea and mention the clinical and laboratory
detection modalities of it?
A17: CSF rhinorrhea: is escape of cerebrospinal fluid from nasal cavity as the result
of dura tear CSF rhinorrhea does not take place, unless there is associated fracture
of cribriform plate of ethmoid.

Clinical detection of CSF rhinorrhea may be complicated by the presence of lacrimal

fluid, blood and nasal secretions. When the blood clots and dries and the flow of
CSF continues, it produces a classical (tramline pattern). It also forms classical
ring around the clotted blood on the pillow. If the patient is in supine position it
passes in the pharynx giving salty metallic taste. 


Traditional methods for detecting CSF leak include testing for glucose or protein,
but these are neither sensitive nor specific.

Testing the discharge for beta-2 transferrin, a brain specific variant of transferrin, is
accepted as the best available diagnostic method
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Q18: Define Diplopia and mention its possible causes and its detection
methods?
A18:
Diplopia (double vision) is a relatively common early clinical finding after orbital
trauma, often simply as a result of edema affecting the extra- ocular muscles

The tethering of the inferior muscles can be further demonstrated by the forced
duction test, which may be carried out under local or general anesthesia. Fine
toothed dissecting forceps are inserted under the globe of the eye via the inferior
conjunctival fornix and the insertion of the inferior rectus is gently grasped enabling
the globe to be forcibly rotated upwards and its freedom of movement compared
with the opposite side. Any increased resistance is readily appreciated and is
diagnostic of muscle tethering.

It is essential to measure this interference with orbital movement by means of a Hess

chart and to monitor any improvement, or lack of it, by repeating the test during the
first 7-10 days after injury.

Q19: Enumerate the indication of treatment of orbital fractures?

1. Significant restriction of eye movement (diplopia) with CT confirmation of
entrapment.
2. Significant enophthalmos. 

3. Large 'blowout' defect 

4. Significant orbital dystopia
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Q20: Mention in table the splinting time for the following

dentoalveolar injuries:
a. subluxation b. Extrusive luxation c. lateral luxation d. avulsion
A20:
a subluxation 7-10 days

b Extrusive luxation 1 to 2 weeks

c lateral luxation 2-8 weeks

d avulsion 7 to 10 days

Q21: enumerate the factors that influence the success of avulsed tooth
repositioning?
A21:
1. The stage of root development; survival of the pulp is possible in teeth with
incomplete root formation 


2. The length of time the tooth is allowed to dry; if the tooth is re-implanted within
30 minutes of avulsion, there is a good chance of successful re-implantation. For
extra-alveolar periods longer than 2 hours, complications associated with notable
root resorption increase greatly. 


3. The length of storage outside the mouth. 


4. The medium used and correct handling and splinting