Prevention of respiratory disorders
The development of adult respiratory distress syndrome and pneumonia is a formidable complication in extensive facial lesions. Mechanical ventilation serves as the primary prevention tool.
The main objectives of mechanical ventilation:
- Reduction of extravascular lung water.
- Restoration of the normal ventilation-perfusion ratio.
- Effective elimination of microatelectasis.
In addition to mechanical ventilation, to protect the respiratory system it is critically important to provide the patient with adequate analgesia, properly plan infusion-transfusion support, and correct blood rheological parameters.
Fluid and energy replenishment
Water-electrolyte balance disorders and excessive catabolism require precise calculation of daily therapy. The physician must account for the patient's baseline status and extrarenal fluid losses.
Infusion regimens:
- Standard regimen: used predominantly in the first three days postoperatively. The volume is calculated using the formula 30 mL per 1 kg of body weight.
- Enhanced regimen: when wound infection joins, the requirement increases sharply, demanding the administration of 70–80 mL/kg.
Parenteral nutrition is used to manage catabolism. The mixtures must include a glucose solution, amino acid complexes, electrolytes, albumin, and vitamins (C and B group).
Intensive therapy of the wound process
Specialized surgical care for facial wounds is always built on three pillars: surgical debridement, systemic therapy, and local wound treatment.
Local impact aims to stimulate microcirculation and regulate proteolytic reactions for rapid healing. For this purpose, the following are used:
- Infusion solutions (Ringer-Locke solution, Rheopolyglucin).
- Local anesthetics (0.25% procaine solution).
- Blood flow-improving drugs (pentoxifylline) and enzyme inhibitors (aprotinin).
- Proteolytic enzymes for cleansing (trypsin, chymotrypsin).
Diagnosis of concomitant maxillofacial injuries
Severe facial injuries are frequently accompanied by mechanical damage to bone structures that requires differential diagnosis.
- Stress symptom: a key marker of a mandibular fracture. It manifests as sharp pain in the defect area when pressure is applied to demonstrably intact bone segments. Pain also increases during chewing and swallowing of food.
- Mechanisms of injury: the most frequent mechanism of a mandibular fracture is bending. If the fracture occurs directly at the impact point, it is called direct; if at a distance, it is called indirect.
- Maxillary fractures: mid-face injuries (Le Fort II) are accompanied by sensory disturbances of the upper lip due to trauma to the infraorbital nerve (n. infraorbitalis).
- «Panda eyes» sign: bilateral hemorrhage into the tissue of the upper and lower eyelids, characteristic of traumatic brain injuries and facial skeleton fractures.
Emergency conditions and immobilization
In facial trauma, there is a high risk of developing life-threatening conditions, particularly dislocational asphyxia. Its main cause is the posterior displacement of the tongue base, which obstructs the airway.
Transportation of patients with polytrauma involving the head and spine must be performed strictly in the supine position.
Various designs are used for the therapeutic immobilization of fractures, among which Tigerstedt splints belong to dental arch splints. For zygomatic bone injuries, fragment repositioning is performed using specialized instruments (e.g., a single-hook retractor), and for upper incisor injuries at the level of the upper third of the root, apicoectomy may be performed.
Briefly: answers to topical questions
What clinical symptoms are characteristic of a mid-level maxillary fracture (Le Fort II)?
A mid-level maxillary fracture (Le Fort II) is characterized by sensory disturbances in the upper lip region. This symptom manifests as paresthesia or anesthesia and is caused by damage to the infraorbital nerve (n. infraorbitalis). Furthermore, according to the classification, such fractures are bilateral, and their fracture lines run symmetrically.
What types of asphyxia are distinguished in maxillofacial trauma?
In maxillofacial trauma, five main types of asphyxia are distinguished.
- Dislocational — occurs due to the displacement of the tongue, jaw fragment, or larynx.
- Obstructive — caused by the closure of the upper respiratory tract by a blood clot or foreign body.
- Stenotic — develops as a result of tracheal compression by edema, hematoma, or emphysema.
- Valvular — occurs when the laryngeal inlet is closed by a soft tissue flap.
- Aspiration — associated with the aspiration of blood, vomitus, or soil into the respiratory tract.
What instruments are used for fragment repositioning in zygomatic bone fractures?
A number of specialized surgical instruments are used for fragment repositioning in zygomatic bone fractures.
- Single-hook retractor — used in Limberg's method.
- Special elevator (including Karapetyan's elevator) — used in Keen's and Gillies-Kilner methods.
- Buyalsky's spatula and Mamonov's retractor — used for reduction according to Villains' method.
- Broad Gillies elevator or specially curved forceps — used in Gillies, Kilner, Stone methods.
- Special original forceps (with sharp teeth) — used for percutaneous reduction according to Duchange's method.
What types of dental arch splints are used for the therapeutic immobilization of jaw fractures?
For the therapeutic (permanent) immobilization of jaw fractures, prefabricated dental splints are used, which are divided into individual and standard types.
- Individual Tigerstedt wire splints — include a smooth arch splint, an arch splint with a spacer bend, and a splint with traction loops.
- Standard Vasilyev ribbon splint — a flat metal ribbon with 14 traction loops.
- Foreign standard splints — structures made of steel wire (Winter splints) and polyamide materials.
Port and Weber splints are also mentioned in sources.
What biomechanical mechanisms of mandibular fractures exist?
There are four main physical biomechanical mechanisms of mandibular fractures.
- Bending leads to fractures in "weak" (most curved and thin) areas of the jaw, such as the condylar process, angle, mental foramen, and canine region.
- Shearing causes a longitudinal fracture of the ramus when an unsupported bone segment shifts relative to a fixed segment.
- Compression leads to a transverse fracture of the ramus, which undergoes compression while fixed in the articular fossa.
- Avulsion causes detachment of the coronoid process due to a sharp reflex contraction of the temporalis muscle attached to it.
Class and exam questions
What is the essence of the load test in jaw fractures?
This symptom consists of pain in the area of the suspected fracture when the physician exerts pressure on knowingly undamaged areas of the mandible.
Where does the condylar process displace during a fracture?
Due to the pull of the lateral pterygoid muscle, the fragment typically displaces medially.
How does the infusion volume change during the development of wound infection?
The volume of administered fluid must be increased from the standard 30 ml/kg to 70–80 ml/kg of the patient's body weight.
What else to study on this topic
- Types and designs of dental splints (Tigerstedt, Weber, and Port splints)
- Surgical instruments for facial bone reduction (single-hook, elevators, forceps)
- Levels of maxillary fractures according to the Le Fort classification (Le Fort I, II, III)
- Indications and technique for apicotomy in dental trauma
- Mechanisms of mandibular fractures (shearing, avulsion, bending, compression, torsion)
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Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"
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