Transcript 03. Identification and assignment of military dentistry

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Dentists serve as officers in the military to
provide preventative and specialty dental
care to soldiers and their families. Dental
careers are available in many specialty areas
including orthodontics, oral surgery and
pediatrics. Dentists on active duty receive
special pay in addition to their officer basic
pay.
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Short Description
Dental care is one of the health services
provided to all military personnel. It is
available in military dental clinics all over
the world. Dental specialists assist military
dentists in examining and treating patients.
They also help manage dental offices.
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What They Do
Dental specialists in the military perform
some or all of the following duties: Help
dentists perform oral surgery
Prepare for patient examinations by
selecting and arranging instruments and
medications
Help dentists during examinations by
preparing dental compounds and operating
dental equipment
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Clean patients’ teeth using scaling and
polishing instruments and equipment
Operate dental X-ray equipment and
process X-rays of patients’ teeth, gums, and
jaws Provide guidance to patients on daily
care of their teeth Perform administrative
duties, such as scheduling office visits,
keeping patient records, and ordering dental
supplies
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Helpful Attributes
Helpful school subjects include biology and
chemistry. Helpful attributes include:
Ability to follow spoken instructions and
detailed procedures
Good eye-hand coordination
Interest in working with people
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Training Provided
Job training consists of classroom
instruction, including practice in dental care
tasks. Further training occurs on the job and
through advanced courses. Course content
typically includes: Preventive dentistry
Radiology (X-ray) techniques
Dental office procedures
Dental hygiene procedures
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Work Environment
Dental specialists in the military usually work
indoors in dental offices or clinics. Some
specialists may be assigned to duty aboard
ships.
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Civilian Counterparts
Civilian dental specialists work in dental
offices or clinics. Their work is similar to
work in the military. They typically
specialize in assisting dentists to treat
patients, provide clerical support (dental
assistants), or clean teeth (dental hygienists).
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Emergency management
Facial exam
Fractures
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Major
Minor
Soft tissue injuries
Unusual injuries
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Acute
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Airway compromise
Exsanguination
Associated intracranial or cervical-spine injury
Delayed
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Meningitis
Oropharyngeal infections
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Estimated 3,000,000 facial trauma cases per
year in USA
Estimated 40 to 50% of motor vehicle victims
have facial injury
No uniform reporting or registry of cases
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Respiratory  upper airway
Visual
Olfactory
Mastication
Cosmetic
Communication
Individual recognition
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Airway control / immobilize cervical spine
Bleeding control
Complete the primary survey
Secondary survey
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Consider NG or OG tube placement
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Plain radiographs if fractures suspected
CT if suspect complex fractures
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Repair soft tissue immediately if no other
injuries
Delay soft tissue repair until patient in OR if
surgery for other injuries necessary
Step 1: Airway control
 Oxygen for all patients
 May need to keep patient sitting or prone
 Stabilize C-spine early
 Large bore (Yankauer) suction available
Step 1: Airway control
 Orotracheal intubation preferred over
nasotracheal if possible midfacial fracture and
invasive airway needed
 Combitube®, retrograde wire, or
cricothyroidostomy if unable to orotracheally
intubate
Step 2 : Bleeding control
 Can be major threat to life
 Use universal precautions
 Direct pressure dressings initially
 Contraindicated: blind vessel clamping
Step 2 : Bleeding control
 Rapid nasal packing may be necessary
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Be sure blood is not just running down posterior
pharynx
Step 2 : Bleeding control
 Rarely: emergent cutdown and ligation of
external carotid artery needed to prevent
exsanguination
 Note: Although shock in facial trauma patient
is usually due to other injuries, it is possible to
bleed to death from a facial injury
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Blood in airway
“Debris” in airway
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Vomitus, avulsed tissue, teeth or dentures, foreign
bodies
Pharyngeal or retropharyngeal tissue swelling
Posterior tongue displacement from mandible
fractures
Scalp
 Check for lacerations, hematomas, stepoffs,
tenderness
 Bleeding maybe brisk until sutured
 Can use stapler for rapid closure
Ears
 Examine pinnae, canal walls, tympanic
membranes
 Suction gently under direct vision if blood in
canal
 Put drop of canal fluid on filter paper for “ring
sign”  CSF leak
 Assess hearing
Eyes
 Pupils, anterior chamber, fundi, extraocular
movements
 Conjunctivae for foreign bodies
 Palpate orbital rims
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No globe palpation if suspect penetration
Eyes
 Lid injury can leave cornea exposed
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Use artificial tears or cellulose gel
Overall facial appearance
 Assess for symmetry, deformity, discoloration,
nasal alignment
 Palpate forehead & malar areas
Nose
 Check septum for hematoma & position
 Check airflow in both nares
 Palpate nasal bridge for crepitus
 Check fluid on filter paper for “ring sign” (for
CSF leak)
Mouth
 Check occlusion
 Reflect upper & lower lips
 Check Stenson's duct for blood
 Palpate along mandibular and maxillary teeth
(be careful !)
Mouth
 Palpate along exterior of mandible
 Pull forward on maxillary teeth
Neurologic
 Skin fold symmetry at rest
 Motor: each division of CN-VII
 Sensation: 3 divisions of CN-V
 Sensation on tongue
 Gag reflex
Major
 Lefort I, II, III
 Mandibular
Minor
 Nasal
 Sinus wall
 Zygomatic
 Orbital floor
 Antral wall
 Alveolar ridge
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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Lefort fractures can coexist with additional
facial fractures
Patient may have different Lefort type fracture
on each side of the face
Pull forward on maxillary teeth
 Lefort I: maxilla only moves
 Lefort II: maxilla & base of nose move:
 Lefort III: whole face moves:
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Horizontal fracture extending through maxilla
between maxillary sinus floor & orbital floor
Crepitus over maxilla
 Ecchymosis in buccal vestibule
 Epistaxis: can be bilateral
 Malocclusion
 Maxilla mobility
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Closed reduction
Intermaxillary fixation: secures maxilla to
mandible
May need wiring or plating of maxillary wall
and / or zygomatic arch
Antibiotics: anti-staphylococcal
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Subzygomatic midfacial fracture with a
pyramid-shaped fragment separated from
cranium and lateral aspects of face
Signs & symptoms
 Midface crepitus
 Face lengthening
 Malocclusion
 Bilateral epistaxis
 Infraorbital paresthesia
 Ecchymoses: buccal vestibule, periorbital,
subconjunctival
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Hemorrhage or airway obstruction may require
emergent surgery
Treatment can often be delayed till edema
decreased
Usually require
 Intermaxillary fixation
 Interosseous wiring or plating of infraorbital
rims, nasal-frontal area, & lateral maxillary
walls
 May need additional suspension wires
 Antibiotics
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Craniofacial dissociation
Bilateral suprazygomatic fracture resulting in a
floating fragment of mid-facial bones, which
are totally separated from the cranial base
Signs and Symptoms
 Face lengthening: “caved-in” or “donkey face”
 Malocclusion: “open bite”
 Lateral orbital rim defect
 Ecchymoses: periorbital, subconjunctival
Signs and Symptoms
 Bilateral epistaxis
 Infraorbital paresthesia
 Often medial canthal deformity
 Often unequal pupil height
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Usually associated with major soft tissue injury
requiring emergent surgery for bleeding
control
Surgery can be delayed till edema resolves
Intermaxillary fixation
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Transosseous wiring or plating
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Frontozygomatic suture
Nasofrontal suture
May need extracranial fixation if concurrent
mandibular fracture
Antibiotics
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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Airway obstruction from loss of attachment at
base of tongue
>50 % are multiple
Condylar fractures associated with ear canal
lacerations & high cervical fractures
High infection potential if any violation of oral
mucosa
Signs and symptoms
 Malocclusion
 Decreased jaw range of motion
 Trismus
 Chin numbness
 Ecchymosis in floor of mouth
 Palpable step deformity
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Tongue blade test: have patient bite down
while you twist. If no fracture, you will be able
to break the blade.
Treatment
 Prompt fixation: intermaxillary fixation (arch
bars), +/- body wiring or plating
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Can occur from direct blow to mandible
Can occur “spontaneously” from yawning or
laughing
Mandible dislocates forward & superiorly
Concurrent masseter & pterygoid spasm
Symptoms
 Patient presents with mouth open, cannot close
mouth or talk well
 Can be misdiagnosed as psychiatric or dystonic
reaction
Treatment
 Manual reduction: place wrapped thumbs on
molars & push downward, then backward
 Be careful not to get bitten
 Usually does not require procedural sedation
or muscle relaxants
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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Often diagnosed clinically: x-ray not needed
Emergent reduction not necessary except to
control epistaxis
Usually do not need antibiotics
Early reduction under local anesthesia useful if
nares obstructed
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Nasal septal hematoma: incise & drain, anterior
pack, antibiotics, follow-up at 24 hours
Follow-up timing for recheck or reduction:
Children: 3 to 5 days
 Adults: 7 days
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
Tripod (tri-malar) fracture
 Depression of malar eminence
 Fractures at temporal, frontal, and maxillary
suture lines
Isolated arch fracture
 Less common
 Shows best on submental-vertex x-ray view
 Painful mandible movement
 Usually treat with fixation wire if arch
depressed
Tripod S & S
 Unilateral
epistaxis
 Depressed malar
prominence
 Subcutaneous
emphysema
 Orbital rim stepoff
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Altered relative
pupil position
Periorbital
ecchymosis
Subconjunctival
hemorrhage
Infraorbital
hypoesthesia
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
Frontal sinus fracture
 Often associated with intracranial injury
 Often show depressed glabellar area
 If posterior wall fracture, then dura is torn
Ethmoid fracture
 Blow to bridge of nose
 Often associated with cribiform plate fracture,
CSF leak
 Medial canthus ligament injury needs
transnasal wiring repair to prevent telecanthus
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“Blow out” fracture of floor
Rule out globe injury
Visual acuity
 Visual fields
 Extraocular movement
 Anterior chamber
 Fundus
 Fluorescein & slit lamp
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Symptoms and signs
 Diplopia: double vision
 Enophthalmos: sunken eyeball
 Impaired EOM’s
 Infraorbital hypesthesia
 Maxillary sinus opacification
 “Hanging drop” in maxillary sinus
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Diplopia with upward gaze: 90%
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Suggests inferior blowout
Entrapment of inferior rectus & inferior oblique
Diplopia with lateral gaze: 10%
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Suggests medial fracture
Restriction of medial rectus muscle
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Sometimes extraocular muscle dysfunction can
be due to edema and will correct without
surgery
Persistent or high grade muscle entrapment
requires surgical repair of orbital floor (bone
grafts, Teflon, plating, etc.)
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Before repair, rule out injury to:
Facial nerve
 Trigeminal nerve
 Parotid duct
 Lacrimal duct
 Medial canthal ligament
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Remove embedded foreign material to prevent
tattooing
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For lip lacerations, place first suture at
vermillion border
Never shave an eyebrow: may not grow back
If debridement of eyebrow laceration needed,
debride parallel to angle of hairs rather than
vertically
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Antibiotics for 3 to 5 days for any intraoral
laceration (penicillin VK or erythromycin) and
if any exposed ear cartilage (antistaphylococcal antibiotic) – no evidence
Remove sutures in 3 to 5 days to prevent crossmarks
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Most face bite wounds can be sutured
primarily
Clean facial wounds can be repaired up to 24
hours after injury
Place incisions or debridement lines parallel to
the lines of least skin tension (Lines of Langer)
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Assess ABC's first
Do complete exam as part of secondary survey
Obtain standard X-rays and / or CT scan as
indicated
Decide if specialist referral and / or operative
repair indicated
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Arrange followup after repair to assess for
delayed complications or cosmetic problems