Medical University Pleven

Department of Surgical Diseases

Polina Marinova MD, PhD
Maxillofacial injuries

KVS
 To be able to recognize life
threatening nature of facial injuries –
Airway obstruction, associated head &
spinal injuries.
 Method of examining facial injuries.
 Diagnosis & principles of management
of facial injuries

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 Road traffic
accidents

 Intentional
violence

 Sporting
activities
 High Impact:
◦ Supraorbital rim – 200 G
◦ Symphysis of the Mandible –100 G
◦ Frontal – 100 G
◦ Angle of the mandible – 70 G
 Low Impact:
◦ Zygoma – 50 G
◦ Nasal bone – 30 G
 At 60% of patients with severe
facial trauma have multisystem
trauma and the potential for
airway compromise.
◦ 20-50% concurrent brain injury.
◦ 1-4% cervical spine injuries.
◦ Blindness occurs in 0.5-3%
KVS
Based on
 Targeting care: Glasgow Coma Scale
(GCS)
 Predicting outcome: Abbreviated
Injury Scale (AIS) and Injury Severity
Score(ISS)
 Assessing critically injured patients:
APACHE II
KVS
 Triage the causalities
(sorting for prioritization)
 A: airway with cervical spine control
 B: breathing and ventilation
 C: circulation and hemorrhage control
 D: disability due to neurologic deficit
 E: exposure and environment control

KVS
 Injuries to facial skeleton →

Immediate airway
obstruction

delayed airway obstruction

KVS
inhalation of tooth fragments

accumulation of blood & secretions

loss of control of tongue in

unconscious/ semiconscious pt. →

KVS
 Control airway:
◦ Chin lift.
◦ Jaw thrust.
◦ Oropharyngeal suctioning.
◦ Manually move the tongue
forward.
◦ Maintain cervical immobilization
 Avoid nasotracheal intubation:
◦ Nasocranial intubation
◦ Nasal hemorrhage
 Avoid Rapid Sequence Intubation:
◦ Failure to intubate or ventilate.
 Consider awake intubation.
 Sedate with benzodiazepines.
 Consider fiberoptic intubation if
available.
 Alternatives include percutaneous
transtracheal ventilation and
retrograde intubation.
 Be prepared for
cricothyroidotomy.
 Maxillofacial bleeding:
◦ Direct pressure.
◦ Avoid blind clamping in wounds.
 Nasal bleeding:
◦ Direct pressure.
◦ Anterior and posterior packing.
 Pharyngeal bleeding:
◦ Packing of the pharynx around ET tube.

KVS
 Obtain a history from the patient,
witnesses and or EMS
 Specific Questions:
◦ Was there LOC? If so, how long?
◦ How is your vision?
◦ Hearing problems?

KVS
 Specific Questions:
◦ Is there pain with eye movement?
◦ Are there areas of numbness or
tingling on your face?
◦ Is the patient able to bite down
without any pain?
◦ Is there pain with moving the jaw?

KVS
 ATLS standard
approach
 Inspection

 Palpation

 Visual examination
 Eye movement
 Diplopia
 Pupil reaction

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 Inspection of the face for asymmetry.
 Inspect open wounds for foreign
bodies.
 Palpate the entire face.
◦ Supraorbital and Infraorbital rim
◦ Zygomatic-frontal suture
◦ Zygomatic arches

KVS
 Inspect the nose for asymmetry,
telecanthus, widening of the nasal
bridge.
 Inspect nasal septum for septal
hematoma, CSF or blood.
 Palpate nose for crepitus, deformity
and subcutaneous air.
 Palpate the zygoma along its arch and
its articulations with the maxilla,
frontal and temporal bone.
 Check facial stability.
 Inspect the teeth for malocclusions, bleeding and
step-off.
 Intraoral examination:
◦ Manipulation of each tooth.
◦ Check for lacerations.
◦ Stress the mandible.
◦ Tongue blade test.
 Palpate the mandible for
tenderness, swelling and step-off.

KVS
 Upper third – above the
eyebrows – involves
frontal sinuses &
supraorbital ridges

 Middle third – above

the mouth
Le Fort I , II , II

 Lower third --
Mandible
 Frontal Sinus/ Bone Fractures
Diagnosis
 Radiographs:
◦ Facial views should include
Waters, Caldwell and lateral
projections.
◦ Caldwell view best evaluates
the anterior wall fractures.

KVS
 CT Head with
bone windows:
◦ Frontal sinus
fractures.
◦ Orbital rim and
nasoethmoidal
fractures.
◦ R/O brain injuries
or intracranial
bleeds.
 Fractures that extend
into the nose through
the ethmoid bones.
 Associated with
lacrimal disruption and
dural tears.
 Suspect if there is
trauma to the nose or
medial orbit.
 Patients complain of
pain on eye movement.
 Clinical findings:
◦ Flattened nasal bridge or a saddle-shaped
deformity of the nose.
◦ Widening of the nasal bridge (telecanthus)
◦ CSF rhinorrhea or epistaxis.
◦ Tenderness, crepitus, and mobility of the nasal
complex.
◦ Intranasal palpation reveals movement of the
medial canthus.
KVS
Three types of NOE fractures
– Type I: Large fragment of medial orbit, medial
canthal insertion is intact

– Type II: Comminution of bones, fracture line does

not extend into area of medial canthal insertion

– Type III: Comminution of bones, fracture line

extends into area of medial canthal insertion

KVS
 Examination for
determination of the extent
of the injury (surgical
exploration)
 Nasal bone
 Orbital and ethmoidal
 Frontal bone

 Debridement and closure of

open wounds

 Reduction and stabilization

of bone fracture

30
  Increase in inter-canthal
distance secondary to
canthus displacement or
detachment

 Seen in association to:

Nasal bone
NEO
Le Forts fractures

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 Transnasal wiring
technique (unilateral
type)

 Canthopexy
◦ Identification of the
ligament
◦ Liberation of the
periorbital tissue
◦ Liberation of the lacrimal
pathway
◦ Nasal transfixation
◦ Contralateral fixation

32
 Anatomy
Star-shape like with four processes
 Frontal process
 Temporal process
 Buttress
 Orbital floor (Maxilla and GWSB)

Temporal fascia
and muscle

Masseter muscle

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The malar bone represent a
strong bone on fragile
supports, and it is for this
reason that, though the
body of the bone is rarely
broken, the four processes-
frontal, orbital, maxillary
and zygomatic are frequent
sites of fracture.

HD Gillies, TP Kilner and D

Stone, 1927 Zygomatic bone fractured as a
block near its principle three
suture lines and often displaces
inwards to a greater or lesser
extent. 34
 Periorbital ecchymosis and edema

 Flattening of the malar prominence

 Flattening over the zygomatic arch

 Pain and tenderness on palpation

 Ecchymosis of the maxillary buccal sulcus

 Deformity at the zygomatic buttress of

the maxilla

 Deformity at the orbital margin

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 Trismus
 Abnormal nerve sensibility
 Epistaxis
 Subconjunctival ecchymosis
 Crepitation from air
emphysema
 Displacement of palpebral
fissure (pseudoptosis)
 Unequal pupillary levels
 Diplopia
 enophthalmos

36
 Occipitomental view

(Posterioanterior oblique)

 (water’s view)

37
  submentovertex

Recommended for isolated

zygomatic arch fracture

38
CT scan
 Coronal sections
 Axial sections

39
 Timing:
 As early as possible unless there are
ophthalmic, cranial or medical complications

 Preiorbital edema and ecchymosis obscure the

fine details of the fracture, intervention can be
postponed but not more than a week

Indications:

•Diplopia
•Restriction of mandibular movement
•Restoration of normal contour
•Restoration of normal skeletal protection for the eye
40
  Temporal approach (Gillies et al
1927)

• Buccal
sulcus
approach
(Keen 1909)

Suitable for isolated

zygomatic fracture with
good stability afterwards

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 Rigid fixation using plate and screws at
 Frontozygomatic suture
 Infraorbial rim
 Inferior buttress of the zygoma

Surgery:

•Lateral eyebrow incision

•Infraorbial approach
•Subciliary (blepharoplasty) incision
•Mid-lower lid incision
•Transconjunctival approach

42
Points of fixation:

Lateral Buttress of Infraorbital

orbital rim zygoma rim and
buttress
43
KVS
 Definition:
◦ Horizontal fracture
of the maxilla at the
level of the nasal
fossa.
◦ Allows motion of
the maxilla while
the nasal bridge
remains stable.
 Clinical findings:
◦ Facial edema
◦ Malocclusion of the
teeth
◦ Motion of the
maxilla while the
nasal bridge
remains stable
 Definition:
◦ Pyramidal fracture
 Maxilla
 Nasal bones
 Medial aspect of the
orbits
 Clinical findings:
◦ Marked facial
edema
◦ Nasal flattening
◦ Traumatic
telecanthus
◦ Epistaxis or
rhinorrhea
◦ Movement of the
upper jaw and the
nose.
 Definition:
◦ Fractures through:
 Maxilla
 Zygoma
 Nasal bones
 Ethmoid bones
 Base of the skull
 Clinical findings:
◦ Dish faced
deformity
◦ Epistaxis and CSF
rhinorrhea
◦ Mobility of the
maxilla, nasal
bones and zygoma
◦ Severe airway
obstruction
 closed reduction with inter maxillary fixation
(unilateral fractures)

 open reduction.

 Open reduction – intra osseous wiring

- by using micro or
miniplates
 In conjunction with other
facial fractures

 As isolated type (Blow out

fracture)

54
Anatomy
The floor is made
of: Maxillary bone
and part of zygoma
bounded laterally
by the inferior
orbital fissure and
small part of the
ethmoid bone

55
 Subconjunctival ecchymosis

 Crepitation from air emphysema

 Displacement of palpebral
fissure

 Unequal pupillary levels

 Diplopia
 enophthalmos

56
 Rational for intervention:

 Small defect with no clinical consequence

may not warrant the surgical intervention.

 Large defect with handicapping symptoms

should be operated.

57
 Intra-sinus
approach to the
orbital floor

 External approach
to the internal
orbital floor

58
 Autologous graft
Bone (cranial, rib, iliac)
Cartilage
 Allogenic materials
Lyophilized dura
 Alloplastic
materials
Siliastic and proplast
implants
Teflon
hydroxyapatite
Titanium mish

59
 Mandibular fractures
are the third most
common facial fracture.
 Assaults and falls on
the chin account for
most of the injuries.
 Multiple fractures are
seen in greater then
50%.
 Associated C-spine
injuries – 0.2-6%.
KVS
 Sites of weakness
◦ Third molar (esp. impacted)
◦ Socket of canine tooth
◦ Condylar neck
 Masseter, Medial and Lateral Pterygoid, and
Temporalis tend to draw fractures medial and
superior
 Almost all fractures of angle unfavorable
 Complete Head and Neck exam
◦ Palpable step off
◦ Tenderness to palpation
◦ Malocclusion
◦ Trismus (35 mm or less)
◦ Sublingual hematoma
◦ Altered sensation of V3
◦ Crepitus
 Mandibular pain.
 Malocclusion of the
teeth
 Separation of teeth
with intraoral bleeding
 Inability to fully open
mouth.
 Preauricular pain with
biting.
.
 Unilateral fractures of Condyle
◦ Decreased translational movement, functional
height of condyle
◦ Deviation of chin away from fracture, open bite
opposite side of fracture
Bilateral fractures of condyle
- Anterior open bite
 Panorex (OPG)
 X ray skull Reverse towns view.
 X Ray mandible PA View, Lateral oblique views
 TMJ views
 CT scan
◦ Not as diagnostic as plain films
for nondisplaced fractures of
mandible.
◦ Most useful for coronoid and
condylar fractures, associated
midface fractures

DZS
 Favorable, non-displaced fractures
 Grossly comminuted fractures when
adequate stabilization unlikely
 Severely atrophic edentulous
mandible
 Children with developing dentition
 Displaced unfavorable fractures
 Mandible fractures with
associated midface fractures
 When MMF contraindicated or not
possible
 Patient comfort
 Facilitate return to work
 Associated condylar fracture
 Associated Midface fractures
 Psychiatric illness
 GI disorders involving severe N/V
 Severe malnutrition
 To avoid tracheostomy in patients who
need postoperative intubation
 Contraindications
◦ General Anesthetic risk too high
◦ Severe comminution and
stabilization not possible
◦ No soft tissue to cover fracture
site
◦ Bone at fracture site diffusely
infected (controversial)
 Length of MMF
◦ Fracture at angle of mandible for adults :
4 wks
◦ Add 2 wks more for symphysis fracture
◦ Add 2 wks for geriatric patients
(edentulous)
◦ Less 1 wk for peadiatric mandibular
fractures.
◦ Less 1 wk for condylar fractures.
◦ Rigid fixation
1. Compression plates (DCP)
2. Lag screws
◦ Semirigid fixation
1. Miniplates
2. Transosseous wiring
3. External fixators
 Compression plates
◦ Rigid fixation
◦ Allow primary bone healing
◦ Difficult to bend
◦ Operator dependent
◦ No need for MMF
 Lag Screws
◦ Rigid fixation (Compression)
◦ Good for anterior mandible fractures,
Oblique body fractures, mandible
angle fractures
◦ Cheap
◦ Technically difficult
◦ Injury to inferior alveolar
neurovascular bundle
 Miniplates
◦ Semi-rigid fixation
◦ Mono cortical screws
◦ Uses tension band principle
◦ Allows primary and secondary bone
healing
◦ Easily bendable
◦ More forgiving
 Areas of tension and compression
 2 mm plates
 Monocortical screws.
 Placed in favourable positions on mandible.
 Micromovements possible favourable to
healing.
 Technically not highly demanding.
 Plate removal is not routinely required.

KVS
 Alternative form of rigid
fixation
 Grossly comminuted fractures,
contaminated fractures, non-
union
 Often used when all else fails
 Lindhal and Hollender
◦ Closed reduction in children, teens,
adults
◦ Intracapsular fractures
◦ Higher incidence of postoperative
sequelae in adults
◦ Children and Teens with less
sequelae, more remodeling
 ORIF, Absolute indications
◦ Displacement into middle cranial
fossa
◦ Inability to achieve occlusion
with closed reduction
◦ Foreign body in joint space
 Relative indications
◦ Bilateral condylar fractures to
preserve vertical height
◦ Associated injuries that dictate
earlier function
 Soft tissue swelling causing airway
compromise with MMF
 Intracapsular fracture on opposite
side where early mobilization
important
 Expose all fracture sites
 Reconstruct the AP projection of face, start from
stable post area (temporal bone, proximal arch
 Reconstruct the width of the face across
zygomatic arches (frontozygomatic suture)
 Recreate NOE area.
 Restore height (fix ramus fractures)
 Restore occlusion.
 Repair the fractures in maxilla and mandible
closer to teeth bearing areas

PGM