Maxillofacial trauma

MAXILLOFACIAL TRAUMA

• Maxillofacial injuries are

commonly encountered in the
practice of emergency medicine.
• More than 50% of patients with
these injuries have multisystem
trauma that requires
coordinated management
INTRODUCTION
• The facial skeleton is divided into 3 parts:
I. The upper 1/3: formed by frontal bone.
II. The middle 1/3: from frontal bone to the level of upper
teeth.
III. The lower 1/3: the mandible.

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ETIOLOGY
• Fights
• Domestic injuries and falls
• RTA
• Occupational hazards- athletic injury, industrial
mishaps
• Iatrogenic
• Human and animal bite
• Pathologic

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Emergency Department Care
 Airway maintenance with cervical spine
protection
 Breathing and ventilation with maximum
flow oxygen
 Maintenance of Circulation & bleeding control
 Disability; neurological status assessment
 Exposure: Completely undress the patient but prevent
hypothermia

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Cont…
 Control airway:
 Maxillofacial bleeding:
• Chin lift, Jaw thrust
• Oropharyngeal toileting and suctioning. • Direct pressure.
• Move the tongue forward.
• Avoid blind clamping
• Immediate restoration of the position of the
soft palate  Nasal bleeding:
• Cervical immobilization
• Direct pressure.
 Avoid nasotracheal intubation:
• Nasocranial intubation • Anterior and posterior packing.
• Nasal hemorrhage
 Pharyngeal bleeding:
• Consider an awake intubation with
Sedation. • Packing of the pharynx around ET tube.
Causes of Respiratory Obstructions Related
to
Maxillofacial Injuries
• Inhalation of blood clot, vomit, saliva, thick mucus or portions of
teeth, bone and dentures
• Inability to protrude the tongue
• Occlusion of the oropharynx by the soft palate after retroposition of
the maxilla
Basic principles of mgt of facial bone #
1. Reduction
2. Fixation
3. Immobilization
1.Reduction :
. Restoration fragments to their original position

Open reduction
Closed reduction • Surgical reduction that allows
• Can be carried out by visual identification of fractured
manipulation or traction fragments
• Occlusion of the teeth is used as
a guide line
• It could be by manipulation or
traction
 Cont…
2) Fixation
• Fractured fragments are fixed to prevent displacement and for
achieving proper approximation
• Direct skeletal fixation: by plates or intraosseous wiring
• Indirect skeletal fixation: by arch bar or intermaxillary fixation

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Cont…
3) Immobilization
The fixation device is retained to stabilize the reduced
fragments until a bony union takes place.
For maxillary # 3 to 4 weeks
For mandibular # 4 to 6 weeks immobilization.
Condylar # 2 to 3 weeks

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Diagnosis of facial fractures
• Midface fractures
• Zygomatic complex fractures
• Nasal fractures
• Mandibular fractures
Fracture of the middle 1/3 of the face
• Boundaries :
• Superiorly : line from FZ
suture, across frontonasal
suture, frontomaxillary
suture.
• Inferiorly : occulusal plane
• Posteriorly : sphenoethmoidal
junction
Cont…
Classification
I. Le Fort I
II. Le Fort II
III. Le Fort III

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Le Fort I #...
Horizontal fracture of the maxilla ,Guerin's fracture
or floating fracture
 Usually bilateral
 Floating of the palate
 Hematoma within the maxillary antrum
 Bilateral hematoma of the cheek
 Deranged occlusion with anterior open bite

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Treatment
Zygomatic maxillary buttress

Nasomaxillary buttresses
Le Fort II #
• Pyramidal or Subzygomatic fracture
• Results from a force delivered at a level of the nasal bones in
superior direction.
• The fracture line occurs along the nasofrontal
suture  lacrimal bone  across the infraorbital rim in the region
of the zygomaticomaxillary suture  above the canine eminence
 inferiorly and distally along the lateral antral
wall, but at a higher level than Le Fort I  across the pterygoid
plate at its middle.
CLINICAL FEATURE
 Extraorally
 Ballooning of the face
Lengthening of the face
Bilateral circumorbital edema and ecchymosis
(Black eye)
Sub conjunctival Hemorrhage
Enophthalmos
Diplopia
Epistaxis
CSF rhinorrhea
Step deformity in the lower border of the orbit
Cont..
 Intraorally
Malocclusion
Gagging of the posterior teeth and anterior open bite
Mobility of the maxilla
Ecchymosis of the sulcus
Treatment

• Intermaxillary fixation
• Interosseous wiring
• Plating of infraorbital rims,
nasal-frontal area, & zm buttress

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Le Fort III fractures (transverse)
• Results when horizontal forces are applied at a level superior enough
(at orbital level) to separate the NOE complex, the zygomas, and the
maxilla from the cranial base (Craniofacial separation/ dysjunction)
• The fracture line courses through the zygomaticotemporal and
zygomaticofrontal sutures lateral orbital wall inferior orbital
fissure medially to the naso-frontal suture  fractures the
pterygoid plate at its base.
Clinical findings
 Extraorally
Severe edema of the face “ballooning”
Lengthening of the face
Flattening of the cheek
Circumorbital ecchymosis
Subconjunctival Haemorrhage
Epistaxis
Enophthalmos
CSF rhinorrhoea
Cont…
 Intraorally
Gagging of the posterior teeth and anterior open bite
Ecchymosis and Haemorrhage of the buccal sulcus
Mobility of the maxilla
Mandibular interference
Cont…
Treatment
• Intraosseous wiring at zygomatico-frontal sutures
• Bilateral fronto-zygomatic suspension after the application of arch
bars.
• Intraosseous wiring may be done at the infraorbital margin, if step
deformity exists
• Plating
Fractures of Zygoma
• The zygoma has 2 major components:
• Zygomatic arch
• Zygomatic body
• Blunt trauma is the most common cause
• Two types of fractures can occur:
• Isolated arch fracture
• Zygomatic complex fracture
Zygoma Arch Fractures

• Can fracture 2 to 3 places along

the arch
• Lateral to each end of the arch
• Fracture in the middle of the arch
• Patients usually present with
pain on opening their mouth or
unable to open (Trismus)
Clinical Findings

• Palpable bony defect

over the arch
• Depressed cheek with
tenderness
• Pain in cheek and jaw
movement
• Limited mandibular
movement
Cont…

• Radiographic imaging:
• Submentovertex view (bucket
handle view)
Closed reduction
Open reduction without fixation
• Reduction using the transoral • Reduction through the temporal
(Keen) approach (Gillies) approach
Zygomatic complex fracture/ ZMC #

• Consist of fractures
through:
• Zygomatico temporal
• Zygomaticofrontal suture
• Inferior orbital rim and
• Floor of orbit
Clinical Features
• Periorbital edema and
ecchymosis
• Paresthesia of the
infraorbital nerve
• Palpation may reveal
step off
• Concomitant globe
injuries are common
Imaging Studies

• Radiographic imaging:
• Waters, Submental and
Caldwell views
• Coronal CT of the facial
bones:
• 3-D reconstruction
Nasal bone fracture

• High Incidence because of its

prominence in nature
• Usually due to direct injury
• can occur as an isolated # or with
other facial fractures
• Result in cosmetic deformity and
functional disturbance.
• Force could be from anterior or lateral
Anterior injuries
• Anterior force may result in smash #
• Comminuted fragments may be driven laterally into the orbit or
upward into the ethmoid region
• May be associated with damage to the nasolacrimal ducts, the
perpendicular plate of the ethmoid, the ethmoid sinuses, the
cribriform plate and the orbital parts of the frontal bone.
• Widening of the intercanthal
distance (traumatic telecanthus)
• Buckling of the nasal septum
may be seen.
Lateral injuries
• Force applied from the side
• May involve only one nasal bone with medial displacement
• Most commonly in adults a violent blow from the side results in # of
both nasal bones and septum with lateral shifting of the entire bony
framework which is called ‘open book’ fracture
Clinical findings
• Nasal deformity
• Edema and tenderness
• Nasal obstruction
• Epistaxis
• Crepitus and mobility
Nasal Fractures
• Diagnosis:
• History and P/E
• Imaging :Lateral , Waters
view or CT
Nasal Fractures
• Treatment:
• Control epistaxis.
• Drain septal hematomas.
• Observation, closed or
open reduction
Treatment
• Observation: Non-displaced #
without nasal deformities or
airway obstruction
Cont…
• Closed reduction: Displaced,
unilateral/bilateral nasal bone #
• Closed reduction should be
performed as soon as the
deformity is identified preferably
10-14 days post injury
• Splinting for 5-10 days
• Open reduction :Unstable or
dislocated nasal bone fractures.
Fracture of the mandible
• Largest ,strongest and heaviest bone of the face
• Classification:
1. Condylar # 35%
2. Angle #20%
3. Body #20%
4. Parasymphysis # 13%
5. Symphysis # 11%
6. Coronoid # 1%

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Signs and symptoms

• Malocclusion
• >50 % are multiple
• Decreased jaw range of motion
• Trismus
• Chin numbness
• Ecchymosis in floor of mouth
• Palpable step deformity
• Airway obstruction from loss of attachment at base of tongue
Management
1. Closed reduction
 Dental wiring or arch bar is used to get the occlusion
 IMF for 4- 6 wks
Indication
 Nondisplaced #
 Lack of soft tissue over the # area
 # of children with developing tooth bud
 Coronoid process #
Cont…
2) Open reduction
Indications
 Displaced fracture
 Multiple fracture
 Associated mid face fracture
 Associated condylar fracture
Contraindicated: if GA is not advisable, sever
comminution or loss of soft tissue & severe infection
to the site

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Complication of maxillofacial fracture
• Paresthesia
• Malunion and deformity
• Infection
• Derangement of occlusion
• Ankylosis of TMJ
• Diplopia

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Mandibular Dislocation
• The mandible can be
dislocated:
• Anterior ~ 70%
• Posterior
• Lateral
• Superior
• Dislocations are mostly
bilateral
Mandibular Dislocation
• Clinical features:
• Inability to close mouth
• Pain
• Facial swelling
• Physical exam:
• Palpable depression
• Jaw will deviate away
• Jaw displaced anterior
Mandibular Dislocation
• Closed reduction:
• Muscle relaxant
• Analgesic
• Closed reduction in the
emergency room
Mandibular Dislocation
• Disposition:
• Avoid excessive mouth opening
• Soft diet
• Analgesics
• Follow up
Injury to the tooth and the periodontium
• Tooth fracture ; Ellis classification
• Concussion
• Subluxation
• Intrusive luxation
• Extrusion luxation
• Lateral luxation
• avulsion
Facial Soft Tissue Injuries
• Before repair, rule out injury to:
• Facial nerve
• Trigeminal nerve
• Parotid duct
• Lacrimal duct
• Medial canthal ligament
Facial Soft Tissue Injuries
• Remove embedded foreign material
• For lip lacerations, place first suture at vermillion border
• Never shave an eyebrow: may not grow back
• 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)
• Remove sutures in 3 to 5 days to prevent cross-marks(rail way marks)
 References
• Neelima anil malik maxillofacial surgery 3rdedition
• Peterson’s Principles of Oral and Maxillofacial Surgery 3rd edition
Thank you for your attention