MAXILLOFACAIL TRAUMA

DR. YIBELTAL M. (DMD)

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 Pathophysiology

• Maxillofacial fractures result from either blunt or penetrating

trauma.

– Nose and mandibular injuries

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 Etiology

• 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%

• 25% of women with facial trauma are victims of domestic

violence.
– Increases to 30% if an orbital wall fracture is present.
• 25% of patients with severe facial trauma will develop Post
Traumatic Stress Disorder
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 Anatomy

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 Anatomy

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 Emergency Management
Airway Control

• Control airway:
– Chin lift.
– Jaw thrust.
– Oropharyngeal suctioning.
– Manually move the tongue forward.
– Maintain cervical immobilization

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 Emergency Management
Hemorrhage Control

• 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.

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 History

• Obtain a history from the patient, witnesses

• Specific Questions:
– Was there LOC? If so, how long?
– How is your vision?
– Hearing problems?

• 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?

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 Physical Examination

• 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

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 Cont….

• 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.

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 Cont………..

• Check visual acuity.

• Check pupils for roundness and reactivity.
• Examine the eyelids for lacerations.
• Test extra ocular muscles.
• Palpate around the entire orbits..
• Examine the cornea for abrasions and lacerations.
• Examine the anterior chamber for blood or hyphema.
• Perform fundoscopic exam and examine the posterior chamber and the
retina.
• Examine and palpate the exterior ears.
• Examine the ear canals.
• Check nuero distributions of the supraorbital, infraorbital, inferior alveolar
and mental nerves.

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 Cont……..

• Examine and palpate the exterior ears.

• Examine the ear canals.
• Check nuero distributions of the supraorbital, infraorbital,
inferior alveolar and mental nerves.
Nasal Fractures
• Most common of all facial fractures.
• Injuries may occur to other surrounding bony structures.
• 3 types:
– Depressed
– Laterally displaced
– Nondisplaced
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 Cont…..

• Ask the patient:

– “Have you ever broken your nose
before?”
– “How does your nose look to
you?”
– “Are you having trouble
breathing?”

• Clinical findings:
– Nasal deformity
– Edema and tenderness
– Epistaxis
– Crepitus and mobility

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 Cont……

• Diagnosis:
– History and physical
exam.
– Lateral or Waters view
to confirm your
diagnosis.

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 Cont…….

• Treatment:
– Control epistaxis.
– Drain septal hematomas.
• Refer patients to OMFS as
outpatient
• Control epistaxis:
1. Direct pressure
2. Topical vasoconstrictor such as
phenylephrine 1% or cocaine
3. Cauterize with silver nitrate.
4. Nasal packing ant/post packing.

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 Zygoma Fractures

• The zygoma has 2 major components:

– Zygomatic arch
– Zygomatic body
• Blunt trauma most common cause.
• Two types of fractures can occur:
– Arch fracture (most common)
– Tripod fracture (most serious)
• 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.
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 # of zygomatic complex
• Zygomatic bone is closely associated with maxilla, frontal
& temporal bones – so they are known as zygomatic
complex #
• Signs & symptoms
• Flattening of cheek because of inward displacement of
fragments
• Unilateral Epistaxis
• Circumorbital ecchymosis
• Subconjunctival hemorrhage
• Limitation of ocular movement
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FIG. 24-1 5 A, Zygomatic complex fracture. B, Lateral view. Isolated zygomatic arch
fracture. C, Sub-rtex view. (A and C modified from Kruger E, Schilli W: Oral and
maxillofacial traumatology, vo! o, 1982, Quintessence.)
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 Cont.
• Anesthesia of cheek, nose, lip
• Edema of cheek & eyelids
• Step deformity in infraorbital margin
• Limitation of mandibular movement
• Ecchymosis & tenderness in upper buccal
sulcus
• Change in sensation of teeth & gum
• enophthalmos
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 Zygoma Arch Fractures
Clinical Findings

• Palpable bony defect over

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

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 Zygoma Arch Fractures
Imaging Studies & Treatment

• Radiographic imaging:
– Submental view
(bucket handle view)
• Treatment:
– Consult maxillofacial
surgeon
– Ice and analgesia
– Possible open
elevation

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 Zygoma Tripod Fractures

• Tripod fractures consist of

fractures through:
– Zygomatic arch
– Zygomaticofrontal
suture
– Inferior orbital rim and
floor

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 Zygoma Tripod Fractures
Clinical Features

• Clinical features:
– Periorbital edema and
ecchymosis
– Hypesthesia of the
infraorbital nerve
– Palpation may reveal
step off
– Concomitant globe
injuries are common

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 Zygoma Tripod Fractures
Treatment

• Nondisplaced fractures without eye involvement

– Ice and analgesics
– Delayed operative consideration 5-7 days
– Decongestants
– Broad spectrum antibiotics
– Tetanus
• Displaced tripod fractures usually require admission for open
reduction and internal fixation.

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 Fractures of middle
third of face

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 Nerve supply & blood supply
• Maxillary branch of trigeminal nerve
• Maxillary artery & its branches

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 Boundaries of middle 1/3 of face
• Superiorly- a line drawn from
zygomaticofrontal suture ,across frontonasal
suture,frontomaxillary suture.
• Inferiorly-occlussal plane of upper teeth.
• Posteriorly-sphenoethmoidal junction.

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 Bones constituting middle1/3 of face
• 2 maxillae
• 2 palatine bones
• 2 zygomatic bones
• 2 zygomatic processes of temporal bone
• 2 nasal bones
• 2 Lacrimal bones
• Ethmoid bone
• 2 inferior conchae
• 2 pterigoid plates of sphenoid
• Vomer
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 Classification
• Lefort I
• Lefort II
• Lefort III

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 Maxillary Fractures
LeFort I

• Definition:
– Horizontal fracture of
the maxilla at the level
of the nasal fossa.
– Allows motion of the
maxilla while the nasal
bridge remains stable.

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 Lefort I #
• Also called horizontal # of maxilla or Guerin's # or floating #
(separation of dentoalveolar part of maxilla
• Fractured fragments are freely mobile
• Horizontal # line above the apices of teeth
• Line starts at the point on lateral margin of anterior nasal
aperture above the nasal floor, passes laterally above the
canine fossa traverses lateral antral wall, dipping down
below the zygomatic buttress across pterigomaxillary fissure
& fractures pterigoid lamina at the junction of lower 1/3 &
upper 2/3
• Usually bilateral

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 Cont.
• Signs & symptoms
• Slight swelling & edema of lower part of face with upper
lip swelling
• Ecchymosis in labial & buccal vestibule
• Contusion of upper lip
• Laceration of upper lip & oral mucosa
• Bilateral epistaxis
• Mobility of dentoalveolar fragment of upper jaw
• Disturbed occlusion
• Inability to masticate food
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 Cont.
• Pain while speaking & moving jaw
• In impacted # upward displacement of entire
fragment & Anterior open bite
• Percussion of upper teeth – dull cracked up
sound

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 cont……

• Clinical findings:
– Facial edema
– Malocclusion of the
teeth
– Motion of the maxilla
while the nasal bridge
remains stable

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 cont………..

• Radiographic findings:
– Fracture line which involves
• Nasal aperture
• Inferior maxilla
• Lateral wall of maxilla
• CT of the face and head
– coronal cuts
– 3-D reconstruction

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 Maxillary Fractures
LeFort II

• Definition:
– Pyramidal fracture
• Maxilla
• Nasal bones
• Medial aspect of
the orbits

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 Lefort II #
• Pyramidal or subzygomatic #
• # line runs below the frontonasal suture crossing the
frontal process of maxilla, passes anteriorly across
the lacrimal bones anterior to lacrimal canal, then
passes downward, forward & laterally crossing
inferior orbital margin in zygomatico maxillay suture,
then it extends downward, forward & laterally to
lateral wall of antrum medial to zygomatico maxillary
suture line, then it passess beneath the zygomatic
buttress fracturing pterigoid lamina at the midway
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09/22/2021 39
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 Cont.
• Signs & symptoms
• Gross edema of middle 1/3 of face giving a moon’s face
appearance
• Bilateral circumorbital edema & ecchymosis ( black eye)
• Bilateral subconjunctival hemorrhage
• Bridge of nose is depressed
• If impaction of fragments is there anterior open bite
• If there is downward & backward displacement of
fragments, elongation & lengthening of face & posterior
gagging of occlusion with anterior open bite

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 Cont.
• Bilateral epistaxis
• Difficulty in mastication & speech
• Loss of occlusion
• Airway obstruction due to posterior displacement of
fragments
• CSF leak may be seen
• Step deformity in infraorbital margin
• Anesthesia or paresthesia of cheek
•
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09/22/2021 43
 cont…………..

• Clinical findings:
– Marked facial edema
– Nasal flattening
– Traumatic telecanthus
– Epistaxis or CSF
rhinorrhea
– Movement of the
upper jaw and the
nose.

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 cont……..

• Radiographic imaging:
– Fracture involves:
• Nasal bones
• Medial orbit
• Maxillary sinus
• Frontal process of
the maxilla
• CT of the face and head

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 Maxillary Fractures
LeFort III

• Definition:
– Fractures through:
• Maxilla
• Zygoma
• Nasal bones
• Ethmoid bones
• Base of the skull

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 Lefort III #
• Also known as high level #
• Force is in lateral direction
• Line starts near frontonasal suture, causing dislocation of
nasal bones & disruption of cribriform plate of ethmoid bone
tearing dura mater & causing CSF rhinorrhea, then crosses
through both nasal bones & frontal process of maxilla, then
traverses upper limit of lacrimal bones, then it crosses thin
orbital plate of ethmoid bone, it passes through medial
orbital wall, then it reaches upper posterior aspect of maxilla
& fractures pterigoid lamina at the base
• Entire middle 1/3 is separated from cranial base

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09/22/2021 48
 Cont.
• Signs & symptoms
• Gross edema of face
• Bilateral circumorbital or periorbital ecchymosis
• Tenderness & separation at frontozyomatic suture
• Dish face deformity
• Enophthalmos
• Diplopia
• Temporary blindness or impairment of vision
• Nasal septal deviation
• Epistaxis
• CSF rhinorrhea

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 cont……

• Radiographic imaging:
– Fractures through:
• Zygomaticfrontal
suture
• Zygoma
• Medial orbital wall
• Nasal bone
• CT Face and the Head

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 Maxillary Fractures
Treatment

• Secure and airway

• Control Bleeding
• Head elevation 40-60 degrees
• Consult with maxillofacial surgeon
• Consider antibiotics
• Admission

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 Mandible Fractures
Pathophysiology

• 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%.

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 Mandible Fractures
Clinical findings

• Mandibular pain.
• Malocclusion of the teeth
• Separation of teeth with
intraoral bleeding
• Inability to fully open
mouth.
• Preauricular pain with
biting.
• Positive tongue blade test.

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 Mandible Fractures

• Radiographs:
– Panoramic view
– Plain view: PA, Lateral and a Townes view

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 Mandibular Fractures
Treatment

• Nondisplaced fractures:
– Analgesics
– Soft diet
– oral surgery referral in 1-2 days
• Displaced fractures, open fractures and fractures with
associated dental trauma
– Urgent oral surgery consultation
• All fractures should be treated with antibiotics and tetanus
prophylaxis.

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 Mandibular Dislocation

• Causes of mandibular dislocation are:

– Blunt trauma
– Excessive mouth opening
• Risk factors:
– Weakness of the temporal mandibular ligament
– Over stretched joint capsule
– Shallow articular eminence
– Neurologic diseases

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 cont…………

• The mandible can be

dislocated:
– Anterior 70% 

– Posterior
– Lateral
– Superior
• Dislocations are mostly
bilateral.

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 cont……..

• Posterior dislocations:
– Direct blow to the chin
– Condylar head is pushed against the mastoid
• Lateral dislocations:
– Associated with a jaw fracture
– Condylar head is forced laterally and superiorly
• Superior dislocations:
– Blow to a partially open mouth
– Condylar head is force upward

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 cont………..

• Clinical features:
– Inability to close
mouth
– Pain
– Facial swelling
• Physical exam:
– Palpable depression
– Jaw will deviate away
– Jaw displaced anterior

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 cont………

• Diagnosis:
– History & Physical
exam
– X-rays
– CT

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 cont………..

• Treatment:
– Muscle relaxant
– Analgesic
– Closed reduction in
the emergency
room

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 cont…….

• Treatment:
– Oral surgeon consultation:
• Open dislocations
• Superior, posterior or lateral dislocations
• Non-reducible dislocations
• Dislocations associated with fractures

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 cont………..

• Disposition:
– Avoid excessive mouth opening
– Soft diet
– Analgesics
– Oral surgery follow up

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