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Maxillofacial Trauma
Joe Lex, MD, FACEP, FAAEM
Temple University School of Medicine
Philadelphia, PA USA
[email protected]
Lecture Outline
• Emergency management
• Facial exam
• Fractures
– Major
– Minor
• Soft tissue injuries
• Unusual injuries
Causes of Mortality
• Acute
– Airway compromise
– Exsanguination
– Associated intracranial or cervicalspine injury
• Delayed
– Meningitis
– Oropharyngeal infections
Epidemiology
• 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
Functions of Face
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Respiratory  upper airway
Visual
Olfactory
Mastication
Cosmetic
Communication
Individual recognition
Management Sequence
• Airway control / immobilize cervical
spine
• Bleeding control
• Complete the primary survey
• Secondary survey
– Consider NG or OG tube placement
Management Sequence
• Plain radiographs if fractures
suspected
• CT if suspect complex fractures
Management Sequence
• Repair soft tissue immediately if no
other injuries
• Delay soft tissue repair until patient
in OR if surgery for other injuries
necessary
Initial Management
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
Initial Management
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
Initial Management
Step 2 : Bleeding control
• Can be major threat to life
• Use universal precautions
• Direct pressure dressings initially
• Contraindicated: blind vessel
clamping
Initial Management
Step 2 : Bleeding control
• Rapid nasal packing may be
necessary
– Be sure blood is not just running
down posterior pharynx
Initial Management
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
Airway Compromise
• Blood in airway
• “Debris” in airway
– Vomitus, avulsed tissue, teeth or
dentures, foreign bodies
• Pharyngeal or retropharyngeal
tissue swelling
• Posterior tongue displacement from
mandible fractures
Secondary Survey
Scalp
• Check for lacerations, hematomas,
stepoffs, tenderness
• Bleeding maybe brisk until sutured
• Can use stapler for rapid closure
Secondary Survey
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
Secondary Survey
Eyes
• Pupils, anterior chamber, fundi,
extraocular movements
• Conjunctivae for foreign bodies
• Palpate orbital rims
– No globe palpation if suspect
penetration
Secondary Survey
Eyes
• Lid injury can leave cornea
exposed
– Use artificial tears or cellulose gel
Secondary Survey
Overall facial appearance
• Assess for symmetry, deformity,
discoloration, nasal alignment
• Palpate forehead & malar areas
Secondary Survey
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)
Secondary Survey
Mouth
• Check occlusion
• Reflect upper & lower lips
• Check Stenson's duct for blood
• Palpate along mandibular and
maxillary teeth (be careful !)
Secondary Survey
Mouth
• Palpate along exterior of mandible
• Pull forward on maxillary teeth
Secondary Survey
Neurologic
• Skin fold symmetry at rest
• Motor: each division of CN-VII
• Sensation: 3 divisions of CN-V
• Sensation on tongue
• Gag reflex
Fracture Classification
Major
• Lefort I, II, III
• Mandibular
Minor
• Nasal
• Sinus wall
• Zygomatic
• Orbital floor
• Antral wall
• Alveolar ridge
Forces Required
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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
Lefort Fractures
• Lefort fractures can coexist with
additional facial fractures
• Patient may have different Lefort
type fracture on each side of the
face
Differentiating Leforts
Pull forward on maxillary teeth
• Lefort I: maxilla only moves
• Lefort II: maxilla & base of nose
move:
• Lefort III: whole face moves:
Lefort I: Nasomaxillary
• 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
Lefort I: Nasomaxillary
• Closed reduction
• Intermaxillary fixation: secures
maxilla to mandible
• May need wiring or plating of
maxillary wall and / or zygomatic
arch
• Antibiotics: anti-staphylococcal
Lefort II: Pyramidal
• Subzygomatic midfacial fracture
with a pyramid-shaped fragment
separated from cranium and lateral
aspects of face
Lefort II: Pyramidal
Signs & symptoms
• Midface crepitus
• Face lengthening
• Malocclusion
• Bilateral epistaxis
• Infraorbital paresthesia
• Ecchymoses: buccal vestibule,
periorbital, subconjunctival
Lefort II: Pyramidal
• Hemorrhage or airway obstruction
may require emergent surgery
• Treatment can often be delayed till
edema decreased
Lefort II: Pyramidal
Usually require
• Intermaxillary fixation
• Interosseous wiring or plating of
infraorbital rims, nasal-frontal area,
& lateral maxillary walls
• May need additional suspension
wires
• Antibiotics
Lefort III
• Craniofacial dissociation
• Bilateral suprazygomatic fracture
resulting in a floating fragment of
mid-facial bones, which are totally
separated from the cranial base
Lefort III
Signs and Symptoms
• Face lengthening: “caved-in” or
“donkey face”
• Malocclusion: “open bite”
• Lateral orbital rim defect
• Ecchymoses: periorbital,
subconjunctival
Lefort III
Signs and Symptoms
• Bilateral epistaxis
• Infraorbital paresthesia
• Often medial canthal deformity
• Often unequal pupil height
Lefort III
• Usually associated with major soft
tissue injury requiring emergent
surgery for bleeding control
• Surgery can be delayed till edema
resolves
• Intermaxillary fixation
Lefort III
• Transosseous wiring or plating
– Frontozygomatic suture
– Nasofrontal suture
– May need extracranial fixation if
concurrent mandibular fracture
• Antibiotics
Forces Required
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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
Mandible Fractures
• 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
Mandible Fractures
Signs and symptoms
• Malocclusion
• Decreased jaw range of motion
• Trismus
• Chin numbness
• Ecchymosis in floor of mouth
• Palpable step deformity
Mandible Fractures
• Tongue blade test: have patient bite
down while you twist. If no fracture,
you will be able to break the blade.
Mandible Fractures
Treatment
• Prompt fixation: intermaxillary
fixation (arch bars), +/- body wiring
or plating
TMJ Dislocation
• Can occur from direct blow to
mandible
• Can occur “spontaneously” from
yawning or laughing
• Mandible dislocates forward &
superiorly
• Concurrent masseter & pterygoid
spasm
TMJ Dislocation
Symptoms
• Patient presents with mouth open,
cannot close mouth or talk well
• Can be misdiagnosed as
psychiatric or dystonic reaction
TMJ Dislocation
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
Forces Required
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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
Nasal Bone Fractures
• 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
Nasal Bone Fractures
• 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
Forces Required
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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
Zygomatic Fractures
Tripod (tri-malar) fracture
• Depression of malar eminence
• Fractures at temporal, frontal, and
maxillary suture lines
Zygomatic Fractures
Isolated arch fracture
• Less common
• Shows best on submental-vertex xray view
• Painful mandible movement
• Usually treat with fixation wire if
arch depressed
Zygomatic Fractures
Tripod S & S
• Unilateral
epistaxis
• Depressed malar
prominence
• Subcutaneous
emphysema
• Orbital rim stepoff
• Altered relative
pupil position
• Periorbital
ecchymosis
• Subconjunctival
hemorrhage
• Infraorbital
hypoesthesia
Forces Required
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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
Supraorbital Fractures
Frontal sinus fracture
• Often associated with intracranial
injury
• Often show depressed glabellar
area
• If posterior wall fracture, then dura
is torn
Supraorbital Fractures
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
Orbital Fractures
• “Blow out” fracture of floor
• Rule out globe injury
– Visual acuity
– Visual fields
– Extraocular movement
– Anterior chamber
– Fundus
– Fluorescein & slit lamp
Orbital Fractures
Symptoms and signs
• Diplopia: double vision
• Enophthalmos: sunken eyeball
• Impaired EOM’s
• Infraorbital hypesthesia
• Maxillary sinus opacification
• “Hanging drop” in maxillary sinus
Orbital Fractures
• Diplopia with upward gaze: 90%
– Suggests inferior blowout
– Entrapment of inferior rectus &
inferior oblique
• Diplopia with lateral gaze: 10%
– Suggests medial fracture
– Restriction of medial rectus muscle
Orbital Fracture: Treatment
• 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.)
Facial Soft Tissue Injuries
• Before repair, rule out injury to:
– Facial nerve
– Trigeminal nerve
– Parotid duct
– Lacrimal duct
– Medial canthal ligament
• Remove embedded foreign
material to prevent tattooing
Facial Soft Tissue Rules
• 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
Facial Soft Tissue Rules
• Antibiotics for 3 to 5 days for any
intraoral laceration (penicillin VK or
erythromycin) and if any exposed
ear cartilage (anti-staphylococcal
antibiotic) – no evidence
• Remove sutures in 3 to 5 days to
prevent cross-marks
Facial Soft Tissue Rules
• 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)
Questions??
Summary
• 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
Summary
• Arrange followup after repair to
assess for delayed complications or
cosmetic problems