Maxillofacial Trauma

Waseem Jerjes

Size of the problem

• Total no facial injuries = 500,000

– 832 per 100,000 population– 340,000 male– 160,000 female– 140,000 are serious injuries

Causes

• Falls 40%• Interpersonal violence 34%• Sports / other 21%• RTA 5%

General principles (remember)

• Primary and secondary survey

• Reconstruction of soft tissues

• Accurate diagnosis• Early surgery (14 days)• Expose all bony fragments• Rigid fixation (IMF, ORIF)• Immediate bone grafting

Look

– Hemorrhage– Otorrhea– Rhinorrhea– Contour deformity– Ecchymosis– Edema– Continuity defects– Malocclusion

Radiographical Investigations

• OPG, PA Mandible (lower third #s)• OM 0, 15, 30 (Middle third #s)• CT (upper third #)

• CT, MRI can be always requested when indicated

Soft tissue injuries of the oral & maxillofacial region

• Skin (minimal debridement)-Nylon 5-6/0

• Muscles+SC tissue-Vicryl 4/0

• Intraoral lacerations-Vicryl 3-4/0

• Small vessels ligation-Vicryl 3/0

• Big vessels ligation-4/0 Prolene

Soft tissue injuries of the oral & maxillofacial region

• Facial nerveEpineural suturing or reapproximation of the ends-

high success rate

• Parotid ductSuspect injury if weakness of the buccal branches

of the facial nerve identifiedExamine the duct opening (stimulate, probe),

repair over thin stentSalivary collections and fistulas, stenosis and

parotitis

Soft tissue injuries of the oral & maxillofacial region

• Lacrimal apparatus Canaliculi, lacrimal sac or duct-repair over

thin silastic stent-insert along the length of the lacrimal system

Hard tissue injuries of the oral & maxillofacial region

• Immediate management • Airway and cervical spine controlStabilization with hard collarRemove vomits, blood, broken teeth and

denturesChin lift, jaw thrust or reduce mid face #Intubation, cricothyroidotomy, tracheostomy

Cervical spine

• High risk groups• Mandible - C1 C2 #• Midface - C5 C6 #

• Assume present

Hard tissue injuries of the oral & maxillofacial region

• BreathingAdequate ventilation and exclude co-existing chest

injury

• Circulation and control bleedingCannulae, infusion, bloods, transfusion Manual reduction of fractures (orthodontic and K

wires) and nasal packing can reduce bleedingPacking and facial bandaging External carotid ligation (behind ramus, maxillary

sinus)

Associated injuries

Ophthalmic assessment10% of patients with facial fractures have

associated eye injuries 10% of patients with major facial fractures

have cervical spine injuries

Mandibular fractures

• Symptoms and signsPain, trismus, malocclusion, crepitus,

bruising (oral/facial), step (mandible border/dentition), paraesthesia (IAN, LN, MN), haematoma

• Locations: condyle, body, angle, symphysis, parasymphysis, alveolus, coronoid process

Mandibular fractures• Common patternsAngle + contralateral bodyParasymphysis and contralateral condyleGuardsman

Deviation on opening-toward the side of the mandibular condyle fracture

Favourable or unfavourable (muscle action)

Radiological investigations (OPG, PA mandible)

Mandibular fractures• Conservative management-unilateral

condyle, symphysis, undisplaced #s• ORIF-monocortical or bicotical screws1 plate (Champy’s-muscles), 2 plates• IMF (arch bars+wires)-condyle. Bilateral

condyles?IMF 3-6weeks, oral hygiene, feeding,

breathing• External fixation (extensive defects,

osteomyelitis)

No displacement>30o Medial rotation>5mm bone overlapLoss of bone contact

Zygomatic fractures• Occurs in a tetrapod fashion Zygomatic process (ZF suture)Greater wing of sphenoid MaxillaTemporal bone (arch)

• Symptoms and singsBruising and swelling (oral/facial), malar

depression, step deformity, subconjunctival haematoma, trismus (coronoid)

Zygomatic fractures

• Symptoms and singsEpistaxis (lining maxillary sinus),

paraesthesia (ION), enophthalmos, dystopia (lateral, vertical or both), diplopia (tethering), reduced visual acuity (retinal detachment)

• Radiological investigations (OM 0, 15, 30), then CT (orbital floor/blow out/panfacial)

Zygomatic fractures

• Locations Undisplaced fracturesIsolated arch fractureUnrotated body fractureBody fracture with medial rotation (ZF)Body fracture with lateral rotation (ZF)Complex fracture (lateral maxillary wall)Associated with orbital floor fracture

Zygomatic fractures

• ManagementConservativeGillies’ liftORIF over 1-3 sites

(ZF, infraorbital rim, lateral maxillary wall)

Maxillary fractures• Le Fort fractures (often asymmetrical)I (Geurin): the “floating palate” fracture Contains alveolus, palate, pterygoid platesII: the “pyramidal” fracture Contains bulk of maxilla, lacrimal crests, piriform

margin, alveolus, palateIII: “craniofacial dysjunction”Contains: detachment of midfacial skeleton from

cranial base

Saggital fractures and dentoalveolar

Maxillary fractures• Symptoms and signs Bruising and swelling (oral/facial),

haematoma, Battle’s sign, malocclusion, epistaxis, enophthalmos, diplopiam paraesthesia (ION), step deformity

Dish-face appearance (displacement) Movement of segments can differentiate

Radiological investigations: OM? CT? 3D-CT

Levels of Maxillary Fractures

Maxillary fractures

• ManagementConservative (non-union)ORIF (bone grafting)

Orbital fractures

• Occurs with:1. Zygomatic fractures2. Nasoethnoidal fractures3. High Le Fort fractures• Isolated fractures-pressure applied to

globe• Orbit fracture at weakest point-

inferomedial floor-paper layer fracture

Orbital fractures

• Symptoms and signsBruising and swelling, subconjunctival

haematoma, periorbital haematoma, step deformity, enophthalmos, diplopia

Radiological investigations: PA skull, OM (tear drop sign, fluid level), CT

Orbital trauma

Penetrating injuryVisual acuityOcular movements

Orbital fractures

• ManagementConservative SurgeryAutologous tissue (split calvarial bone graft,

rib, iliac crest, superficial segment of anterior maxilla)

Alloplastic material (titanium-mesh, Gore- Tex, Silicone, Medpor wafers)

Nasal Fractures• Most commonly fractured nasal bone• Lateral impact-deviation of nasal septum and

bones• Frontal impact-collapse of the nasal dorsum,

splaying of the nasal bones, dislocation of the septum

• Plane 1: disruption of the cartilagenous cartilage. Plane 2: disruption of the bony septum and nasal bones. Plane 3: involve the piriform aperture and medial orbital rim (mild NE #)

Nasal Fractures• Symptoms and signsBruising and swelling, obvious deformityCheck for septal haematoma-pressure-septum

necrosis• Radiological investigations: PA and lateral skull • ManagementConservativeRelocate the nasal septum and nasal bones

followed by packing and splintingSecondary rhinoplasty

Nasoethmoidal fractures

• Caused by trauma to the interorbital region

• Occurs with ethmoidal sinus, medial orbital wall, root of nose #s

• Symptoms and signsBruising and swelling, step deformity,

telecanthus (medial canthal tendon), enophthalmos, diplopia

Radiological investigations: CT

Nasoethmoidal fractures

• ManagementConservativeORIF Nasal bones elevation and nasomaxillary buttress

reconstructionMedial canthal tendon: plating, transnasal fixation

Lacrimal system, no exploration, injuries settle within 6 weeks

Frontal sinus fracture

• Symptoms and signsDepression or laceration over the supraorbital

ridge, glabella, or lower forehead, bony defectMay be associated with NOE complex and midface

(nasofrontal duct)CSF rhinorrhea-posterior table frontal sinuscan result in cosmetic deformity and mucocele

formationRadiological investigations: CT

Anterior wall Posterior wall

Combined anterior + posterior wall

Classification of frontal sinus fractures

or

Frontal sinus fracture• ManagementConservativeORIF of the anterior wallSinus obliteration and ORIF of anterior wall

(damage drainage system)Cranialization (CSF leak)Cranialization with dural repair

• Complications: meningitis, cerebral abscesses, mucoceles, osteitis

High resolution CT scans required

Note: Combined anterior/posterior and posterior wall fractures will almost certainly involve the duct

Obstruction of drainage

Chronic sinusitis

Mucopyocele

Osteomyelitis

Brain abscess

Possible result of blocked fronto-nasal duct

Retrobulbar Haemorrhage

• Bleeding into non yielding space, the orbit, cause an increased orbital pressure

• This causes impaired venous outflow and increased intraoccular pressure and decreased perfusion

• Resulting in ischaemia and retinal infarction and blindness

Retrobulbar haemorrhage

PainProptosisLoss of visual acuity

Retrobulbar Haemorrhage

• Diagnosis is important, 90 minutes to correct vascular insult or irreversible damage results.

• TreatmentMedicalMassage eye redistribution of extraoccular fluidSit patient up & sedateMannitol 20% 2g/kg iv over 4 minutes monitor

U&Es repeat 6 to 8 hourlyAcetazolamide 500mg iv (delayed effect)

Retrobulbar Haemorrhage• TreatmentMedicalMegadose corticosteroids 3-4 mg/kg

dexamethasone sodium phosphate followed by 1-3 mg/kg 6 hourly for 5 to 7 days (reduces secondary injury)

Papaverine (smooth muscle relaxant) 30-60 mg iv slowly over 1 to 2 minutes can be repeated 3hrly

If no improvement after 20 to 30 minutes surgical decompression is indicated

Retrobulbar Haemorrhage

• Treatment SurgicalIf post-operative and orbital septum violated

simple remove all suturesLateral canthotomy with or without

cantholysisTransantral ethmoidectomy (Lynch)

Summary

Thank you