MAXILLOFACIAL TRAUMA

FEU-NRMF Medical Center Department of Otolaryngology

Head and Neck Surgery

Objectives:
Review head and neck soft tissue and skeletal anatomy Discuss how to diagnose and identify common maxillofacial injuries Discuss the initial management of maxillofacial injuries Discuss the principles of management of maxillofacial injuries

ETIOLOGY

Vehicular Accidents vs. Physical Altercations

PRIORITIES Airway Breathing Circulation Disability Exposure

Airway Management
Endotracheal

Intubation

Tracheostomy

SOFT TISSUE INJURIES

Contusion-Hematoma Abrasions Lacerations a. linear laceration b. jagged laceration Avulsions

Soft Tissue Swelling

Contusion Hematoma

Abrasions

Lacerations

Avulsion

Facial laceration

S/P Suturing of facial laceration

Vertical Buttress

Vertical Buttresses

Horizontal Buttresses

Horizontal Buttresses

NASAL TRAUMA
Nasal

bone is most frequently fractured facial bone History of blow to the face (nose) Related to nasal septum

NASAL ANATOMY

External nose composed of bony & cartilaginous framework

Internal nose bounded by sphenoid, cribriform plate of the ethmoid, septum & maxillary bone

Blood supply: ECA ( facial & internal maxillary) ICA ( ophthalmic & ethmoid )

Nerve supply: trigeminal sphenopalatine ganglion olfactory nerves

Nasal Bone Fracture

Signs and symptoms: Nasal deformity Edema / hematoma Crepitation / motion on palpation Nasal obstruction Epistaxis

Nasal Bone Fractures

X-rays: Waters View Soft tissue lateral view

Management of Nasal Bone Fracture

CLOSED REDUCTION Indications: Non-comminuted fractures Mild to moderate displacement Recent fractures

Asch forcep

Closed Reduction of Nasal bone fracture should be done within: 7 - 10 days in Adults 2 - 4 days in Children

MANDIBLE

Mechanism of Injury
DIRECT BLOW BODY Ipsilateral body Contralateral angle or subcondylar SYMPHYSIS

Parasymphyseal

Bilateral Condylar

Types of Mandibular fracture

Favorable vs. Unfavorable

Favorable fracture

muscle forces tend to keep fragments together

Unfavorable fracture

muscle forces tend to pull fragments apart

Two Groups of Muscles Acting on Fracture Segments

Posterior Group Masseter Lateral pterygoid Medial pterygoid Temporalis Anterior Group Geniohyoid Digastric Mylohyoid Genioglossus

Mandibular Fracture

Favorable fracture: A and B Unfavorable fracture: C and D

Mandibular Trauma
Signs and symptoms: Malocclussion (open bite deformity) Hyposthesia of lower lip & gingiva Mucosal disruption Tooth loosening Trismus

Mandibular Fractures

Step Defect

Crepitus Bony segments Subcutaneous emphysema Abnormal mobility

Mandibular Fractures

Sublingual ecchymosis

Step defects

Mandibular fractures

malocclusion

ridge discontinuity

Radiographic Evaluation

Panorex

Goals of Management
Restore pre-injury occlusion Immobilization to allow time for healing Maintain adequate nutrition Avoid infection, malunion or non-union

Indications for Closed Reduction

1. 2. 3. 4.

5.

Minimally displaced fracture Favorable fracture Condylar fracture Alveolar fracture For temporizing prior to definitive management

Maxillo-Mandibular Fixation (MMF)

4 6 weeks

Indications for Open Reduction Internal Fixation (ORIF)

1. 2.

3.
4. 5.

Unfavorable fracture Incomplete or poor dentition Failure of closed reduction Multiple or comminuted Open wound (laceration near fracture line)

Post-op: ORIF of mandibular body fracture using titanium plates

Maxillary Trauma
- Direction of fracture displacement depends on the degree, direction and point of impact of forces

Maxillary Fracture
Weakest

areas of midfacial complex when assaulted from a frontal direction at different levels
Rene Le Fort, 1901

Le Fort I: above the level of teeth Le Fort II: at level of nasal bones Le Fort III: at orbital level

Classification of Maxillary Fractures ( Le Fort )

Le Fort I Guerin / Transverse Maxillary Le Fort II Pyramidal Le Fort III Craniofacial Dysjunction

Le Fort I Fracture
Transverse Maxillary (Guerin Fracture)

Le Fort II Fracture
Pyramidal

Most common of Maxillary fractures

Le Fort III Fracture

Craniofacial Dysjunction

Signs and Symptoms

1. 2.

3.
4. 5.

6.

7.

Anterior Drawers sign Open bite deformity/ Asymmetry Epistaxis Dishpan or Panface Hypoesthesia Swelling, tenderness & hematoma of midface CSF rhinorrhea

Radiographic evaluation:
Waters view Caldwell view Lateral view

Gold Standard: CT scan

Diagnosis of Le Fort II and III

Clinical evaluation provides only a rough impression since swelling hides the underlying bony structures Plain film radiographs, axial and coronal CT images are the basis for precise diagnosis & treatment plan

Management of Maxillary Fractures

Le Fort I : interdental & intermaxillary for 4-6 weeks Le Fort II : as above plus fixation from zygomatic suture or orbital rim Le Fort III : interdental & intermaxillary fixation, suspension from zygomatic suture & wiring from infraorbital rim

ZYGOMATIC TRAUMA
Zygoma
very strong bone articulates with frontal, maxillary and sphenoid bone Most common cause of fracture is trauma

Types of Zygomatic fracture

Simple

Arch fracture Tripod Fracture -involves 3 suture lines

ZYGOMATIC FRACTURES
Signs and Symptoms: Diplopia, unequal pupillary level Hyposthesia, cheek numbness Trismus Epistaxis Periorbital hematoma/ecchymosis Depressed cheek prominence

Radiographic Findings

Submentovertex

Axial CT scan

Management of Zygomatic Fractures

Open Reduction

Lid or infraciliary incision

Gilles approach

Anatomy of Orbit

The orbit is a bony pyramid with the optic foramen at its apex

Floor - roof of maxillary sinus Medial wall - Lamina papyracea of ethmoid bone Lateral wall- Zygoma and sphenoid bone (greater wing) Superior wall - Frontal bone (floor of frontal sinus and anterior fossa)

Blow-out fracture of the Orbit An orbital floor fracture characterized by dehiscence of the bone, herniation of orbital contents & possible entrapment of orbital muscles Results from blunt trauma to globe

ORBITAL BLOWOUT
Mechanism of Injury

ORBITAL TRAUMA

Have an ophthalmologic evaluation

Orbital rim is intact in pure blow out fracture

Signs & Symptoms of Blow-out fractures

Diplopia : (+) Forced Duction Test Enophthalmos Infraorbital hyposthesia Periorbital ecchymosis Epistaxis

Radiographic Evaluation

Waters x-ray

CT Scan

3D CT

Management of Blow-out fractures

Open Reduction via: - Low lid incision - Caldwell-Luc approach

FRONTAL SINUS ANATOMY

Anterior

table - part of forehead and supraorbital rim Posterior table - anterior wall of anterior cranial fossa Inferiorly, the nasofrontal duct drains the sinus into the nose

FRONTAL SINUS TRAUMA

Direct blow to the frontal area 5 15% of all facial fractures

Least common

Signs & Symptoms

Hematoma Swelling over frontal sinus area Ecchymosis Epistaxis or CSF rhinorrhea Associated nasal or skull fractures

FRONTAL SINUS TRAUMA

Neurosurgical consultation and comanagement if necessary Radiographs: Caldwell and Lateral projections CT scan

CSF rhinorrhea
Handkerchief

test Benedicts test for glucose Beta 2 transferrin determination

Frontal sinus obliteration

Exploration

of frontal sinus via osteoplastic flap Examine and repair dura if necessary Remove all mucosa from the sinus Fill the sinus with fat to prevent communication with nose and reepithelialization

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