Maxillofacial Injury

Emergency Nurse
Practitioners

Always assume a
head injury with
facial injuries until
proven otherwise!

Introduction to Maxillofacial Injury

Anatomy.
Injury Mechanism.
Assessment.
Diagnosis / Treatment.
Documentation.
Points of Referral.

Anatomy
Facial Muscle Groups

Anatomy
Nerves

Anatomy
Bones

Dental Anatomy
Teeth

Injury Mechanism
Assault.
Sport.
Blunt Trauma.
Illness/Chronic.

Assessment
Who
What
Where
When
How
Why

Assessment
LOOK
Appearance
Facial Palsy
Wounds

FEEL
Bones
Nerve Supply
L.O.C

MOVE
Talking
Movements

Facial Nerves

Facial wound Assessment

Wound assessment

Facial Wounds
Cosmetic.
Early Suture removal.
Steristrip and glue where possible.
Consider head injury.
Referral for complex wounds / vermillion border/
Full thickness wounds to cheek.
Consider aftercare in treatment ie. Children and
men shaving.
HIGH infection risk.

Facial / Oral wounds

Mucosa heals well.
Tongue lacerations.
Suture with absorbable suture.
Give good oral hygiene advice.
Children to see dentist if lost milk tooth
no benefit to attempting re-implant.

Blow out fractures

Blow out fractures are the most common.
Occur when the globe sustains a direct
blunt force
2 mechanisms of injury:
Blunt trauma to the globe
Direct blow to the infraorbital rim

Orbital Blowout Fractures

Clinical Findings
Periorbital tenderness, swelling, bruising.
Enopthalmus or sunken eyes.
Impaired ocular motility.
Infraorbital anesthesia.
Step off deformity

Mechanism of Blowout fractures

Signs of Orbital blow out fracture

Blow Out Fractures

X-ray Blowout Fracture

The floor of the orbit is the most common portion of the orbit to sustain
fracture. A classic radiographic finding in blow-out fractures is the presence
of a polypoid mass (the tear-drop) protruding from the floor of the orbit into
the maxillary antrum The tear-drop represents the herniated orbital
contents, periorbital fat and inferior rectus muscle.

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)

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.

Clinical findings
Palpable bony defect over the arch
Depressed cheek with tenderness
Pain in cheek and jaw movement
Limited mandibular movement

Zygoma Tripod Fractures

Tripod fractures consist of fractures
through:
Zygomatic arch
Zygomaticofrontal suture
Inferior orbital rim and floor

Zygoma Tripod Fractures

Clinical features:
Periorbital swelling and bruising
Hypesthesia (sensory loss) of the infraorbital
nerve
Palpation may reveal step off
Concomitant globe injuries are common

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.

Maxillary Fractures
High energy injuries.
Patients often have significant multisystem
trauma.
Classified as LeFort fracturesThe Le Fort
fracture was named after French surgeon
Ren Le Fort (1869-1951), who described
them in the early 20th century .

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.

Maxillary Fractures
LeFort II
Clinical findings:
Marked facial swelling
Nasal flattening
Traumatic telecanthus (widening of bridge of
nose between eyes)
Epistaxis or CSF rhinorrhea
Movement of the upper jaw and the nose.

Maxillary Fractures
LeFort III
Radiographic imaging:
Fractures through:
Zygomaticfrontal suture
Zygoma
Medial orbital wall
Nasal bone

CT Face and the Head

Maxillary Fractures
Treatment
Secure and support airway
Control Bleeding
Head elevation 40-60 degrees
Consult with maxillofacial surgeon
Consider antibiotics
Admission

Mandibular fractures

Mandible Fractures
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%.

Mandible Fractures
Mandibular pain.
Malocclusion of the teeth
Separation of teeth with
intraoral bleeding
Inability to fully open
mouth.
Pre-auricular pain with
biting.
Positive tongue blade
test.

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

Mandibular Dislocation
The mandible can be
dislocated:

Anterior 70%
Posterior
Lateral
Superior

Dislocations are
mostly bilateral.

Mandibular Dislocation
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

Mandibular Dislocation
Clinical features:
Inability to close mouth
Pain
Facial swelling

Physical exam:
Palpable depression
Jaw will deviate away
Jaw displaced anterior

Mandibular Dislocation
Treatment:
Muscle relaxant
Analgesic
Closed reduction in
the emergency room

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

Dental Injuries

Avulsed Tooth

Displaced tooth

Dental Injury
Loose tooth
Avulsed (dislocated)
Clean saline (dont touch root), remove clot, insert tooth, bite
on gauze and refer.
Phone advice: advise to attend and store tooth in mouth
between bottom lip and gum. (in milk as a second best for
children/confused patients). Optimum time 30mins, beyond 1
hour tooth probably beyond saving.

Intruded
no treatment, but refer

Extruded
attempt replacement and refer

Displaced
Clean, replace and refer.

Dental Pain
Well documented as one of most painful
experiences.
Consider treatment to date.
Have a low threshold for antibiotic therapy
Options Metronidazole
Augmentin
Consider referral if systemic effects ie: Temp /
Lymphadenopthy / Severe Facial swelling.
Analgesics with good advice.
See dentist ASAP but not today!

Documentation
Teeth Include
dental state/ loose
teeth/ decay/ absence
/ milk teeth
Illustrate using
Grid
8

Documentation
Feel Facial nerve cranial nerve 7.
Palpate externally and intra-orally.
Nose clear nostrils?
Jaw crepitus?
Head injury assessment.
Pain.

Documentation
Move -

Jaw / mouth Movements.

Eye / Eyebrow Movements.
Dental opposition.
Tongue movements.

Points for referral

Complex wounds Max Fax.
Obvious need for x-ray ED.
Extensive facial swelling from dental
infection Max Fax.
After re-implanting avulsed tooth Max
Fax.
Uncontrollable traumatic epistaxis
Senior ED or ENT.

Facial piercings

Types of piercing rings/studs

Piercing removal
History, how long has it been there?, Discharge,
bleeding, pain.
Think! What sort of locking mechanism has the
ring/Jewellery got?
Infected? Antibiotics- caution sepsis
Use appropriate instruments
Consider L.A. if difficult removal
If child then topical anaesthetic prior to removal
Do not replace piercing post removal