MAXILLO FACIAL TRAUMA - An Overview

Dr Dheeraj SJR, ENT

INTRODUCTION

• Injuries of face are the reason for 10% of A&E attendance

• In the past, outcome of facial fracture management was

judged entirely on the basis final dental occlusion

• Restoration of vertical and transverse facial proportions is

equally important

• CSF Rhinorrhea & Retrobulbar hematoma must be

excluded in all middle third fractures

AETIOLOGY

• Low energy injuries - heal well (1) Physical assault

(2) Sports injuries(3) Animal bites

• High energy injuries - don't heal well(1) Road traffic accidents(2) Industrial injuries(3) Attempted suicides - eg: jumping from height(4) Military injuries - GSW

AETIOLOGY (...contd)

• Exact mechanism of injury must be ascertained

• Importance : Medicolegal reasons

Adequate screening to detect other

injuries

Prognosis for stability of repair

PRIMARY SURVEY

ATLS protocols must be followed

• A - Airway - Secure the airway

• B - Breathing - spontaneous / assisted ventillation

• C - Circulation - control blood loss & maintain blood volume

• D - Disability - assessment of level of consciousness &

neurological dysfunction ; GCS

• E - Exposure - adequate exposure of all injuries

PRIMARY SURVEY (...contd)Bleeding control

• Haemorrhage from facial fractures can be torrential & needs

immediate attention

• Ant & post nasal packing has been replaced by the use of

EPISTAT

• Inadvertent intubation of ant cranial fossa via cribriform plate

or medial wall of orbit must be avoided

• In case of intense shock rule out abdominal / thoracic / pelvic /

orthopaedic injuries

SECONDARY SURVEY

• Secondary survey is carried out to exclude other injuries & to

categorize the extent of facial injuries

• Soft tissues of face are carefully scrutinized

• Facial N function must be noted

• Parotid duct integrity must be assessed

• Ocular movements & visual acuity

• Palpate orbital margins, zygomatic projection, nasal skeleton,

mandibular outline

• Dental examination for any # or missing teeth, dental occlusion

and maxillary or mandibular instability

CLASSIFICATION• For the sake of description and management, the injuries

of maxillofacial region can be divided into :

1. Bony injuries

2. Soft tissue injuries

FRACTURES OF MIDFACIAL SKELETON

LATERAL CENTRALZygomatic Maxillary

Nasal

Naso-orbito-ethmoid

MIDFACIAL FRACTURES (...contd)

• Le Fort described 3 levels of midfacial fractures

• Pure Lefort # are accurate only for low energy injuries

• LeFort I (Transverse)

Runs just above the floor of nasal cavity through the nasal septum,

maxillary sinuses & inf parts of medial and lateral pterygoid plates

• Le Fort II (Pyramidal)

Runs from the floor of the maxillary sinuses superiorly to the

infraorbital margin & through the zygomaticomaxillary suture.Within

the orbit it passes across the lacrimal bone to the nasion

MIDFACIAL FRACTURES (...contd)

• Le Fort III (Craniofacial disjunction)

# line traverses the medial wall of orbit to the sup orbital

fissure and exits across the Gr wing of sphenoid &

zygomatic bone to the zygomaticofrontal suture.

Posteriorly # line runs inf to the optic foramen, across

the lesser wing of sphenoid to the pterygomaxillary

fissure & sphenopalatine foramen.

MIDFACIAL FRACTURES

In short •Le Fort 1 results in a floating palate•Le Fort 2 results in a floating maxilla•Le Fort 3 results in a floating face

MAXILLARY FRACTURES • Clinical features :

Epistaxis

Circumorbital ecchymosis (panda facies)

Facial edema

Emphysema

Lengthening of face

Anterior open bite in Le fort 2 & 3

Infra-orbital N sensory deficit

Bruising at the junction of soft and hard palate

MAXILLARY FRACTURES - ManagementEMERGENCY MANAGEMENT

• Hemostasis using epistat or nasal packing

• Secure the airway

REDUCTION

• If there is retroposition of maxilla it can be pulled forward

using index and middle finger placed behind patient's palate

• Maxilla can be mobilised by a combination of digital

pressure & traction on arch bars or interdental wires.

• Rowe maxillary disimpaction foreps can also be used

ROWE MAXILLARY DISIMPACTION FORCEPS

MAXILLARY FRACTURES - Management

FIXATIONMaxilla can be stabilised by a number of methods

(1) Intermaxillary fixation(2) External fixation(3) Internal suspension(4) Internal fixation

MIDFACIAL FRACTURES - ManagementINTERMAXILLARY FIXATION (IMF)

• Can be used when the # is at a lower level (Le fort 1) and not grossly

displaced

• Done by wiring the teeth together (using teeth as biological bone pins) -

dental wires, arch bars, leonard button

• Advantage - Easy technique

• Disadvantage - Period of immobilization was inconveniet & uncomfortable

- Dietary restrictions

- Fixation is often inadequate esp if dentition is incomplete

- Needle stick injuries to doctor and nursing staff

EXTERNAL FIXATION

• Has been largely superseded by internal fixation

• Maxilla is fixed by attaching a fork to the teeth with a silver cap splint and this is in turn anchored to stable bone above #

• Halo frame, Levant frame

• Is extremely rapid and allows surgeon to make fine adjustments during the initial phase of bony healing (1st 2 weeks)

• Disadv - Nonaccurate reduction

- Poor facial appearance

INTERNAL SUSPENSION

• Provide rapid stabilization of maxilla without need for ext fixation

• Fractured maxillary elements are suspended from various points

on the craniofacial skeleton above # line - zygomatic arch, orbital

rim

• Simple & rapid

• Positioning of maxilla is difficult to achieve

• Relatively poor fixation

INTERNAL FIXATION

• 1.5 mm low-profile miniplates placed along buttresses provide satisfactory stabilization

• # of ant & lat maxilla can be accessed through a gingivo-buccal incision

• Posterior limit of incision should not beyond 1st permenant molar

• Infraorbital rim needs to be reduced & fixed in Le Fort 2 #, zygomatic injuries, nasomaxillary #

• Diff types of skin incision can be used - Transconjuctival, Infraorbital, Transconjuctival with transcaruncular extension etc

ZYGOMATIC COMPLEX FRACTURES• Is the 2nd most common # in the maxillofacial region

• Blow to zygomatic bone causes either a depressed # of entire

zygomatic bone or a # of zygomatic arch

• Originally termed as TRIPOD #, because of disruption of 3

articulations - Fronto-zygomatic; Infraorbital rim; Zygomatico

maxillary buttress

• Classified according to their rotation about vertical & horizontal axes

Vertical axis - runs b/w frontozygomatic suture & 1st molar

Horizontal axis - plane of zygomatic arch

• Zygomatic arch tends to break at its weakest point - ie just posterior

to zygomatico temporal suture

CLINICAL FEATURES

• Subconjuctival haemorrhage - invariably present in zygomatic

body #

• Restricted eye movements particularly in upward gaze (if there

is orbital floor dehiscence)

• Step deformity of infraorbital margin

• Tenderness of frontozygomatic suture

• Palpable depression & limited mouth opening - in arch #

• Limited sensation on cheek - if zygomaticotemporal or

zygomaticobuccal N are damaged

MANAGEMENT

• Minimally displaced #

Conservative management

Strict instruction to avoid nose blowing for 2 - 3 weeks

Review after 10 days when the edema has subsided

• Displaced #

Reduction with / without fixation

• Methods for reduction -

(a) Gilles temporal approach (b) Dingman supraorbital approach

(c) Poswilo hook approach (d) Intraoral / Keen approach

(e) Coronal approach

• Fixation is not necessary for

medially displaced # ,

# with rotation around vertical axis

# of arch

• Unstable # requiring fixation are -

# with inferior displacement of arch

# with rotation around horizontal axis

# with diastasis at frontozygomatic suture

POSTOPERATIVE CARE• Patient is instructed not to blow the nose• Pt is observed for features of retrobulbar h'ge during 1st 12 hrs

Increasing painProptosisOphthalmoplegiaDiplopiaDiminishing visual acuityTense globe - palpable increase in ocular pressureDilated pupil & loss of direct light reflex

• Urgent exploration & evacuation of hematoma• Medical management

Inj dexamethasone - 4 mg/kg bolus & 2 mg/kg 6 hrlyAcetazolamide - 500 mg i.vMannitol 20% 200ml

ORBITAL FLOOR #

• Also called BLOWOUT # of orbit

• Occurs when a nonpenetrating blunt object strikes the globe

• Increased intraorbital pressure

• Blowing out of thin walls of orbit (esp floor)

• Herniation of orbital contents into maxillary antrum

CLINICAL FEATURES

• Cardinal signs - Enophthalmos & Hypoglobus (depressed

pupillary level)

• Supratarsal hallowing

• Hooding of eye

• Narrowing of palpebral fissure width

• Infraorbital N deficit

• Trap door phenomenon

Orbital fat or Inf oblique muscle gets trapped in the #

Diplopia on upward gaze

MANAGEMENT• Significant orbital floor injury requires exploration & repair

• Approach is determined by size & position of blowout #

• All soft tissue components should be mobilized and supported

by a graft

• Smaller defects - Silastic or PDS grafts

Silastic has tendancy to become infected & extrude

• Larger blowout # - Bone from iliac crest / rib / calvarium

• TRANSANTRAL APPROACH

• INFRAORBITAL APPROACH

• ENDOSCOPIC TRANSANTRAL REPAIR

NASO-ORBITO-ETHMOID COMPLEX #

• Occurs when the force directly hits over the nasion

• Involves nasal bones, perpendicular plate of ethmoid, ethmoid air

cells, medial wall of orbit

• Medial canthal ligament can be avulsed

• Markowitz et al classified it in terms of its attachment to medial

canthal ligaments

TYPE I Single large central fragment bearing the canthal ligaments

TYPE II Fragmentation of central fragment, medial canthal ligament attached to bone

TYPE III Comminution of the central frgment with no bone attached to canthal ligaments

CLINICAL FEATURES

• Pug nose - Depression of nasal bridge & elevation of nasal tip

• Signs of medial canthal ligament disruption

TELECANTHUS - Widening of intercanthal distance > 35 mm

Narrowing of palpebral fissure

Epiphora

• Periorbital ecchymosis

• Orbital hematoma - d/t bleeding from Ant & Post ethmoidal arteries

• CSF rhinorrhoea - if there is # of cribriform plate

MANAGEMENT• Closed reduction

Uncomplicated NOE # may be reduced with Ashe's forceps & stabilized with a wire passed through # segments and septumIntransal packing ; Splinting for 10 days

• Open reduction

All 3 types of # are stabilized using miniplates

In type 1 # - Coronal flap intraorally + subciliary incision

In type 2 & 3 - Transcanthal canthopexy to reduce telecanthus &

to hold medial canthal lig in place (using plate / wire)

Lacrimal duct injuries are best managed conservatively if there is

no open laceration to it

FRACTURES OF NASAL BONES & SEPTUM

• Nasal bone # is the most common # of maxillofacial region

• Isolated # of nasal pyramid - 40% of all facial #

• Relatively little force required to fracture nasal bone : 25-75 lb / in2

Grading on the basis of extent of deformity

Grade 0 - bones perfectly straight

Grade 1 - bones deviated < half the width of nasal bridge

Grade 2 - bones deviated half to one full width of nasal bridge

Grade 3 - bones deviated >one full width of nasal bridge

Grade 4 - bones almost touching the cheek

Classification on the basis of nature of injury

(a) # as a result of lateral force - nose is displaced away

from the midline on the side of the injury --> Angulated Nose

(b) # as a result of frontal blow - nasal bones are pushed up

and splayed so that the upper nose (bridge) appears broad,

but the height of the nose is collapsed --> Depressed Nose

Pattern of nasal #

• Nasal # can be subdivided into 3 broad categories that

characterise the patern of damage sustained with increasing force

• Class I Class II Class III

Class I• Are the result of small degree of force & hence the extent of deformity is

not marked

• Are mostly depressed # of Nasal bone

• # line runs parallel to the dorsum of the nose and naso maxillary suture and joins at a point where the nasal bone becomes thicker (ie about 2/3 of the way along its length)

• Class I fracture of nasal bone is purely a clinical diagnosis

Class II• Are the result of moderate degree of force & are often associated

with significant cosmetic deformity

• In addition to nasal bones, frontal process of maxila and septal structures are also involved

• For a successful result both the nasal bones as well as the septum will have to be reduced

• Precise nature of the deformity depends on the direction of the blow sustained

• The perpendicular plate of ethmoid is invariably involved in these fractures, and is characteristically C shaped (Jarjaway fracture of nasal septum).

Class III• Are the most severe nasal injuries encountered & are caused by

high velocity trauma• Also termed as Naso-orbito-ethmoid # & often have associated #

of maxilla• Two types of naso ethmoidal fractures have been recognised:

Type I: In this group the anterior skull base, posterior wall of the frontal sinus and optic canal remain intactType II: Here the posterior wall of the frontal sinus is disrupted with multiple fractures involving the roof of ethmoid and orbit

CLINICAL FEATURES

• Pain

• Swelling over nose

• Epistaxis

• Nasal deformity

• Nasal tenderness and crepitus

• Periorbital ecchymosis

Management• # of nasal bones, if left uncorrected, could lead to loss of structural

integrity and the soft tissue changes that follow may lead to both unfavorable appearance and function

• Management is based solely on the clinical assessment of function and appearance

• Bleeding must first be controlled by nasal packing.

• Patients may also have considerable amount of swelling . Conservative management for 1-2 weeks for the oedema to subside enable precise assessment of bony injury

• Fracture reduction should be accomplished when accurate evaluation and manipulation of the mobile nasal bones can be performed; this is usually within 5-10 days in adults and 3-7 days in children.

Radiological investigations:1. Plain xray nasal bones2. Xray paranasal sinuses water's view3. CT scan paranasal sinuses - This is a must in all cases of class II and class III fractures of nasal bones for precise estimation of damage.

Class I #

• Most class I # can be managed by closed reduction and imobilisation by application of POP. Digital pressure alone commonly does the job.

• If the fractured fragments are impacted then a Welsham's forceps will have to be used to disimpact and reduce the fractured nasal bone.

Class II

• Closed reduction do not give optimal results because the septal

fracture is not corrected.

• Since the fractured fragments of the perpendicular plate of

ethmoid and the septal cartilage fragments are not repositioned

the results of closed reduction are not satisfactory.

• In these patients closed manipulation of nasal bones should

always be accompanied by open correction of septal deformity

Class III

• Must be treated with open reduction and internal fixation

• The problem here is eventhough the nasal bones can be reduced,the adjacent supporting bones (components of the ethmoidal labyrinth) donot support the nasal bones due to their brittleness

• It is always better to reconstruct and stabilise the anterior table of the frontal bone so that other parts of nasal skeleton can derive support from it

• Formerly transnasal wires were used to fix the nasal bones, but now a days plates and screws are preferred

MANDIBULAR FRACTURES• Mandiblular # can be due to direct or indirect blow

• # occur at points of potential weakness where the bone is

relatively thin

• It is common for the mandible to fracture in > 1 places

• Displacement depends on many factors, the important ones are

pull of attached muscles - Masseter, Pterygoids, Temporalis and

direction of # line

• Vertically favourable - runs forward from lingual to buccal

• Horizontally fav - runs forward superiorly to inferiorly

DINGMAN CLASSIFICATION OF MANDIBULAR #

CLINICAL FEATURES

• # of Angle, Body & Symphysis

(1) Pain & paradoxical movement; crepitus on distraction of #

segments

(2) Blood stained saliva

(3) Anaesthesia of lower lip

(4) Step deformity palpable externally or intraorally

(5) Asymmetry of lower dental arch & malocclusion

(6) Hematoma in floor of mouth / buccal sulcus

CLINICAL FEATURES

• # of Condyle

(1) Tenderness over TM joint

(2) Trismus

(3) Jaw deviation to injured side, on mouth opening

(4) Dental malocclusion

CONDYLAR FRACTURE

FRACTURE OF ANGLE

FRACTURE OF BODY

MANAGEMENT

• Closed reduction

• External fixation

• Internal fixation

Closed Reduction

• Done by intermaxillary fixation (IMF)

• Limited role in modern maxillofacial surgery

• Has still a part to play in

(1) pts with undisplaced fracture & no neural deficits who don't want

surgery

(2) pts with unicondylar fracture

• Intact dental arch - Dental tie wire

• Incomplete arch - Arch bars, Intermaxillary bone pins, Cast silver splints

• Edentulous pts - Gunning splints

External Fixation• Mostly replaced by rigid & semirigid internal fixators

• Only indicated for pts with gross tissue loss & pathological #

• Simplest technique - Placement of cortical screws and

connecting them with an external bar made of acrylic

• mini - Pennig orthopaedic fixator

Internal Fixation• Bone plates should be placed through intra-oral route wherever

possible

• External incisions are used for lower border of mandible & condylar

neck; also preferred in grossly resorbed edentulous mandible

• In simple mandibular #, mono-cortical 2mm plates provide

adequate fixation

• In ant mandible 2 plates are used while posteriorly one plate is

sufficient

• In complicated # with gross comminution, tissue loss, infection a

load bearing osteosynthesis with rigid internal fixation & bicortical

screws are required

• Management of condylar # is controversial

• Bilat displaced condylar neck # & high intracapsular

# have poor outcome and are better managed by

Open reduction

FRACTURES OF FRONTAL SINUS• # of frontal sinus may lead to deformity & be complicated by

infections

• Classified according to involvement of ant / post tables & whether

Frontonasal duct is involved or not

• Ant table # - no deformity --> conservative management

- depressed # --> reduction & fixation

• Post table #

commonly accompanied with dural tears, brain injury, CSF leak

demands neurosurgical assessment

dural tear repaired with temporalis fascia

small frontal sinus is obliterated with fat

SUPRAORBITAL RIDGE FRACTURE

• Clinical features :

(1) Periorbital ecchymosis

(2) Flattening of eye brow

(3) Proptosis

(4) Impacted bone fragment in orbit

• Managed by open reduction via an incision either in the brow

or in transverse skin line of forehead followed by internal

fixation

• Facial wounds should be closed as soon as possible provided they are clean.

• Meticulous debridement with antiseptic solution is essential

• It is crucial to ensure that any underlying bony injury is repaired to enable correct support & soft tissue draping.

• Identification & repair of key landmarks like vermillion border of lip, eyebrows, alar margin of nose & eyelids is essential for a good cosmetic result.

• Facial N & Parotid duct are frequently damaged in significant soft tissue injury.

• Facial N is easiest to find & repair in the 1st 48 hrs while the peripheral branches can still be stimulated.

• Use of deep sutures (vicryl) to take out tension out of the wound & to avoid deadspace.

PAEDIATRIC FACIAL INJURIES• Fortunately serious maxillofacial injuries are uncommon in children.

• Minor injuries particularly soft tissue & dentoalveolar are frequent.

• Treatment concepts & protocols are similar to adult patients, but most will require Gen anaesthesia or sedation.

• Consideration should be given to excision of wound margins and the use of resorbable sutures to avoid unnecessary gen anaesthesia for suture removal.

• Dental injuries to upper ant teeth are very common and hence opinion of paedodontist or maxillofacial surgeon must be taken.

• Reimplant avulsed teeth as soon as possible

• # of condyle are usually treated conservatively as there is immense remodelling capacity.

• Use short screw so as not to damage unerupted teeth.

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