Maxillo facial injuries

Department of dentistryTata Main HospitalDr K V Sebastian

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Maxillofacial injuries

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Learning Objectives

• To be able to recognize life threatening nature of facial injuries – Airway obstruction, associated head & spinal injuries.

• Method of examining facial injuries.• Diagnosis & principles of management of

facial injuries

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Anatomy

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Anatomy

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Causes

• Road traffic accidents

• Intentional violence

• Sporting activities

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Pathophysiology

• High Impact:– Supraorbital rim – 200 G– Symphysis of the Mandible –100 G– Frontal – 100 G– Angle of the mandible – 70 G

• Low Impact:– Zygoma – 50 G– Nasal bone – 30 G

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Severity

• @60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise.– 20-50% concurrent brain injury.– 1-4% cervical spine injuries.– Blindness occurs in 0.5-3%

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Assessment

Based on• Targeting care: Glasgow Coma Scale (GCS)• Predicting outcome: Abbreviated Injury Scale

(AIS) and Injury Severity Score(ISS)• Assessing critically injured patients: APACHE II

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Initial hospital care

• Triage the causalities(sorting for prioritization)

• A: airway with cervical spine control• B: breathing and ventilation• C: circulation and hemorrhage control• D: disability due to neurologic deficit• E: exposure and environment control

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Clinical effects

• Injuries to facial skeleton →

Immediate airway obstruction

delayed airway obstruction

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Immediate airway obstruction

inhalation of tooth fragments

accumulation of blood & secretions

loss of control of tongue in unconscious/ semiconscious pt. →

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Emergency ManagementAirway Control

• Control airway:– Chin lift.– Jaw thrust.– Oropharyngeal suctioning.– Manually move the tongue forward.– Maintain cervical immobilization

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Emergency ManagementIntubation Considerations

• Avoid nasotracheal intubation:– Nasocranial intubation– Nasal hemorrhage

• Avoid Rapid Sequence Intubation:– Failure to intubate or ventilate.

• Consider awake intubation.• Sedate with benzodiazepines.

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Emergency ManagementIntubation Considerations

• Consider fiberoptic intubation if available. • Alternatives include percutaneous

transtracheal ventilation and retrograde intubation.

• Be prepared for cricothyroidotomy.

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Emergency ManagementHemorrhage Control

• Maxillofacial bleeding:– Direct pressure.– Avoid blind clamping in wounds.

• Nasal bleeding:– Direct pressure.– Anterior and posterior packing.

• Pharyngeal bleeding:– Packing of the pharynx around ET tube.

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History

• Obtain a history from the patient, witnesses and or EMS

• Specific Questions:– Was there LOC? If so, how long?– How is your vision?– Hearing problems?

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History

• Specific Questions:– Is there pain with eye movement?– Are there areas of numbness or tingling on your

face?– Is the patient able to bite down without any pain?– Is there pain with moving the jaw?

Clinical examination

• ATLS standard approach• Inspection

• Palpation

• Visual examination• Eye movement• Diplopia• Pupil reaction

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Physical Examination

• Inspection of the face for asymmetry.• Inspect open wounds for foreign bodies.• Palpate the entire face.– Supraorbital and Infraorbital rim– Zygomatic-frontal suture– Zygomatic arches

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Physical Examination

• Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge.

• Inspect nasal septum for septal hematoma, CSF or blood.

• Palpate nose for crepitus, deformity and subcutaneous air.

• Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.

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Physical Examination

• Check facial stability.• Inspect the teeth for malocclusions, bleeding and

step-off.• Intraoral examination: – Manipulation of each tooth.– Check for lacerations.– Stress the mandible.– Tongue blade test.

• Palpate the mandible for tenderness, swelling and step-off.

Fractures of Facial Skeleton

• Upper third – above the eyebrows – involves frontal sinuses & supraorbital ridges

• Middle third – above the mouth

Le Fort I , II , II

• Lower third -- Mandible

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Imaging of Facial TraumaFrontal Sinus/ Bone Fractures

Diagnosis• Radiographs:– Facial views should include Waters, Caldwell and lateral projections.– Caldwell view best evaluates the anterior wall fractures.

Frontal Sinus/ Bone FracturesDiagnosis

• CT Head with bone windows:– Frontal sinus fractures. – Orbital rim and

nasoethmoidal fractures.

– R/O brain injuries or intracranial bleeds.

Naso-Ethmoidal-Orbital Fracture

• Fractures that extend into the nose through the ethmoid bones.

• Associated with lacrimal disruption and dural tears.

• Suspect if there is trauma to the nose or medial orbit.

• Patients complain of pain on eye movement.

Naso-Ethmoidal-Orbital Fracture

• Clinical findings:– Flattened nasal bridge or a saddle-shaped

deformity of the nose.– Widening of the nasal bridge (telecanthus)– CSF rhinorrhea or epistaxis.– Tenderness, crepitus, and mobility of the nasal

complex.– Intranasal palpation reveals movement of the

medial canthus.

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3D Reconstruction

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Nasoorbitalethmoidal(NOE)

Fractures

Three types of NOE fractures

– Type I: Large fragment of medial orbit, medial canthal insertion is intact

– Type II: Comminution of bones, fracture line does not extend into area of medial canthal insertion

– Type III: Comminution of bones, fracture line extends into area of medial canthal insertion

Management of nasal-orbital ethmoid fractures

• Examination for determination of the extent of the injury (surgical exploration)

• Nasal bone• Orbital and ethmoidal• Frontal bone

• Debridement and closure of open wounds

• Reduction and stabilization of bone fracture

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Detached canthusTraumatic telecanthus

• Increase in inter-canthal distance secondary to

canthus displacement or detachment

• Seen in association to:Nasal boneNEOLe Forts fractures

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Surgical management of detached canthus

• Transnasal wiring technique (unilateral type)

• Canthopexy – Identification of the ligament– Liberation of the periorbital

tissue– Liberation of the lacrimal

pathway– Nasal transfixation– Contralateral fixation

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Zygomatic bone complex

• AnatomyStar-shape like with four processes• Frontal process• Temporal process• Buttress• Orbital floor (Maxilla and GWSB)

Temporal fascia and muscle

Masseter muscle33

Zygomatic complex and arch fracture

The malar bone represent a strong bone on fragile

supports, and it is for this reason that, though the

body of the bone is rarely broken, the four processes- frontal, orbital, maxillary

and zygomatic are frequent sites of fracture.

HD Gillies, TP Kilner and D Stone, 1927

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Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent.

Signs and symptoms

• Periorbital ecchymosis and edema

• Flattening of the malar prominence

• Flattening over the zygomatic arch

• Pain and tenderness on palpation

• Ecchymosis of the maxillary buccal sulcus

• Deformity at the zygomatic buttress of the maxilla

• Deformity at the orbital margin

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• Trismus• Abnormal nerve sensibility• Epistaxis• Subconjunctival ecchymosis• Crepitation from air emphysema• Displacement of palpebral fissure

(pseudoptosis) • Unequal pupillary levels• Diplopia• enophthalmos

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• Occipitomental view

(Posterioanterior oblique)

• (water’s view)

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• submentovertex

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Recommended for isolated zygomatic arch fracture

CT scan• Coronal sections• Axial sections

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Treatment Timing:• As early as possible unless there are ophthalmic, cranial

or medical complications

• Preiorbital edema and ecchymosis obscure the fine details of the fracture, intervention can be postponed but not more than a week

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Indications:

• Diplopia• Restriction of mandibular movement

• Restoration of normal contour• Restoration of normal skeletal protection for the eye

Methods of reduction

• Temporal approach (Gillies et al 1927)

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Suitable for isolated zygomatic fracture with good stability afterwards

• Buccal sulcus approach (Keen 1909)

Open reduction and fixation

• Rigid fixation using plate and screws at• Frontozygomatic suture• Infraorbial rim• Inferior buttress of the zygoma

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Surgery:

•Lateral eyebrow incision•Infraorbial approach•Subciliary (blepharoplasty) incision•Mid-lower lid incision•Transconjunctival approach

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Infraorbital rim and buttress

Lateral orbital rim

Buttress of zygoma

Points of fixation:

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Isolated Zygomatic Arch Fractures

Maxillary FracturesLeFort 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 FracturesLeFort I

• Clinical findings:– Facial edema– Malocclusion of the

teeth– Motion of the maxilla

while the nasal bridge remains stable

Maxillary FracturesLeFort II

• Definition:– Pyramidal fracture

• Maxilla• Nasal bones • Medial aspect of the

orbits

Maxillary FracturesLeFort II

• Clinical findings:– Marked facial edema– Nasal flattening– Traumatic telecanthus– Epistaxis or CSF

rhinorrhea – Movement of the

upper jaw and the nose.

Maxillary FracturesLeFort III

• Definition:– Fractures through:

• Maxilla• Zygoma• Nasal bones• Ethmoid bones• Base of the skull

Maxillary FracturesLeFort III

• Clinical findings:– Dish faced deformity– Epistaxis and CSF

rhinorrhea – Mobility of the maxilla,

nasal bones and zygoma

– Severe airway obstruction

Le Fort fractures seldom confine to exactly to the original classification & combinations of any of

the fractures may occur.

Coronal & Axial CT scan

Treatment

• closed reduction with inter maxillary fixation (unilateral fractures)

• open reduction.

• Open reduction – intra osseous wiring - by using micro or

miniplates

Internal orbital fractures

• In conjunction with other facial fractures

• As isolated type (Blow out fracture)

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Anatomy The floor is made of:

Maxillary bone and part of zygoma bounded laterally by the inferior orbital fissure and small part of the ethmoid bone

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Clinical and radiographical presentation

• Subconjunctival ecchymosis

• Crepitation from air emphysema

• Displacement of palpebral fissure

• Unequal pupillary levels

• Diplopia• enophthalmos

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Treatment

• Rational for intervention:

• Small defect with no clinical consequence may not warrant the surgical intervention.

• Large defect with handicapping symptoms should be operated.

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Method of reconstruction

• Intra-sinus approach to the orbital floor

• External approach to the internal orbital floor

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Materials in orbital reconstruction

• Autologous graftBone (cranial, rib, iliac) Cartilage

• Allogenic materialsLyophilized dura

• Alloplastic materialsSiliastic and proplast

implantsTeflonhydroxyapatiteTitanium mish

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Mandible FracturesPathophysiology

• 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%.

• Associated C-spine injuries – 0.2-6%.

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Epidemiology

• Sites of weakness– Third molar (esp. impacted)– Socket of canine tooth– Condylar neck

Haug et al

Favorable vs. Unfavorable

• Masseter, Medial and Lateral Pterygoid, and Temporalis tend to draw fractures medial and superior

• Almost all fractures of angle unfavorable

Physical Exam

• Complete Head and Neck exam– Palpable step off– Tenderness to palpation– Malocclusion– Trismus (35 mm or less)– Sublingual hematoma– Altered sensation of V3– Crepitus

Mandible FracturesClinical findings

• Mandibular pain.• Malocclusion of the teeth• Separation of teeth with

intraoral bleeding• Inability to fully open

mouth.• Preauricular pain with

biting. .

Physical Exam

• Unilateral fractures of Condyle– Decreased translational movement, functional

height of condyle– Deviation of chin away from fracture, open bite

opposite side of fractureBilateral fractures of condyle

- Anterior open bite

Radiographic Evaluation• Panorex (OPG)• X ray skull Reverse towns view.• X Ray mandible PA View, Lateral oblique views• TMJ views

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Radiographic Evaluation

• CT scan– Not as diagnostic as plain films for nondisplaced

fractures of mandible.– Most useful for coronoid and condylar fractures,

associated midface fractures

Closed Reduction

• Favorable, non-displaced fractures• Grossly comminuted fractures when adequate

stabilization unlikely• Severely atrophic edentulous mandible• Children with developing dentition

Open Reduction

• Displaced unfavorable fractures• Mandible fractures with associated midface

fractures• When MMF contraindicated or not possible• Patient comfort• Facilitate return to work

Open Reduction

• Associated condylar fracture• Associated Midface fractures• Psychiatric illness• GI disorders involving severe N/V• Severe malnutrition• To avoid tracheostomy in patients who need

postoperative intubation

Open Reduction

• Contraindications– General Anesthetic risk too high– Severe comminution and stabilization not possible– No soft tissue to cover fracture site– Bone at fracture site diffusely infected

(controversial)

Closed Reduction

• Length of MMF– Fracture at angle of mandible for adults : 4 wks– Add 2 wks more for symphysis fracture– Add 2 wks for geriatric patients (edentulous)– Less 1 wk for peadiatric mandibular fractures.– Less 1 wk for condylar fractures.

Open ReductionTechniques

– Rigid fixation 1. Compression plates (DCP)2. Lag screws– Semirigid fixation1. Miniplates 2. Transosseous wiring3. External fixators

Rigid Fixation

• Compression plates– Rigid fixation– Allow primary bone healing– Difficult to bend– Operator dependent– No need for MMF

Open Reduction

• Lag Screws– Rigid fixation (Compression)– Good for anterior mandible fractures, Oblique

body fractures, mandible angle fractures– Cheap– Technically difficult– Injury to inferior alveolar neurovascular bundle

Lag Screw Technique

Lag Screw Technique

Semi Rigid Fixation

• Miniplates– Semi-rigid fixation– Mono cortical screws– Uses tension band principle– Allows primary and secondary bone healing– Easily bendable– More forgiving– Short period MMF Recommended

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Champey’s miniplate osteosynthesis

• Areas of tension and compression• 2 mm plates • Monocortical screws.• Placed in favourable positions on mandible.• Micromovements possible favourable to

healing.• Technically not highly demanding.• Plate removal is not routinely required.

External Fixation

• Alternative form of rigid fixation• Grossly comminuted fractures, contaminated

fractures, non-union• Often used when all else fails

Condylar and Subcondylar

• Lindhal and Hollender– Closed reduction in children, teens, adults– Intracapsular fractures– Higher incidence of postoperative sequelae in

adults– Children and Teens with less sequelae, more

remodeling

Condylar and Subcondylar

• ORIF, Absolute indications– Displacement into middle cranial fossa– Inability to achieve occlusion with closed

reduction– Foreign body in joint space

Condylar and Subcondylar

• Relative indications– Bilateral condylar fractures to preserve vertical

height– Associated injuries that dictate earlier function• Soft tissue swelling causing airway compromise with

MMF• Intracapsular fracture on opposite side where early

mobilization important

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Panfacial fractures

• Expose all fracture sites• Reconstruct the AP projection of face, start from

stable post area (temporal bone, proximal arch• Reconstruct the width of the face across

zygomatic arches (frontozygomatic suture)• Recreate NOE area.• Restore height (fix ramus fractures)• Restore occlusion.• Repair the fractures in maxilla and mandible

closer to teeth bearing areas

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TMH statistics 2010-11

Etiology RTA Sports injury

Inter personnel violence

Gunshot injuries

Fractures138

128 2 3 5

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TMH statistics 2010-11

Type Mandible Maxilla Zygoma Combined

Fractures138

76 34 6 22

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TMH statistics 2010-11

Treatment Closed reductio

n

Open reductio

n

No treatment

Total Implant removal

Mandible 04 72 0 76 8

Maxilla 3 27 4 34 1

Zygoma 0 3 3 6 0

Combined 0 22 0 22 1

Thank you

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