Maxillofacial trauma Associate prof. Elitsa Deliverska, PhD, Department of DOMFS, FDM, MU-Sofia General trauma is:

- The leading cause of death from 1- 44 years. - Fourth only to Cancer, Heart disease and Chronic Respiratory disease - Trauma affects 135,000,000 people a year: 103 people /Minute !

Mortality - Primarily associated with brain and spine injury - Severe facial fractures may interfere with airway and breathing

Morbidity - Disability concerns - Cosmetic concerns - 60% of patients with severe facial trauma have multisystem trauma and the

potential for airway compromise. 0-50% concurrent brain injury. 1-4% cervical spine injuries. Blindness occurs in 0.5-3%

Maxillofacial Trauma- causes – MVA, – violence – home accidents, – athletic injuries, – animal bites, – industrial accidents – gunshots

Key features • Young men have the highest risk of facial injury because of interpersonal violence

and sport activities. • Alcohol and drug abuse are implicated in 15%-40%, and 47% of injuries, respectively.

http://www.journal-imab-bg.org/issue-2012/book2/JofIMAB2012vol18b2p147-149.pdf

• Falls are the most common cause of facial injury in people over 60 and cause a large proportion of the total number of facial injuries.

Prevention • seat Belts and air Bags - proved to be effective in reducing injuries and fatalities in

motor vehicle accidents • alchohol and drug abusement penalties • Reduce the speed of MV • Plastic splints • Helmet use reduces the risk of cranial trauma 85% and the protective effect for facial

injury is 65% for the upper and mid facial regions.

• • Fig.1 • Protective headgear • Mouthguards in boxing - Mouthguards that are 6mm thick dissipate forces 4 times

greater than those 2mm thick. • Helmets in cycling - the depth and density of the lining material rather than the shell

governs how well a helmet will perform. • Thermoplastic splints manufactured using 3-dimensional scans of the face allow a

quicker return to contact sport for players with a facial fracture. (fig.1)

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

Maxillofacial trauma is one of the most challenging area within the specialty of oral and maxillofacial surgery. Appropriate and timely management of facial injuries becomes even more challenging following high velocity trauma, when significant injuries elsewhere may, or may not, take priority. Due to the high frequency of maxillofacial trauma, the maxillofacial surgeon is an integral part of the trauma team. During and immediately after the ‘golden hour’, maxillofacial surgeons may need to provide an advisory service or to intervene in some way. ATLS is system that prioritizes diagnosis and effective management of life-threatening injuries. Having originally been conceived in Nebraska in the 1970s, its principles are now taught in courses all over the world and form the cornerstone of management of the patients with multiple trauma. Aims:

• To rapidly accurately assess trauma patients • Early recognition timely intervention of life-threatening conditions • To resuscitate stabilize trauma patients • To understand the priorities in trauma management (Triage) • To organize quality trauma care in hospital

Initial hospital care- ATLS system • 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

Regular reassessment of patients is very important!!! Algorithm include:

1. Primary Survey (ABCDEs) 2. Resuscitation 3. Secondary Survey- Head-to-toe evaluation, GCS 4. Definite care of patient.

Management of trauma patient could be divided in: A. Pre-hospital Phase:

• Receiving hospital is notified first. • Send to the closest, appropriate facility.

B. In Hospital Phase: • Advanced planning for the trauma at arrival. • Method to summon extra medical assistance • Transfer agreement with verified trauma center established. • Protect from communicable disease.

Emergency Management AIRWAY CONTROL

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

To assure airway keep in mind: • Tongue falling back tendency • Blood clots in the mouth/throat • Fractured teeth segments • Broken fillings • Dentures • Hemorrhage control • Soft tissue lacerations management • Support of bone fragments- need of temporary immobilization • Pain control • Infection control e.g. compound fractures • Fluid resuscitation

BREATHING If there is no evidence of airway compromise, our attention moves to the lungs. There are six causes of airway respiratory compromise:

- Upper airway obstruction - Tension pneumothorax - Open pneumothorax - Flail chest - Massive haemothorax - Cardiac tamponade

Cervical spine protection • ATLS teaches us that “trauma occurring above the clavicle should raise a high index

of suspicion for a potential cervical spine injury” and strict application of this principle means all patients with maxillofacial or craniofacial trauma must be included in this group. Accordingly, all maxillofacial trauma patients must be managed as such:

• Cervical spine collar until clinical and radiological clearance is confirmed

• Comprehensive neurological examination, including cranial nerves • Specific assessment for cerebrospinal fluid rhinorrhea

HEMORRHAGE CONTROL

• Circulation-Blood volume & cardiac output • Level of consciousness • Skin colour • Pulse Maxillofacial bleeding:

-Direct pressure -Avoid blind clamping in wounds - Ligation - Electrocauterization- after good visualization to avoid nerve injury

• Nasal bleeding: -anterior/posterior nasal packing

• Pharyngeal bleeding: - Packing of the pharynx around ET tube, suturing of soft tissue

Disability (neurological status) The possibility of brain injury is assessed. A decrease in the patient’s level of consciousness may be due to a primary brain injury. This is assessed easily through:

1) Pupil size and reactivity 2) Whether the patient is alert, responds to verbal stimuli, responds only to pain or is

unresponsive. Glasgow Coma Scale (GCS) Useful clinical method for monitoring the status of patients following a head trauma. This gives a score of 15 based on the patient’s best motor, verbal and eye responses.

Score of 15: fully alert, cooperative and comprehensive patient Score of 8 or less: presence of serious cranial trauma

EXPOSURE / ENVIRONMENT

- To facilitate a whole body examination, all clothing from the patient should be removed. This allows an adequate assessment of the whole body(spinal column, the posterior aspects of the limbs and the perineum).

- Prevention of hypothermia through: • Covering of patient with blankets • Warming of intravenous fluids • Maintenance of warm environment in the resuscitation room

SECONDARY SURVEY Head-to-toe evaluation, GCS, CT scan Radiographic Signs of Facial Fractures

Direct Signs nonanatomic linear lucencies cortical defect or diastatic suture bone fragments overlapping causing a "double-density" asymmetry of face

Indirect Signs - soft tissue swelling - periorbital or intracranial air - fluid in a paranasal sinus

No other part of the body is as aesthetically significant, conspicuous and unique as the face. Because of an individual's self-image and self-esteem any injury affecting maxillofacial area requires particular attention because of esthetic demanding. Classification of soft tissue Injuries Opened- Vulnus

• excoriatio • scissum • caesum • lacerum • contusum • conquassatum • Morsum • Punctum • sclopetarium • mixta

Closed- Contusio • Petechiae • Ecchymosis • Vibices • Sugelatio • Suffusio • Haematoma

Soft Tissue injury

• Can look dramatic • Can mask damage to underlying structures • Lacrimal ducts, parotid gland, nerves • Must assess facial nerve function

• Remove foreign bodies • Debride • Excellent Blood supply helps for a healing!

Wound could be: Clean Contaminated Infected Healing of the wounds

- By primary intention - By secondary intention

History could be obtained by the patient, witnesses and or EMS • Specific Questions:

– Was there LOC (loss of consciousness)? If so, how long? – How is your vision? Is there pain with eye movement? – Pain/injury in abdomen, pelvis, chest, extremities – 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?

Are your teeth meeting normally? Key features for MFT (maxillofacial trauma) history

- Mechanism of injury - Previous facial injuries - Premorbid history - Loss of consciousness - Medications, Allergies, Tetanus status - Associated injuries

Physical Examination- extraoral - 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 – Nasal bones, mandibular contour, TMJ, etc.

– Physical Examination- intraoral

- Inspect the teeth for malocclusions, bleeding and step-off. - Manipulation of each tooth. - Check for lacerations. - Stress the mandible. - Tongue blade test. - Palpate the mandible bimanually for tenderness, swelling and step-off.

Open patient’s mouth and grasp the maxilla arch, place the fingers other hand on the forehead. Push back and forth, up and down and check for movement. Inspect the teeth for malocclusions, bleeding and step-off. If teeth are missing, account for to be sure they have not been aspirated. Nasal bone fracture Ask the patient: “Have you ever broken your nose before?” “How does your nose look to you?” “Are you having trouble in breathing?

Clinical findings:

- Nasal deformity - Edema and tenderness - Epistaxis - Crepitus and mobility

Symptoms:

- PAIN - SWELLING - AIRWAY OBSTRUCTION - EPISTAXIS (profuse bleeding from the nose) - CREPITANCE (the crackling heard and the sensation felt when broken bones are

moved over each other) - ECCHYMOSIS (a purplish area of the nose resulting from fracture and caused by

extravasation of blood into the skin) - SEPTAL HEMATOMA (a mass of extravasated blood that confined within the nasal

septum) Management- proper reduction of the fragments and anterior nasal packing for 3-4 days (if need plaster bandage above the nose for 9-12 days) COMPLICATIONS

Septal haematoma (incision and drainage is needed to prevent septal necrosis)

CSF rhinorrhea (due to fracture of the cribriform plate) Deformity of nose, with obstruction of the nasal passages

Maxillary fractures

- High-energy injury - Malocclusion - Facial lengthening - CSF rhinorrhea in some cases - Periorbital ecchymosis

The most severe maxillary fracture is Le fort III/ Craniofacial dysfunction/ High level fracture/ Suprazygomatic fracture and the following symptoms could be detected:

1. Oedema of face (Panda facies) 2. Bilateral periorbital edema 3. Bilateral circumorbital ecchymosis (Racoon eyes) 4. Bilateral subconjunctival haemorrhage 5. Dish face deformity 6. Depressed nose, flattening of nose 7. Epistaxis 8. CSF rhinorrhea, CSF otorrhoea or haemotympanum 9. Limited ocular movement and Diplopia, Eno/exophthalmos 10. Dystopia, hooding of eyes with antimongloid slant 11. Malocclusion – posterior gagging of occlusion 12. Inability to open mouth 13. Mobility of fractured fragment at NF, FZ sutures 14. Tenderness over zygomatic bone, arch and FZ suture

15. Ecchymosis at mastoid process (Battle’s sign) MANAGEMENT

1. Emergency care and stabilization 2. Initial assessment with accurate diagnosis 3. Determination of priority of treatment 4. Definitive treatment

- Precise anatomical reduction of the fragment - Restore function - Stable fixation of the reduced fragment - Restore the dental occlusion - Relieve pain - Continuing care

Optimum time for reduction of midface fracture is 5th to 8th post injury day. After this with every succeeding day disimpaction become difficult and open reduction more essential

Management: disimpaction and proper reduction of the fragments and stable fixation, IMF(intermaxillary fixation, maxillomandibular fixation) for accurate occlusion. Fixation: with direct osteosyntesis or suspensive fixation a modo Adams, Lisney etc. FACTOR AFFECTING SCREW STABILITY 1. Minimum 2 screws required in each bone segment to prevent rotation in X and Y axis 2. Farther the point of stabilization the more effective the device is in preventing

rotation 3. Large diameter screws are not used because of constraint imposed by particular

anatomic location 4. All screw require adequate intervening bone between adjacent holes to preserve

integrity of screw bone interface Complications Immediate 1. Airway 2. Nasal hemorrhage 3. Ophthalmic complications 4. Inaccurate reduction 5. Insecure fixation Late complications 1. Non union 2. mal occlusion 3. Cranial nerve dysfunction 4. Secondary nasal deformity 5. Dacrocystitis 6. Facial asymmetry Mandibular fracture - Mandibular fractures are the second most common facial fracture after nasal bone. - Assaults, MVA, and falls on the chin account for most of the injuries. - Multiple fractures of the facial skeleton could be detected.

- Associated injuries – in at about 37% of cases. According the nature of fracture: Green stick Simple Compound Comminuted According degree of displacement: Favorable, unfavorable

Clinical findings These fractures manifest clinically with:

- Mandibular pain, tenderness. - Malocclusion of the teeth - Step off deformity in dental line - Separation of teeth with intraoral bleeding - Ecchymosis to the floor of the mouth - Inability to fully open mouth. - Altered sensation of V3 - Crepitus - Preauricular pain with biting when there is a fracture of the condyle.

Management Principles…….

Repositio anatomica et restitutio functionalis • Reduction • Fixation • Immobilization- to restore the occlusion Methods • Close reduction- prosthetic methods • Open reduction- surgical methods • Circum wiring- suspensive fixation

Closed Reduction INDICATIONS • Favorable, non-displaced fractures • Grossly comminuted fractures when adequate stabilization unlikely • Severely atrophic edentulous mandible • Children with developing dentition CONTRAINDICATIONS: 1. Alcoholics 2. Seizure disorder 3. Mental retardation 4. Nutritional concerns 5. Respiratory diseases 6.Unfavorable fractures

Suspensive wiring Open Reduction Indications • Displaced unfavorable fractures • Mandible fractures with associated midface fractures • When MMF contraindicated or not possible • Patient comfort • Facilitate return to work • Associated condylar fracture • Associated Midface fractures • Psychiatric illness • Severe malnutrition • To avoid tracheostomy in patients who need postoperative intubation Contraindications • General Anaesthetic risk too high • Severe comminution and stabilization not possible • Soft tissue deficiency to cover fracture site • Bone at fracture site diffusely infected (controversial) The period of stable IMF fixation required to ensure full restoration of function varies according to: 1. Site of fracture 2. Presence of retained teeth in the line of fracture 3. Age of the patient 4. Presence or absence of infection Length of MMF for closed reduction technique - Fracture at angle of mandible for adults: 4 weeks - Add 2 weeks more for symphysis fracture - Add 2 weeks for geriatric patients (edentulous) - Less 1 week for pediatric mandibular fractures. - Less 1 week for condylar fractures.

Generally: 4-6-8 weeks MMI/IMF immobilization for mandible body and angle and 3 weeks MMI/IMF immobilization for condylar fractures Length of MMF for open reduction technique- 1 to 2 weeks.

COMPLICATIONS Misapplied fixation Infection TMJ ankylosis Nerve damage Displaced teeth Gingival and periodontal complications Malunion Nonunion Delayed healing process Maloclusion

Zygomatic bone 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)

Signs and symptoms- ophthalmic, abnormal sensation, inability for wide mouth opening, pain

- 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 - Epistaxis - inability for wide mouth opening- due to coronoid process impingement

Management 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 Indications for surgery:

• Visual compromise, extraocular muscle dysfunction, displacement of globe • Displaced fractures • Restriction of mandibular movement • Restoration of normal contour • Restoration of normal skeletal protection for the eye • Infraorbital nerve dysfunction

Surgical approach Indirect

Extraoral approach- Temporal approach (Gillies et al 1927) Intraoral approach- Buccal sulcus approach (Keen 1909) Percutaneous approach- bone hook tech, Girald screw Direct Open reduction and rigid fixation using plate and screws at:

Frontozygomatic suture Infraorbial rim Inferior buttress of the zygoma

Materials in orbital reconstruction

Autologous graft Bone (cranial, rib, iliac) Cartilage

Allogenic materials Lyophilized dura

Alloplastic materials Siliastic and proplast implants Teflon hydroxyapatite Titanium mesh

Reference:

• Oral & maxillofacial trauma-Fonseca & walker vol 2 • Oral & maxillofacial surgery-Fonseca vol 3 • Oral & maxillofacial trauma-Rowe & Williams vol 2 • Fractures of middle third of face-Killey & Kay • Oral & maxillofacial surgery-Fragiskos • Maxillofacial trauma & facial reconstruction-Peter Ward Booth • Oral & maxillofacial surgery-Peter Ward Booth: vol 2 • Peterson’s principles of Oral and maxillofacial surgery-2 nd edition 2014 • Лицевочелюстна и орална хирургия, Угринов и кол., София, 2006 г