Maxillofacial Trauma By Daniel Cerbone D.O. St. Barnabas Hospital Emergency Department

PathophysiologyMaxillofacial fractures result from either blunt or penetrating trauma.Penetrating injuries are more common in city hospitals.Midfacial and zygomatic injuries.Blunt injuries are more frequently seen in community hospitals.Nose and mandibular injuries.

PathophysiologyHigh Impact:Supraorbital rim 200 GSymphysis of the Mandible 100 GFrontal 100 GAngle of the mandible 70 GLow Impact:Zygoma 50 GNasal bone 30 G

Etiology@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%

Etiology25% of women with facial trauma are victims of domestic violence.Increases to 30% if an orbital wall fx is present.25% of patients with severe facial trauma will develop Post Traumatic Stress Disorder

Anatomy

Anatomy

Emergency ManagementAirway ControlControl airway:Chin lift.Jaw thrust.Oropharyngeal suctioning.Manually move the tongue forward.Maintain cervical immobilization

Emergency ManagementIntubation ConsiderationsAvoid nasotracheal intubation:Nasocranial intubationNasal hemorrhageAvoid Rapid Sequence Intubation:Failure to intubate or ventilate.Consider an awake intubation.Sedate with benzodiazepines.

Emergency ManagementIntubation ConsiderationsConsider fiberoptic intubation if available. Alternatives include percutaneous transtracheal ventilation and retrograde intubation.Be prepared for cricothyroidotomy.

Emergency ManagementHemorrhage ControlMaxillofacial 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.

HistoryObtain a history from the patient, witnesses and or EMS.AMPLE historySpecific Questions:Was there LOC? If so, how long?How is your vision?Hearing problems?

HistorySpecific 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?

Physical ExaminationInspection of the face for asymmetry.Inspect open wounds for foreign bodies.Palpate the entire face.Supraorbital and Infraorbital rimZygomatic-frontal sutureZygomatic arches

Physical ExaminationInspect 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.

Physical ExaminationCheck 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.

Physical ExaminationCheck visual acuity.Check pupils for roundness and reactivity.Examine the eyelids for lacerations.Test extra ocular muscles.Palpate around the entire orbits..

Physical ExaminationExamine the cornea for abrasions and lacerations.Examine the anterior chamber for blood or hyphema.Perform fundoscopic exam and examine the posterior chamber and the retina.

Physical ExaminationExamine and palpate the exterior ears.Examine the ear canals.Check nuero distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves.

Frontal Sinus/ Bone FracturesPathophysiology

Results from a direct blow to the frontal bone with blunt object.Associated with:Intracranial injuriesInjuries to the orbital roofDural tears

Frontal Sinus/ Bone FracturesClinical FindingsDisruption or crepitance orbital rimSubcutaneous emphysemaAssociated with a laceration

Frontal Sinus/ Bone FracturesDiagnosisRadiographs:Facial views should include Waters, Caldwell and lateral projections.Caldwell view best evaluates the anterior wall fractures.

Frontal Sinus/ Bone FracturesDiagnosisCT Head with bone windows:Frontal sinus fractures. Orbital rim and nasoethmoidal fractures.R/O brain injuries or intracranial bleeds.

Frontal Sinus/ Bone FracturesTreatment

Patients with depressed skull fractures or with posterior wall involvement.ENT or nuerosurgery consultation.Admission.IV antibiotics.Tetanus.Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

Frontal Sinus/ Bone FracturesComplications

Associated with intracranial injuries:Orbital roof fractures.Dural tears.Mucopyocoele.Epidural empyema.CSF leaks.Meningitis.

Naso-Ethmoidal-Orbital FractureFractures 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 FractureClinical 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.

Naso-Ethmoidal-Orbital FractureImaging studies:Plain radiographs are insensitive.CT of the face with coronal cuts through the medial orbits.Treatment:Maxillofacial consultation.? Antibiotic

Nasal FracturesMost common of all facial fractures.Injuries may occur to other surrounding bony structures.3 types:DepressedLaterally displacedNondisplaced

Nasal FracturesAsk the patient:Have you ever broken your nose before?How does your nose look to you?Are you having trouble breathing?

Nasal FracturesClinical findings:Nasal deformityEdema and tendernessEpistaxisCrepitus and mobility

Nasal FracturesDiagnosis:History and physical exam.Lateral or Waters view to confirm your diagnosis.

Nasal FracturesTreatment:Control epistaxis.Drain septal hematomas.Refer patients to ENT as outpatient.

Orbital Blowout FracturesBlow out fractures are the most common.Occur when the the globe sustains a direct blunt force2 mechanisms of injury:Blunt trauma to the globeDirect blow to the infraorbital rim

Orbital Blowout FracturesClinical FindingsPeriorbital tenderness, swelling, ecchymosis.Enopthalmus or sunken eyes.Impaired ocular motility.Infraorbital anesthesia.Step off deformity

Orbital Blowout FracturesImaging studiesRadiographs:Hanging tear drop signOpen bomb bay doorAir fluid levelsOrbital emphysema

Orbital Blowout FracturesImaging studiesCT of orbitsDetails the orbital fractureExcludes retrobulbar hemorrhage.CT HeadR/o intracranial injuries

Orbital Blowout FracturesTreatmentBlow out fractures without eye injury do not require admissionMaxillofacial and ophthalmology consultationTetanusDecongestants for 3 daysProphylactic antibioticsAvoid valsalva or nose blowing Patients with serious eye injuries should be admitted to ophthalmology service for further care.

Zygoma FracturesThe zygoma has 2 major components:Zygomatic archZygomatic bodyBlunt 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 archLateral to each end of the archFracture in the middle of the archPatients usually present with pain on opening their mouth.

Zygoma Arch FracturesClinical Findings

Palpable bony defect over the archDepressed cheek with tendernessPain in cheek and jaw movementLimited mandibular movement

Zygoma Arch FracturesImaging Studies & Treatment

Radiographic imaging:Submental view (bucket handle view)Treatment:Consult maxillofacial surgeonIce and analgesiaPossible open elevation

Zygoma Tripod Fractures

Tripod fractures consist of fractures through:Zygomatic archZygomaticofrontal sutureInferior orbital rim and floor

Zygoma Tripod FracturesClinical Features

Clinical features:Periorbital edema and ecchymosisHypesthesia of the infraorbital nervePalpation may reveal step offConcomitant globe injuries are common

Zygoma Tripod FracturesImaging Studies

Radiographic imaging:Waters, Submental and Caldwell viewsCoronal CT of the facial bones:3-D reconstruction

Zygoma Tripod FracturesTreatment

Nondisplaced fractures without eye involvementIce and analgesicsDelayed operative consideration 5-7 daysDecongestants Broad spectrum antibiotics TetanusDisplaced tripod fractures usually require admission for open reduction and internal fixation.

Maxillary FracturesHigh energy injuries.Impact 100 times the force of gravity is required .Patients often have significant multisystem trauma.Classified as LeFort fractures.

Maxillary FracturesLeFort IDefinition: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 IClinical findings:Facial edemaMalocclusion of the teethMotion of the maxilla while the nasal bridge remains stable

Maxillary FracturesLeFort IRadiographic findings:Fracture line which involvesNasal apertureInferior maxillaLateral wall of maxillaCT of the face and head coronal cuts3-D reconstruction

Maxillary FracturesLeFort IIDefinition:Pyramidal fractureMaxillaNasal bones Medial aspect of the orbits

Maxillary FracturesLeFort IIClinical findings:Marked facial edemaNasal flatteningTraumatic telecanthusEpistaxis or CSF rhinorrhea Movement of the upper jaw and the nose.

Maxillary FracturesLeFort IIRadiographic imaging:Fracture involves:Nasal bonesMedial orbitMaxillary sinusFrontal process of the maxilla CT of the face and head

Maxillary FracturesLeFort IIIDefinition:Fractures through:MaxillaZygomaNasal bonesEthmoid bonesBase of the skull

Maxillary FracturesLeFort IIIClinical findings:Dish faced deformityEpistaxis and CSF rhinorrhea Motion of the maxilla, nasal bones and zygomaSevere airway obstruction

Maxillary FracturesLeFort IIIRadiographic imaging:Fractures through:Zygomaticfrontal sutureZygomaMedial orbital wallNasal boneCT Face and the Head

Maxillary FracturesTreatmentSecure and airwayControl BleedingHead elevation 40-60 degreesConsult with maxillofacial surgeonConsider antibioticsAdmission

Mandible FracturesPathophysiologyMandibular 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%.

Mandible FracturesClinical findingsMandibular pain.Malocclusion of the teethSeparation of teeth with intraoral bleedingInability to fully open mouth.Preauricular pain with biting. Positive tongue blade test.

Mandible FracturesRadiographs:Panoramic viewPlain view: PA, Lateral and a Townes view

Mandibular FracturesTreatmentNondisplaced fractures:AnalgesicsSoft dietoral surgery referral in 1-2 daysDisplaced fractures, open fractures and fractures with associated dental traumaUrgent oral surgery consultationAll fractures should be treated with antibiotics and tetanus prophylaxis.

Mandibular DislocationCauses of mandibular dislocation are:Blunt traumaExcessive mouth openingRisk factors:Weakness of the temporal mandibular ligamentOver stretched joint capsule Shallow articular eminenceNeurologic diseases

Mandibular DislocationThe mandible can be dislocated:Anterior 70%PosteriorLateralSuperior Dislocations are mostly bilateral.

Mandibular DislocationPosterior dislocations:Direct blow to the chinCondylar head is pushed against the mastoidLateral dislocations:Associated with a jaw fractureCondylar head is forced laterally and superiorlySuperior dislocations:Blow to a partially open mouthCondylar head is force upward

Mandibular DislocationClinical features:Inability to close mouthPainFacial swellingPhysical exam:Palpable depressionJaw will deviate awayJaw displaced anterior

Mandibular DislocationDiagnosis:History & Physical examX-raysCT

Mandibular DislocationTreatment:Muscle relaxantAnalgesicClosed reduction in the emergency room

Mandibular DislocationTreatment:Oral surgeon consultation:Open dislocationsSuperior, posterior or lateral dislocationsNon-reducible dislocationsDislocations associated with fractures

Mandibular DislocationDisposition:Avoid excessive mouth openingSoft dietAnalgesicsOral surgery follow up

*Maxillofacial fractures result from either blunt or penetrating trauma.Penetrating injuries are more common in city hospitals.--------Midfacial and zygomatic injuries.Blunt injuries are more frequently seen in community hospitals.--------Nose and mandibular injuries.

*The amount of force to fracture different facial bones have been studied and have been divided into High impact (greater then 50 times gravity) and Low Impact (less then 50 times gravity). High Impact:Supraorbital rim 200 GSymphysis of the Mandible 100 GFrontal 100 GAngle of the mandible 70 GLow Impact:Zygoma 50 GNasal bone 30 G

* @60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise. As many as 20-50% of the patients with facial trauma sustain concurrent brain injury, especially those with upper face and midface fractures. 1-4% of these patients have cervical spine injuries. Remember to always r/o cervical spine injuries clinically and radiographically in such patients. Blindness can occur in .5-3% of these trauma pts and are mostly seen in patients with Lefort 3 (2.2%) and Lefort 2 (.64%).

* As many as one forth of the women with facial trauma are victims of domestic violence. If a women has an orbital fracture, the likelihood of sexual assault or domestic violence increases to more then 30%. In addition to physical consequences of facial trauma, there are psychological costs as well. More then a one quarter of patients with severe facial trauma will develop Post Traumatic Stress Disorder. ***Emergency management consists of Controlling the airway:Chin lift.Jaw thrust.Oropharyngeal suctioning.Manually move the tongue forward.Maintain cervical immobilization

* Since the cribiform plate may be disrupted, avoid nasotracheal intubation. Nasotracheal intubation can result in nasocranial intubation or dramatic nasal hemorrhage. RSI carries a particular risk in facial trauma. These include failure to intubate and subsequent failure to ventilate with a bag valve mask 2nd to facial distortion and should also be avoided. Consider awake intubation and use Benzodiazepines or another induction agent that minimizes resp. depression. If paralytics are used, be prepared for immediate backup cricothyroidotomy. *If available, fiberoptic intubation may be helpful. Other alternatives include percutaneous transtracheal ventilation and retrograde intubation. Always be prepared to perform cricothyroidotomy.

* Bleeding from facial injuries typically is profuse but rarely causes hypovolemia or shock. In hypotensive patients, look for other sources of blood loss such as intrathoracic, intraabdominal, and retroperitoneal hemorrhage. Try to control bleeding with direct pressure. Blind clamping should be avoided because injury to important nonvascular structures such as the facial nerve and parotid duct can result. Anterior and posterior packing may be needed in patients with nasal bleeding that does not resolve with direct pressure alone. Pharyngeal bleeding may require packing around the ET tube. Once the airway is secured and gross hemorrhage is controlled, only then search for life threatening injuries to the chest, abd and pelvis. *After your ABCs and all life threatening injuries have been addressed, Obtain a history from the pt, witnesses and or EMS. A-allergies, M-medications, P-pmedhx, L-last meal, E-events leading to the injury.Specific questions:Was there LOC? If so,how long?How is your vision? Monocular double vision-lens dislocation, corneal/retinal injury. Binocular double vision- dysfunction of the EOM or nerves.

*Ask specific questions.:

Is there pain with eye movement?-injury to the globe, orbitAre there areas of numbness or tingling on your face?-nerve entrap.Is the patient able to bite down without any pain?Is there pain with moving the jaw?-fx, impingement temporalis m.

*Inspection of the face for asymmetry.Best done at the head of the bed.Ask the patient to smile, frown, whistle, raise their eyebrows, close their eyes. Inspect open wounds for foreign bodies.Palpate the entire face.Supraorbital and Infraorbital rimZygomatic-frontal sutureZygomatic archesNote ecchymosis (Battles sign, Raccoon eyes)

*Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. Measure the distance between the medial canthi. In normal patients the distance is 35-40mm. If its greater then 40 mm you should suspect nasoethmoid-orbital trauma.Inspect nasal septum for septal hematoma, CSF or blood. (place a drop of blood on a paper towel and look for a halo sign, nonspecific).Palpate nose for crepitus, deformity and subcutaneous air.Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.

*Open pts mouth and grasp the maxilla arch, place the 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.Intraoral exam: Manipulate each tooth, check for lacerations, stress the mandible, tongue blade test. (Bite down on the tongue blade, Twist the blade to try to break it. Pts with broken jaw will reflexively open their mouth.) 95% sensitive and 65% specific. Palpate the mandible for tenderness, swelling and step-off. * Check visual acuity. Snell chart, finger counting or presence or absence of light perception. Check pupils for roundness and reactivity. Tear drop pupil ruptured or penetrated globe injury. Examine for exopthalmus or enopthalmus Examine the lids for lacerations. Check for injuries to the medial 3rd of the eyelids for damage to the lacrimal apparatus. Check for disruption of the levator palpebral muscles. Test extra ocular muscles.Testing for restriction. Restriction of upward gaze can be seen with zygomatic or infra orbital wall fxs. Palpate around the entire orbits. Tenderness, subcutaneous air and deformity. Palpate the medial orbit area to r/o naso ethmoidal orbital fx. (place a Q tip inside the nose to the medial canthus, place your finger outside the medial canthus. If the bone moves NEO fx.)

* Examine the cornea for abrasions and lacerations. Fluorescein if needed. Examine the anterior chamber for blood or hyphema. When the patient is stable try to do a slit lamp examination. Perform fundoscopic exam and examine the posterior chamber and the retina. Looking for retinal detachment.* Examine and palpate the exterior ears. Look for ecchymosis, hematomas,battle sign. Examine the ear canal. Look for lacerations, TM ruptures, Place your finger into the ear canal and have the pt open their mouth to check for condylar fx or dislocation. Check nuero distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves. Supraorbital n.- forehead and vertex of scalp. Infraorbital n.- midface,maxillary incisors and premolar teeth, upper lip, lower eyelid, side of nose. Inferior alveolar n.- mandibular teeth, lower lip and chin. Mental n.- chin and lower lip.

* Frontal bone and sinus injuries usually are a result from a direct blow to the frontal bone with a blunt object. Classically a lead pipe or brick. They may also result from motor vehicle trauma in which the patients head strikes the dashboard. This fracture is frequently associated with intracranial injury, secondary to disruption of the posterior table of the sinus. Dural tears are frequent and patients may have associated injuries to the orbital roof.* Examination usually demonstrates step off, crepitance or subcutaneous emphysema of the supraorbital rim. Often, there is an associated laceration. All open wounds should be inspected for foreign body and bony injury. Remember, patients with frontal sinus fractures require through head, neck, and neurological exam, including ophthalmologic consultation.Picture: Fracture defect seen at the base of a laceration over the frontal sinus.*Patients with a suggested mechanism or PE should get either skull films, or a caldwell view of the face. (Caldwell view is the best for anterior wall fxs.).

Picture: Caldwell view* CT scan of the head with bone windows should be done to r/o intracranial pathology, but also to r/o depressed or posterior fxs.

Picture: CT of a patient which demonstrates a fracture of the anterior table of the frontal sinus.*Patients with depressed skull fractures or with posterior wall involvement require:ENT or nuerosurgery consultation.Admission.IV antibiotics.Tetanus.Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

*Associated with with intracranial injuries:Orbital roof fractures.Dural tears.Mucopyocoele.Epidural empyema.CSF leaks.Meningitis.

*NEO fracture is defined as a fracture that extends into the nose through the ethmoid bones. These fractures are associated with lacrimal disruption and dural tears. Suspect this type of a fracture if there is trauma to the nose or medial orbit. Patients typically complain of pain on eye movement.*

Clinical findings:Flattened nasal bridge or a saddle-shaped deformity of the nose.Widening of the nasal bridge - telecanthusCSF rhinorrhea or epistaxis.Tenderness, crepitus, and mobility of the nasal complex.Intranasal palpation reveals movement of the medial canthus.

* Plain radiographs are insensitive. If the examination is suggestive, order a CT of the face to include coronal sections and thin axial slices through the medial orbit wall. If an NEO fracture is present, consult a maxillofacial surgeon. As with many facial fractures, ABs are frequently prescribed for CSF leaks, but their efficacy is question.

*Most common of all facial fractures.Injuries may occur to other surrounding bony structures. Including fxs to the orbit, frontal sinus, or cribiform plate. Suspect these injuries if the patient had LOC, Hx of a mechanism with significant force or findings of facial bone injuries.3 types of nasal fxs:DepressedLaterally displacedNondisplaced

*Ask the patient:Have you ever broken your nose before?How does your nose look to you?Are you having trouble breathing?You want to ask these questions because nasal trauma may be do to old or new trauma.*On physical exam, observe deformity, palpate for crepitus and mobility. It is important to do an intra nasal exam to inspect for bleeding and for a septal hematoma. If clear rhinorrhea is present, suspect other injuries, such as fxs to the ethmoid bone.Picture: Deformity is evident on examination. Note peri-ocular ecchymosis indicating the possibility of other injuries.

* Nasal bone fxs can be dx clinically by hx and physical examination. Plain nasal films consisting of a lateral view or a Waters view can confirm your dx but are of little practical use.

Picture: Radiograph of a displaced fracture of the nasal spine, for which no treatment other then ice and analgesics is needed.*Treatment: Control epistaxis:Direct pressureTopical vasoconstrictor such as phenylephrine 1% or cocaineCauterize with silver nitrate.Nasal packing ant/post packing. Draining septal hematomas. anesthetize the area. Using a # 11 blade incise the inferior portion of the hematoma and allow it to drain. Then pack the nose with vaseline gauze to prevent reacumulation of blood.If there is no epistaxis or deformity, treat the patient with ice and analgesics. If obvious deformity is present, including new septal deviation or deformity, treat with ice and analgesics and refer to ENT in 2-5 days for reduction. Picture: This is a picture of a septal hematoma, Notice a blueish, grapelike mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle nose deformity.*Blowout fxs are the most common of the orbital fxs. They occur when the globe sustains direct blunt force. The first is a true blowout fx, where all the energy is transmitted to the globe. Since the spherical globe is stronger than the thin orbital floor, the force is then transmitted to the thin orbital floor or medially through the ethmoid bones with the resultant fx. The object causing the injury must be smaller then 5-6cm, otherwise the globe is protected by the surrounding orbit. Fists or small balls are the typical causative agents. The second mechanism occurs when the energy from the blow is transmitted to the to the infraorbital rim causing a buckling of the floor. Entrapment and globe injury is less likely with this injury.

*Patients usually present with: 1. Periorbital tenderness, swelling, ecchymosis.2. Enopthalmus or sunken eyes.3. Impaired ocular motility. Usually caused by entrapment of the inferior rectus muscle.4. Infraorbital anesthesia. This develops when the infraorbital nerve is contused by the initial trauma or when the compressed by bony fragments. Anesthesia of the maxillary teeth and upper lip is more reliable then numbness over the cheek.5. Step off deformity can be appreciated over the infraorbital rim. Subcutaneous emphysema is pathognomonic for a fracture into a sinus or nasal antrum.Picture: The inferior rectus muscle is entrapped within the blow out fx. When the patient tries to look upward, the affected eye has limited upward gaze. The patient experiences diplopia with this maneuver. *Facial films should consist of Waters, Caldwell and lateral projections. Waters view is the best for displaying the inferior orbital rims. When reading the films look for the following: Hanging tear drop sign-herniation of the periorbital fat into the maxillary sinus.Open bomb bay door or trap door sign- Bony fragments protrude into the maxillary sinus.Air fluid levels- and maxillary clouding secondary to bleeding. Orbital emphysemaX ray: Demonstrates a fx of the floor of the R orbit, with a tear drop sign due to the extruded orbital contents. There is a associated air fluid level in the maxillary sinus due to blood. Atlas pg 15.

*CT of the orbits with coronal cuts is considered the DOC,

Higher sensitivity then radiographs and helps with the planning operative repair.

Picture: Ct of a patient demonstrating the entrapped muscle extruding into the maxillary sinus.*Blow out fractures without eye injury do not require admissionMaxillofacial and ophthalmology consultationTetanusDecongestants for 3 daysProphylactic antibioticsAvoid valsalva or nose blowing Patients with serious eye injuries should be admitted to ophthalmology service for further care.

*The zygoma has 2 major components, the zygomatic arch and the body. The arch forms the the inferior and lateral orbit, and the body forms the malar eminence of the face. Fractures to the zygoma are usually the result of blunt trauma. Direct blow to the arch can result in isolated arch fractures. These are the most common. While tripod fractures are more serious and are caused by more extensive trauma.*Zygoma arch fractures can fracture in 2-3 places along the arch. 1. Lateral to each end of the arch. 2. Fracture in the middle of the arch causing a V fracture which could impinge on the temporalis muscle.Patients usually present with pain on opening their mouth.

*Clinical findings:Palpable bony defect over the archDepressed cheek with tenderness on palpation.Pain in cheek and jaw movement and limited mandibular movement which is due to impingement of the coronoid process of the mandible on the arch during mouth opening or impingement of the temporalis muscle. Picture: patient with blunt trauma to the zygoma. Flattening of the right malar eminence is evident.*X-ray: bucket handle view of the zygomatic arch demonstrating a depressed fracture. Treatment:Consult maxillofacial surgeonIce and analgesiaPossible open elevation if cosmetic correction is desired or if there is entrapment of the mandible persists.*Tripod fractures consist of fractures through:Zygomatic archZygomaticofrontal sutureInferior orbital rim and floorPicture: Diagram of a tripod fracture. Note the disruption of both the lateral orbital rim and the orbital floor, as well as the zygomatic arch.*Clinical features:Periorbital edema and ecchymosisHypesthesia of the infraorbital nervePalpation may reveal step offConcomitant globe injuries are common

*Plain films including the waters, submental and caldwell views. Can demonstrate the fracture and evaluate the zygomaticomaxillary complex, but a Coronal CT of the facial bones will best show involvement and the degree of displacement.Picture: CT 3-D. The fracture lines involved in a tripod fracture are demonstrated in this 3-D reconstruction.

*Maxillofacial consultationNondisplaced fractures without eye involvementIce and analgesicsDelayed operative consideration 5-7 daysDecongestants Broad spectrum antibiotics since the fracture crosses into the maxillary sinus. TetanusDisplaced tripod fractures usually require admission for open reduction and internal fixation*Fractures of the maxilla are high energy injuries. An impact 100 times the force of gravity is required to break the midface. These patients often have significant multisystem trauma. Many require resuscitation and admission. The fractures of the maxilla are classified as LeFort Fractures. *LeFort I:Horizontal fracture of the maxilla at the level of the nasal fossa.Allows motion of the maxilla while the nasal bridge remains stable.The fracture is below the infraorbital nerve, so there is no hypesthesia. *LeFort I: Physical exam:Facial edemaMalocclusion of the teethMotion of the maxilla while the nasal bridge remains stable

*Radiographic findings:Fracture line which involvesNasal apertureInferior maxillaLateral wall of maxillaCT of the face with coronal cuts is superior to plain films. Head CT should also be done to r/o intracranial injury.

*LeFort II:Pyramidal fracture which includes a fracture through:MaxillaNasal bonesMedial aspect of the orbits

*Clinical findings:Marked facial edemaNasal flatteningTraumatic telecanthusEpistaxis or CSF rhinorrhea Movement of the upper jaw and the nose. Picture: This patient sustained a Lefort II/III fracture.

*Plain facial films will reveal the presence of facial fractures, but are less helpful in determining the type or extent . Head and facial CT, including three dimensional re-creations, offer much more useful information.*Lefort III fractures also known as craniofacial dissociation(separates the face from the cranium) involves fractures through the maxilla, zygoma, nasal bones, ethmoid bones and the bones of the base of the skull. *Clinical Findings:Patients with LeFort III fractures on physical exam have whats known as the dish faced deformity which is facial flattening and elongation with the eyes markedly swollen shut. Since the maxilla is pushed inward, the patients mandible appears forward. Epistaxis and CSF rhinorrhea are usually present. Movement of the entire face is noted with distraction. These patients are also at high risk for airway obstruction. *Radiographic imaging:Fractures through:Zygomaticfrontal sutureZygomaMedial orbital wallNasal bone extending posteriorly through the orbit into the spheno-palatine fossa.Again, head and facial CT will offer more information.

* Emergency care for all these fractures involves airway maintenance, with Intubation or cricothyrotomy if necessary. Airway compromise is possible with any of these fractures but probably more common with LeFort II and III fractures. CSF rhinorrhea is uncommon in LeFort I fracture but is often seen in LeFort II and III fractures. If CSF rhinorrhea is present or intracranial air is seen on X ray or an open skull fracture is present, the patient should be admitted and place in a head elevated position (40-60 degrees) if possible. Prophylactic antibiotics are often given in these patients (Rocephin) though it has not been shown to prevent meningitis or brain abscess. Patients with maxillary fractures also have significant epistaxis which requires nasal packing. Operative intervention may be needed if bleeding doe not resolve with packing alone. Look for associated injuries, especially intracranial, spinal, thoracic and abdominal. Incidence of blindness is high for LeFort II and III fractures so it is important to get opth. consultation. Patients with Complex maxillary fractures require admission for open reduction and internal fixation. *Following nasal and zygomatic fractures, mandibular fractures are the third most common type of facial fracture. Assault and fall on the chin account for most of the injuries. Because of its ring shape, fractures are often multiple in up to 50% of the cases. The most common area fractured is the condyle @ 36%. Patients with a mandibular fracture, have a 0.2-6% increased risk of associated C-spine injury.*These fractures manifest clinically with mandibular pain, tenderness and malocclusion. A step off in the dental line or ecchymosis to the floor of the mouth are often present and is highly suggested of a mandibular fracture. Patients are unable to fully open their mouth.Patients may have preauricular pain with biting when there is a fracture of the condyle. Picture 1: The open fracture line is evident clinically. There is slight mal-alignment of the teeth.Picture 2: Hemorrhage or ecchymosis in the sublingual area is pathognomonic for an mandibular fracture.

*The best view for evaluating mandibular trauma is the dental panoramic view. If that is not available, plain films should include AP, bilateral oblique and a townes view to evaluate the condyles.Picture: Dental panoramic view of the mandible. Note fractures in the area of the left angle and right body.*Nondisplaced fractures:AnalgesicsSoft dietoral surgery referral in 1-2 daysDisplaced fractures, open fractures and fractures with associated dental traumaUrgent oral surgery consultation, these patients are usually admitted, These patients either need closed reduction with occlusion fixation or open reduction.All patients with mandibular fractures should be treated with antibiotics and tetanus prophylaxis. Antibiotics of choice are PCN, clindamycin or a 1st generation ceph.

* Dislocation generally results from a direct blow to chin while the mouth is open, or more commonly in predisposed individuals after a vigorous yawn. Opening the mouth excessively wide while eating or laughing may also result in dislocation. It can also be seen in patients who have had a seizure, and in patients who have had a dystonic reaction from their neuroleptic medication. Weakness of the temporal mandibular ligament, overstretched joint capsule, shallow articular eminence, patients with neurologic diseases which result in increased muscular activity and extrapyramidal effects of neuroleptic medications are predisposing factors.

*The mandible can be dislocated in the anterior, posterior, lateral and superior plane. Anterior dislocation is the most common and occurs when the condyle is forced in front of the articular eminence. Anterior dislocation occurs in up to 70% of the normal individuals but can be spontaneously reduced by the patient. Once the jaw is dislocated, muscular spasm, particularly the temporalis and lateral pterygoid muscles tend to prevent reduction.Dislocations are most frequently bilateral, but they also can be unilateral.

*Posterior dislocations are rare. They occur from a direct blow to the chin that does not break the condylar neck. The condylar head is pushed against the mastoid. As a result the condylar head may prolapse into the external auditory canal.Lateral dislocations are associated with a jaw fracture. With a lateral dislocation the condylar head is forced laterally and superiorly into the temporal space.Superior dislocations occur from a blow to a partially open mouth that forces the condylar head upward. Associated injuries include cerebral contusions, facial nerve palsy and deafness.

*Patients present with the inability to close an open mouth. Other associated symptoms include pain, discomfort and facial swelling near the TMJ. Unilateral dislocation results in deviation of the mandible to the unaffected side. Bilateral dislocation causes the mandible to be displace anteriorly. Picture: TMJ Dislocation Note the asymmetric jaw deviation toward the unaffected side. Always consider the possibility of an associated underlying fracture or cervical spine injury.

*The diagnosis of mandibular dislocation is made by H&P. X-rays should be performed if the Dx is in question or there is Hx of trauma to exclude fracture. Panoramic view usually demonstrates the pathology and excludes other mandibular injuries. If a fracture is still in questioned after X-rays, a CT can be done to provide more information.Picture: Radiograph demonstrates an anterior mandibular dislocation. The location of the condyle is indicated by the open arrow.

*Reduction may be attempted in closed anterior dislocations without fracture. A short acting muscle relaxant (Versed) helps to decrease muscle spasm. An analgesic may also be considered. The patient should be seated. Facing the patient the examiner places his or hers thumbs in the patients mouth, over the mandibular molars as far back as possible. The fingers should curve beneath the angle and the body of the mandible. The examiner applies downward and backward pressure with his or hers thumbs until the condyle slides back into the articular eminence. When the dislocation is bilateral, it may be easier to relocate one side at a time. If reduction is successful, the patient should be able to close his or her mouth immediately. Post reduction films are not usually required unless the procedure was difficult or traumatic. Complications from the reduction are unusual and include iatrogenic fracture or avulsion of the articular cartilage.*Oral surgery should be consulted in patients who are found to have either an open dislocation, superior, posterior or lateral dislocations, non reducible dislocation or a dislocation associated with a fracture.*Disposition:After successful reduction, patients should be placed on a soft diet and cautioned not to open their mouths more then 2 cm for the following 2 weeks. Analgesics should be prescribed to manage discomfort. Dental follow up should be arranged. Patients with chronic dislocations may require operative intervention.