MaxillofacialTrauma

DEPTOFORAL&MAXFAXSURGERY
SRMDENTALCOLLEGE
KATTANKULATHUR

Pathophysiology

Maxillofacialfracturesresultfromeitherblunt
orpenetratingtrauma.
Penetratinginjuriesaremorecommonincity
hospitals.
Midfacialandzygomaticinjuries.

Bluntinjuriesaremorefrequentlyseenin
communityhospitals.
Noseandmandibularinjuries.

Pathophysiology

HighImpact:
Supraorbitalrim 200G
SymphysisoftheMandible100G
Frontal 100G
Angleofthemandible 70G

LowImpact:
Zygoma 50G
Nasalbone 30G

Etiology

@60%ofpatientswithseverefacialtrauma
havemultisystemtraumaandthepotentialfor
airwaycompromise.
2050%concurrentbraininjury.
14%cervicalspineinjuries.
Blindnessoccursin0.53%

Etiology

25%ofwomenwithfacialtraumaarevictims
ofdomesticviolence.
Increasesto30%ifanorbitalwallfxispresent.

25%ofpatientswithseverefacialtraumawill
developPostTraumaticStressDisorder

Anatomy

Anatomy

EmergencyManagement
AirwayControl

Controlairway:
Chinlift.
Jawthrust.
Oropharyngealsuctioning.
Manuallymovethetongueforward.
Maintaincervicalimmobilization

EmergencyManagement
IntubationConsiderations

Avoidnasotrachealintubation:
Nasocranialintubation
Nasalhemorrhage

AvoidRapidSequenceIntubation:
Failuretointubateorventilate.

Consideranawakeintubation.
Sedatewithbenzodiazepines.

EmergencyManagement
IntubationConsiderations

Considerfiberopticintubationifavailable.
Alternativesincludepercutaneous
transtrachealventilationandretrograde
intubation.
Bepreparedforcricothyroidotomy.

EmergencyManagement
HemorrhageControl

Maxillofacialbleeding:
Directpressure.
Avoidblindclampinginwounds.

Nasalbleeding:
Directpressure.
Anteriorandposteriorpacking.

Pharyngealbleeding:
PackingofthepharynxaroundETtube.

History

Obtainahistoryfromthepatient,witnesses
andorEMS.
AMPLEhistory
SpecificQuestions:
WasthereLOC?Ifso,howlong?
Howisyourvision?
Hearingproblems?

History

SpecificQuestions:
Istherepainwitheyemovement?
Arethereareasofnumbnessortinglingonyour
face?
Isthepatientabletobitedownwithoutanypain?
Istherepainwithmovingthejaw?

PhysicalExamination

Inspectionofthefaceforasymmetry.
Inspectopenwoundsforforeignbodies.
Palpatetheentireface.
SupraorbitalandInfraorbitalrim
Zygomaticfrontalsuture
Zygomaticarches

PhysicalExamination
Inspectthenoseforasymmetry,telecanthus,
wideningofthenasalbridge.
Inspectnasalseptumforseptalhematoma,CSFor
blood.
Palpatenoseforcrepitus,deformityand
subcutaneousair.
Palpatethezygomaalongitsarchandits
articulationswiththemaxilla,frontalandtemporal
bone.

PhysicalExamination
Checkfacialstability.
Inspecttheteethformalocclusions,bleedingand
stepoff.
Intraoralexamination:

Manipulationofeachtooth.
Checkforlacerations.
Stressthemandible.
Tonguebladetest.

Palpatethemandiblefortenderness,swellingand
stepoff.

PhysicalExamination

Checkvisualacuity.
Checkpupilsforroundnessandreactivity.
Examinetheeyelidsforlacerations.
Testextraocularmuscles.
Palpatearoundtheentireorbits..

PhysicalExamination

Examinethecorneaforabrasionsand
lacerations.
Examinetheanteriorchamberforbloodor
hyphema.
Performfundoscopicexamandexaminethe
posteriorchamberandtheretina.

PhysicalExamination

Examineandpalpatetheexteriorears.
Examinetheearcanals.
Checknuerodistributionsofthesupraorbital,
infraorbital,inferioralveolarandmental
nerves.

FrontalSinus/BoneFractures
Pathophysiology

Resultsfromadirectblowtothefrontalbone
withbluntobject.
Associatedwith:
Intracranialinjuries
Injuriestotheorbitalroof
Duraltears

FrontalSinus/BoneFractures
ClinicalFindings
Disruptionor
crepitanceorbitalrim
Subcutaneous
emphysema
Associatedwitha
laceration

FrontalSinus/BoneFractures
Diagnosis
Radiographs:
Facialviewsshould
includeWaters,
Caldwellandlateral
projections.
Caldwellviewbest
evaluatestheanterior
wallfractures.

FrontalSinus/BoneFractures
Diagnosis
CTHeadwithbone
windows:
Frontalsinusfractures.
Orbitalrimand
nasoethmoidal
fractures.
R/Obraininjuriesor
intracranialbleeds.

FrontalSinus/BoneFractures
Treatment
Patientswithdepressedskullfracturesorwith
posteriorwallinvolvement.

ENTornuerosurgeryconsultation.
Admission.
IVantibiotics.
Tetanus.

Patientswithisolatedanteriorwallfractures,
nondisplacedfracturescanbetreatedoutpatient
afterconsultationwithneurosurgery.

FrontalSinus/BoneFractures
Complications

Associatedwithintracranialinjuries:
Orbitalrooffractures.
Duraltears.
Mucopyocoele.
Epiduralempyema.
CSFleaks.
Meningitis.

NasoEthmoidalOrbital
Fracture
Fracturesthatextendinto
thenosethroughthe
ethmoidbones.
Associatedwithlacrimal
disruptionandduraltears.
Suspectifthereistrauma
tothenoseormedial
orbit.
Patientscomplainofpain
oneyemovement.

NasoEthmoidalOrbital
Fracture

Clinicalfindings:
Flattenednasalbridgeorasaddleshaped
deformityofthenose.
Wideningofthenasalbridge(telecanthus)
CSFrhinorrheaorepistaxis.
Tenderness,crepitus,andmobilityofthenasal
complex.
Intranasalpalpationrevealsmovementofthe
medialcanthus.

NasoEthmoidalOrbital
Fracture

Imagingstudies:
Plainradiographsareinsensitive.
CTofthefacewithcoronalcutsthroughthe
medialorbits.

Treatment:
Maxillofacialconsultation.
?Antibiotic

NasalFractures

Mostcommonofallfacialfractures.
Injuriesmayoccurtoothersurroundingbony
structures.
3types:
Depressed
Laterallydisplaced
Nondisplaced

NasalFractures

Askthepatient:
Haveyoueverbrokenyournosebefore?
Howdoesyournoselooktoyou?
Areyouhavingtroublebreathing?

NasalFractures
Clinicalfindings:

Nasaldeformity
Edemaandtenderness
Epistaxis
Crepitusandmobility

NasalFractures
Diagnosis:
Historyandphysical
exam.
LateralorWatersview
toconfirmyour
diagnosis.

NasalFractures
Treatment:
Controlepistaxis.
Drainseptal
hematomas.
ReferpatientstoENT
asoutpatient.

OrbitalBlowoutFractures

Blowoutfracturesarethemostcommon.
Occurwhenthetheglobesustainsadirect
bluntforce
2mechanismsofinjury:
Blunttraumatotheglobe
Directblowtotheinfraorbitalrim

OrbitalBlowoutFractures
ClinicalFindings
Periorbitaltenderness,
swelling,ecchymosis.
Enopthalmusor
sunkeneyes.
Impairedocular
motility.
Infraorbital
anesthesia.
Stepoffdeformity

OrbitalBlowoutFractures
Imagingstudies
Radiographs:

Hangingteardropsign
Openbombbaydoor
Airfluidlevels
Orbitalemphysema

OrbitalBlowoutFractures
Imagingstudies
CToforbits
Detailstheorbital
fracture
Excludesretrobulbar
hemorrhage.

CTHead
R/ointracranialinjuries

OrbitalBlowoutFractures
Treatment
Blowoutfractureswithouteyeinjurydonotrequire
admission

Maxillofacialandophthalmologyconsultation
Tetanus
Decongestantsfor3days
Prophylacticantibiotics
Avoidvalsalvaornoseblowing

Patientswithseriouseyeinjuriesshouldbeadmitted
toophthalmologyserviceforfurthercare.

ZygomaFractures

Thezygomahas2majorcomponents:
Zygomaticarch
Zygomaticbody

Blunttraumamostcommoncause.
Twotypesoffracturescanoccur:
Archfracture(mostcommon)
Tripodfracture(mostserious)

ZygomaArchFractures

Canfracture2to3placesalongthearch
Lateraltoeachendofthearch
Fractureinthemiddleofthearch

Patientsusuallypresentwithpainonopening
theirmouth.

ZygomaArchFractures
ClinicalFindings
Palpablebonydefect
overthearch
Depressedcheekwith
tenderness
Painincheekandjaw
movement
Limitedmandibular
movement

ZygomaArchFractures
ImagingStudies&Treatment
Radiographicimaging:
Submentalview
(buckethandleview)

Treatment:
Consultmaxillofacial
surgeon
Iceandanalgesia
Possibleopen
elevation

ZygomaTripodFractures
Tripodfractures
consistoffractures
through:
Zygomaticarch
Zygomaticofrontal
suture
Inferiororbitalrimand
floor

ZygomaTripodFractures
ClinicalFeatures
Clinicalfeatures:
Periorbitaledemaand
ecchymosis
Hypesthesiaofthe
infraorbitalnerve
Palpationmayreveal
stepoff
Concomitantglobe
injuriesarecommon

ZygomaTripodFractures
ImagingStudies
Radiographicimaging:
Waters,Submentaland
Caldwellviews

CoronalCTofthe
facialbones:
3Dreconstruction

ZygomaTripodFractures
Treatment
Nondisplacedfractureswithouteyeinvolvement

Iceandanalgesics
Delayedoperativeconsideration57days
Decongestants
Broadspectrumantibiotics
Tetanus

Displacedtripodfracturesusuallyrequireadmission
foropenreductionandinternalfixation.

MaxillaryFractures

Highenergyinjuries.
Impact100timestheforceofgravityis
required.
Patientsoftenhavesignificantmultisystem
trauma.
ClassifiedasLeFortfractures.

MaxillaryFractures
LeFortI
Definition:
Horizontalfractureof
themaxillaatthelevel
ofthenasalfossa.
Allowsmotionofthe
maxillawhilethenasal
bridgeremainsstable.

MaxillaryFractures
LeFortI
Clinicalfindings:
Facialedema
Malocclusionofthe
teeth
Motionofthemaxilla
whilethenasalbridge
remainsstable

MaxillaryFractures
LeFortI
Radiographicfindings:
Fracturelinewhich
involves
Nasalaperture
Inferiormaxilla
Lateralwallofmaxilla

CTofthefaceand
head
coronalcuts
3Dreconstruction

MaxillaryFractures
LeFortII
Definition:
Pyramidalfracture
Maxilla
Nasalbones
Medialaspectofthe
orbits

MaxillaryFractures
LeFortII
Clinicalfindings:
Markedfacialedema
Nasalflattening
Traumatictelecanthus
EpistaxisorCSF
rhinorrhea
Movementofthe
upperjawandthe
nose.

MaxillaryFractures
LeFortII
Radiographicimaging:
Fractureinvolves:

Nasalbones
Medialorbit
Maxillarysinus
Frontalprocessofthe
maxilla

CTofthefaceand
head

MaxillaryFractures
LeFortIII
Definition:
Fracturesthrough:

Maxilla
Zygoma
Nasalbones
Ethmoidbones
Baseoftheskull

MaxillaryFractures
LeFortIII
Clinicalfindings:
Dishfaceddeformity
EpistaxisandCSF
rhinorrhea
Motionofthemaxilla,
nasalbonesand
zygoma
Severeairway
obstruction

MaxillaryFractures
LeFortIII
Radiographicimaging:
Fracturesthrough:

Zygomaticfrontalsuture
Zygoma
Medialorbitalwall
Nasalbone

CTFaceandtheHead

MaxillaryFractures
Treatment

Secureandairway
ControlBleeding
Headelevation4060degrees
Consultwithmaxillofacialsurgeon
Considerantibiotics
Admission

MandibleFractures
Pathophysiology
Mandibularfracturesare
thethirdmostcommon
facialfracture.
Assaultsandfallsonthe
chinaccountformostof
theinjuries.
Multiplefracturesare
seeningreaterthen50%.
AssociatedCspine
injuries 0.26%.

MandibleFractures
Clinicalfindings
Mandibularpain.
Malocclusionoftheteeth
Separationofteethwith
intraoralbleeding
Inabilitytofullyopen
mouth.
Preauricularpainwith
biting.
Positivetonguebladetest.

MandibleFractures
Radiographs:
Panoramicview
Plainview:PA,LateralandaTownesview

MandibularFractures
Treatment
Nondisplacedfractures:
Analgesics
Softdiet
oralsurgeryreferralin12days

Displacedfractures,openfracturesandfractures
withassociateddentaltrauma
Urgentoralsurgeryconsultation

Allfracturesshouldbetreatedwithantibioticsand
tetanusprophylaxis.

MandibularDislocation

Causesofmandibulardislocationare:
Blunttrauma
Excessivemouthopening

Riskfactors:
Weaknessofthetemporalmandibularligament
Overstretchedjointcapsule
Shallowarticulareminence
Neurologicdiseases

MandibularDislocation
Themandiblecanbe
dislocated:

Anterior70%
Posterior
Lateral
Superior

Dislocationsare
mostlybilateral.

MandibularDislocation
Posteriordislocations:
Directblowtothechin
Condylarheadispushedagainstthemastoid

Lateraldislocations:
Associatedwithajawfracture
Condylarheadisforcedlaterallyandsuperiorly

Superiordislocations:
Blowtoapartiallyopenmouth
Condylarheadisforceupward

MandibularDislocation
Clinicalfeatures:
Inabilitytoclose
mouth
Pain
Facialswelling

Physicalexam:
Palpabledepression
Jawwilldeviateaway
Jawdisplacedanterior

MandibularDislocation
Diagnosis:
History&Physical
exam
Xrays
CT

MandibularDislocation
Treatment:
Musclerelaxant
Analgesic
Closedreductioninthe
emergencyroom

MandibularDislocation

Treatment:
Oralsurgeonconsultation:

Opendislocations
Superior,posteriororlateraldislocations
Nonreducibledislocations
Dislocationsassociatedwithfractures

MandibularDislocation

Disposition:
Avoidexcessivemouthopening
Softdiet
Analgesics
Oralsurgeryfollowup