Facial Injuries

Yamur AYDIN M.D.

Associate Proffessor
University of Istanbul, Cerrahpasa Medical Faculty
Department of Plastic, Aesthetic and Reconstructive
Surgery

soft tissue injuries

facial bone fractures

Emergency Treatment
Clear Airway and provide patent airway
Cleaning of blood, vomit and theet from inside of mouth with fingers
Aspiration of blood, saliva, and gastric contents
Early Intubation or Tracheostomy

Control Hemorrhage
Direct pressure on the wound
Tying of bleeding vessels(a. Facialis, a. Temporalis superfic., a.
Angularis, a. Carotis externa)
Angiographic demonstration and embolization of the bleeding point
Anterior-posterior nasal packing

Treat Shock
Evaluate Associated Injuries ( cervical vertebrea, skull base,
intracranial, thoracal, intraabdominal)

Diagnosis and treatment of facial injuries

Indications of Tracheostomy
Panfacial fracures(combined mandible, maxilla and
nasal fractures)
The multiply fractured mandible with significant swelling
of the neck and floor of the mouth
Patients who require prolonged intermaxillary fixation
who have significant head or chest injuries
Possibility of prolonged postop. airway problems
Severe facial and neck edema resulting from soft tissue
injuries such as severe facial burns
Unrelieved obstruction of airway in the region of larynx or
the hypopharynx

Clear Airway and provide patent airway

Control Hemorrhage

Nasal tamponage

Soft tissue Injuries

Laceration(most common form of facial injury)
Contusion (with or without hematoma)
Abrasion
Avulsion
Puncture
Accidental Tattoo
Retained Foreign Bodies

Treatment of Soft Tissue Injuries

Primary closure
Delayed primary closure
Secondary healing
Tertiary healing (skin grafts, flaps)

Wound Closure-I
The time lapse between injury and repair is
important in terms of the possibility of infection
and the choice of repair techniques
Primary closure is treatment of choice
It is applied immediately after the trauma if the
wound is sharp and clean
debridement, excision of a millimeter or two of
the wound edge
The wound edges is approximated with sutures

Wound Closure-II
The contused, dirty and heavy contamined
wounds are not closed by primaryly
Shotgun wounds, animal and human bites
are not closed primarly as well

Delayed Primary Closure

The wound must be prepared with
debridment and dressing
Cleaning
Irrigation
Debridment

The wound can be closed primarly after

24-48 hours, If it is clean and free of
devitalized tissue

Secondary Closure
If the wound is heavily contamined and
infected, contains necrotic and devital
tissues after 48 hours, The wound can be
closed after cleaning of the wound or can
be left to secondary healing
Secondary healing occurs with secondary
wound contracture and marginal
epithelization

Etiology of Facial Injuries

Traffic accidents
Interpersonel violence
Spor accidents

Home accidents
Occupational accidents
Shot-gun injuries

Symptom and Signs

Soft tissue Injury
Swelling
Pain or localized tenderness
Crepitation from areas of
underlying bone fracture
Hypostesia and paralysis in
the distribution of specific
nerve
Malocclusion
Class I :Normal oclusion
Class II :Retrognathi
Class III :Prognathi

Visual disturbance
Diplopia or decrease in vision

Facial asimmetry, deformity

Obstructed respiration
Lacerations inside of mouth
Ecchymosis
Bleeding

Clinical Examination-I
Evaluation for symmetry and deformity
Inspection of face ( comparing 2 sides)
Palpation of all bony surfaces in an orderly
manner (sup. and inf. orbital rims, nose, the
brows, the zygomatic arches, malar eminence,
border of mandible)
Inspection of intraoral area for lacerations and
abnormalities of the dentition
Palpation of dental arches for abnormal mobility

Clinical Examination-II
Maxillary and mandibular dental arches are
carefully visualized and palpated for bone
irregularity, bruise, hematoma, tenderness or
crepitus
Sensory and motor nerve functions in the facial
area evaluated
Extraocular movements and muscle of facial
expression must be examined
Globe functions (pupillary size and symmetry,
globe excursion, eyelid excursion, double vision
and visual loss) and fundoscopic examination

Facial Injuries
Midface Fractures
Le-Fort Maxillary Fractures
Lower Level fractures (Le-Fort I, Transverse, Guerin)
transverse fracture separating the maxillary alveolus from the
upper mid face

Upper Level Fractures

Le-Fort II(Pyramidal fracture) : separates a pyramid-shaped
central fragment containing the maxillary dentition from the
remainder of the orbits and upper craniofacial skeleton
Le-Fort III (craniofacial dysjunction) : separates the maxilla at
the level of the upper portion of the zygoma, orbital floor, and
nasoethmoid region from the remainder of the upper
craniofacial skeleton

Le-Fort Maxillary Fractures

Maxillary Fractures
Symptoms and Signs
Periorbital hematoma
Nasopharyngeal bleeding
Pain
Swelling on the face
Intraoral lacerations
Malocclusion
Elongation of the face
Maxillary retrusion
Anterior open bite
Abnormal mobility on the dental arc
Rinorea and pneumocephaly (% 25 in LeFort II and III)

Dental Occlusion

Normal occlusion

Mandibular retrognathia

Mandibular prognathia

Bimanual maxillary examination for abnormal movement

Imaging
Plain radiographs : Waters and lateral view
Axial and coronal CT scans of the midface
3 D CT

Waters radiograph

3D CT

Coronal CT

Dish-shaped face, loss of facial projection, bilateral conjunctival hemoraji

Vertical butresses of maxilla and mandible

Goals of treatment

restoration of the proper facial aesthetics including preservation of

midface width, height and projection

Treatment of Maxilla Fractures

Open reduction and intermaxillary fixation and spanning

each of the butresses with plate and screws

Orbital Fractures
Classification
Orbital floor blow-out fractures
Pure (nonfractured infraorbital rim)
Inpure (fractured infraorbital rim)

Orbital fractures (without blow-out)

Lineer fractures
Combined with maxillary fractures
Zygomatic fractures

A- small orbital blow-out fracture is

confined to the orbital floor
B- larger blow-out fracture extends to
involve to the lower medial orbit as well as
orbital floor

Bone graft for repair of medial blow-out

fracture

Symptom and Signs

palpebral and subconjunctival hematoma
Diplopia (most common looking superiorly or inferiorly)
Numbness in the inferior orbital nerve
distribution
Enophthalmos
Positive forced duction test
Radiological evidence of orbital floor fracture
and entrapment of soft tissues on the CT scans
with both axial and coronal views
Assessment of the visual system is essential

Coronal CT

Orbital Blow-out fracture

Treatment of Orbital Blow-out

Fracture
There are two major surgical indications for
orbital fracture repair
Muscle entrapment (confirmed by forced duction and CT scan)
volume increase (> 2cm2 defects enophthalmos and globe
dystopia developes)

Subciliar or transconjunctival approach

Entrapped soft tissues are brought back from maxiillary
sinus
Defect are bridged with bone grafts or alloplastic
materials(silicone, titanium mesh, medpor, proplast etc.)

The Superior Orbital Fissure and Orbital

Apex Syndrome
ptosis of the eyelid
proptosis of the globe
paralysis of cranial nerve III, IV, and VI
anesthesia in the distribution of the first
division of the trigeminal nerve
If blindness occurs in combination with the
superior orbital fissure syndrome, the
condition is termed the orbital apex
syndrome.

Nasoethmoidal Orbital Fractures

Symptoms and signs
Telecanthus
Decrease in the dorsal nasal projection
Rinorea

Treatment:open reduction with a

combination of interfragmentary wiring and
plate and screw fixation

Nasoethmoidal Orbital Fractures

and their treatment

Zygoma Fractures

Symptoms
periorbital and subconjunctival hematoma
numbness in the infraorbital nerve
distribution
epistaxis (ipsilateral or bilateral)
Disturbed occlusion and range of motion
of the mandible (inward displacement of the zygomatic arch)
Lack of prominence of the malar eminence

The Physical Signs

periorbital and subconjunctival hematoma,
loss of prominence of malar eminence,
numbness in the distribution of the infraorbital
nerve
inferior globe dystopia or enophthalmos
inferior displacement of the palpebral fissure.
Step or level discrepancies may be palpated
over fracture sites
tenderness at the sites of the fracture.

periorbital ecchymosis, edema, antimongoloid slant, and

subconjunctival hemorrhage.

Frontal

Worms-eye view.

Axial CT scan
isolated depressed left
zygomatic arch fracture.

The Radiographic Evaluation

Plain films of the Caldwell, Waters, and
submental vertex
Axial and Coronal CT scan

TREATMENT

Treatment of zygomatic fracture with Gillies method

Open reduction and rigid fixation with plates and screws at

frontozygomatic suture, inferior orbital rim, and zygomaticomaxillary butress

Orbitazygomatic fracture- Repositon and rigid internal fixation

Axial CT

Zygomatic Fracture

Nasal Fractures

Various types of
fractures of nasal
bones

Hematoma of Septum

Symptoms
Pain
Swelling
Respiratory obstruction
Crepitation on palpation
Nasal deformity
Deviation of the septum
Mucosal lacerations intranasally
Septal hematoma

Reduction of nasal fracture with an Asch forceps

Mandibular Fractures
the second most common facial bone injury
Mandibular fractures are classified according to
the state of the dentition (dentulous, partially
dentulous, edentulous) or the region of the
mandible in which the fracture occurs (condyle,
condylar neck, ramus, coronoid, angle, body,
symphysis)
They are classified as either open or closed,
depending on whether or not they have a
communication with a skin laceration

subcondylar area
angle region weakened by the
presence of the third molar
tooth
the parasymphysis weakened
by mental foramen and canine
where the long root of the
cuspid tooth

Anatomic regions and frequency of fractures in those regions

Symptoms and Signs

Pain
Swelling
Tenderness
Malocclusion
Frequently, the patient volunteers that the teeth
do not feel like they are coming together
properly.
Numbness in the distribution of the mental nerve
Fractured teeth, gaps, or level discrepancies in dentition,
asymmetries of the dental arch, the presence of intraoral
lacerations, loose teeth, and crepitance indicate the possibility of
a mandibular fracture

Radiographic Evaluation
Plain films: anteroposterior, lateral and oblique views
CT scan
Panorex examination

Panorex examination of mandible

Treatment
The treatment of mandibular fractures involves
establishing proper occlusal relationships and
then providing co-aptation of the edges of the
bone fracture with fixation
Closed reduction and Intermaxillary fixation
Open reduction and rigid internal fixation

Intermaxillary fixation

Treatment of mandibular fracture by application of an arch bar and

plating at the inferior border

Facial Fractures in Children

Facial fractures in children account for about 5% of all facial injuries
Most of these fractures occur in children > 5 years of age
Subcondylar fracture is seen most often
Childrens bones are soft, and frequently displace without fracture
In children, bone healing progresses rapidly. It may be difficult to
reduce a LeFort fracture properly, even after one week
children are able to provide some adjustment with growth such that
minor occlusal deformities
It is often more difficult to apply intermaxillary fixation devices in
patients with primary or mixed dentition because of the shape of the
teeth
The sinuses are small, and the pattern of the orbit and maxillary
fractures is different
Children have shallowly rooted teeth, and the shape of the crowns
may make the application of interdental wires more difficult
An acrylic splint may be used sometimes to align mandibular
fractures. Intermaxillary fixation is generally necessary for only 3
weeks.