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Composed mainly of the frontal bone, temporal bones, nasal bone, zygomas, maxilla, and mandible.
Ethmoid, lacrimal, sphenoid bones contribute to inner portion of orbits
Upper third - above superior orbital rim
Middle third (midface)- superior orbital rim down through maxillary teeth
Lower third - mandible

Maxillofacial
Trauma
Patient evaluation

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History
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Physical exam
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Other systems:
- Airway
- Circulation
- CNS (GCS)

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Orbit
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Nasal airway
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Dental occlusion
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Neurovascular

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Contusion
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Avulsion
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Laceration
(loss of soft tissue – penetrating trauma)

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First, inspect face for deformity and asymmetry
Enophthalmos, proptosis, ocular integrity, ocular movements
Nasal septum for position, integrity, and presence of septal hematoma
Epistaxis or CSF rhinorrhea

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Complete neurological exam must be performed on any patient with suspected facial trauma
Sensation - test all 3 major branches of the trigeminal nerve
Motor function - assess facial nerve by having patient wrinkle forehead, smile, bare teeth, and close eyes tightly

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Palpation of facial structures - the infraorbital and supraorbital ridges, zygoma, nasal bones, lower maxilla, and mandible
Assess for tenderness, bony deformities, crepitus, . . .
Malocclusion or step-off in dentition may be sign of mandibular fracture

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Should focus on bony integrity, fluid-filled sinuses, herniation of orbital contents, and subcutaneous air
Overall status of the patient, physical exam findings, and the clinician’s initial impression determine timing and nature of imaging ordered

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Traditionally the mainstay in the radiographic evaluation of facial trauma
Standard plain film facial series: Waters
(occipitomental), Caldwell
(occipitofrontal), and lateral views
Panoramic films are used to best evaluate mandibular fractures

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Offers a viable, cost-effective alternative to plain films
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Very helpful in the evaluation of facial trauma when facial edema, lacerations, other injuries, or altered level of consciousness limit usefulness of clinical exam

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Limited role of MR in evaluation of facial trauma due to insensitivity of MR to fractures
Used to provide complimentary information to CT in the evaluation of the eye and its associated structures

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Most common site of facial trauma due to location
May be displaced medialy, laterally or posteriorly
Requires control of epistaxis and drainage of septal hematoma, if present

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Class 1 - frontal or frontolateral trauma
- vertical septal fracture
- depressed or displaced distal of nasal bones part
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Class 2 - lateral trauma fracture
- horizontal or C-shaped septal fracture
- bony or cartilaginous septum
- frontal process of maxilla fracture

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Class 3 - high velocity trauma
- fracture extends to ethmoid labyrinth
- bony septum rotates posteriorly
- bridge collapse up
- upturned tip, revealing nostrils
- depressed nasal bones pushed under frontal bones
- apparent inter-ocular space widening

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Diagnosis:
- physical exam (asymmetry, deviation, epistaxis, swelling, . . .)
Radiography:
- do not have a role in management
Timing:
- before 10 days to 2 weeks
- within two hours after injury

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Managements: (closed & open reduction)
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Complications:
- septal hematoma
- CSF leakage
- ophthalmologic compl.

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Tripod fracture: zygomaticofrontal suture, zygomaticotemporal suture, and infraorbital foramen
Present with flatness of the cheek, anesthesia in the distribution of the infraorbital nerve, diplopia, or palpable step defect

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Le Fort I – maxilla
Le Fort II – maxilla, nasal bones, and medial aspects of orbits (pyramidal disjunction)
Le Fort III – maxilla, zygoma, nasal bones, ethmoids, vomer, and all lesser bones of the cranial base
(craniofacial disjunction)
Usually in combination

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Fractures of the orbital floor may occur with orbital wall fractures or as an isolated injury.
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When the orbital floor, being the weakest area, herniation of orbital contents down into the maxillary sinus may occur (hanging drop sign).
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Patients may present with enophthalmos, impaired ocular motility, diplopia due to entrapment of the inferior rectus muscle within the fracture fragments, and infraorbital hypoesthesia.

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Orbital Fractures
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Usually through floor or medial wall
Enophthalmos
Anesthesia
Diplopia
Infraorbital stepoff deformity
Subcutaneous emphysema

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This child presented with diplopia following blunt trauma to the right eye.
On exam, he was unable to move his right eyeball up on upward gaze.

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A: Orbital blowout fracture with displacement of the floor
(arrow), distortion of the inferior rectus, and herniation of orbital fat through defect. Arrowhead indicates medial fracture.
B: Note opacified left anterior ethmoid air cells and displaced medial orbital fracture (arrowheads).

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Frontal Sinus/Bone Fractures
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Direct blow
Frequent intracranial injuries
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Mucopyoceles
Consult with NS for treatment, disposition and antibiotics
Nasoethmoidal-Orbital Injuries
› Lacrimal apparatus disruption
Bimanual palpation if medial canthus pain
CT face

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Fracture of the orbital canal
 Extraocular motor palsies and blindness
 If significant retrobulbar hemorrhage, may need cantholysis to save vision
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› Arch fracture
Tripod fracture
 Most common
 Most serious
 Outpatient
 Lateral subconjunctival hemorrhage
 Need ORIF

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Second most common facial fracture
› Plain films
Often multiple
› Panorex
Malocclusion
› CT
Intraoral lacerations
Sublingual ecchymosis
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Nerve injury
Open Fractures
 Prophylactic Ab.

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Simple
 Greenstick fracture (rare, exclusively in children)
 Fracture with no displacement (Linear)
 Fracture with minimal displacement
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Displaced fracture
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Comminuted fracture
Extensive breakage with possible bone and soft tissue loss
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Compound fracture
Severe and tooth bearing area fractures
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Pathological fracture
(osteomyelities, neoplasm and generalized skeletal disease)
39

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They can be vertically or horizontally in direction
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They are influenced by the medial pterygoid-masseter “sling”
 If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled lingually
 If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled lingually
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Favourable fracture line makes the reduced fragment easier to stabilize
41

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Note fractures in left angle and right body of mandible
Multiple fractures are present more than 50% of the time and are usually on contralateral sides of the symphysis

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Facial trauma is defined as injury to the soft tissues of the face (including the ears) and to the facial bony structures.
May result in hemorrhage and airway obstruction accompanied by multisystem involvement (as many as 60% of patients have associated injuries)
Evaluation includes history, physical exam, and diagnostic imaging

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Reduction of fragments in good position
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Immobilization until bony union occurs
These are achieved by:
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Close reduction and immobilization
Open reduction and rigid fixation
Other objective of mandible fracture treatment:
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Control of bleeding
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Control of infection
45

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No treatment
Soft diet
Maxillomandibular fixation
Open reduction - non-rigid fixation
Open reduction - rigid fixation
External pin fixation
Lag screw

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Arch bars
▶ IMF prior to rigid fixation
▶ For the purpose of close reduction
48

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TMJ ank.
Pediatric
Dental root
Inf. Alveolar N.
airway

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Facial N.
Lacrimal ap.
Foreign body
Borders & margins injury
(Vermilion border- nasal ala- eyelidshelix)