Maxillofacial trauma
Most common cause of facial injuries includes motor vehicle or
motorcycle accident, alteracation, athletic, falls and home accident.
Facial injuries deserve special attention because of their life and aesthetic
significant.
Trauma to face is life threathing because of:
1. Its area of airway passage (mouth and nose)
2. Its very vascular area (carotid arteries, vertebral arteries)
3. It may be associated with other injuries to brain and spine.
Facial injuries classified into:
1. Soft tissue injury.
2. Skeleton injury.
3. Both are affected.
Evaluation and initial management:
1. History: ask about the mechanism of injury and if the patient is
2.
unconscious we take the history from witness which includes the
mechanism of injury, history of previous medical or surgical
disease.
Clinical examination: the examination should be quick and
proper.
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Begin with overall inspection noting any facial asymmetries,
hemorrhage and ecchymosis
Neurological examination of 12 cranial nerves and sensory
examination(ophthalmic, maxillary and mandibular)
All bony surfaces are palpated to assess areas of tenderness,
crepitation or any bone defect.
3. Investigation: these include general blood examination e.g.
Hb, PCV, ESR, WBC count.
Also radiological examination which include:
A. Plain film: which have limited role in the radiological
evaluation of facial trauma. Include:
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Lateral skull film.
Postanterior view.
Panorex radiographs for evaluation of mandible.
Submentvertex view for zygomatic arch.
Spinal vertebral X-ray.
B.maxillofacial computer tomography (CT/SCAN):
which is study of choice for evaluation of most of facial injuries
include axial and coronal.
Emergency treatment:
1. Maintenance of airway: there are many causes of
airway obstruction in facial injuries:
 Bleeding interferes with respiration.
 Displaced facial fractures.
 When there is mandibular fracture, the tongue fall back
against the pharynx.
 Fracture or avulse teeth, vomits, forgien bodies.
 Swelling, edema, hematoma narrowing the airway.
Edema tends to develop within 60-90 mints. So patient initially in
such case have good airway later it become potentially occluded.
The patient place in prone position, and often assures that there is no
cervical spine fracture, the neck is extended.
The obstruction by foreign bodies and avulse teeth can be cleared by
sweeping fingers deeply into mouth and oral pharynx.
In some cases intubations may be needed, when there is a difficulty in
intubations or in patient with significant neck swelling and fracture
mandible are indication of tracheostomy.
2. Control hemorrhage:
although hemorrhage from
facial wound appears alarming, it seldom to be the sole causes of the
shock, except in case of close range shotgun wound.
Hemorrhage can be controlled temporarily by direct pressure.
In rare situation of uncontrolled hemorrhage from nose or
nasopharynx angiographic embolization.
3. Aspiration:
aspiration of blood, saliva or gastric contents
frequently accompanies maxillofacial injury. It prevented by
endotracheal Intubations.
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4. Shock: shock is only occasional causes by facial injury alone.
Extensive facial injury, penetration ocular injury may cause shock by
pain.
When patient with facial injury is found in shock, associated injuries
should be suspected.
5. Identification of other injuries:
e.g. abdominal or
thoracic injuries, intracranial injuries. Cervical spine injuries most
injuries to be missed, so patient should be in cautious move and apply
cervical collar to patient at site of injury.
In case of injury to cranial nerve in face, anesthesia or parasthesia
along the course of nerve indicate fracture proximally. Such as loss of
sensation in lower lip indicate fracture mandibular body.
Where as facial nerve palsy indicates injury to facial nerve which
could be penetrating wounds of parotid or in case of absences of soft
tissue injury may suggest temporal bone fracture.
Soft tissue injuries:
After life threating problem have been resolved, soft tissue injuries are
repaired under local or general anesthesia.
Soft tissues injuries can wait without repair up to 24 hours without
compromising final result provided the bleeding has been controlled
and wound is dressed.
Debridment of wound in face should be conservative.
Soft tissue injuries may include:
 Contusion: which is busing injury cause by blunt trauma, can
be associated with underlying hematoma.
 Abrasion: This is loss of superficial layer of skin.
 Puncture: it may be associated with injury of deep structures.
 Accident tattoo: in which small dermis embedded particles.
 Laceration injury: which most form facial injury and
should be repaired in layers.
 Avulsion injury: in which there is loss of tissues.
 Clean cut injury.
Special region consideration:
1. Cheek and temporal region: high risk of injury to facial nerve
and parotid gland.
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2. Eyelid injuries: required precise alignment of tarsal plate and lid
margin.
3. Lip injuries: align the whitroll and vermilion border first.
4. Eyebrow: should be never shaved and must be repaired with
precise attention to its shape and border. Muscles division under brow
should always repair to prevent spreading and depression scar.
5. Noses: once the bony framework is accurately restored, soft
tissues need only to be approximated According to anatomical
arrangement.
Skeletal injuries:
Maxillary fractures:
Lefort fractures first described by anatomist Rene le fort in 1901.
1. Lefort Ι (transverse fracture): it separated maxillary alveolus
at the lower margin of pyriform aperture and extended through
maxillary sinus.
2. Lefort ΙΙ (pyramidal fracture): extended from lefort Ι
through infrorbital rim and cross the bridge of nose either high or low
fashion.
3. Lefort ΙΙΙ (craniofacial disjunction): the fracture line
extended across the floor of the orbit and up through nasofrontal area
separated the frontal bone from zygoma and orbit. 
Mandibular fractures:
The neck of condyle is the most common site fallowed by the angle of
mandible; the least common site is the region of canine tooth.
Mandibular fracture can be classified according:
1. Region of mandible: condyle and condylar neck, ramus,
coronoid, angle, body, symphysis.
2. Open or closed: depending on whether or not have
communication with skin laceration.
3. according to direction: whether oblique, transverse,
comminuted.
Usually patient presented with pain, swelling, tenderness and
malocclusion. Also numbness in distribution of mental nereve, bleeding
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from laceration or from socket of tooth, trismus (pain on moving the jaw)
is noted
On palpation we can feel crepitus, tenderness and when patient to open
his or her mouth ask, the jaw deviated toward one side.
Radiographic evaluation of mandible consists of plain film, CT/SCAN,
Panorex examination.
Zygomatic fractures:
May result in disarticulation
zygomaticomaxillary sutures lines.
of
zygomatictemporal
and
Clinical features:
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Malar flattening.
Infraorbital nerve parasthesia.
Tenderness and brusisng.
In case of isolated zygomatic arch fractures there will be limitation
of mandibular range of motion.
Bony orbit fractures:
Inferior and medial wall are most frequently involved usually patient
presented with diplopia due to injury of muscles or nerve,and also
presented with subconjectival hemorrhage. patient could presented with
enopthalmus i.e. inward movement of eye globe due to pressure from
outside or patient could presented with exopthalmus which indicated
retrorbital hematoma.
Nasal bone fractures:
Nasal fractures are either laterally or posteriorly displace.
Symptoms and signs:
1. Swelling over the external surface of the nose with swelling in the
medial orbital region.
2. Pain, respiratory obstruction.
3. Crepitation, nasal deformity, septum deviation.
4. Nasal bleedings (epistaxsis)
5. Mucosal laceration presented with hematoma.
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Radiographic examination is not absolutely indicated and usually need to
exclude other injuries.
Treatment:
1. Septal hematoma should be drainage surgically because it causes
dissolution of the cartilage because of pressure necrosis.
2. Corticosteroids are used to minimize edema and facilitated
evaluation of fracture reduction.
3. epistaxsis can be arrest by:
 Raise head up.
 Cold bandage.
 Pressure on nose externally.
 Or by internal pressure by gauze with Vaseline.
4. Management of fractures should done immediately before a
significant edema is developed or after edema is resolve usually after 5-7
days during this period the patient should give steroid and antibiotics.
Management of fractures by refracturing the bone and reposition of nasal
bone in proper architecture, and with used of internal packs with jipsona
used externally to hold the bone.
Internal packs are removed in day 3, while external jipsona are removed
in 12 days.
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