5.0 Diagnosis and Management
Maxillofacial Trauma
of
Hard
Tissue
Trauma - "Physical force that results in injury"
Learning objectives
At the end of this session the learner should be able to:
List the priorities in the management of a trauma victim
Describe immediate first aid measures for facial injuries
Describe a system of assessment of patients with facial trauma
List appropriate investigations to aid in assessment & diagnosis
The first contact
ATLS... ABCDE
GCS and pupillary exam
Secondary survey
A complete secondary survey is a head to toe examination in which the maxillofacial
region is one part.
The secondary survey starts with the history. From patient or witnesses or
paramedics.
History
A
allergies
M
medications
P
past medical history
L
last meal
E
events (of present episode)
Time, place, mechanism of injury.
Loss of consciousness
Maxillofacial Examination
Facial Thirds
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EXTRA-ORAL
Inspection
Bleeding / CSF leak
Symmetry
Swelling
Skin
Facial animation (VII)
Mouth opening and deviation (record maximal inter-incisal distance)
Palpation
Tenderness
Bony steps
Mobility/Crepitation
Facial sensation (V)
INTRA-ORAL
Inspection
Check occlusion
Haematomas or lacerations
Teeth examine and record
Gaps or steps in dental arches
Palpation
Tenderness
Abnormal mobility
Le Fort levels
Radiographic examination
OPG
Facial bones and SMV
CT scans
CLASSIFICATION OF FRACTURES
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Closed
Open
Comminuted
LOWER THIRD
Anterior mandible - # between mental nerves (Symphysis / Parasymphysis)
Body - Behind mental nerve but anterior to masseter
Angle - Fracture posterior to the anterior border of masseter and below mandibular
foramen
Ramus - Fracture above mandibular foramen
Subcondylar
Intracapsular
Coronoid
Dento-alveolar
MIDDLE THIRD
Le Fort 1
Le Fort II
Le Fort III
Zygomatic
Nasal
Naso-Orbital
Naso-Ethmoidal
Orbital
UPPER THIRD
Frontal Bone
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SPECIFIC SYMPTOMS AND SIGNS and RADIOGRAPHIC EVALUATION
Mandibular fractures
Mental paraesthesia or anaesthesia
Deranged occlusion
Radiographs: OPG and PA mandible
Middle third fractures
Deranged occlusion
Mobility of middle third according to level of fracture
(Look for evidence of midline palatal split)
Infra-orbital paraesthesia (Le Fort II & III)
CSF Rhinorrhoea (Le Fort II & III)
Radiographs: Occipito-mental, Submento-vertex, ?CT with reformat
Zygomatic fractures
Trismus
Infra-orbital paraesthesia
Flattening
Radiographs: Occipito-mental, Submento-vertex
Internal Orbital (Blow-out fractures)
Diplopia
Tethering of eye movement
Infra-orbital paraesthesia
Ophthalmic / Orthoptic evaluation strongly recommended
Radiographs: Occipito-mental and CT in coronal plane
Orbital roof fractures (Superior orbital fissure syndrome)
Orbital apex involvement may be associated with optic nerve injury
Retrobulbar haemorrhage – rare but potentially sight-threatening.
Can complicate any periorbital trauma or surgery.
Characterised by pain, proptosis, deteriorating vision, paralysis of eye & dilating pupil
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Nasal
Deformity
Septal deviation
Radiographs are normally NOT required
Naso-orbital
Palpable step of orbital rim with clinically intact zygomatic complex and usually no
infra-orbital paraesthesia
Radiographs: Occipito-mental
Naso-Ethmoidal
Nasal tip elevation with loss of nasal profile due to impaction of nasal bridge.
Canthal detachment (Normal intercanthal distance in adults 31-33mm)
CSF Rhinorrhoea
Radiographs: Occipito-mental and lateral face + CT scans in transverse plane + 3D
reformat
Frontal
Deformity
CSF Rhinorrhoea
Radiographs: Occipito-mental + CT scan in transverse plane
A simple mnemonic can be applied to the clinical examination of patients with facial
fractures which can be helpful in indicating the presence or absence of fractures in
the early stages when deformity, steps, asymmetry, mobility, diplopia and other signs
may be masked by swelling and examination is difficult due to pain.
B
Bruising
O
Occlusion
O
Opening
B
Bleeding
E
Eyes
S
Sensation
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Bruising: External bruising is not necessarily indicative of a fracture, it just means
that the patient has been hit by something. However, some bruising is more
significant and should raise your suspicions of a broken bone: Bilateral periorbital
bruising (“Panda eyes”) is commonly associated with middle third, pan-facial and
anterior skull base fractures. Battles sign is bruising over the mastoid process and is
suggestive of a middle cranial fossa skull base fracture – this sign can take
hours/days to develop. Palatal bruising is highly suggestive of a fracture of the
maxilla but can take hours or days to develop.
Occlusion: If the patient has teeth then the occlusion is a very sensitive indicator of
possible fractures involving tooth-bearing bones. If the patient has a history of
trauma to the face and complains of a deranged occlusion then there is a fracture
present until proved otherwise. The occlusion mey be deranged in zygomatic
fractures because occasionally the zygoma may be driven inwards and displace the
maxilla (or a dento-alveolar segment) downwards.
Opening: Mouth opening may be painful, limited or may deviate – all of which may
suggest a fracture. Mandibular fractures will usually be associated with painful,
limited opening and if a condyle is involved then the jaw may deviate towards the
side of the fracture (unlike a unilateral dislocation when the jaw will deviate away
from the affected side). Mouth opening may be limited and painful in the presence of
a zygomatic fracture because a depressed zygoma may impinge on the coronoid
process of the mandible
Bleeding: Subconjunctival haemorrhage without posterior limit means a broken
orbito-zygomatic bone until proved otherwise. A subconjunctival haemorrhage with
posterior limit or no haemorrhage at all DOES NOT exclude a fracture.
Sublingual haematomas with a history of facial trauma means a broken mandible
until proved otherwise. This sign can take many hours or days to develop and its
absence in the early stages does not exclude a fracture.
Eyes: Eyes are commonly injured as part of oral and maxillofacial trauma and
should always be included in your examination. Diplopia and enophthalmos are
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associated with orbital wall blow-out fractures but are often not evident until the
swelling has substantially resolved.
Sensation:
Numbness of the lower lip in the context of facial trauma is highly
suggestive of a fractured mandible (lying somewhere between the lingula and the
mental foramen) and numbness of the cheek, nose, upper lip or maxillary teeth
indicates a fracture involving the orbitozygomatic complex. Numbness of the
maxillary teeth alone can be a subtle sign of an orbital floor fracture affecting
branches of the middle or anterior superior dental nerve.
FIRST AID
Manually reduce maxilla if displaced/mobile and associated with troublesome
haemorrhage. Temporarily stabilise with your fingers or gags, or get patient to bite
on props (NOT IF THERE IS ALSO A FRACTURED MANDIBLE)
Nasal packs to control epistaxis (use of dedicated balloon catheter / urinary
catheters in an emergency). Nasal packing will be ineffective if the maxilla is mobile
and you have not taken steps to temporarily stabilise it (see above)
Bridle wire to stabilise fractures involving the dental arches.
Analgesia may be required but avoid use of opiates in head injured patients.
Fractured teeth may require dressing or pulpectomy.
DEFINITIVE TREATMENT
When possible study models are very helpful in planning treatment and can also be
used to fabricate custom arch bars when required.
Reduction (Open or Closed)
Fixation (Internal or external)
Immobilisation
Physiotherapy
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POST-OPERATIVE CARE
Intermaxillary fixation (IMF)
This has implications in relation to airway maintenance. Patients may require high
dependency nursing. Nursing staff may be required to release IMF in an emergency
and should therefore be shown how the fixation may be released.
Oral Hygiene
This is important in preventing wound infections. Patients should be requested to
refrain from smoking for a period of at least 2 weeks following surgery.
Eye Observations
Regular eye observations should be carried out for all injuries associated with orbital
fractures, especially internal orbital fractures. This is normally performed by
competent nursing staff.
Removal of internal fixation
This is sometimes necessary following successful bony union and is usually
indicated when plates and screws become infected or symptomatic.
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