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Maxillofacial Trauma
Waseem Jerjes
Size of the problem
• Total no facial injuries = 500,000
– 832 per 100,000 population– 340,000 male– 160,000 female– 140,000 are serious injuries
Causes
• Falls 40%• Interpersonal violence 34%• Sports / other 21%• RTA 5%
General principles (remember)
• Primary and secondary survey
• Reconstruction of soft tissues
• Accurate diagnosis• Early surgery (14 days)• Expose all bony fragments• Rigid fixation (IMF, ORIF)• Immediate bone grafting
Look
– Hemorrhage– Otorrhea– Rhinorrhea– Contour deformity– Ecchymosis– Edema– Continuity defects– Malocclusion
Radiographical Investigations
• OPG, PA Mandible (lower third #s)• OM 0, 15, 30 (Middle third #s)• CT (upper third #)
• CT, MRI can be always requested when indicated
Soft tissue injuries of the oral & maxillofacial region
• Skin (minimal debridement)-Nylon 5-6/0
• Muscles+SC tissue-Vicryl 4/0
• Intraoral lacerations-Vicryl 3-4/0
• Small vessels ligation-Vicryl 3/0
• Big vessels ligation-4/0 Prolene
Soft tissue injuries of the oral & maxillofacial region
• Facial nerveEpineural suturing or reapproximation of the ends-
high success rate
• Parotid ductSuspect injury if weakness of the buccal branches
of the facial nerve identifiedExamine the duct opening (stimulate, probe),
repair over thin stentSalivary collections and fistulas, stenosis and
parotitis
Soft tissue injuries of the oral & maxillofacial region
• Lacrimal apparatus Canaliculi, lacrimal sac or duct-repair over
thin silastic stent-insert along the length of the lacrimal system
Hard tissue injuries of the oral & maxillofacial region
• Immediate management • Airway and cervical spine controlStabilization with hard collarRemove vomits, blood, broken teeth and
denturesChin lift, jaw thrust or reduce mid face #Intubation, cricothyroidotomy, tracheostomy
Cervical spine
• High risk groups• Mandible - C1 C2 #• Midface - C5 C6 #
• Assume present
Hard tissue injuries of the oral & maxillofacial region
• BreathingAdequate ventilation and exclude co-existing chest
injury
• Circulation and control bleedingCannulae, infusion, bloods, transfusion Manual reduction of fractures (orthodontic and K
wires) and nasal packing can reduce bleedingPacking and facial bandaging External carotid ligation (behind ramus, maxillary
sinus)
Associated injuries
Ophthalmic assessment10% of patients with facial fractures have
associated eye injuries 10% of patients with major facial fractures
have cervical spine injuries
Mandibular fractures
• Symptoms and signsPain, trismus, malocclusion, crepitus,
bruising (oral/facial), step (mandible border/dentition), paraesthesia (IAN, LN, MN), haematoma
• Locations: condyle, body, angle, symphysis, parasymphysis, alveolus, coronoid process
Mandibular fractures• Common patternsAngle + contralateral bodyParasymphysis and contralateral condyleGuardsman
Deviation on opening-toward the side of the mandibular condyle fracture
Favourable or unfavourable (muscle action)
Radiological investigations (OPG, PA mandible)
Mandibular fractures• Conservative management-unilateral
condyle, symphysis, undisplaced #s• ORIF-monocortical or bicotical screws1 plate (Champy’s-muscles), 2 plates• IMF (arch bars+wires)-condyle. Bilateral
condyles?IMF 3-6weeks, oral hygiene, feeding,
breathing• External fixation (extensive defects,
osteomyelitis)
No displacement>30o Medial rotation>5mm bone overlapLoss of bone contact
Zygomatic fractures• Occurs in a tetrapod fashion Zygomatic process (ZF suture)Greater wing of sphenoid MaxillaTemporal bone (arch)
• Symptoms and singsBruising and swelling (oral/facial), malar
depression, step deformity, subconjunctival haematoma, trismus (coronoid)
Zygomatic fractures
• Symptoms and singsEpistaxis (lining maxillary sinus),
paraesthesia (ION), enophthalmos, dystopia (lateral, vertical or both), diplopia (tethering), reduced visual acuity (retinal detachment)
• Radiological investigations (OM 0, 15, 30), then CT (orbital floor/blow out/panfacial)
Zygomatic fractures
• Locations Undisplaced fracturesIsolated arch fractureUnrotated body fractureBody fracture with medial rotation (ZF)Body fracture with lateral rotation (ZF)Complex fracture (lateral maxillary wall)Associated with orbital floor fracture
Zygomatic fractures
• ManagementConservativeGillies’ liftORIF over 1-3 sites
(ZF, infraorbital rim, lateral maxillary wall)
Maxillary fractures• Le Fort fractures (often asymmetrical)I (Geurin): the “floating palate” fracture Contains alveolus, palate, pterygoid platesII: the “pyramidal” fracture Contains bulk of maxilla, lacrimal crests, piriform
margin, alveolus, palateIII: “craniofacial dysjunction”Contains: detachment of midfacial skeleton from
cranial base
Saggital fractures and dentoalveolar
Maxillary fractures• Symptoms and signs Bruising and swelling (oral/facial),
haematoma, Battle’s sign, malocclusion, epistaxis, enophthalmos, diplopiam paraesthesia (ION), step deformity
Dish-face appearance (displacement) Movement of segments can differentiate
Radiological investigations: OM? CT? 3D-CT
Levels of Maxillary Fractures
Maxillary fractures
• ManagementConservative (non-union)ORIF (bone grafting)
Orbital fractures
• Occurs with:1. Zygomatic fractures2. Nasoethnoidal fractures3. High Le Fort fractures• Isolated fractures-pressure applied to
globe• Orbit fracture at weakest point-
inferomedial floor-paper layer fracture
Orbital fractures
• Symptoms and signsBruising and swelling, subconjunctival
haematoma, periorbital haematoma, step deformity, enophthalmos, diplopia
Radiological investigations: PA skull, OM (tear drop sign, fluid level), CT
Orbital trauma
Penetrating injuryVisual acuityOcular movements
Orbital fractures
• ManagementConservative SurgeryAutologous tissue (split calvarial bone graft,
rib, iliac crest, superficial segment of anterior maxilla)
Alloplastic material (titanium-mesh, Gore- Tex, Silicone, Medpor wafers)
Nasal Fractures• Most commonly fractured nasal bone• Lateral impact-deviation of nasal septum and
bones• Frontal impact-collapse of the nasal dorsum,
splaying of the nasal bones, dislocation of the septum
• Plane 1: disruption of the cartilagenous cartilage. Plane 2: disruption of the bony septum and nasal bones. Plane 3: involve the piriform aperture and medial orbital rim (mild NE #)
Nasal Fractures• Symptoms and signsBruising and swelling, obvious deformityCheck for septal haematoma-pressure-septum
necrosis• Radiological investigations: PA and lateral skull • ManagementConservativeRelocate the nasal septum and nasal bones
followed by packing and splintingSecondary rhinoplasty
Nasoethmoidal fractures
• Caused by trauma to the interorbital region
• Occurs with ethmoidal sinus, medial orbital wall, root of nose #s
• Symptoms and signsBruising and swelling, step deformity,
telecanthus (medial canthal tendon), enophthalmos, diplopia
Radiological investigations: CT
Nasoethmoidal fractures
• ManagementConservativeORIF Nasal bones elevation and nasomaxillary buttress
reconstructionMedial canthal tendon: plating, transnasal fixation
Lacrimal system, no exploration, injuries settle within 6 weeks
Frontal sinus fracture
• Symptoms and signsDepression or laceration over the supraorbital
ridge, glabella, or lower forehead, bony defectMay be associated with NOE complex and midface
(nasofrontal duct)CSF rhinorrhea-posterior table frontal sinuscan result in cosmetic deformity and mucocele
formationRadiological investigations: CT
Anterior wall Posterior wall
Combined anterior + posterior wall
Classification of frontal sinus fractures
or
Frontal sinus fracture• ManagementConservativeORIF of the anterior wallSinus obliteration and ORIF of anterior wall
(damage drainage system)Cranialization (CSF leak)Cranialization with dural repair
• Complications: meningitis, cerebral abscesses, mucoceles, osteitis
High resolution CT scans required
Note: Combined anterior/posterior and posterior wall fractures will almost certainly involve the duct
Obstruction of drainage
Chronic sinusitis
Mucopyocele
Osteomyelitis
Brain abscess
Possible result of blocked fronto-nasal duct
Retrobulbar Haemorrhage
• Bleeding into non yielding space, the orbit, cause an increased orbital pressure
• This causes impaired venous outflow and increased intraoccular pressure and decreased perfusion
• Resulting in ischaemia and retinal infarction and blindness
Retrobulbar haemorrhage
PainProptosisLoss of visual acuity
Retrobulbar Haemorrhage
• Diagnosis is important, 90 minutes to correct vascular insult or irreversible damage results.
• TreatmentMedicalMassage eye redistribution of extraoccular fluidSit patient up & sedateMannitol 20% 2g/kg iv over 4 minutes monitor
U&Es repeat 6 to 8 hourlyAcetazolamide 500mg iv (delayed effect)
Retrobulbar Haemorrhage• TreatmentMedicalMegadose corticosteroids 3-4 mg/kg
dexamethasone sodium phosphate followed by 1-3 mg/kg 6 hourly for 5 to 7 days (reduces secondary injury)
Papaverine (smooth muscle relaxant) 30-60 mg iv slowly over 1 to 2 minutes can be repeated 3hrly
If no improvement after 20 to 30 minutes surgical decompression is indicated
Retrobulbar Haemorrhage
• Treatment SurgicalIf post-operative and orbital septum violated
simple remove all suturesLateral canthotomy with or without
cantholysisTransantral ethmoidectomy (Lynch)
Summary
Thank you