Faciomaxillary trauma Classification Diagnosis and Management

1. Facio-maxillary injuries
classification – diagnosis-
management
P r e s e n t o r : D r. S i va s a n k a r
Po s t G ra d u a t e
G e n e ra l s u r g e r y

2. Introduction
Maxillofacial
trauma
Soft tissue,Skeletal and Visceral Injuries
Nasal, A u d itor y, Man d ib u lar or O c u lar F u n c tion
Interfered
D isfig u rement & D isab ility  Psyc h olog ical
Trau ma

3. Etiology
• Motor Vehicle Collision
• Assault
• Falls
• Gun Shot wounds and War injuries
• Sports Accidents
• Occupational – Industrial Mishaps

4. Faciomaxillary trauma associated
with
• Airway compromise
• Blindness
• Concomitant Traumatic Brain injury
• C- Spine injury
• Poly trauma

5. Phases of Facio maxillary trauma
Management
• Emergency Care
• Initial Care
• Definitive Care
• Reconstruction

6. Phases of Facio maxillary trauma
Management – emergency Care
Phase
• Preserve Airway or Establish if Compromised
• Check for Breathing and Ventilate mechanically if need
• Control Bleeding and ensure Circulation
• C-spine Stabilization
• Control Life threatening injuries associated
 Head Injuries
Chest Injuries
Fractures
Intra abdominal Bleeding

8. Airway management
• Complications:
• Airway compromise
• Haemorrhage
• Trismus
• Cervical spine injury
• Pneumoencephalus
• Injury to oesophagus
• Subcutaneous emphysema and pneumomediastinum

9. SIMPLE AIRWAY STRATEGY
• Chin lift,
• Jaw thrust,
• Administration of 100% oxygen.
• Placement of an oropharyngeal , nasopharyngeal airway or LMA ,
in inadequately breathing patients, ventilation with a self-inflating bag.

10. Definitive airway
1. Direct laryngoscopy and tracheal intubation.
2. Video laryngoscopy and intubation.
3. Fibre-optic tracheal intubation.
4. Lightwand-guided tracheal intubation
• ATLS guidelines suggest that airway management provider should
proceed with the method of intubation with which they are most
proficient.

12. Phases of Facio maxillary trauma
Management – INITIAL Care Phase
• Emergency care of Stabilised patient
• Initial Stabilisation of Fractures
• Debridement & Dressing of Soft tissues
• Elective Surgical Airway
• Physical Exam & History
• Lab tests
• Complete H&N Examn.
 Diagnosis of Faciomaxillary Injuries

13. History
• History related to Head Injury
• History of blindness/ Diminished Vision
• History of hard of hearing
• History of Double Vision
• History of Numbness or Tingling
• History of Pain in Jaw movements

14. Inspection
o Foreign bodies
o Facial Asymmetry
o Nasal Deviation
o Septal Hematoma, CSF Rhinorrhea
o CSF Otorrhea , Blood in EAM
o Malocclusion and Loss of teeth
o Battle Sign and Raccoon Sign

15. Battle sign & Raccoon Sign
Suggestive of
Basilar #

16. CSF Otorrhea and Rhinorrhea

17. Palpation
• Step Defect
• Crepitus –
• Bone “give away”
• Subcutaneous Emphysema
• Mobility

18. Cranial Nerve Examination
• Visual and Pupillary changes CN II
• Abnormalities of Ocular Movements CN III IV VI
• Motor Function of Facial Muscle CN VII
• Muscles of mastication CN V
• Sensation facial area CN V

19. Classification
Maxillofacial
trauma

20. Soft tissue injuries
1
• UPPER FACE
• Scalp ,Forehead, Brow
2
• MIDDLE FACE
• Eyelid and lacrimal system/ Nose
3
• LOWER FACE
• Lip and Intra Oral

21. Soft tissue injuries
• Contusion
• Abrasive injuries
• Lacerations
• Avulsive injuries
• Accidental tattoo
• Puncture wounds

22. Accidental tattoo
(Dermal imbedded particles)
• Should be removed promptly from abrasion
• Fixation occurs in 24 -48 hrs
• Scrub with stiff bristle brush to remove

23. Soft tissue Facial Injuries - General
• Rich Blood Supply – Large Laceration survive with Small Pedicles
• “Good Wash, Limited Debridement , Apt Antibiotics ”

24. Soft Tissue Facial Injuries- Lip
• Fibres of Orbicularis Oris Run transverse – gives FALSE Appearance of
Avulsion
• Survey: Oral Mucosal Injuries/ Foreign Bodies
• Good Wash, Primary Closure (Mucosa [Avoid Salivary Contamination] &
Skin)
• Suturing by Alignment Vermilion Border
• Gram NEGATIVE ANAEROBES Cover

25. Soft Tissue Injuries- Avulsive Faciomaxillary
Injuries
• MVC Impact/ GSW close Range- Full Thickness tissue Loss
• Asso. With Hypovolemic Shock, Airway Impairment
• Serial Saline Dressing Parallel (from ABC to hemodynamic Stability)
• Serial Wound Debridement to address Necrosis and evolving tissue
loss
• Reconstruction ( tissue transfer- Local/ Regional/Free Flap)

26. Skeletal Injuries - FACE
U p p e r Fa c e1
• FRONTO ZYGOMATIC, FRONTAL SINUS AND FRONTAL
BONE
M i d d l e Fa c e2
• ZYGOMATIC ARCH, NASAL BONE, ORBIT, NASO
ETHMOID AND MAXILLA
L owe r Fa c e3
• MANDIBLE

27. Nasal Fractures
• MC facial Fracture
• Nasal Deformity in Laterally Displaced fractures- Inspirational Difficulty
• Posterior Displacement with Extension to Frontal And Ethmoid Bones
• Cl/F: Facial Edema, Ecchymoses, Bony Crepitus, nasal deformity, Epistaxis

28. Nasal Fractures
Nasal Mucosa has Rich
blood supply : Hemorrhage-
Hematomas Risk
Septal Hematoma – Rx –
drainage (to prevent Septal
Necrosis, Perforation, Saddle
Nose Deformity.)
Epistaxis – Nasal Packing,
Baloon compression, LA+
Adrenaline

29. Nasal packing

30. Nasal Fractures - Management
• CT is IMAGING OF CHOICE as it defines anatomy and severity of #
better
C l o s e d R e d u c t i o n u n d e r LA – Simple Nasal #,
O p e n R e d u c t i o n u n d e r GA – Open #/Nasal retrusion,
Persistent Deformity

31. Naso-Orbit-Ethmoid #
Marcowitz and Mason
Classification
based on whether the medial canthal
tendons attached the central fragment.
 Type I injury, - medial canthal tendon
attaches a single-segment central
fragment (A).
 Type II injury - central fragment is
comminuted, with the medial canthal
tendon attached (B).
 Type III injury - MCT is separated with
the comminuted central fragment

32. Naso-Orbit-Ethmoid #
• Re attachment of MCT significantly impacts the facial function and
appearance.
• Transnasal wiring achieved after adequate exposure via coronal
incision, and surgeons needed to drill two (for unilateral injury) or
four holes (for bilateral injury) in medial orbital wall reconstruction,
which must accord to the position where the MCT normally attaches

33. Maxillary Fractures
• LeFort I – (Guerin fractures/floating maxilla)
Horizontal #,Oral-located above roots of tooth, Maxillary part- Mobile
• LeFort II -Pyramidal Outline, Nasal bone fracture
• LeFort III –suprazygomatic fracture
Complex , Cranio Facial Dissociation, Orbit fracture
Substantial Bleed from Nose or/and Oral cavity
NG tube is contraindicated

34. II
II
I
III

36. Investigation:
CT scan with 3D reconstruction

37. MANAGEMENT
• Open reduction and intermaxillary fixation should be
performed to establish correct occlusion
• Followed by rigid fixation at the piriform rims and
zygomaticomaxillary buttress

38. Zygoma Fractures
• Tripod # - Zygomatico Maxillary Complex;
• Quadramalar #- ZMC+Sphenoid
4 principle fracture lines
• Lateral orbital rim
• Inferior orbital rim
• Zygomatic arch
• Zygomatico maxillary buttress

39. Cl/f:
• Infraorbital nerve trap – Paraesthesia of I/L cheek
• Periorbital ecchymosis and Edema.
• Facial Emphysema – secondary to Maxillary sinus disruption.
• Loss of Malar prominence
• Trismus- Zygoma impinges on coronoid process
• Bone Step Deformity – Zygomatico Frontal suture, Zygomatic arch,
inferior orbital Rim

40. • Ophthal Consult to rule out globe injury before Surgical intervention.
• CT is IMAGING OF CHOICE as it defines anatomy and severity of #
better:
• layering of blood in maxillary sinus,
• Tripod #,soft tissue air emphysema
• Non displaced # - Conservative ;
• Displaced # -ORIF

41. MANAGEMENT - surgical fixation

42. Mandibular Fractures
• 2nd MC Facial #.
• 10% Asso. With Head and c spine injuries.
• Muscles attached to Mandible contract to distract the fracture
segments.
• Inferior Alveolar Nerve trapping.
• Cl/F: Malocclusion of teeth, trismus.
• Asso. Dental injuries causes bleeding – sublingual hematoma

44. Investigations
• OPG Imaging of Choice;
• CT images defines Suture lines & segments.
• 3D reconstruction of fracture helps in surgical planning.

46. Reduction and fixation
1. Closed reduction is done by manual manipulation of the teeth or
gradual reduction by elastic traction done, e.g. simple and undisplaced
fractures can be reduced by closed method.
2. Open reduction is done by direct vision, i.e. by exploration of
fracture (e.g. widely displaced, multiple fractures are reduced by open
method).

47. Orbital Fractures
• High force to thin orbital bones – “Blow Out” Fashion
• Floor > Medial wall of orbit often fractured.
• Soft tissue emphysema due to Maxillary Sinus involvement.
• Muscle Entrapment – Inferior Rectus and Inferior Oblique muscle
involvement – Diplopia, upward gaze restriction in I/L eye.
• Globe injuries like corneal abarasion, hyphema, Globe rupture.
• Exophthalmos initially followed by enophthalmos after edema settles,
Epistaxis.
• Coronal CT useful in defining soft tissue details and fractures.

49. Ocular Injuries
• MC cause of monocular blindness
• Blunt/ Penetrating/ impalement / MVC Airbag deployment
• Asso. with Orbit #- so Ophthal. Consult routine
• Usually Missed Blunt trauma asso. Ocular Injuries can be picked in
Ophthal. examn.
• VA, Light perception and projection of Injured and Uninjured be
Mandatorily documented.

50. • Cl/F: Orbital pain,visual changes, eno- /exophthalmos, hyphema,
decreased Eye movments
• CT scan to assess Soft tissue injury, #, retained foreign Body or
ruptured globe.
• Ruptured Globe – Most serious – early evaluation essential.

51. Parotid Injury
• UNCOMMON
• Need to aptly address to
avoid complication
• Parotid Duct injury must be
considered.
• Line between Tragus to
Middle of upper lip
• Stenson’s Duct 7cm long
• Associated with buccal
branch of Facial n. injury.

52. • Massage and induce Salivation or Cannulate papilla in front of
Second Molar
• Sialography +/- CT is Highly Sensitive
• consensus in the literature that acute parotid injuries should be
explored primarily and the injured structures repaired, if possible

53. Facial Nerve Injury
• Facial nerve Injury revealed from
impairement of its physiologic functions :
lacrimation, salivation, and eye closure.
• MRI with gadolinium enhancement for
soft tissues
• CT is ideal for assessing bony structures
• Asso. with temporal bone fractures
(more with Transverse than Longitudinal
#)
• Longitudinal is MC 80% Temporal bone
fracture.
• GSW/ Penetrating are other causes

54. • Corticosteroids are commonly used as primary therapy or an adjunct
to surgical intervention
• nerve repair should be followed, including performance of direct end-
to-end nerve anastomosis (for transected nerves) or interpositional
nerve grafting, whichever can offer tension-free secure connection.
• Interposition grafts or cable grafts -with the sural nerve or greater
auricular, or hypoglossal-facial nerve anastomosis

56. Trigeminal nerve Injury
• Signs and symptoms are highly dependent branches affected. V1,
V2, and V3 and their specific branches present chronic and burning
pain to paresthesias and difficulty chewing
• inferior alveolar and lingual nerves are the most commonly injured
peripheral branches of the trigeminal nerve.
• Infraorbital nerve is also susceptible to injury

57. • MRI Imaging of Choice
• . Timing of surgery varies by cause
• Immediate repair, if Possible OR
• Delayed reconstruction, in gross wound contamination, and large soft
tissue defects.
• Delayed repairs within 1 week, or when early secondary repair has
started (granulation tissue formation, etc.), also have excellent
prognosis for recovery of sensation

58. Dento Alveolar injury
• Tooth injuries
1. Luxation
Complete
Partial
2. Subluxation
3. Fracture

59. Dento alveolar fracture
• Any portion of alveolar process involved.
• Maligned and displaced teeth.
Cl/f
• Soft tissue laceration
• Damage to teeth
• Alveolar fracture

60. Management
• Dentoalveolar fracture requires early reduction and stabilisation or
immobilisation by splinting to adjacent stable teeth.
• The wiring techniques are simple and rapid immobilisation of the
alveolar segments utilising the teeth for support is possible:
1. Direct interdental wiring
2. Continuous or multiple loop wiring
3. Arch bars—Stabilisation with arch bars give the best form of
immobilisation, though sometimes a simple resin composite splint may
also help

61. Dental wiring techniques

62. Route of feeding after faciomaxillary trauma
and postoperatively
• Oro and naso gastric feeding
• Cervical pharyngostomy
Alternative feeding method for patients with severe facial trauma
Advantage –nasal and oral cavity can be kept clear of tubes

64. THANK YOU