Faciomaxillary Injuries

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Faciomaxillary Injuries

  1. 1. Faciomaxillary injuries
  2. 2. Learning Objectives <ul><li>To be able to recognize life threatening nature of facial injuries – Airway obstruction, associated head & spinal injuries. </li></ul><ul><li>Method of examining facial injuries </li></ul><ul><li>Classification of facial # </li></ul><ul><li>Diagnosis & principles of management of facial injuries </li></ul><ul><li>To appreciate the importance of careful cleaning & accurate suturing of facial lacerations. </li></ul>
  3. 3. Causes <ul><li>Sporting activities </li></ul><ul><li>Road traffic accidents </li></ul><ul><li>Intentional violence </li></ul>
  4. 4. Clinical effects <ul><li>Injuries to facial skeleton -> </li></ul><ul><li>Immediate airway obstruction </li></ul><ul><li>delayed airway obstruction </li></ul>
  5. 5. Immediate airway obstruction <ul><li>inhalation of tooth fragments </li></ul><ul><li>accumulation of blood & secretions </li></ul><ul><li>loss of control of tongue in unconscious/ semiconscious pt. -> </li></ul><ul><li>Nurse in semi prone position </li></ul>
  6. 6. delayed airway obstruction <ul><li>edema of tongue </li></ul><ul><li>pharyngeal structures </li></ul>
  7. 7. Examination of the pt. <ul><li>spinal & head injuries - Edema of face makes routine examination of face & head injuries observations difficult. </li></ul><ul><li>Lacerations should be explored and cleansed, </li></ul><ul><li>Whole head should be checked- occiput, mastoid </li></ul>
  8. 8. Examination of the pt. <ul><li>Facial asymmetry & displacements examined from the front </li></ul><ul><li>Gentle palpation wearing sterile gloves over the face & inside the mouth will detect step deformities, bone fragments </li></ul><ul><li>Middle third # -> Epistaxis </li></ul>
  9. 9. Examination of the pt. <ul><li>Le Fort II & III # may be associated with CSF rhinorrhoea </li></ul><ul><li>Zygoma # -> subconjunctival hemorrhage </li></ul><ul><li>Cranial nerves </li></ul>
  10. 10. Radiology <ul><li>Posteroanterior occipitomental (OM) radiograph taken at 15 0 – 30 0 -> suitable to illustrate the displacement of middle1/3 # </li></ul><ul><li>A panoramic oral radiograph(orthopantomogram) </li></ul>
  11. 11. Coronal & Axial CT scan
  12. 12. #s Facial Skeleton <ul><li>Upper third – above the eyebrows – involves frontal sinuses & supraorbital ridges </li></ul><ul><li>Middle third – above the mouth </li></ul><ul><li>Le Fort I , II , II </li></ul><ul><li>Lower third -- Mandible </li></ul>
  13. 13. Middle 1/3 #s <ul><li>Le Fort I # . </li></ul><ul><li>Separates the alveolus and palate from the facial skeleton above. </li></ul><ul><li># line runs from the nasal pyriform aperture -> lateral &medial walls of max. antrum ->posteriorly to include the lower part of the pterygoid plates </li></ul>
  14. 14. Diagnosis <ul><li>suggested by the malocclusion </li></ul><ul><li>mobility of the fractured segment by doing digital manipulation of the incisor teeth region </li></ul>
  15. 15. Treatment <ul><li>closed reduction with inter maxillary fixation </li></ul><ul><li>open reduction. </li></ul><ul><li>Open reduction – intra osseous wiring </li></ul><ul><li>- by using small plates </li></ul>
  16. 16. Le Fort II # <ul><li>Pyramidal in shape </li></ul><ul><li>Runs through the bridge of the nose & ethmoids -> medial part of the infraorbital rim & infraorbital foramen -> posteriorly through the lat wall of the max. antrum at a higher level than Le F.I to the pterygoid plates at the back </li></ul><ul><li>Cribriform plate may be fractured > CSF rhinorhhoea </li></ul><ul><li>Treatment – Reduction of the maxilla& internal fixation of the fragments </li></ul>
  17. 17. Le Fort III # <ul><li>Effectively separates facial skeleton from the base of the skull </li></ul><ul><li># -> nasal bridge, septum & ethmoids ->irregularly through the bones of orbit -> frontozygomatic suture -> lateral wall of the max. sinus at a higher level & the pterygoid plates </li></ul><ul><li>Crbriform plate #->CSF rhinorhoea </li></ul>
  18. 18. Clinical features & management <ul><li>Clinical features – facial elongation, massive facial edema & mobility entire middle third of the face. </li></ul><ul><li>Treatment – Internal fixation by a craniofacial approach </li></ul>
  19. 19. Le Fort #s seldom confine to exactly to the original classification & combinations of any of the #s may occur.
  20. 20. Zygomatic complex <ul><li>Fractures occur through points of weakness – the </li></ul><ul><li>infra orbital margin, frontozygomatic </li></ul><ul><li>suture, zygomatic </li></ul><ul><li>arch, and ant. &lat. </li></ul><ul><li>walls of the max. </li></ul><ul><li>sinus. </li></ul><ul><li>Tears of antral </li></ul><ul><li>mucosa -> epistaxis </li></ul><ul><li>Injury to infraorbital </li></ul><ul><li>nerve -> parasthesia </li></ul>
  21. 21. Zygomatic complex <ul><li>If the floor of the orbit is disrupted , orbital contents prolapse into the max. antrum -> entrapment of the inferior oblique & inferior rectus -> diplopia </li></ul><ul><li>Medial displacement of the arch impinches on the coronoid process -> difficulty in opening the jaw </li></ul><ul><li>O/E – swelling of both upper & lower eyelid with subconjuntival hemorrhage(post. Limit cannot be seen) </li></ul>
  22. 22. Zygomatic complex <ul><li>Complications – flat cheek, enophthalmos,infraorbital anesthesia , restriction of jaw opening. </li></ul><ul><li>The fracture is visualized by a 30 0 occipto-mental view. </li></ul><ul><li>Treatment – open reduction & internal fixation </li></ul>
  23. 23. Lower 1/3 of the face <ul><li>Sites of Mandible # </li></ul><ul><li>1. Neck of the condyle </li></ul><ul><li>2. Angle of the mouth> last molar tooth </li></ul><ul><li>3. Anterior to the mental foramen > canine tooth </li></ul>
  24. 24. # Mandible <ul><li>Guardsman fracture – </li></ul><ul><li>Blow to the chin -> </li></ul><ul><li># symphysis or parasymphysis </li></ul><ul><li>unilateral or bilateral condylar # (Indirect transmission of kinetic energy) </li></ul>
  25. 25. C/F <ul><li>pain on moving the jaw </li></ul><ul><li>malocclusion, lacerations </li></ul><ul><li>ecchymosis of the floor of the mouth. </li></ul><ul><li>Palpation – fracture line, false motion </li></ul>
  26. 26. # Mandible <ul><li>Management : </li></ul><ul><li>Compound # - broad spectrum antibiotics </li></ul><ul><li>Intermaxillary fixation (IMF) </li></ul><ul><li>Open reduction & internal fixation with stainless steel / titanium plates. </li></ul>
  27. 27. Soft tissue injuries of the face <ul><li>Facial soft tissues have an excellent blood supply -> heals well </li></ul><ul><li>Suturing at the earliest after debridement under local anesthesia /GA </li></ul><ul><li>Replace tissues accurately esp. vermilion border </li></ul><ul><li>Hemostasis essential. Muscles & underlying tissues should be sutured with absorbable suture materials. Fine monofilament sutures to be used . Alt. sutures to be removed on th3rd day, the remaining on the 5 th day </li></ul>

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