This document provides information on the management of maxillofacial trauma. It discusses the initial management including airway control and bleeding control. It then describes the secondary survey examining different areas of the face and head. It also classifies common types of facial fractures such as Lefort fractures, mandibular fractures, and fractures of the zygomatic bone and orbit. It concludes with discussing management of soft tissue injuries to the face.

1. Maxillofacial
Trauma
{
DR. RITESHSHIWAKOTI
MScD PROSTHODONTICS
S NO: 20130204556

2. Acute
 Airway compromise
 Exsanguination
 Associated intracranial or cervical-spine injury
Delayed
 Meningitis
 Oropharyngeal infections
Causes of Mortality

3.  Respiratory  upper airway
 Visual
 Olfactory
 Mastication
 Cosmetic
 Communication
 Individual recognition
Functions of Face

4. Airway control / immobilize cervical spine
Bleeding control
Complete the primary survey
Secondary survey
Consider NG or OG tube placement
Management Sequence

5.  Plain radiographs if fractures suspected
 CT if suspect complex fractures
Management Sequence

6.  Repair soft tissue immediately if no other
injuries
 Delay soft tissue repair until patient in OR , if
surgery for other injuries necessary
Management Sequence

7. Step 1: Airway control
 Oxygen for all patients
 May need to keep patient sitting or prone
 Stabilize C-spine early
 Large bore (Yankauer) suction available
Initial Management

8. Step 1: Airway control
 Orotracheal intubation preferred over
nasotracheal if possible midfacial fracture and
invasive airway needed
 Combitube , retrograde wire, or
cricothyroidostomy if unable to orotracheally
intubate
Initial Management

9. Step 2 : Bleeding control
 Rapid nasal packing may be necessary
 Be sure blood is not just running down posterior
pharynx

10. Step 2 : Bleeding control
 Rarely: emergent cutdown and ligation of
external carotid artery needed to prevent
exsanguination
 Note: Although shock in facial trauma patient
is usually due to other injuries, it is possible to
bleed to death from a facial injury

11. Step 2 : Bleeding control
 Rarely: emergent cutdown and ligation of
external carotid artery needed to prevent
exsanguination
 Note: Although shock in facial trauma patient
is usually due to other injuries, it is possible to
bleed to death from a facial injury

12.  Blood in airway
 “Debris” in airway
 Vomitus, avulsed tissue, teeth or dentures,
foreign bodies
 Pharyngeal or retropharyngeal tissue swelling
 Posterior tongue displacement from mandible
fractures
Airway Compromise

13. Scalp
 Check for lacerations, hematomas, stepoffs,
tenderness
 Bleeding maybe brisk until sutured
 Can use stapler for rapid closure
Secondary Survey

14. Ears
 Examine pinnae, canal walls, tympanic
membranes
 Suction gently under direct vision if blood in
canal
 Put drop of canal fluid on filter paper for “ring
sign”  CSF leak
 Assess hearing

15.  Eyes
 Pupils, anterior chamber, fundi, extraocular
movements
 Conjunctivae for foreign bodies
 Palpate orbital rims
 No globe palpation if suspect penetration

16. Eyes
 Lid injury can leave cornea exposed
 Use artificial tears or cellulose gel

17. Overall facial appearance
 Assess for symmetry, deformity, discoloration,
nasal alignment
 Palpate forehead & malar areas

18. Nose
 Check septum for hematoma & position
 Check airflow in both nares
 Palpate nasal bridge for crepitus
 Check fluid on filter paper for “ring sign” (for
CSF leak)

19. Mouth
 Check occlusion
 Reflect upper & lower lips
 Check Stenson's duct for blood
 Palpate along mandibular and maxillary teeth

20.  Major
 Lefort I, II, III
 Mandibular
ϕ Minor
ϕ Nasal
ϕ Sinus wall
ϕ Zygomatic
ϕ Orbital floor
ϕ Antral wall
ϕ Alveolar ridge
Fracture Classification

21.  Lefort fractures can coexist with additional
facial fractures
 Patient may have different Lefort type fracture
on each side of the face
Lefort Fractures

22. Pull forward on maxillary teeth
 Lefort I: maxilla only moves
 Lefort II: maxilla & base of nose move:
 Lefort III: whole face moves:

23.  Horizontal fracture extending through maxilla
between maxillary sinus floor & orbital floor
 Crepitus over maxilla
 Ecchymosis in buccal vestibule
 Epistaxis: can be bilateral
 Malocclusion
 Maxilla mobility
Lefort I: Nasomaxillary

24.  Closed reduction
 Intermaxillary fixation: secures maxilla to
mandible
 May need wiring or plating of maxillary wall
and / or zygomatic arch
 Antibiotics: anti-staphylococcal

25.  Subzygomatic midfacial fracture with a
pyramid-shaped fragment separated from
cranium and lateral aspects of face
Lefort II: Pyramidal

26. Signs & symptoms
 Midface crepitus
 Face lengthening
 Malocclusion
 Bilateral epistaxis
 Infraorbital paresthesia
 Ecchymoses: buccal vestibule, periorbital,
subconjunctival

27.  Hemorrhage or airway obstruction may require
emergent surgery
 Treatment can often be delayed till edema
decreased

28. Usually require
 Intermaxillary fixation
 Interosseous wiring or plating of infraorbital
rims, nasal-frontal area, & lateral maxillary
walls
 May need additional suspension wires
 Antibiotics

29.  Craniofacial dissociation
 Bilateral suprazygomatic fracture resulting in a
floating fragment of mid-facial bones, which
are totally separated from the cranial base
Lefort III

30. Signs and Symptoms
 Face lengthening: “caved-in” or “donkey face”
 Malocclusion: “open bite”
 Lateral orbital rim defect
 Ecchymoses: periorbital, subconjunctival

31. Signs and Symptoms
 Bilateral epistaxis
 Infraorbital paresthesia
 Often medial canthal deformity
 Often unequal pupil height

32.  Usually associated with major soft tissue injury
requiring emergent surgery for bleeding
control
 Surgery can be delayed till edema resolves
 Intermaxillary fixation

33.  Transosseous wiring or plating
 Frontozygomatic suture
 Nasofrontal suture
 May need extracranial fixation if concurrent
mandibular fracture
 Antibiotics

34.  Airway obstruction from loss of attachment at
base of tongue
 >50 % are multiple
 Condylar fractures associated with ear canal
lacerations & high cervical fractures
 High infection potential if any violation of oral
mucosa
Mandible Fractures

35. Signs and symptoms
 Malocclusion
 Decreased jaw range of motion
 Trismus
 Chin numbness
 Ecchymosis in floor of mouth
 Palpable step deformity

36.  Tongue blade test: have patient bite down
while you twist. If no fracture, you will be able
to break the blade.

37. Treatment
 Prompt fixation: intermaxillary fixation (arch
bars), +/- body wiring or plating

38.  Can occur from direct blow to mandible
 Can occur “spontaneously” from yawning or
laughing
 Mandible dislocates forward & superiorly
 Concurrent masseter & pterygoid spasm
TMJ Dislocation

39. Symptoms
 Patient presents with mouth open, cannot close
mouth or talk well
 Can be misdiagnosed as psychiatric or dystonic
reaction

40. Treatment
 Manual reduction: place wrapped thumbs on
molars & push downward, then backward
 Be careful not to get bitten
 Usually does not require procedural sedation
or muscle relaxants

41.  Often diagnosed clinically: x-ray not needed
 Emergent reduction not necessary except to
control epistaxis
 Usually do not need antibiotics
 Early reduction under local anesthesia useful if
nares obstructed
Nasal Bone Fractures

42.  Nasal septal hematoma: incise & drain, anterior
pack, antibiotics, follow-up at 24 hours
 Follow-up timing for recheck or reduction:
 Children: 3 to 5 days
 Adults: 7 days

43. Tripod (tri-malar) fracture
 Depression of malar eminence
 Fractures at temporal, frontal, and maxillary
suture lines
Isolated arch fracture
 Less common
 Shows best on submental-vertex x-ray view
 Painful mandible movement
 Usually treat with fixation wire if arch
depressed
Zygomatic Fractures

44. Tripod S & S
 Unilateral epistaxis
 Depressed malar
prominence
 Subcutaneous
emphysema
 Orbital rim step-off
 Altered relative
pupil position
 Periorbital
ecchymosis
 Subconjunctival
hemorrhage
 Infraorbital
hypoesthesia

45. Frontal sinus fracture
 Often associated with intracranial injury
 Often show depressed glabellar area
 If posterior wall fracture, then dura is torn
Ethmoid fracture
 Blow to bridge of nose
 Often associated with cribiform plate fracture,
CSF leak
 Medial canthus ligament injury needs
transnasal wiring repair to prevent telecanthus
Supraorbital Fractures

46.  “Blow out” fracture of floor
 Rule out globe injury
 Visual acuity
 Visual fields
 Extraocular movement
 Anterior chamber
 Fundus
 Fluorescein & slit lamp
Orbital Fractures

47. Symptoms and signs
 Diplopia: double vision
 Enophthalmos: sunken eyeball
 Impaired EOM’s
 Infraorbital hypesthesia
 Maxillary sinus opacification
 “Hanging drop” in maxillary sinus

48.  Diplopia with upward gaze: 90%
 Suggests inferior blowout
 Entrapment of inferior rectus & inferior oblique
 Diplopia with lateral gaze: 10%
 Suggests medial fracture
 Restriction of medial rectus muscle

49.  Sometimes extraocular muscle dysfunction can
be due to edema and will correct without
surgery
 Persistent or high grade muscle entrapment
requires surgical repair of orbital floor (bone
grafts, Teflon, plating, etc.)

50.  Before repair, rule out injury to:
 Facial nerve
 Trigeminal nerve
 Parotid duct
 Lacrimal duct
 Medial canthal ligament
 Remove embedded foreign material to prevent
tattooing
Facial Soft Tissue
Injuries

51.  For lip lacerations, place first suture at
vermillion border
 Never shave an eyebrow: may not grow back
 If debridement of eyebrow laceration needed,
debride parallel to angle of hairs rather than
vertically

52.  Antibiotics for 3 to 5 days for any intraoral
laceration (penicillin VK or erythromycin) and
if any exposed ear cartilage (anti-staphylococcal
antibiotic) – no evidence
 Remove sutures in 3 to 5 days to prevent cross-marks

53.  Most face bite wounds can be sutured
primarily
 Clean facial wounds can be repaired up to 24
hours after injury
 Place incisions or debridement lines parallel to
the lines of least skin tension (Lines of Langer)

55. Defect following
surgical procedure
{

56.  Cleft lip
 Cleft palate
 misaligned jaws.
 Accident victims suffering facial injuries,
 Dental implant surgery,
 patients with tumors and cysts of the jaws and
functional and esthetic conditions of the
maxillofacial areas.
Condition requiring
surgery

57.  Surgery performed at outside institution
without reconstruction after parotid surgery.

59.  If cleft lip is present, its repair can precede
palatoplasty. Although early repair seems to
have an advantage in decreasing the chances of
speech delays, the risk for facial growth
abnormalities and other midface-related
problems may be increased.

60.  General Principles of Facial Reconstruction
 Development of Facial Surgical Reconstruction
 Replacing Tisssue Loss
 Returning to Normal
 Facial Reconstruction by Unit
 Facial Function over Form
 Invisible Scars
Facial Reconstruction
following Trauma or Surgery

61.  Our faces play a pivotal role in our daily social
interactions, through expression of emotions,
appearance and most importantly identity.
 The face is our carte visite, the place where our
individuality and our personality is manifested.
 It is understandable then that permanent scarring of
the face caused by severe trauma or surgery can be
profoundly damaging for the person affected.
 For this reason facial reconstruction is extremely
important and there are a number of fundamental
general principles that underpin the surgical
techniques employed.
General principles

62.  The first attempts at facial reconstruction took place
several hundred years ago and are attributed to one
of the forefathers of modern reconstructive surgery,
the genius Gaspare Tagliacozzi. Tagliacozzi was
Professor of Anatomy at the Medical School of
Bologna in Italy in the late 16th century. He is
credited with being the first surgeon to attempt
reconstruction of the nose by using a flap of skin
taken from the forearm. The flap, called a pedicle,
was attached to the nose and the patient's arm was
bandaged in a raised position until the skin of the
arm had attached itself to the nose. The pedicle was
then cut from the arm and the attached skin could
then be shaped so that it resembled the nose.
The development

63.  This in effect corresponds to a method that
was later called "Robin
Hood's tissue apportionment", where tissue from an
area of abundance is used to make up for tissue
deficiencies in another part of the body. This was
achieved by using "advancement" or "rotational"
flaps. The full development of this notion gave birth
to modern ideas of "transfer" of flaps from other
areas of the body and ultimately "transplantation" of
flaps. The former requires the employment of
"micro-vascular" techniques that involve the
"transfer" of tissue together with their supporting
arteries and veins, which then have to be connected
to the recipient vessels in the neck.

64.  Close collaboration with immunological
manipulation techniques is also necessary as
part of anti-rejection treatment of the
"transplant". The reported success stories of
total face transplants ultimately signify how
advanced reconstructive surgery has become.
However, surgical success would not be
possible without close interaction between
various medical disciplines including
immunology, intensive care and post-surgery
neurological and psychological rehabilitation.

65.  Dr Ralph Millard, one of the founders of
modern reconstructive surgery, summarised
the main "executional principles" on which
reconstruction of the face should be based by
stating that "tissue losses should be replaced in
kind.”
Replacing tissue

66.  What this means in practice is that bone should
be replaced with bone, muscle with muscle and
skin with skin. Nevertheless, the 3-dimensional
complexity of the anatomy of facial structures,
including a multitude of small muscles
attached to thin, sometimes hollow bones of
irregular, complex shape makes such a
principle difficult to apply successfully.

67.  In particular, "transitional" areas between dry
skin and moist mucosa, such as at the junction
of the outer lip to vermillion border and inner
lip and the junction of thin eyelid skin to the
tarsal plate and the conjunctiva of the eye make
reconstructive planning a daunting surgical
task.


68.  For the reason set out above, the further
principle of "return what is normal to the
normal position and retain it there" is of
paramount importance. Displacement, or loss
of structures, can occur as a direct result of
trauma or planned surgical excision or even
scar contraction. The surgical correction needs
to take into account the normal appearance or
in cases of long established deficit the aesthetic
projection of what normal would have been for
the missing facial structure.
Returning to normal

69.  Nowadays, this can be facilitated with the use of
technology, namely with the use of 3-dimensional
images obtained by computer tomography. By using
these radiological images and by utilising 3-
dimensional "printers" it is possible to create
custom-made plastic models, where the missing part
has been recreated as a "mirror" image of the
opposite healthy side. Obviously there are more
complex defects or defects of a single structure, such
as the nose, where the recreated missing part
represents an estimate of the size and shape of the
deficient organ. This assessment is based on data on
size and shape depending on the gender, age and
ethnic variation of the patient and ultimately on the
anticipated symmetry of the new "organ" in relation
to the surrounding structures.

70. Reconstruction by unit

71.  This diagram* demonstrates how the face can
be divided into "unit borders" that are
demarcated by natural folds, creases and
generally "transitional" anatomical areas.
Respecting the boundaries of these "aesthetic
units" during surgical procedures gives a more
"natural" expression to the reconstructed area,
concealing the differences in texture, thickness,
composition, colour and light reflection
between the native and the reconstructed
tissues.

72.  In addition, this breaking down of the face into
aesthetic units provides the surgeon with an
operative "road map" of the exact
reconstructive needs caused by the defect. In
this way, a complex 3-dimensional defect
involving various anatomical borders can be
divided into smaller anatomical units, which
can then be considered almost independently
during the planning of the surgical procedure.

73.  There are a number of other principles that
could be included but amongst them I would
just like to underline the importance of
"function over form”, especially applicable
with patients being treated for major trauma or
defects following major ablative surgery.
 The functions of the face can be grouped into
physiological, expressive and aesthetic. The
face also plays a very important role in the
patient's identity.
Importance of function
over form

74.  The physiological functions of the face include
the crucial anatomical barrier that the skin of
the face provides between the internal and
external environments and the abundance of
sensory cutaneous nerves that can be seen as
the primary sensory organ of the body. The
mouth forms part of the alimentary tract; and
the nose (and secondarily mouth),
the respiratory tract, whilst also hosting the
olfactory nerve endings that provide the all-important
sense of smell.

75.  Finally the external parts of the eyelids protect
the orbital globes from mechanical injury while
the internal side together with
the conjunctiva provides a pliable, thin layer
protecting the cornea of the globe.
 The expressive function of the face is
underscored by its importance as the main
instrument of non-verbal communication,
allowing us to express and communicate our
thoughts and feelings. Finally, the aesthetic
function of the face allows social acceptance
and integration.

76.  The quest of modern facial reconstructive
surgery techniques then is to provide, as far as
possible, "invisible scars" in the face, which
means concealing outside the most visible
anatomical areas. Fortunately the face does
offer such an opportunity. There is a vast array
of operations that can be performed through
the oral cavity including surgical procedures
for the bones of the mid- and lower third of the
face and their overlying soft tissues.
Invisible scars

77.  Equally, surgery around the orbital globes can be
performed through the conjunctiva, allowing access
to the eye socket and the supportive bone with no
need for skin incisions. Finally, the combination of
facial incisions in conjunction with concealing
incisions behind the ears or within the hairline can
provide almost seamless, invisible access to the
entire surface of the face and the facial skeleton. This
allows not only cosmetic improvement of facial
features, but primarily serves the ongoing need for
social integration by minimising defects and scars
and subsequently by minimising the indelible traces
of previous illnesses