Maxillo facial injury

1. Maxillo facial injuries
Dr Karthik K
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2. KVS
Maxillofacial injuries

3. Learning Objectives
• To be able to recognize life threatening
nature of facial injuries – Airway obstruction,
associated head & spinal injuries.
• Method of examining facial injuries.
• Diagnosis & principles of management of
facial injuries
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4. Anatomy
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5. Anatomy
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6. Causes
• Road traffic accidents
• Intentional violence
• Sporting activities
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7. Pathophysiology
• High Impact:
– Supraorbital rim – 200 G
– Symphysis of the Mandible –100 G
– Frontal – 100 G
– Angle of the mandible – 70 G
• Low Impact:
– Zygoma – 50 G
– Nasal bone – 30 G
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8. Severity
• @60% of patients with severe facial trauma
have multisystem trauma and the potential for
airway compromise.
– 20-50% concurrent brain injury.
– 1-4% cervical spine injuries.
– Blindness occurs in 0.5-3%
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9. Assessment
Based on
• Targeting care: Glasgow Coma Scale (GCS)
• Predicting outcome: Abbreviated Injury Scale
(AIS) and Injury Severity Score(ISS)
• Assessing critically injured patients: APACHE II
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10. Initial hospital care
• Triage the causalities(sorting for prioritization)
• A: airway with cervical spine control
• B: breathing and ventilation
• C: circulation and hemorrhage control
• D: disability due to neurologic deficit
• E: exposure and environment control
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11. Clinical effects
• Injuries to facial skeleton →
Immediate airway obstruction
delayed airway obstruction
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12. Immediate airway obstruction
inhalation of tooth fragments
accumulation of blood & secretions
loss of control of tongue in unconscious/
semiconscious pt. →
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13. Emergency Management
Airway Control
• Control airway:
– Chin lift.
– Jaw thrust.
– Oropharyngeal suctioning.
– Manually move the tongue forward.
– Maintain cervical immobilization
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14. Emergency Management
Intubation Considerations
• Avoid nasotracheal intubation:
– Nasocranial intubation
– Nasal hemorrhage
• Avoid Rapid Sequence Intubation:
– Failure to intubate or ventilate.
• Consider awake intubation.
• Sedate with benzodiazepines.
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15. Emergency Management
Intubation Considerations
• Consider fiberoptic intubation if available.
• Alternatives include percutaneous
transtracheal ventilation and retrograde
intubation.
• Be prepared for cricothyroidotomy.
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16. Emergency Management
Hemorrhage Control
• Maxillofacial bleeding:
– Direct pressure.
– Avoid blind clamping in wounds.
• Nasal bleeding:
– Direct pressure.
– Anterior and posterior packing.
• Pharyngeal bleeding:
– Packing of the pharynx around ET tube.
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17. History
• Obtain a history from the patient, witnesses
and or EMS
• Specific Questions:
– Was there LOC? If so, how long?
– How is your vision?
– Hearing problems?
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18. History
• Specific Questions:
– Is there pain with eye movement?
– Are there areas of numbness or tingling on your
face?
– Is the patient able to bite down without any pain?
– Is there pain with moving the jaw?
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19. Clinical examination
• ATLS standard approach
• Inspection
• Palpation
• Visual examination
• Eye movement
• Diplopia
• Pupil reaction
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20. Physical Examination
• Inspection of the face for asymmetry.
• Inspect open wounds for foreign bodies.
• Palpate the entire face.
– Supraorbital and Infraorbital rim
– Zygomatic-frontal suture
– Zygomatic arches
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21. Physical Examination
• Inspect the nose for asymmetry, telecanthus,
widening of the nasal bridge.
• Inspect nasal septum for septal hematoma, CSF or
blood.
• Palpate nose for crepitus, deformity and
subcutaneous air.
• Palpate the zygoma along its arch and its
articulations with the maxilla, frontal and temporal
bone.
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22. Physical Examination
• Check facial stability.
• Inspect the teeth for malocclusions, bleeding and
step-off.
• Intraoral examination:
– Manipulation of each tooth.
– Check for lacerations.
– Stress the mandible.
– Tongue blade test.
• Palpate the mandible for
tenderness, swelling and step-off.
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23. Fractures of Facial Skeleton
• Upper third – above the
eyebrows – involves frontal
sinuses & supraorbital
ridges
• Middle third – above the
mouth
Le Fort I , II , II
• Lower third -- Mandible

24. Imaging of Facial Trauma
Frontal Sinus/ Bone Fractures
Diagnosis
• Radiographs:
– Facial views should include
Waters, Caldwell and lateral projections.
– Caldwell view best evaluates
the anterior wall fractures.
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25. Frontal Sinus/ Bone Fractures
Diagnosis
• CT Head with bone
windows:
– Frontal sinus fractures.
– Orbital rim and
nasoethmoidal
fractures.
– R/O brain injuries or
intracranial bleeds.

26. Naso-Ethmoidal-Orbital
Fracture
• Fractures that extend into
the nose through the
ethmoid bones.
• Associated with lacrimal
disruption and dural tears.
• Suspect if there is trauma
to the nose or medial
orbit.
• Patients complain of pain
on eye movement.

27. Naso-Ethmoidal-Orbital
Fracture
• Clinical findings:
– Flattened nasal bridge or a saddle-shaped
deformity of the nose.
– Widening of the nasal bridge (telecanthus)
– CSF rhinorrhea or epistaxis.
– Tenderness, crepitus, and mobility of the nasal
complex.
– Intranasal palpation reveals movement of the
medial canthus.

28. 3D Reconstruction
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29. Nasoorbitalethmoidal
(NOE)
Fractures
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Three types of NOE fractures
– Type I: Large fragment of medial orbit, medial canthal
insertion is intact
– Type II: Comminution of bones, fracture line does not
extend into area of medial canthal insertion
– Type III: Comminution of bones, fracture line extends
into area of medial canthal insertion

30. Management of nasal-orbital ethmoid
fractures
• Examination for determination
of the extent of the injury
(surgical exploration)
• Nasal bone
• Orbital and ethmoidal
• Frontal bone
• Debridement and closure of
open wounds
• Reduction and stabilization of
bone fracture
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31. Detached canthus
Traumatic telecanthus
• Increase in inter-canthal distance
secondary to
canthus displacement or detachment
• Seen in association to:
Nasal bone
NEO
Le Forts fractures
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32. Surgical management of detached canthus
• Transnasal wiring
technique (unilateral type)
• Canthopexy
– Identification of the ligament
– Liberation of the periorbital
tissue
– Liberation of the lacrimal
pathway
– Nasal transfixation
– Contralateral fixation
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33. Zygomatic bone complex
• Anatomy
Star-shape like with four processes
• Frontal process
• Temporal process
• Buttress
• Orbital floor (Maxilla and GWSB)
Temporal fascia
and muscle
Masseter muscle
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34. Zygomatic complex and arch fracture
The malar bone represent a
strong bone on fragile
supports, and it is for this
reason that, though the
body of the bone is rarely
broken, the four processes-
frontal, orbital, maxillary
and zygomatic are frequent
sites of fracture.
HD Gillies, TP Kilner and D Stone, 1927
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Zygomatic bone fractured as a block
near its principle three suture lines
and often displaces inwards to a
greater or lesser extent.

35. Signs and symptoms
• Periorbital ecchymosis and edema
• Flattening of the malar prominence
• Flattening over the zygomatic arch
• Pain and tenderness on palpation
• Ecchymosis of the maxillary buccal sulcus
• Deformity at the zygomatic buttress of the
maxilla
• Deformity at the orbital margin
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36. • Trismus
• Abnormal nerve sensibility
• Epistaxis
• Subconjunctival ecchymosis
• Crepitation from air emphysema
• Displacement of palpebral fissure
(pseudoptosis)
• Unequal pupillary levels
• Diplopia
• enophthalmos
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37. • Occipitomental view
(Posterioanterior oblique)
• (water’s view)
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38. • submentovertex
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Recommended for isolated
zygomatic arch fracture

39. CT scan
• Coronal sections
• Axial sections
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40. Treatment
Timing:
• As early as possible unless there are ophthalmic, cranial
or medical complications
• Preiorbital edema and ecchymosis obscure the fine
details of the fracture, intervention can be postponed
but not more than a week
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Indications:
•Diplopia
•Restriction of mandibular movement
•Restoration of normal contour
•Restoration of normal skeletal protection for the eye

41. Methods of reduction
• Temporal approach (Gillies et al 1927)
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Suitable for isolated
zygomatic fracture with
good stability afterwards
• Buccal sulcus
approach
(Keen 1909)

42. Open reduction and fixation
• Rigid fixation using plate and screws at
• Frontozygomatic suture
• Infraorbial rim
• Inferior buttress of the zygoma
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Surgery:
•Lateral eyebrow incision
•Infraorbial approach
•Subciliary (blepharoplasty) incision
•Mid-lower lid incision
•Transconjunctival approach

43. 43
Infraorbital rim
and buttress
Lateral
orbital rim
Buttress of
zygoma
Points of fixation:

44. Isolated Zygomatic Arch Fractures
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45. Maxillary Fractures
LeFort I
• Definition:
– Horizontal fracture of
the maxilla at the level
of the nasal fossa.
– Allows motion of the
maxilla while the nasal
bridge remains stable.

46. Maxillary Fractures
LeFort I
• Clinical findings:
– Facial edema
– Malocclusion of the
teeth
– Motion of the maxilla
while the nasal bridge
remains stable

47. Maxillary Fractures
LeFort II
• Definition:
– Pyramidal fracture
• Maxilla
• Nasal bones
• Medial aspect of the
orbits

48. Maxillary Fractures
LeFort II
• Clinical findings:
– Marked facial edema
– Nasal flattening
– Traumatic telecanthus
– Epistaxis or CSF
rhinorrhea
– Movement of the
upper jaw and the
nose.

49. Maxillary Fractures
LeFort III
• Definition:
– Fractures through:
• Maxilla
• Zygoma
• Nasal bones
• Ethmoid bones
• Base of the skull

50. Maxillary Fractures
LeFort III
• Clinical findings:
– Dish faced deformity
– Epistaxis and CSF
rhinorrhea
– Mobility of the maxilla,
nasal bones and
zygoma
– Severe airway
obstruction

51. Le Fort fractures seldom confine
to exactly to the original
classification & combinations of
any of the fractures may occur.

52. Coronal & Axial CT scan

53. Treatment
• closed reduction with inter maxillary fixation
(unilateral fractures)
• open reduction.
• Open reduction – intra osseous wiring
- by using micro or
miniplates

54. Internal orbital fractures
• In conjunction with other facial
fractures
• As isolated type (Blow out
fracture)
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55. Anatomy
The floor is made of:
Maxillary bone and
part of zygoma
bounded laterally by
the inferior orbital
fissure and small part
of the ethmoid bone
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56. Clinical and radiographical presentation
• Subconjunctival ecchymosis
• Crepitation from air emphysema
• Displacement of palpebral fissure
• Unequal pupillary levels
• Diplopia
• enophthalmos
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57. Treatment
• Rational for intervention:
• Small defect with no clinical consequence may
not warrant the surgical intervention.
• Large defect with handicapping symptoms
should be operated.
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58. Method of reconstruction
• Intra-sinus approach to
the orbital floor
• External approach to
the internal orbital
floor
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59. Materials in orbital reconstruction
• Autologous graft
Bone (cranial, rib, iliac)
Cartilage
• Allogenic materials
Lyophilized dura
• Alloplastic materials
Siliastic and proplast
implants
Teflon
hydroxyapatite
Titanium mish
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60. Mandible Fractures
Pathophysiology
• Mandibular fractures are
the third most common
facial fracture.
• Assaults and falls on the
chin account for most of
the injuries.
• Multiple fractures are
seen in greater then 50%.
• Associated C-spine
injuries – 0.2-6%.

61. KVS

62. Epidemiology
• Sites of weakness
– Third molar (esp. impacted)
– Socket of canine tooth
– Condylar neck

63. Haug et al

64. Favorable vs. Unfavorable
• Masseter, Medial and Lateral Pterygoid, and
Temporalis tend to draw fractures medial and
superior
• Almost all fractures of angle unfavorable

66. Physical Exam
• Complete Head and Neck exam
– Palpable step off
– Tenderness to palpation
– Malocclusion
– Trismus (35 mm or less)
– Sublingual hematoma
– Altered sensation of V3
– Crepitus

67. Mandible Fractures
Clinical findings
• Mandibular pain.
• Malocclusion of the teeth
• Separation of teeth with
intraoral bleeding
• Inability to fully open
mouth.
• Preauricular pain with
biting.
.

68. Physical Exam
• Unilateral fractures of Condyle
– Decreased translational movement, functional
height of condyle
– Deviation of chin away from fracture, open bite
opposite side of fracture
Bilateral fractures of condyle
- Anterior open bite

70. Radiographic Evaluation
• Panorex (OPG)
• X ray skull Reverse towns view.
• X Ray mandible PA View, Lateral oblique views
• TMJ views

71. Radiographic Evaluation
• CT scan
– Not as diagnostic as plain films for nondisplaced
fractures of mandible.
– Most useful for coronoid and condylar fractures,
associated midface fractures
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72. Closed Reduction
• Favorable, non-displaced fractures
• Grossly comminuted fractures when adequate
stabilization unlikely
• Severely atrophic edentulous mandible
• Children with developing dentition

73. Open Reduction
• Displaced unfavorable fractures
• Mandible fractures with associated midface
fractures
• When MMF contraindicated or not possible
• Patient comfort
• Facilitate return to work

74. Open Reduction
• Associated condylar fracture
• Associated Midface fractures
• Psychiatric illness
• GI disorders involving severe N/V
• Severe malnutrition
• To avoid tracheostomy in patients who need
postoperative intubation

75. Open Reduction
• Contraindications
– General Anesthetic risk too high
– Severe comminution and stabilization not possible
– No soft tissue to cover fracture site
– Bone at fracture site diffusely infected
(controversial)

76. Closed Reduction
• Length of MMF
– Fracture at angle of mandible for adults : 4 wks
– Add 2 wks more for symphysis fracture
– Add 2 wks for geriatric patients (edentulous)
– Less 1 wk for peadiatric mandibular fractures.
– Less 1 wk for condylar fractures.

79. Open Reduction
Techniques
– Rigid fixation
1. Compression plates (DCP)
2. Lag screws
– Semirigid fixation
1. Miniplates
2. Transosseous wiring
3. External fixators

80. Rigid Fixation
• Compression plates
– Rigid fixation
– Allow primary bone healing
– Difficult to bend
– Operator dependent
– No need for MMF

82. Open Reduction
• Lag Screws
– Rigid fixation (Compression)
– Good for anterior mandible fractures, Oblique
body fractures, mandible angle fractures
– Cheap
– Technically difficult
– Injury to inferior alveolar neurovascular bundle

83. Lag Screw Technique

84. Lag Screw Technique

85. Semi Rigid Fixation
• Miniplates
– Semi-rigid fixation
– Mono cortical screws
– Uses tension band principle
– Allows primary and secondary bone healing
– Easily bendable
– More forgiving
– Short period MMF Recommended

87. Champey’s miniplate osteosynthesis
• Areas of tension and compression
• 2 mm plates
• Monocortical screws.
• Placed in favourable positions on mandible.
• Micromovements possible favourable to
healing.
• Technically not highly demanding.
• Plate removal is not routinely required.
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88. External Fixation
• Alternative form of rigid fixation
• Grossly comminuted fractures, contaminated
fractures, non-union
• Often used when all else fails

89. Condylar and Subcondylar
• Lindhal and Hollender
– Closed reduction in children, teens, adults
– Intracapsular fractures
– Higher incidence of postoperative sequelae in
adults
– Children and Teens with less sequelae, more
remodeling

90. Condylar and Subcondylar
• ORIF, Absolute indications
– Displacement into middle cranial fossa
– Inability to achieve occlusion with closed
reduction
– Foreign body in joint space

91. Condylar and Subcondylar
• Relative indications
– Bilateral condylar fractures to preserve vertical
height
– Associated injuries that dictate earlier function
• Soft tissue swelling causing airway compromise with
MMF
• Intracapsular fracture on opposite side where early
mobilization important

93. Panfacial fractures
• Expose all fracture sites
• Reconstruct the AP projection of face, start from
stable post area (temporal bone, proximal arch
• Reconstruct the width of the face across
zygomatic arches (frontozygomatic suture)
• Recreate NOE area.
• Restore height (fix ramus fractures)
• Restore occlusion.
• Repair the fractures in maxilla and mandible
closer to teeth bearing areas
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94. TMH statistics 2010-11
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Etiology RTA Sports
injury
Inter
personnel
violence
Gunshot
injuries
Fractures
138
128 2 3 5

95. TMH statistics 2010-11
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Type Mandible Maxilla Zygoma Combined
Fractures
138
76 34 6 22

96. TMH statistics 2010-11
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Treatment Closed
reductio
n
Open
reductio
n
No
treatment
Total Implant
removal
Mandible 04 72 0 76 8
Maxilla 3 27 4 34 1
Zygoma 0 3 3 6 0
Combined 0 22 0 22 1

97. Thank you

98. KVS
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