Facial TraumaBabak Saedi MDOtolaryngologist

Tehran University of Medical Sciences

The External Bony Facial Skeleton

Composed mainly of the frontal bone, temporal bones, nasal bone, zygomas, maxilla, and mandible.

Ethmoid, lacrimal, sphenoid bones contribute to inner portion of orbits

Upper third - above superior orbital rim Middle third (midface)- superior orbital

rim down through maxillary teeth Lower third - mandible

Bones of the Facial Skeleton

Maxillofacial Trauma

Maxillofacial Trauma

Patient evaluation

Patient Evaluation

History

Physical exam

Other systems: - Airway - Circulation - CNS (GCS)

Physical examination

Orbit

Nasal airway

Dental occlusion

Neurovascular

Soft tissue damage

Contusion

Avulsion

Laceration

(loss of soft tissue – penetrating

trauma)

Physical Examination

First, inspect face for deformity and asymmetry

Enophthalmos, proptosis, ocular integrity, ocular movements

Nasal septum for position, integrity, and presence of septal hematoma

Epistaxis or CSF rhinorrhea

Physical Examination

Complete neurological exam must be performed on any patient with suspected facial trauma

Sensation - test all 3 major branches of the trigeminal nerve

Motor function - assess facial nerve by having patient wrinkle forehead, smile, bare teeth, and close eyes tightly

Physical Examination

Palpation of facial structures - the infraorbital and supraorbital ridges, zygoma, nasal bones, lower maxilla, and mandible

Assess for tenderness, bony deformities, crepitus, . . .

Malocclusion or step-off in dentition may be sign of mandibular fracture

Diagnostic Imaging

Should focus on bony integrity, fluid-filled sinuses, herniation of orbital contents, and subcutaneous air

Overall status of the patient, physical exam findings, and the clinician’s initial impression determine timing and nature of imaging ordered

Plain films

Traditionally the mainstay in the radiographic evaluation of facial trauma

Standard plain film facial series: Waters (occipitomental), Caldwell (occipitofrontal), and lateral views

Panoramic films are used to best evaluate mandibular fractures

CT scan

Offers a viable, cost-effective alternative

to plain films

Very helpful in the evaluation of facial

trauma when facial edema, lacerations,

other injuries, or altered level of

consciousness limit usefulness of clinical

exam

MRI

Limited role of MR in evaluation of facial trauma due to insensitivity of MR to fractures

Used to provide complimentary information to CT in the evaluation of the eye and its associated structures

Nasal bone

Nasal Fractures

Most common site of facial trauma due to location

May be displaced medialy, laterally or posteriorly

Requires control of epistaxis and drainage of septal hematoma, if present

Nasal fractures - classification

Class 1 - frontal or frontolateral trauma

- vertical septal fracture

- depressed or displaced distal part of nasal bones

Class 2 - lateral trauma

- horizontal or C-shaped septal fracture

- bony or cartilaginous septum fracture

- frontal process of maxilla fracture

Nasal fractures - classification

Class 3 - high velocity trauma- fracture extends to ethmoid

labyrinth- bony septum rotates

posteriorly- bridge collapse- upturned tip, revealing

nostrils- depressed nasal bones

pushed up under frontal bones- apparent inter-ocular space

widening

Nasal fracture

Diagnosis: - physical exam (asymmetry,

deviation, epistaxis, swelling, . . .) Radiography: - do not have a role in management Timing: - before 10 days to 2 weeks - within two hours after injury

Nasal fracture

Managements: (closed & open reduction)

Complications: - septal hematoma - CSF leakage - ophthalmologic compl.

Septal haematoma

closed reduction

Zygomatic Fractures

Tripod fracture: zygomaticofrontal suture, zygomaticotemporal suture, and infraorbital foramen

Present with flatness of the cheek, anesthesia in the distribution of the infraorbital nerve, diplopia, or palpable step defect

Tripod Fracture

Maxillary Fractures Le Fort I – maxilla Le Fort II – maxilla,

nasal bones, and medial aspects of orbits (pyramidal disjunction)

Le Fort III – maxilla, zygoma, nasal bones, ethmoids, vomer, and all lesser bones of the cranial base (craniofacial disjunction)

Usually in combination

LeFort Fractures

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Blowout Fracture of the Orbit

Fractures of the orbital floor may occur with orbital wall fractures or as an isolated injury.

When the orbital floor, being the weakest area, herniation of orbital contents down into the maxillary sinus may occur (hanging drop sign).

Patients may present with enophthalmos, impaired ocular motility, diplopia due to entrapment of the inferior rectus muscle within the fracture fragments, and infraorbital hypoesthesia.

Maxillofacial Trauma-Specific Fractures

Orbital Fractures› Usually through

floor or medial wall› Enophthalmos› Anesthesia› Diplopia› Infraorbital stepoff

deformity› Subcutaneous

emphysema

Blowout Fracture of the Orbit

This child presented with diplopia following blunt trauma to the right eye. On exam, he was unable to move his right eyeball up on upward gaze.

CT: Blowout Fracture of Orbit

A: Orbital blowout fracture with displacement of the floor (arrow), distortion of the inferior rectus, and herniation of orbital fat through defect. Arrowhead indicates medial fracture.

B: Note opacified left anterior ethmoid air cells and displaced medial orbital fracture (arrowheads).

Maxillofacial Trauma-Specific Fractures

Frontal Sinus/Bone Fractures› Direct blow› Frequent intracranial injuries› Mucopyoceles› Consult with NS for treatment, disposition

and antibiotics Nasoethmoidal-Orbital Injuries

› Lacrimal apparatus disruption› Bimanual palpation if medial canthus pain› CT face

Maxillofacial Trauma-Specific Fractures

Orbital Fissure Syndrome› Fracture of the orbital canal

Extraocular motor palsies and blindness If significant retrobulbar hemorrhage, may

need cantholysis to save vision

Zygomatic Fractures› Tripod fracture

Most serious Lateral subconjunctival hemorrhage Need ORIF

› Arch fracture Most common Outpatient

repair

Maxillofacial Trauma-Specific Facial Fractures Mandibular Fractures

› Second most common facial fracture

› Often multiple› Malocclusion› Intraoral lacerations› Sublingual ecchymosis› Nerve injury

› Plain films› Panorex› CT

› Open Fractures Prophylactic Ab.

Anatomic units of the mandible

Types of fracture

Simple Greenstick fracture (rare, exclusively in

children) Fracture with no displacement (Linear) Fracture with minimal displacement

Displaced fracture

Comminuted fractureExtensive breakage with possible bone and

soft tissue loss Compound fractureSevere and tooth bearing area fractures Pathological fracture(osteomyelities, neoplasm and generalized

skeletal disease)39

Angle’s classification

Favourable or unfavourable

They can be vertically or horizontally in direction

They are influenced by the medial pterygoid-masseter “sling”

If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled lingually

If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled lingually

Favourable fracture line makes the reduced fragment easier to stabilize

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Panoramic X-Ray Film of the Mandible

Note fractures in left angle and right body of mandible

Multiple fractures are present more than 50% of the time and are usually on contralateral sides of the symphysis

Approach to the Patient with Traumatic Injury of the Face

Facial trauma is defined as injury to the soft tissues of the face (including the ears) and to the facial bony structures.

May result in hemorrhage and airway obstruction accompanied by multisystem involvement (as many as 60% of patients have associated injuries)

Evaluation includes history, physical exam, and diagnostic imaging

Principles of treatmentsimilar to elsewhere fractures in the body

Reduction of fragments in good position

Immobilization until bony union occurs

These are achieved by: Close reduction and immobilization Open reduction and rigid fixation

Other objective of mandible fracture treatment:

Control of bleeding

Control of infection45

Treatment options

No treatment Soft diet Maxillomandibular fixation Open reduction - non-rigid fixation Open reduction - rigid fixation External pin fixation Lag screw

Maxillomandibular fixation

Close reduction

Arch bars

▶ IMF prior to rigid fixation

▶ For the purpose of close reduction

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Maxillomandibular fixation

Open reduction - nonrigid fixation

Open reduction - Rigid fixation

External Fixation

Lag screw

Special Considerations

TMJ ank. Pediatric Dental root Inf. Alveolar N. airway

Special Considerations

Facial N. Lacrimal ap. Foreign body Borders & margins injury (Vermilion border- nasal ala- eyelids-

helix)