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INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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Maxillofacial TraumaEvaluation and Management
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Maxillofacial Trauma
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Maxillofacial Injuries
• Treatment divided into following phasesEmergency or initial careEarly careDefinitive careSecondary care or revision
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Emergency Care
• Preserve the airway• Control of hemorrhage• Prevent or control shock• C-Spine stabilization• Control of life-threatening injuries
head injuries, chest injuries, compound limb fractures, intra-abdominal bleeding
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Emergency Care
• Evaluate the airwayExistence & identification of obstructionManually clear of fractured teeth, blood
clots, denturesEndotracheal intubation & packing of
oronasal airway
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Emergency Care• Airway Management
Maintain an intact airwayProtect airway in jeopardyProvide an airway
• C-Spine injury may be present• Altered level of consciousness is the
most common cause of upper airway obstruction
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Airway Management• Chin lift to open intact
airway• Intubation
Oral: C-spine injury absent on X ray
Nasotracheal intubation: C-spine injury suspected or certain
• Surgical AirwayCricothyroidotomyTracheosotomy
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Emergency Care• Extensive vascularity of head & neck
may lead to massive blood lossMonitor vital signs closelyIntravenous infusion
• Penetrating injuries need to be exploredArteriogramEsophagram
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Treatment of Blood Loss & Shock• Hemorrhage most common cause of
shock after injury• Multiple injury patients have hypovolemia• Goal is to restore organ
perfusion
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Treatment of Blood Loss & Shock• External bleeding controlled by direct
pressure over bleeding site• Gain prompt access to vascular
system with IV catheters• Fluid replacement
Ringer’s LactateNormal salineTransfusion
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Stabilization of associated injuries• C-spine injury is primary concern
with all maxillofacial trauma victimsAny patient with injury above clavicle or
head injury resulting in unconscious state
Any injury produced by high speedSigns/symptoms of C-Spine injury
Neurologic deficitNeck pain
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Stabilization of associated injuries• C-spine injury suspected
Avoid any movement of spinal column
Establish & maintain proper immobilization until vertebral fractures or spinal cord injuries ruled outLateral C-spine
radiographsCT of C-spineNeurologic exam
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Head/Neck/C-Spine Stabilization
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Lateral C-Spine Film
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C-spine CTs
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Early CareEmergency care has stabilized patientInitial stabilization of fracturesDebridement & dressing of soft tissuesElective tracheostomyPhysical exam & historyLaboratory testsComplete head & neck examination
Diagnosis of maxillofacial injuries
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Diagnosis of Maxillofacial Injuries
• Inspection• Palpation• Diagnostic Imaging
Plain filmsCTStereolithography (where available)
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Diagnosis of Maxillofacial Injuries• INSPECTION
HemorrhageOtorrheaRhinorrheaContour deformityEcchymosisEdemaContinuity defectsMalocclusion
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Inspection
Sublingual ecchymosis Step defects, ridgediscontinuity, malocclusion
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Diagnosis of Maxillofacial Injuries
• PALPATION“Step” DefectCrepitus
Bony segmentsSubcutaneous
emphysemaMobility
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Diagnosis of Maxillofacial Injuries• DIAGNOSTIC IMAGING
PanorexPlain filmsCTStereolithography
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CT Scans
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3D CT
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Stereolithography
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Definitive Care• Soft Tissue Injuries
ContusionsAbrasionsLacerations
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Soft tissue injuryFacial lacerations not complicated by
associated injury can be managed in an ER setting
Large extensive facial and scalp lacerations are preferably closed in an operating room environment
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Soft tissue injury• Hemostasis• Debridement• Approximate wound edges
SuturesSteristrips
• Dressings• Antibiotics/Tetanus
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Facial lacerations
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Associated Soft Tissue Injury• Lacrimal System• Parotid Duct• Facial Nerve
Surgical repair if posterior to vertical line drawn from outer canthus of eye
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Associated Soft Tissue Injury
Remember to think in 3Dfor there are alwaysother structures involved!
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Mandibular Fractures• Mandible is second
most common fractured facial bone
• 50% of mandibular fractures are multipleExamine patient and
radiographs closely and suspect additional fractures
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Mandibular Fractures• Clinical Signs and
SymptomsTenderness & painMalocclusionEcchymosis in floor of
mouthMucosal lacerationsStep defects inferior
borderCN V3 Disturbances
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Mandibular Fractures• Treatment depends on fracture site
and amount of segment displacement• Closed reduction
Application of arch barsPlacement into intermaxillary fixation
(IMF)• Open Reduction
Internal wire fixationBone plates
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Closed Reduction with IMF
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Open Reduction
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Open Reduction
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Midface Fractures• LeFort I Transverse Maxillary• Lefort II Pyramidal• Lefort III Craniofacial Dysjunction• Zygomatic Complex• Orbital Floor • Nasal Fractures• Naso-orbital/Ethmoid
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Midface Fractures• Three buttresses
allow face to absorb forceNasomaxillary
(medial) buttressZymaticomaxillary
(lateral) buttressPyterigomaxillary
(posterior) buttress
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Lefort Classification• Weakest areas of midfacial complex
when assaulted from a frontal direction at different levels (Rene’ Lefort, 1901)Lefort I: above the level of teethLefort II: at level of nasal bonesLefort III: at orbital level
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Lefort ClassificationProvides uniform method to describe
the level of major fracture linesAllows references regarding the
probable points of stability for surgical treatment
Does not incorporate vertical or segmental fractures, comminution or bone loss
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Lefort I FractureTransverse Maxillary
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Lefort II FracturePyramidal
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Lefort III FractureCraniofacial Dysjunction
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Facial Examination• Evaluate for laceration• Obvious depression in skull• Asymmetry• Discharge from nose or ear
Assume CSF leak• Palpation to note bone
discontinuityBimanually in systematic
manner
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Facial Examination• Evaluate mandibular
opening• Palpation of buccal vestibule
Crepitus of lateral antral wall• Occlusion evaluated
Absence and quality of dentition noted
• Ecchymosis common finding• Pharynx evaluated for
laceration & bleeding
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Facial Examination• Orbits evaluated
Periorbital edema and ecchymosis
Gross visual acuity determined
DiplopiaPupillary size & shapeSubconjunctival
hemorrhageFunduscopic evaluation
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Facial Examination• Orbits evaluated
Lid lacerationsAttachment of medial
canthal tendonRounding of lacrimal
lakeIncreased
intercanthal distanceEpiphora
Prompt Ophthamology consult
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Facial ExaminationOrbits Evaluated
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Facial ExaminationPalpation of Midface/bridge of nose
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Radiographic Evaluation• Plain Films
Lateral SkullWaters ViewPosteroanterior view of skullSubmental vertex
• CT Scan1.5 mm cutsaxial and coronal views
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Radiographic Evaluation
Lateral skull Water’s Viewwww.indiandentalacademy.com
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Radiographic Evaluation
CT Scan 3D CT
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Radiographic Evaluation
Stereolithographyallows actual modelof defect. A nice reconstruction tool to use if available
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Treatment of Midface Fractures
• Once patient’s condition stabilized, no need to rush to surgeryAddress rapidly
developing edemaFormulate treatment planObserve sequelae in the
case of orbital injuries
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Diagnosis of Lefort I Fractures
• Direction of force• Maxilla displaced
posteriorly and inferiorlyOpen bite deformity
• Hypoesthesia of infraorbital nerve
• Malocclusion• Mobility of maxilla
Noted by grasping maxillary incisors
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Treatment of Lefort I FracturesDirect exposure of all
involved fracturesReduction and anatomic
realignment of the maxillary buttresses to reestablishAnterior projectionTransverse widthOcclusion
Restoration of occlusion using IMF
Internal fixation using miniplate fixation
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Treatment of Lefort I Fractures
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Diagnosis of Lefort II and III• Clinical evaluation provides only a
rough impression since swelling hides the underlying bony structures
• Plain film radiographs and axial and coronal CT images are the basis for precise diagnosis & treatment plan
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Diagnosis Lefort II and III
• Bilateral periorbital edema & ecchymosis
• Step deformity palpated infraorbital & nasofrontal area
• CSF rhinorrhea• Epistaxis
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Treatment of Lefort II and III• Fractures should be treated as early as
the general condition of the patient allows
• Team approach to treatmentNeurosurgeryOphthamologyENTPlastic surgeryOral/Maxillofacial surgery
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Treatment of Lefort II and III• Intubation must not interfere with ability
to use IMF• Exposure & visualization of all fractures
Approaches to inferior rimInfraorbitalSubciliaryTransconjunctivalMid lower lid
Coronal approachGingivobuccal incision
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FracturesTeeth and occlusion
are the key to reconstruction and
provide the foundation upon
which other facial structures are built
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Treatment of Lefort II and IIISeverely comminuted fractures
preliminary approximation may be performed with wire
Establishment of the correct occlusionCorrect reconstruction of the outer facial
frame for proper facial dimensionsCorrect position for nasoethmoidal
complex
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Treatment of Lefort II and IIIReestablishment of the correct
intercanthal distanceInfraorbital rim fixatedOrbit is reconstructedOcclusion unit with IMF is fixated
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Lefort II & III Reconstruction
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Lefort II & III Reconstruction
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Nasal-Orbital-Ethmoid (NOE) Fractures
Usually not isolated eventFrequently associated with
multiple midface fracturesSecondary to traumatic
insult to radix area of noseLow resistance to
directional force35-80 gm necessary to
produce fracture
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Nasal-Orbital-Ethmoid Fractures
• DiagnosisOphthalmalogic evaluation
Document visual acuityPupillary response to light
Neurologic evaluationFrontal lobe contusionGlasgow coma scale– Increase in ICP and need for monitoring
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Nasal-Orbital-Ethmoid Fractures• Nasal fracture
Comminuted with posterior displacement
Widened nasal bridgeSplaying of nasal complex
EpistaxisSevere periorbital edema &
ecchymosisSubconjunctival hemorrhage
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Nasal-Orbital-Ethmoid Fractures• Clinical signs & symptoms
Traumatic telecanthusDifficult to measure due to
edema– Average 33-34 mm
Can measure interpupillary distance and divide in half for approximate intercanthal distance– Average 60-65 mm
Damage to lacrimal apparatus-epiphora
CSF leak
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Nasal-Orbital-Ethmoid Fractures• Radiographic examination
CT - definitive imaging modalityAxial images
supplemented with coronal
Plain films to fail demonstrate the degree and location of fractures secondary to over-lapping of bony archi- tecture
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Nasal-Orbital-Ethmoid FracturesCT Scans
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Nasal Fractures• Depression or
angulation• Periorbital ecchymosis• Epistaxis• Tenderness• Crepitus• Septal deviation• Septal hematoma
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Nasal Hemorrhage
• Nasal packing• Merocel sponge• Nasopharyngeal
balloonEpistatFoley catheter
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Nasal-Orbital-Ethmoid Fractures• Nasal fractures
Rule out septal hematomaRemove clots with suction,
incise and drain if present to prevent septal necrosis
Closed reduction for simple fractures
Open reduction for severely displaced fractures
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Nasal-Orbital-Ethmoid FracturesNasal Fractures
• TreatmentRestoration of form
and functionProper reduction of
nasal fracturesCorrection of medial
canthal ligament disruption
Correction of lacrimal system injuries
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Nasal-Orbital-Ethmoid Fractures
• Surgical considerationsDefinitive surgery as
soon as possible after:Appropriate
consultationsDefinitive radiographic
imagingSignificant edema
allowed to resolve
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Nasal-Orbital-Ethmoid Fractures
• Surgical considerationsThe final phase involves reduction of
the NOE and nasal bone fracturesAccess to NOE through existing
lacerations, bicoronal flap, or local incisions
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Nasal-Orbital-Ethmoid Fractures• Lacrimal system injury
When the medial canthal ligament has been injured or displaced, damage to the lacrimal system should be assumed
Nasolacrimal duct is often damaged within its bony course
Epiphora: Need to evaluate patency of the nasolacrimal system
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Nasal-Orbital-Ethmoid FracturesSurgical Reduction
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Nasal-Orbital-Ethmoid FracturesSurgical Reduction
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Gunshot wound management
• Advanced trauma life supportPrimary survey
ABC’sC-Spine stabilizationNeurological assessment
Secondary surveyDetermine extent of injury
Definitive treatment
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Animal BitesHemostasisDebridementApproximate
wound edgesDressingsAntibiotics/Tetanus
Augmentin
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