MAXILLOFACIAL TRAUMA

Karen Adiel Rances, MD, FPSO-HNS

• Identifying Data:
• DP, a 26y/o, Male, single from Tabaco City.
•
• Chief Complaint:
• Multiple facial injuries secondary to
motorcycle crash.
 History of Present Illness:

• NOI: Motorcycle crash

• DOI: February 18, 2018
• TOI: 11:30pm
• POI: Tinambak, Tabaco Albay

• Few hours prior to admission, DP was on a drinking spree with his

friends. After finishing 4 bottles of Red Horse Beer he decided to go
home. On his way home, it rained heavily mid-way. He decided to
continue driving his motorcycle despite the rain, then suddenly a
dog crossed the street which he didn’t noticed. He tried to avoid
the dog, which made his motorcycle skid and bumped on a nearby
street light, hence the admission.
•
 Physical Examination
• Look for facial asymmetry.
– Stand at the head of the bed and look down from above to check
the level of the cheekbones.
– The nasal bridge width is usually half the interpupillary distance.
• Inspect for bruising, swelling, lacerations, missing tissue,
foreign bodies and bleeding.
• Palpate for bony injury and crepitus systematically.
• Inspect the eyes.
– Examine eye movements.
– Assess pupils.
– Check for foreign bodies and lacerations by everting the eyelids.
 Physical Examination
• More detailed examination is required by an
ophthalmologist if eye trauma is suspected.
• Nose:
– Look for dislocation and telecanthus (widening and flattening
of the nasal bridge).
– Palpate for tenderness and crepitus.
– Look for septal haematoma, lacerations and CSF rhinorrhoea.
• Ears: look for lacerations and CSF in the canal.
– Assess the tympanic membrane.
• Inspect the tongue and mouth.
 Physical Examination
• Palpate the mandible and temporomandibular joint,
looking for mobility or crepitus and bruising.
• Assessment for Le Fort fractures:
– put one hand on the anterior maxillary teeth, the other on the
nasal bridge.
– Only the teeth will move in a Le Fort I fracture.
– If the nasal bridge moves, a Le Fort II or III fracture is present.
• Assess the teeth.
– Look for avulsed or mobile teeth.
– Look for jaw malocclusion.
– If a tooth has been avulsed, note whether it has been aspirated.
 Physical Examination
• Tongue blade test:
– ask the patient to bite down hard on a tongue blade.
 They will be in too much pain to do this if the jaw is
fractured.
• Place a finger in the patient's ear canal to palpate the
mandibular condyle.
– Ask the patient to open and close the mouth.
– If there is pain or lack of movement, this indicates a
condylar fracture.
• Perform a complete cranial nerve examination.
the bottom right window.

Maxillofacial region
 Epidemiology
• Average age ~ 25.8 years - 35.4 years
• Male to female (sex ratio: 3:1)
• Most of maxillofacial fractures happen in the
summer (42.16%) and spring (27.7%)
• Increase of accidents in holiday seasons of the
year.
• In Hogg et al. study fractures happened at the
weekends (51%) in the summer most often
 Epidemiology
• Etiology of maxillofacial fracture
– 33.7% car crash,
– 21.7% falling from height,
– 15.75% car accident with motorcycle,
– 12% motorcycle or bike rollover,
– 8.4% car accident with pedestrian,
– 6% car rollover and 2.4% car crash with bike were
reported.
 Epidemiology
• Car accidents are the most important reason of maxillofacial
fractures.
• Type of trauma in the patients
– 55.4% fracture in rim of orbit,
– 34.93% in zygoma,
– 32.53% in maxilla,
– 31.32% in nasal bone,
– 13.25% in mandible,
– 9.63% Le Fort fracture (common type of Le Fort fracture was type 2
(72.2%)
• In a ten years study of Gassner et al. most fractures were
included of fracture of mid face (72.5%), mandible (24.3%)
WHAT ARE THE SALIENT POINTS IN A HISTORY OF A
TRAUMA PATIENT?
 History-taking
• The mechanism (blunt versus blast versus
penetrating)
• Time
• Degree of contamination
• Events since the injury should be documented.
• When secondary to a motor vehicle accident,
information related to the status of the
windshield, steering column, and airbags should
be elicited
 History-taking
• exposure to chemical, fire, smoke, or extreme
temperatures were encountered are
important.
• Information related to events preceding the
event, such as timing of the last meal or use of
medications or substances that might alter
mental status and ability to respond
coherently, are relevant.
 History-taking
• The patient’s medical history, including
medications and tetanus status are also
relevant.
• For penetrating injuries related to gunshot
wounds, information related to the type of
firearm, number of shots, and proximity of the
victim can predict the extent of damage and
the level of threat to internal organs.
 History-taking
• When able, the patients should be asked
about any new deficits or changes to their
hearing, vision, voice, occlusion, or other
neurologic deficits, as well as if they have new
rhinorrhea or epistaxis.
• They should specifically be asked about and
observed for signs of difficulty breathing, and
whether they feel short of breath.
HOW DO YOU ASSESS A PATIENT AT THE
ER WITH FACIAL TRAUMA? WHAT ARE
THE LIFE THREATENING CONSIDERATIONS
IN THE INITIAL ASSESSMENT?
 4 life-threatening considerations in initial assessment

• 1. Maintenance of airway
 Fractures may be displaced and narrow the airway
 Swelling, hematoma may narrow airway
 Symptoms include:Noisy respiration, stridor, hoarseness, retraction,
drooling, inability to handle secretions
 Treatment options: – endotracheal intubation, tracheostomy
• 2. Prevention of hemorrhage
 Profuse bleeding can be from partially transected veins or arteries
 Bleeding can come from deep tissues, sinus lining
 Avoid blindly applying clamps as this can result in facial nerve paralysis
 For uncontrollable bleeding: – Reduction of fractures (or facial
compression dressing) – Nasal packing – Embolization – External carotid
ligation
 4 life-threatening considerations in initial assessment

• 3. Identification and prevention of aspiration

Aspiration can occur in maxillofacial trauma
Associated brain injury can depress LOC
Aspirated material can be blood, gastric contents, teeth
If there is a concern, prevention is by endotracheal
intubation
• 4. Identification of other injuries
 Brain
 Globe
 Spine
WHAT IS THE PROTOCOL FOR THE AIRWAY
MANAGEMENT IN MAXILLOFACIAL TRAUMA?
• On account of its location in the “crumple zone” of
the face, even minor injuries can result in
significant casualty to the airway.
• Complicated by the presence of broken teeth,
dentures, foreign bodies, avulsed tissues, multiple
mandibular fractures, and massive edema of glottis
which can cause a direct threat to the airway.
• Alcohol, drugs, and head injury along with ingested
and pooled blood can trigger nausea and vomiting.
• The act of vomiting prompts a rise in
intracranial tension which in turn increases the
bleeding and salivation that occludes the
airway.
• Vomiting and risk of aspiration are particularly
high when patients are in supine position.
• In patients with multiple facial fractures, the
displacement of maxilla or mandible posteriorly
can decrease the airway patency.
WHAT ARE THE LABORATORIES OR
IMAGING NEEDED BY THE PATIENT?
 Diagnostics
• CT scan is the workhorse for identifying facial fractures.
• In massive facial trauma, three-dimensional reconstructions of
facial injuries may prove instrumental when planning repair.
• Imaging may also be helpful to examine for presence of foreign
bodies.
• Glass is easily detected on plain films in wounds deeper than
subcutaneous fat.
• The radiodensity of wood is not visible on plain film, but is
detectable on magnetic resonance imaging (MRI).
• There is also increasing support for using ultrasound to detect
radiolucent foreign bodies.
• Vascular imaging is recommended for penetrating
injuries to Zones I and III of the head and neck, and for
fractures of the carotid canal noted on other CT
imaging and associated with neurological deficits.
• Choice of the appropriate imaging study will be a
function of the suspected injuries determined on the
primary assessment.
• MRI imaging may be indicated for brain parenchymal
injuries, while enhanced CT scanning may be helpful in
ruling out a concomitant stroke in an elderly patient.
Zones of the neck for classification of
penetrating injuries
• Laboratory Tests
– All patients should have basic blood chemistries,
blood counts, coagulation panel, and alcohol and
other drug studies when indicated.
– These tests are especially important in preparation
for taking the patient to the operating room.
 Nasoorbitoethmoidal (NOE)
• Confluence of the nose, orbit,
ethmoids, the base of the
frontal sinus, and the floor of
the anterior cranial base.
• The area includes the
insertion of the medial
canthal tendon(s).
• NOE fractures are most
commonly classified according
to Markowitz BL, Manson PN,
Sargent L, et al (1991)
Markowitz Type 1
Markowitz Type 2
Markowitz Type 3
• NOE fractures are often
associated with frontal
sinus fractures.
• NOE complex fractures
involve the medial
vertical (nasomaxillary)
buttresses of the facial
skeleton
 Clinical Examination
• The patient often has
swelling in the medial
canthal area and pain and
crepitation with palpation.
• The nose can be retruded
and impacted at the
nasofrontal suture area
with lack of support for
the nasal septum and
cartilages.
 Bow string test

• The surgeon may

be able to grab the
eyelid or use a
forceps to grab the
skin in the medial
canthal area and
pull it laterally
(“bow-string”
test).
 Intercanthal distance

• There will be a lack of

definition of the bony
anatomy in the medial
canthal area and possible
lateral splaying of the
medial canthus with
increased intercanthal
distance
 Bimanual palpation

• Another test is to place an

instrument in the nose and
push laterally in the medial
canthal area to test for
instability and crepitation,
which suggests an unstable
NOE fracture.
 Make sure to rule out CSF leak

• Tilt test with positive halo sign

• CT scan with thin coronal cuts (0.5 mm) of the
cribriform plate
• Comparison of the concentration of glucose
between fluid and patient’s serum
• Laboratory analysis for beta-transferrin
• Application of fluorescent dyes and direct
visualization of the leak via transnasal
endoscopy. (Note: in many countries the use
of intrathecal dyes is not approved and,
therefore, special permission from the patient
may be necessary.)
 The ZEB pattern can be com
patterns

Classifications of Le Fort FractureThe regions involved in any specifie

purple, such as bilateral Le Fort patt
also illustrated within the detailed pa

• Le Fort type 1 Figure 34

Le Fort I Le F
– horizontal maxillary
fracture, separating the
teeth from the upper face
– fracture line passes through
the alveolar ridge, lateral
nose and inferior wall of
the maxillary sinus

NOE and Zygoma en bloc

 patterns

The regions involved in any specified pattern or associated pattern

Classifications of Le Fort Fracture
purple, such as bilateral Le Fort patterns (Figure 34). NOE and Zy
also illustrated within the detailed panoramic view.

• Le Fort type 2 34
Figure

– pyramidalLefracture,
Fort I
with the teeth Le Fort II Le
at the pyramid base, and
nasofrontal suture at its apex
– fracture arch passes through the
posterior alveolar ridge, lateral
walls of maxillary sinuses,
inferior orbital rim and nasal bones
– uppermost fracture line can pass
through the nasofrontal junction or
the frontal process of the maxilla 3

NOE and Zygoma en bloc Le

 patterns

regions involved in any specified pattern or associated patterns are highlighted in

Classifications of Le Fort Fracture
ple, such as bilateral Le Fort patterns (Figure 34). NOE and Zygoma en bloc patterns are
illustrated within the detailed panoramic view.

re 34
Fort I
• Le Fort typeLe 3Fort II Le Fort III
– craniofacial disjunction
• fracture line passes through
nasofrontal suture, maxillo-
frontal suture, orbital wall,
and zygomatic arch

E and Zygoma en bloc Le Fort I and II

c Figure 30 d
a b

c d
UCM = Upper Central Midface - Nasal skeleton including bone and nasofrontal maxilla; ICM =
Intermediate Central Midface - Parapiriform maxilla and infraorbital maxilla; LCM = Lower Central
Midface - Maxillary bodies including infrazygomatic maxilla; Z = Zygoma / zygomatic arch.
Reproduced from Kunz et al (6)

28/11/2013 page 25/4

c d

UCM = Upper Central Midface - Nasal skeleton including bone and nasofrontal maxilla; ICM =
Intermediate Central Midface - Parapiriform maxilla and infraorbital maxilla; LCM = Lower Central
Midface - Maxillary bodies including infrazygomatic maxilla; Z = Zygoma / zygomatic arch.
• A memory aid is:
– Le Fort 1 is a floating palate
– Le Fort 2 is a floating maxilla
– Le Fort 3 is a floating face
 Practical points

• fracture of the pterygoid plates is mandatory to

diagnose Le Fort fractures
• if the anterolateral margins of the nasal fossa are intact
it excludes a type 1 fracture
• if the infraorbital rims are intact it excludes a type 2
fracture
• if the zygomatic arch is intact it excludes a type 3
fracture
• if the nasofrontal suture is involved, then it either a
type 2 or 3 fracture
 Mandibular fracture
• Patients usually report malocclusion and pain over the
fracture site.
• The mandible will usually fracture in two places.
• This is usually the site of direct impact and a fracture in an
area opposite this site.
• This second fracture commonly involves the mandibular
condyle or mandibular angle on the contralateral side
(indirect fracture).
• If the impact hits the middle of the mandible (symphysis),
additional indirect fractures of both condyles are common.
 Mandibular fracture
• The mandibular condyles must be carefully assessed
when a patient presents with a blow or laceration to the
chin.
• Have a high index of suspicion of condylar fractures in
children who have fallen, as these injuries are often
missed and can result in lifelong pain and disability.
• Because of pain and discomfort mandibular fractures
should be referred within 24 hours.
• The initial oral inspection should include locating missing
teeth, obvious fracture sites and any intra-oral laceration.
 Mandibular fracture
• The lower dental arch should be evaluated to ensure it remains
intact.
• As with maxillary fractures, all missing teeth should be accounted
for which may require radiographic evaluation of the chest.
• Complete disruption of the mandible and the subsequent loss of
dental alignment can mimic a missing tooth.
• Post-traumatic malocclusion is often reported by the patient and
should generally be visible by intra-oral inspection.
• Test occlusion by asking the patient to close their mouth to identify
any malalignment of the teeth.
• A step in the occlusal plane with a ruptured gingiva at the site or a
sublingual haematoma are strong indicators of mandibular fracture.
The defined regions for the mandible are described in details by Cornelius et al (3) and
illustrated in Figure 4.

Figure 4

Reproduced from Cornelius et al (3).

Four transitional zones between adjacent symphysis and body subdivisions (1 = anterior
transitional zones), and between adjacent body and angle/ramus subdivisions (2 = posterior
transitional zones) are defined and the rules for classification of fracture location and
continuity across subdivisions are applied within AO COIAC.
 Approaches
• Facial fractures are often
associated with
lacerations.
• These existing soft-tissue
injuries can be used to
access directly the facial
bones for management
of the fractures.
 Approaches to maxilla
• Relevant to the required
exposure in trauma of the
midface two different
approaches are possible:
– the maxillary vestibular
approach
– the midfacial degloving
approach.
 Lower Eyelid
• There are three basic
approaches through the
external skin of the lower
eyelid to give access to the
inferior, lower medial, and
lateral aspects of the orbital
cavity:
– subciliary (A)
– subtarsal (B)
– infraorbital (C)
Transconjunctival
 Glabellar
• The glabellar approach
can be particularly
advantageous in elderly
patients who have
developed horizontal
glabellar furrows due to
the action of the procerus
muscle.
Coronal
 Superolateral rim of the orbit
• There are two periorbital
approaches to the
superolateral rim of the
orbit: the lateral eyebrow
approach (supraorbital
eyebrow approach) or the
upper-eyelid approach.
• The preauricular
approach can be used
to access and treat
fractures in the
mandibular condylar
head and neck region.
• Endonasal approaches to
the nasal skeleton can be
used for primary
treatment of traumatic
injuries and for secondary
procedures such as
septorhinoplasty to
correct posttraumatic
secondary deformities.
• The external rhinoplasty
approach to the nasal
skeleton can be used for
primary treatment of
traumatic injuries and for
secondary procedures such
as septorhinoplasty to
correct posttraumatic nasal
deformities.
• Common indirect
approaches for reduction
of the zygomatic arch
include: the temporal
(Gillies) approach and the
transoral (Keen) approach.
 Management
• The goal is to restore the anatomy in all three dimensions,
plating the maxillofacial buttresses wherever necessary.
• One of the biggest advancements in the management of
panfacial fractures is recent developments in 3-D imaging,
mainly in CT and cone beam technology.
• Radiographic evaluation should not be restricted to the 3-D
views since multiplanar 2-D view may show critical features
not seen in the 3-D views.
• The availability of an intraoperative model or skull greatly
facilitates proper contouring of hardware and facilitates
proper skeletal reconstruction.
 Management
• There are two options for sequencing:
1. Re-establish the maxillo-mandibular unit as the
first major step of the sequencing (bottom-up)
2. Starting with the reduction and fixation at the
level of the calvarium and working in a caudal
direction (top-down).
ORIF
Complications associated with management
of maxillofacial trauma
1 Complications in fracture healing
2 Complications related to fixation devices
3 Postoperative facial deformity
4 Ophthalmic complications
5 Infections
6 Hard and soft tissue loss
7 Growth and TMJ problems
8 Nerve injury
 Complications in fracture healing

• Delayed union
• Nonunion
• Malunion
 COMPLICATIONS RELATED TO FIXATION
DEVICES
• screw loosening
• breakage
• metal sensitivity
• thermal sensitivity
• tooth injury
• nerve injury
• malocclusion or growth restrictions
• Common infringements of rigid fixation principles:
– a plate that is too small
– one plate instead of two
– placement of a screw into the line of fracture
– too few screws per side of fracture
– inadequate plate bending
 POST-TRAUMATIC FACIAL DEFORMITY

• Deformity can manifest as asymmetry, loss of

facial height, facial width problems, loss of
projection and loss of occlusion.
• Facial deformity of soft or hard tissue can be a
result of diagnostic errors, poor surgical
technique, inadequate reductions and fixation
or no treatment at all.
 OPHTHALMIC COMPLICATIONS

• Early complications:
– traumatic optic neuropathy, retrobulbar hematoma, globe
rupture, vision loss, diplopia, muscle entrapment,
enophthalmos, corneal abrasion, superior orbital fissure
syndrome, orbital emphysema, blindness, sympathetic
ophthalmia.
• Late complications:
– persistent diplopia, enophthalmos, exophthalmos, lower lid
malposition, exposure keratitis, blindness, sympathetic
ophthalmia
– Lower-lid malpositions include scleral show, lower-lid retraction,
ectropion and entropion.
 INFECTIONS

• Causes
– instability, failed hardware, teeth in the line of
fracture, medically compromised patients, delay of
treatment and noncompliant patients
 SOFT AND HARD TISSUE DAMAGE AND LOSS

• facial fat atrophy

• nerve damage
• shortening of the upper lip length
• a widened alar base
• Parotid fistula
 GROWTH RESTRICTION

• Unilateral or bilateral condylar fracture, if

misdiagnosed or inadequately treated can
lead to an open bite and decreased mouth
opening eventually leading to a retrognathic
appearance
• Temporomandibular joint ankylosis may also
develop, resulting in severe growth restriction
in children.