Maxillofacial Trauma

Maxillofacial Trauma Common as a result of blunt injury Mandibular:Zygoma:Maxillary in ratio of 6:2:1 50% due to assaults 50% of which alcohol related 25% of women with facial trauma are victims of domestic violence

Need ATLS approach Main cause of death = airway obstruction May require surgical airway 10-15% have C-spine injury (if unconscious) At risk of aspiration – missing teeth Significant haemorrhage can be difficult to control Facial injury = head injury

Pathophysiology High Impact: Low 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

General Examination Look for swelling/bruising/deformity etc. Palpate all bony margins for tenderness and steps Intra-oral examination Facial stability Facial sensation Eye examination

Mandibular Injury Assaults and falls on the chin account for most of the injuries Often injured at site distant from point of impact Multiple fractures are seen in greater then 50% Condyler fractures commonly missed Usually open #’s

Clincial Features Occlusion of bite is the key point in history Parasthesia of mental nerve Intra-oral examination important (Sublingual haematoma). Crepitus + mobility TMJ and ear examination

Mandible Imaging OPT (oral-pan-tomogram) OPG (ortho-pan-tomogram) PA mandible ± Lateral oblique

Mandibular Fracture Management Undisplaced fractures: Analgesics Soft diet Max-fax referral – usually outpatient Displaced fractures and those associated with dental trauma Max-fax referral for inpatient care All fractures should be treated with antibiotics and tetanus prophylaxis.

TMJ Dislocation Causes of mandibular dislocation are: Blunt trauma Excessive mouth opening – clinical diagnosis The mandible can be dislocated: Anterior 70% Posterior Lateral Superior Mostly bilateral

Treatment: Analgesic Manual reduction ±Sedation Soft Diet Avoid Mouth opening

Zygoma Fractures Direct blunt trauma most common cause Two types of fractures can occur Arch fracture (most common) Tripod fracture (most serious) Zygomatic arch Zygomaticofrontal suture Inferior orbital rim and floor

Clinical Features Palpable bony defect over the arch Depressed cheek with tenderness Pain in cheek and jaw movement Limited mandibular movement Infra-orbital nerve parasthsia in 80-90%

Midface fractures High energy injury Le Fort I Low level maxilla fracture May have elongated face Movement of maxilla, but nose stable Le Fort II Pyramidal or nasomaxillary fracture Dished in face followed by evere facial swelling Movement of maxilla and nose Le Fort III Craniofacial dysjunction Mid face fractured off skull base - mobile Risk of severe pharyngeal bleeding CSF leaks are common with Le Fort II & III fractures These fractures may be asymmetrical

Orbital floor/Peri-orbital Injuries Consider associated eye injury with any facial injury – thus all require eye exam Ophthalmoplegia & Diplopia Hypoglobus Enophthalmus Proptosis Visual loss Lid and lacrimal duct damage

Orbital Blowout Fractures Occur when the the globe sustains a direct blunt force Imaging: Hanging tear drop sign Open bomb bay door Air fluid levels Orbital emphysema

Imaging Occipto-mental (OM) 15/30 views Submento-vertical view for arch fractures Maxillary sinus opacification Follow McGrigors lines OM Hotspots

Reviewing facial Xrays

Facial Fracture Management ABCDE approach Protect airway if needed Control Bleeding If able, more comfortable sitting up Max-fax review Consider antibiotics

Management Surgery is indicated if – Impairment of function: ↓mouth opening Displaced fractures ?Cosmetic concern Often best performed when swelling settled Avoid nose blowing (surgical emphysema) and pressurised environments Soft Diet

Others Dento-alveolar injury Frontal sinus fracture Naso-ethmoid fracture Nasal fracture

Questions? ?

Summary Commonly related to blunt trauma Mandibular:Zygoma:Maxillary in ratio of 6:2:1 Often needs ATLS style approach Thorough examination Methodical approach to xray review Consider antibiotics and tetanus Involvement of Max-fax team