Facial Injuries Yağmur AYDIN M.D. Associate Proffessor University of Istanbul, Cerrahpasa Medical Faculty Department of Plastic, Aesthetic and Reconstructive Surgery

soft tissue injuries facial bone fractures

Emergency Treatment Clear Airway and provide patent airway Cleaning of blood, vomit and theet from inside of mouth with fingers Aspiration of blood, saliva, and gastric contents Early Intubation or Tracheostomy Control Hemorrhage Direct pressure on the wound Tying of bleeding vessels(a. Facialis, a. Temporalis superfic., a. Angularis, a. Carotis externa) Angiographic demonstration and embolization of the bleeding point Anterior-posterior nasal packing Treat Shock Evaluate Associated Injuries ( cervical vertebrea, skull base, intracranial, thoracal, intraabdominal) Diagnosis and treatment of facial injuries

Indications of Tracheostomy Panfacial fracures(combined mandible, maxilla and nasal fractures) The multiply fractured mandible with significant swelling of the neck and floor of the mouth Patients who require prolonged intermaxillary fixation who have significant head or chest injuries Possibility of prolonged postop. airway problems Severe facial and neck edema resulting from soft tissue injuries such as severe facial burns Unrelieved obstruction of airway in the region of larynx or the hypopharynx

Clear Airway and provide patent airway

Control Hemorrhage Nasal tamponage

Soft tissue Injuries Laceration(most common form of facial injury) Contusion (with or without hematoma) Abrasion Avulsion Puncture Accidental Tattoo Retained Foreign Bodies

Treatment of Soft Tissue Injuries Primary closure Delayed primary closure Secondary healing Tertiary healing (skin grafts, flaps)

Wound Closure-I The time lapse between injury and repair is important in terms of the possibility of infection and the choice of repair techniques Primary closure is treatment of choice It is applied immediately after the trauma if the wound is sharp and clean debridement, excision of a millimeter or two of the wound edge The wound edges is approximated with sutures

Wound Closure-II The contused, dirty and heavy contamined wounds are not closed by primaryly Shotgun wounds, animal and human bites are not closed primarly as well

Delayed Primary Closure The wound must be prepared with debridment and dressing Cleaning Irrigation Debridment The wound can be closed primarly after 24-48 hours, If it is clean and free of devitalized tissue

Secondary Closure If the wound is heavily contamined and infected, contains necrotic and devital tissues after 48 hours, The wound can be closed after cleaning of the wound or can be left to secondary healing Secondary healing occurs with secondary wound contracture and marginal epithelization

Etiology of Facial Injuries Traffic accidents Interpersonel violence Spor accidents Home accidents Occupational accidents Shot-gun injuries

Symptom and Signs Soft tissue Injury Swelling Pain or localized tenderness Crepitation from areas of underlying bone fracture Hypostesia and paralysis in the distribution of specific nerve Malocclusion Class I :Normal oclusion Class II :Retrognathi Class III :Prognathi Visual disturbance Diplopia or decrease in vision Facial asimmetry, deformity Obstructed respiration Lacerations inside of mouth Ecchymosis Bleeding

Clinical Examination-I Evaluation for symmetry and deformity Inspection of face ( comparing 2 sides) Palpation of all bony surfaces in an orderly manner (sup. and inf. orbital rims, nose, the brows, the zygomatic arches, malar eminence, border of mandible) Inspection of intraoral area for lacerations and abnormalities of the dentition Palpation of dental arches for abnormal mobility

Clinical Examination-II Maxillary and mandibular dental arches are carefully visualized and palpated for bone irregularity, bruise, hematoma, tenderness or crepitus Sensory and motor nerve functions in the facial area evaluated Extraocular movements and muscle of facial expression must be examined Globe functions (pupillary size and symmetry, globe excursion, eyelid excursion, double vision and visual loss) and fundoscopic examination

Le-Fort Maxillary Fractures Facial Injuries Midface Fractures Le-Fort Maxillary Fractures Lower Level fractures (Le-Fort I, Transverse, Guerin) transverse fracture separating the maxillary alveolus from the upper mid face Upper Level Fractures Le-Fort II(Pyramidal fracture) : separates a pyramid-shaped central fragment containing the maxillary dentition from the remainder of the orbits and upper craniofacial skeleton Le-Fort III (craniofacial dysjunction) : separates the maxilla at the level of the upper portion of the zygoma, orbital floor, and nasoethmoid region from the remainder of the upper craniofacial skeleton

Le-Fort Maxillary Fractures

Maxillary Fractures Symptoms and Signs Periorbital hematoma Nasopharyngeal bleeding Pain Swelling on the face Intraoral lacerations Malocclusion Elongation of the face Maxillary retrusion Anterior open bite Abnormal mobility on the dental arc Rinorea and pneumocephaly (% 25 in LeFort II and III)

Dental Occlusion Normal occlusion Mandibular retrognathia Mandibular prognathia

Bimanual maxillary examination for abnormal movement

Imaging Plain radiographs : Waters’ and lateral view Axial and coronal CT scans of the midface 3 D CT Waters’ radiograph 3D CT Coronal CT

Dish-shaped face, loss of facial projection, bilateral conjunctival hemoraji

Vertical butresses of maxilla and mandible

Goals of treatment restoration of the proper facial aesthetics including preservation of midface width, height and projection

Treatment of Maxilla Fractures Open reduction and intermaxillary fixation and spanning each of the butresses with plate and screws

Orbital Fractures Classification Orbital floor blow-out fractures Pure (nonfractured infraorbital rim) Inpure (fractured infraorbital rim) Orbital fractures (without blow-out) Lineer fractures Combined with maxillary fractures Zygomatic fractures

A- small orbital blow-out fracture is confined to the orbital floor B- larger blow-out fracture extends to involve to the lower medial orbit as well as orbital floor Bone graft for repair of medial blow-out fracture

Symptom and Signs palpebral and subconjunctival hematoma Diplopia (most common looking superiorly or inferiorly) Numbness in the inferior orbital nerve distribution Enophthalmos Positive forced duction test Radiological evidence of orbital floor fracture and entrapment of soft tissues on the CT scans with both axial and coronal views Assessment of the visual system is essential

Coronal CT Orbital Blow-out fracture

Treatment of Orbital Blow-out Fracture There are two major surgical indications for orbital fracture repair Muscle entrapment (confirmed by forced duction and CT scan) volume increase (> 2cm2 defects enophthalmos and globe dystopia developes) Subciliar or transconjunctival approach Entrapped soft tissues are brought back from maxiillary sinus Defect are bridged with bone grafts or alloplastic materials(silicone, titanium mesh, medpor, proplast etc.)

The Superior Orbital Fissure and Orbital Apex Syndrome ptosis of the eyelid proptosis of the globe paralysis of cranial nerve III, IV, and VI anesthesia in the distribution of the first division of the trigeminal nerve If blindness occurs in combination with the superior orbital fissure syndrome, the condition is termed the “orbital apex syndrome.”

Nasoethmoidal Orbital Fractures Symptoms and signs Telecanthus Decrease in the dorsal nasal projection Rinorea Treatment:open reduction with a combination of interfragmentary wiring and plate and screw fixation

Nasoethmoidal Orbital Fractures and their treatment

Zygoma Fractures

Symptoms periorbital and subconjunctival hematoma numbness in the infraorbital nerve distribution epistaxis (ipsilateral or bilateral) Disturbed occlusion and range of motion of the mandible (inward displacement of the zygomatic arch) Lack of prominence of the malar eminence

The Physical Signs periorbital and subconjunctival hematoma, loss of prominence of malar eminence, numbness in the distribution of the infraorbital nerve inferior globe dystopia or enophthalmos inferior displacement of the palpebral fissure. Step or level discrepancies may be palpated over fracture sites tenderness at the sites of the fracture.

periorbital ecchymosis, edema, antimongoloid slant, and subconjunctival hemorrhage.

Worm’s-eye view. Frontal Axial CT scan isolated depressed left zygomatic arch fracture.

The Radiographic Evaluation Plain films of the Caldwell, Water’s, and submental vertex Axial and Coronal CT scan

Treatment of zygomatic fracture with Gillies method

Open reduction and rigid fixation with plates and screws at frontozygomatic suture, inferior orbital rim, and zygomatico-maxillary butress

Orbitazygomatic fracture- Repositon and rigid internal fixation

Axial CT Zygomatic Fracture

Nasal Fractures

Various types of fractures of nasal bones

Hematoma of Septum

Symptoms Pain Swelling Respiratory obstruction Crepitation on palpation Nasal deformity Deviation of the septum Mucosal lacerations intranasally Septal hematoma

Reduction of nasal fracture with an Asch forceps

Mandibular Fractures the second most common facial bone injury Mandibular fractures are classified according to the state of the dentition (dentulous, partially dentulous, edentulous) or the region of the mandible in which the fracture occurs (condyle, condylar neck, ramus, coronoid, angle, body, symphysis) They are classified as either open or closed, depending on whether or not they have a communication with a skin laceration

Anatomic regions and frequency of fractures in those regions subcondylar area angle region weakened by the presence of the third molar tooth the parasymphysis weakened by mental foramen and canine where the long root of the cuspid tooth Anatomic regions and frequency of fractures in those regions

Symptoms and Signs Pain Swelling Tenderness Malocclusion Frequently, the patient volunteers that the teeth do not feel like they are “coming together properly.” Numbness in the distribution of the mental nerve Fractured teeth, gaps, or level discrepancies in dentition, asymmetries of the dental arch, the presence of intraoral lacerations, loose teeth, and crepitance indicate the possibility of a mandibular fracture

Radiographic Evaluation Plain films: anteroposterior, lateral and oblique views CT scan Panorex examination

Panorex examination of mandible

Treatment The treatment of mandibular fractures involves establishing proper occlusal relationships and then providing co-aptation of the edges of the bone fracture with fixation Closed reduction and Intermaxillary fixation Open reduction and rigid internal fixation

Intermaxillary fixation

Treatment of mandibular fracture by application of an arch bar and plating at the inferior border

Facial Fractures in Children Facial fractures in children account for about 5% of all facial injuries Most of these fractures occur in children > 5 years of age Subcondylar fracture is seen most often Children’s bones are soft, and frequently displace without fracture In children, bone healing progresses rapidly. It may be difficult to reduce a LeFort fracture properly, even after one week children are able to provide some adjustment with growth such that minor occlusal deformities It is often more difficult to apply intermaxillary fixation devices in patients with primary or mixed dentition because of the shape of the teeth The sinuses are small, and the pattern of the orbit and maxillary fractures is different Children have shallowly rooted teeth, and the shape of the crowns may make the application of interdental wires more difficult An acrylic splint may be used sometimes to align mandibular fractures. Intermaxillary fixation is generally necessary for only 3 weeks.