Babak Saedi MD Otolaryngologist Tehran University of Medical Sciences Facial Trauma Babak Saedi MD Otolaryngologist 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

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 Displaced fracture Comminuted fracture Greenstick fracture (rare, exclusively in children) Fracture with no displacement (Linear) Fracture with minimal displacement Displaced fracture Comminuted fracture Extensive breakage with possible bone and soft tissue loss Compound fracture Severe and tooth bearing area fractures Pathological fracture (osteomyelities, neoplasm and generalized skeletal disease)

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

FAVORABLE FX ARE THOSE FX WHERE MUSCLES TEND TO DRAW THE FRAGMENTS TOGHETHER. RAMUS FX ARE ALMOST ALWAYS FAVORABLE SECONDARY TO THE ELEVATING FORCES OF THE JAW ELEVATORS . UNFAV MOST ANGLE FX ARE HORIZONTALLY UNFAV. B/C OF THE PULL OF THE JAW ELEVATORS VERTICALLY UNFAVORABLE FX OF THE SYMPHYSIS AND PARASYMPYSIS TEND TO COLLAPSE INWARD IN A SISSOR LIKE FASHION SECONDARY TO THE JAW DEPRESSORS ESP. MYOHYOID

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 treatment similar 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 infection

Treatment options No treatment Soft diet Maxillomandibular fixation Open reduction - non-rigid fixation Open reduction - rigid fixation External pin fixation Lag screw ISOLATEDNONDISPLACED FX OF THE CORONOID PORCESS DO NOT REQUIRE SPECIFIC TX - REALLY ONLY TIME YOU NEED TO TX IS IF IT IS IMPINGING ON THE ZYGOMA AND PT IS UNABLE TO OPEN MOUTH. UNILATERAL NONDISPLACED FX OF THE SUBCONDYLAR AREA OF THE MNADBILE AND NORMAL OCCLUSION - TX WITH SOFT DIET ONLY. PT’S WHO DEVELOP MALOCCLUSION AND/OR PERSISTANT PAIN SHOULD BE MANAGED WITH MMF

Maxillomandibular fixation CANDY CANE WIRES WEAR FACETS REMEMBER, MMF CONTRAINDICATED IN EPILEPTICS, ALCHOLICS, PSHYCHIATRIC ANDFRAIL PTS WHO CANNOT TOLERATED. ALSO DIABETICS

Close reduction Arch bars ▶ IMF prior to rigid fixation ▶ For the purpose of close reduction

Maxillomandibular fixation MMF IN A PATIENT, CAN USES WIRE OR ELASTICS IN DOING THIS YOU WANT TO AVOID FIXING THE INCISORS AS THESE CAN BE ORTHODONTICALLY MOVED BY THE WIRES.

Open reduction - nonrigid fixation CLASSICAL INDICATION FOR OPEN REDUCTION MALOCCLUSION DESPITE MMF DISPLACED UNFAVORABLE FX THROUGH THE ANGLE DISPLACED, UNFAVORABLE FX OF THE BODY OR THE PARASYMPHYSIS MULTIPLE FX OF THE FACIAL BONES - MANDIBLE IS FIXED FIRST PROVIDING A STABLE BASE FOR RESTORATION - BOTTOM UP MALUNION - OSTEOTOMIES AND ORIF ----- NON RIGID FIXATION MORE FORGIVING, EASIER TO PLACE. STILL REQUIRES MMT, USEFUL IN ANGLE AND PARASYMPHYSEAL FX. CAN GO EXTRAORAL OR TRANSORAL(FOR A HIGH WIRE)

Open reduction - Rigid fixation ARCH BARS ARE ALWAYS PLACED FIRST THEN ORIF. CAN USE 2.4 AND 2.0 ,TWO 2.0 PLATES, COMBO’S OF THESE WITH ARCH BARS AS TENSION BANDS WHEN FITTING PLATES IT IS IMPORTANT THAT THE PLATE IS BENT SO THAT IF FITS THE CURVE OF THE MANDIBLE. DCP CAN B E USED(AS WITH LAG SCREW YOU WANT TO BE EXPERIENCED TO DO THIS AS IMPROPER PLACEMENT CAN LEAD TO MALUNION) IT CAN BE USED FOR MOST OF THE BODY, ANGLE, SYMPYSEAL OR PARASYMPHYSEAL FX. TO PUT IN DCP - FIT 4 HOLE PLATE WITH 2 HOLES ON EITHER SIDE OF FX. THE DCP IS SECURED BY DRILLING A HOLE AT THE OUTER EDGE OF THE INNER ECCENTRIC COMPRESSION HOLE. THIS IS REPEATED ON THE OTHER SIDE. THESE HOLES ARE DRILLED WITH A 2.1 MM DRILL BIT AND 2.7 MM SCREWS ARE PLACED SO THAT COMPRESSION IS OBTAINED. NEXT THE OTHER TWO LATERAL DRILL HOLES ARE DRILLED AND SCREWS PLACED IN A NORMAL FASHION. DISADVAT INCLUDE TRAUMATIC BONE LOSS, EXTENSIVE COMMUNUTION, AND SEVERE BONE ATROPHY CAN USE PERCUTANOUES SYSTEM FOR ANGLE AND BODY FX

External Fixation USUALLY NECESSARY IN COMMUNUTED FX. THOSE WHO CANNOT TOLERATE MMF OR GSW

Lag screw LAG SCREW TECHNIQUE CAN BE USEFUL FOR THE OBLIQUE HORIZONTALLY DIRECTED ANGLE FX OR A PARASYMPHYSEAL FX. ONLY USE IF EXPERIENCED. FIRST THE OUTER SEGMENT OF BONE IS DRILLED WITH A 2.7 MM DRILL BIT, ONCE YOU REACH THE INNER CORTEX STOP AND USED A 2MM DRILL BIT THROUGH THE INNER CORTEX, THEM APPLY A SCREW SLIGHTLY LARGER THAN 2MM. TIGHTENING THE SCREW FORCES THE OUT FRAGMENT AGAINST THE HEAD AND THE DEEP FRAGMENT IN THEN BROUGHT UP INTO CONTACT WITH THE OUTER FRAGMENT SINCE LAG SCREW AND DCP COMPRESS THE BONE CAN RESULT IN ATROPHY AND MALUNIION. THOSE FX. THAT HAVE A STRAIGHT COURSE FROM THE BUCCAL TO THE LINGUAL CORTEX LEND THEMSELVES MORE TO COMPRESSION RATHER THAN THOSE FX THAT ARE OBLIQUE OR SAGITALL BETTER FOR LAG. DO NOT USE COMPRESSION IN CASES OF INFECTION OR COMMINUTION- USE LARGE RECON PLATES 2.4MM

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)