1. Maxillofacial Trauma

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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.

11. 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

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

13. 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

14. 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%

15. 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

16. 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

17. 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

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

19. Reviewing facial Xrays

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

21. 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

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

23. Questions? ?

24. 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