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

2. soft tissue injuries
facial bone fractures

3. 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

4. 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

6. Clear Airway and provide patent airway

7. Control Hemorrhage
Nasal tamponage

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

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

10. 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

11. 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

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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. Le-Fort Maxillary Fractures

20. 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)

21. Dental Occlusion Normal occlusion Mandibular retrognathia
Mandibular prognathia

22. Bimanual maxillary examination for abnormal movement

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

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

25. Vertical butresses of maxilla and mandible

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

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

28. 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

29. 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

31. 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

32. Coronal CT
Orbital Blow-out fracture

33. 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.)

34. 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.”

35. 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

37. Nasoethmoidal Orbital Fractures
and their treatment

38. Zygoma Fractures

39. 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

40. 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.

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

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

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

44. Treatment of zygomatic fracture with Gillies method

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

47. Orbitazygomatic fracture- Repositon and rigid internal fixation

48. Axial CT
Zygomatic Fracture

49. Nasal Fractures

50. Various types of fractures of nasal bones

51. Hematoma of Septum

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

53. Reduction of nasal fracture with an Asch forceps

54. 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

55. 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

56. 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

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

58. Panorex examination of mandible

59. 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

60. Intermaxillary fixation

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

62. 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.