1. FRACTURES OF MAXILLA AND MANDIBLEBy
DR.CHAMPA SUSHEL
MBBS- FCPS
ASSISTANT PROFESSOR
SURGICAL UNIT -4

2. Etiology
Maxillofacial fractures result from either blunt or penetrating trauma.
@60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise.
20-50% concurrent brain injury.
1-4% cervical spine injuries.
Blindness occurs in 0.5-3%
@60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise.
As many as 20-50% of the patients with facial trauma sustain concurrent brain injury, especially those with upper face and midface fractures.
1-4% of these patients have cervical spine injuries. Remember to always r/o cervical spine injuries clinically and radiographically in such patients.
Blindness can occur in .5-3% of these trauma pts and are mostly seen in patients with Lefort 3 (2.2%) and Lefort 2 (.64%).

3. Etiology
25% of women with facial trauma are victims of domestic violence.
25% of patients with severe facial trauma will develop Post Traumatic Stress Disorder
As many as one forth of the women with facial trauma are victims of domestic violence. If a women has an orbital fracture, the likelihood of sexual assault or domestic violence increases to more then 30%.
In addition to physical consequences of facial trauma, there are psychological costs as well. More then a one quarter of patients with severe facial trauma will develop Post Traumatic Stress Disorder.

4. Anatomy

5. Anatomy

6. Emergency Management Airway Control
Control airway:
Chin lift.
Jaw thrust.
Oropharyngeal suctioning.
Manually move the tongue forward.
Maintain cervical immobilization
Emergency management consists of Controlling the airway:
Chin lift.
Jaw thrust.
Oropharyngeal suctioning.
Manually move the tongue forward.
Maintain cervical immobilization

7. Emergency Management Intubation Considerations
Avoid nasotracheal intubation
Consider fiberoptic intubation if available.
Alternatives include percutaneous transtracheal ventilation and retrograde intubation.
Be prepared for cricothyroidotomy.
If available, fiberoptic intubation may be helpful. Other alternatives include percutaneous transtracheal ventilation and retrograde intubation. Always be prepared to perform cricothyroidotomy.

9. Emergency Management Hemorrhage Control
Maxillofacial bleeding:
Direct pressure.
Avoid blind clamping in wounds.
Nasal bleeding:
Anterior and posterior packing.
Pharyngeal bleeding:
Packing of the pharynx around ET tube.
Bleeding from facial injuries typically is profuse but rarely causes hypovolemia or shock. In hypotensive patients, look for other sources of blood loss such as intrathoracic, intraabdominal, and retroperitoneal hemorrhage.
Try to control bleeding with direct pressure. Blind clamping should be avoided because injury to important nonvascular structures such as the facial nerve and parotid duct can result. Anterior and posterior packing may be needed in patients with nasal bleeding that does not resolve with direct pressure alone. Pharyngeal bleeding may require packing around the ET tube.
Once the airway is secured and gross hemorrhage is controlled, only then search for life threatening injuries to the chest, abd and pelvis.

10. History Obtain a history from the patient /witnesses AMPLE history
Specific Questions:
Was there loss of conscious? If so, how long?
How is your vision?
Hearing problems?
After your ABC’s and all life threatening injuries have been addressed, Obtain a history from the pt, witnesses and or EMS.
A-allergies, M-medications, P-pmedhx, L-last meal, E-events leading to the injury.
Specific questions:
Was there LOC? If so,how long?
How is your vision? Monocular double vision-lens dislocation, corneal/retinal injury. Binocular double vision- dysfunction of the EOM or nerves.

11. History Specific Questions: Is there pain with eye movement?
Are there areas of numbness or tingling on your face?
Is the patient able to bite down without any pain?
Is there pain with moving the jaw?
Ask specific questions.:
Is there pain with eye movement?-injury to the globe, orbit
Are there areas of numbness or tingling on your face?-nerve entrap.
Is the patient able to bite down without any pain?
Is there pain with moving the jaw?-fx, impingement temporalis m.

12. Physical Examination Inspection of the face for asymmetry.
Inspect open wounds for foreign bodies.
Palpate the entire face.
Supraorbital and Infraorbital rim
Zygomatic-frontal suture
Zygomatic arches
Inspection of the face for asymmetry.Best done at the head of the bed.
Ask the patient to smile, frown, whistle, raise their eyebrows, close their eyes. Inspect open wounds for foreign bodies.
Palpate the entire face.
Supraorbital and Infraorbital rim
Zygomatic-frontal suture
Zygomatic arches
Note ecchymosis (Battle’s sign, Raccoon eyes)

13. Physical Examination
Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge.
Inspect nasal septum for septal hematoma, CSF or blood.
Palpate nose for crepitus, deformity and subcutaneous air.
Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.
Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. Measure the distance between the medial canthi. In normal patients the distance is 35-40mm. If its greater then 40 mm you should suspect nasoethmoid-orbital trauma.
Inspect nasal septum for septal hematoma, CSF or blood. (place a drop of blood on a paper towel and look for a halo sign, nonspecific).
Palpate nose for crepitus, deformity and subcutaneous air.
Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.

14. Physical Examination Check facial stability.
Inspect the teeth for malocclusions, bleeding and step-off.
Intraoral examination:
Manipulation of each tooth.
Check for lacerations.
Stress the mandible.
Tongue blade test.
Palpate the mandible for tenderness, swelling and step-off.
Open pts mouth and grasp the maxilla arch, place the other hand on the forehead. Push back and forth, up and down and check for movement. Inspect the teeth for malocclusions, bleeding and step-off.
If teeth are missing, account for to be sure they have not been aspirated.
Intraoral exam: Manipulate each tooth, check for lacerations, stress the mandible, tongue blade test. (Bite down on the tongue blade, Twist the blade to try to break it. Pts with broken jaw will reflexively open their mouth.) 95% sensitive and 65% specific.
Palpate the mandible for tenderness, swelling and step-off.

15. Physical Examination Check visual acuity.
Check pupils for roundness and reactivity.
Examine the eyelids for lacerations.
Test extra ocular muscles.
Palpate around the entire orbits..
Check visual acuity. Snell chart, finger counting or presence or absence of light perception.
Check pupils for roundness and reactivity. Tear drop pupil – ruptured or penetrated globe injury. Examine for exopthalmus or enopthalmus
Examine the lids for lacerations. Check for injuries to the medial 3rd of the eyelids for damage to the lacrimal apparatus. Check for disruption of the levator palpebral muscles.
Test extra ocular muscles.Testing for restriction. Restriction of upward gaze can be seen with zygomatic or infra orbital wall fx’s.
Palpate around the entire orbits. Tenderness, subcutaneous air and deformity. Palpate the medial orbit area to r/o naso ethmoidal orbital fx. (place a Q tip inside the nose to the medial canthus, place your finger outside the medial canthus. If the bone moves NEO fx.)

16. Physical Examination Examine the cornea for abrasions and lacerations.
Examine the anterior chamber for blood or hyphema.
Perform fundoscopic exam and examine the posterior chamber and the retina.
Examine the cornea for abrasions and lacerations. Fluorescein if needed.
Examine the anterior chamber for blood or hyphema. When the patient is stable try to do a slit lamp examination.
Perform fundoscopic exam and examine the posterior chamber and the retina. Looking for retinal detachment.

17. Physical Examination Examine and palpate the exterior ears.
Examine the ear canals.
Check nuero distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves.
Examine and palpate the exterior ears. Look for ecchymosis, hematomas,battle sign.
Examine the ear canal. Look for lacerations, TM ruptures, Place your finger into the ear canal and have the pt open their mouth to check for condylar fx or dislocation.
Check nuero distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves.
Supraorbital n.- forehead and vertex of scalp.
Infraorbital n.- midface,maxillary incisors and premolar teeth, upper lip, lower eyelid, side of nose.
Inferior alveolar n.- mandibular teeth, lower lip and chin.
Mental n.- chin and lower lip.

18. Maxillary Fractures High energy injuries.
Impact 100 times the force of gravity is required .
Patients often have significant multisystem trauma.
Classified as LeFort fractures.
Fractures of the maxilla are high energy injuries. An impact 100 times the force of gravity is required to break the midface. These patients often have significant multisystem trauma. Many require resuscitation and admission. The fractures of the maxilla are classified as LeFort Fractures.

19. Maxillary Fractures LeFort I
Definition:
Horizontal fracture of the maxilla at the level of the nasal fossa.
Allows motion of the maxilla while the nasal bridge remains stable.
LeFort I:
Horizontal fracture of the maxilla at the level of the nasal fossa.
Allows motion of the maxilla while the nasal bridge remains stable.
The fracture is below the infraorbital nerve, so there is no hypesthesia.

20. Maxillary Fractures LeFort I
Clinical findings:
Facial edema
Malocclusion of the teeth
Motion of the maxilla while the nasal bridge remains stable
LeFort I: Physical exam:
Facial edema
Malocclusion of the teeth
Motion of the maxilla while the nasal bridge remains stable

21. Maxillary Fractures LeFort I
Radiographic findings:
Fracture line which involves
Nasal aperture
Inferior maxilla
Lateral wall of maxilla
CT of the face and head
coronal cuts
3-D reconstruction
Radiographic findings:
Fracture line which involves
Nasal aperture
Inferior maxilla
Lateral wall of maxilla
CT of the face with coronal cuts is superior to plain films. Head CT should also be done to r/o intracranial injury.

22. Maxillary Fractures LeFort II
Definition:
Pyramidal fracture
Maxilla
Nasal bones
Medial aspect of the orbits
LeFort II:
Pyramidal fracture which includes a fracture through:
Maxilla
Nasal bones
Medial aspect of the orbits

23. Maxillary Fractures LeFort II
Clinical findings:
Marked facial edema
Nasal flattening
Traumatic telecanthus
Epistaxis or CSF rhinorrhea
Movement of the upper jaw and the nose.
Clinical findings:
Marked facial edema
Nasal flattening
Traumatic telecanthus
Epistaxis or CSF rhinorrhea
Movement of the upper jaw and the nose.
Picture: This patient sustained a Lefort II/III fracture.

24. Maxillary Fractures LeFort II
Radiographic imaging:
Fracture involves:
Nasal bones
Medial orbit
Maxillary sinus
Frontal process of the maxilla
CT of the face and head
Plain facial films will reveal the presence of facial fractures, but are less helpful in determining the type or extent . Head and facial CT, including three dimensional re-creations, offer much more useful information.

25. Maxillary Fractures LeFort III
Definition:
Fractures through:
Maxilla
Zygoma
Nasal bones
Ethmoid bones
Base of the skull
Lefort III fractures also known as craniofacial dissociation(separates the face from the cranium) involves fractures through the maxilla, zygoma, nasal bones, ethmoid bones and the bones of the base of the skull.

26. Maxillary Fractures LeFort III
Clinical findings:
Dish faced deformity
Epistaxis and CSF rhinorrhea
Motion of the maxilla, nasal bones and zygoma
Severe airway obstruction
Clinical Findings:
Patients with LeFort III fractures on physical exam have what’s known as the dish faced deformity which is facial flattening and elongation with the eyes markedly swollen shut. Since the maxilla is pushed inward, the patients mandible appears forward. Epistaxis and CSF rhinorrhea are usually present. Movement of the entire face is noted with distraction. These patients are also at high risk for airway obstruction.

27. Maxillary Fractures LeFort III
Radiographic imaging:
Fractures through:
Zygomaticfrontal suture
Zygoma
Medial orbital wall
Nasal bone
CT Face and the Head
Radiographic imaging:
Fractures through:
Zygomaticfrontal suture
Zygoma
Medial orbital wall
Nasal bone extending posteriorly through the orbit into the spheno-palatine fossa.
Again, head and facial CT will offer more information.

28. Maxillary Fractures Treatment
Secure airway
Control Bleeding
Head elevation degrees
Consult with maxillofacial surgeon
Consider antibiotics
Admission
Emergency care for all these fractures involves airway maintenance, with Intubation or cricothyrotomy if necessary. Airway compromise is possible with any of these fractures but probably more common with LeFort II and III fractures. CSF rhinorrhea is uncommon in LeFort I fracture but is often seen in LeFort II and III fractures. If CSF rhinorrhea is present or intracranial air is seen on X ray or an open skull fracture is present, the patient should be admitted and place in a head elevated position (40-60 degrees) if possible. Prophylactic antibiotics are often given in these patients (Rocephin) though it has not been shown to prevent meningitis or brain abscess. Patients with maxillary fractures also have significant epistaxis which requires nasal packing. Operative intervention may be needed if bleeding doe not resolve with packing alone.
Look for associated injuries, especially intracranial, spinal, thoracic and abdominal. Incidence of blindness is high for LeFort II and III fractures so it is important to get opth. consultation. Patients with Complex maxillary fractures require admission for open reduction and internal fixation.

29. Mandible Fractures Pathophysiology
Mandibular fractures are the third most common facial fracture.
Assaults and falls on the chin account for most of the injuries.
Multiple fractures are seen in greater then 50%.
Associated Cervical spine injuries – 0.2-6%.
Following nasal and zygomatic fractures, mandibular fractures are the third most common type of facial fracture. Assault and fall on the chin account for most of the injuries. Because of its ring shape, fractures are often multiple in up to 50% of the cases. The most common area fractured is the 36%. Patients with a mandibular fracture, have a 0.2-6% increased risk of associated C-spine injury.

30. Mandible Fractures Clinical findings
Mandibular pain.
Malocclusion of the teeth
Separation of teeth with intraoral bleeding
Inability to fully open mouth.
Preauricular pain with biting.
Positive tongue blade test.
These fractures manifest clinically with mandibular pain, tenderness and malocclusion. A step off in the dental line or ecchymosis to the floor of the mouth are often present and is highly suggested of a mandibular fracture. Patients are unable to fully open their mouth.
Patients may have preauricular pain with biting when there is a fracture of the condyle.
Picture 1: The open fracture line is evident clinically. There is slight mal-alignment of the teeth.
Picture 2: Hemorrhage or ecchymosis in the sublingual area is pathognomonic for an mandibular fracture.

31. Mandible Fractures Radiographs: Panoramic view
Plain view: PA and Lateral view
The best view for evaluating mandibular trauma is the dental panoramic view. If that is not available, plain films should include AP, bilateral oblique and a townes view to evaluate the condyles.
Picture: Dental panoramic view of the mandible. Note fractures in the area of the left angle and right body.

32. Mandibular Fractures Treatment
Nondisplaced fractures:
Analgesics
Soft diet
oral surgery referral in 1-2 days
Displaced fractures, open fractures and fractures with associated dental trauma
Urgent oral surgery consultation
All fractures should be treated with antibiotics and tetanus prophylaxis.
Nondisplaced fractures:
Analgesics
Soft diet
oral surgery referral in 1-2 days
Displaced fractures, open fractures and fractures with associated dental trauma
Urgent oral surgery consultation, these patients are usually admitted, These patients either need closed reduction with occlusion fixation or open reduction.
All patients with mandibular fractures should be treated with antibiotics and tetanus prophylaxis. Antibiotics of choice are PCN, clindamycin or a 1st generation ceph.

33. Mandibular Dislocation
Causes of mandibular dislocation are:
Blunt trauma
Excessive mouth opening
Risk factors:
Weakness of the temporal mandibular ligament
Over stretched joint capsule
Shallow articular eminence
Neurologic diseases
Dislocation generally results from a direct blow to chin while the mouth is open, or more commonly in predisposed individuals after a vigorous yawn. Opening the mouth excessively wide while eating or laughing may also result in dislocation. It can also be seen in patients who have had a seizure, and in patients who have had a dystonic reaction from their neuroleptic medication.
Weakness of the temporal mandibular ligament, overstretched joint capsule, shallow articular eminence, patients with neurologic diseases which result in increased muscular activity and extrapyramidal effects of neuroleptic medications are predisposing factors.

34. Mandibular Dislocation
The mandible can be dislocated:
Anterior 70%
Posterior
Lateral
Superior
Dislocations are mostly bilateral.
The mandible can be dislocated in the anterior, posterior, lateral and superior plane. Anterior dislocation is the most common and occurs when the condyle is forced in front of the articular eminence. Anterior dislocation occurs in up to 70% of the normal individuals but can be spontaneously reduced by the patient.
Once the jaw is dislocated, muscular spasm, particularly the temporalis and lateral pterygoid muscles tend to prevent reduction.
Dislocations are most frequently bilateral, but they also can be unilateral.

35. Mandibular Dislocation
Clinical features:
Inability to close mouth
Pain
Facial swelling
Physical exam:
Palpable depression
Jaw will deviate away
Jaw displaced anterior
Patients present with the inability to close an open mouth. Other associated symptoms include pain, discomfort and facial swelling near the TMJ. Unilateral dislocation results in deviation of the mandible to the unaffected side. Bilateral dislocation causes the mandible to be displace anteriorly.
Picture: TMJ Dislocation
Note the asymmetric jaw deviation toward the unaffected side. Always consider the possibility of an associated underlying fracture or cervical spine injury.

36. Mandibular Dislocation
Diagnosis:
History & Physical exam
X-rays CT
The diagnosis of mandibular dislocation is made by H&P. X-rays should be performed if the Dx is in question or there is Hx of trauma to exclude fracture. Panoramic view usually demonstrates the pathology and excludes other mandibular injuries. If a fracture is still in questioned after X-rays, a CT can be done to provide more information.
Picture: Radiograph demonstrates an anterior mandibular dislocation. The location of the condyle is indicated by the open arrow.

37. Mandibular Dislocation
Treatment:
Muscle relaxant
Analgesic
Closed reduction in the emergency room
Reduction may be attempted in closed anterior dislocations without fracture. A short acting muscle relaxant (Versed) helps to decrease muscle spasm. An analgesic may also be considered. The patient should be seated. Facing the patient the examiner places his or hers thumbs in the patients mouth, over the mandibular molars as far back as possible. The fingers should curve beneath the angle and the body of the mandible. The examiner applies downward and backward pressure with his or hers thumbs until the condyle slides back into the articular eminence. When the dislocation is bilateral, it may be easier to relocate one side at a time. If reduction is successful, the patient should be able to close his or her mouth immediately. Post reduction films are not usually required unless the procedure was difficult or traumatic. Complications from the reduction are unusual and include iatrogenic fracture or avulsion of the articular cartilage.

38. Mandibular Dislocation
Treatment:
Oral surgeon consultation:
Open dislocations
Superior, posterior or lateral dislocations
Non-reducible dislocations
Dislocations associated with fractures
Oral surgery should be consulted in patients who are found to have either an open dislocation, superior, posterior or lateral dislocations, non – reducible dislocation or a dislocation associated with a fracture.

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