1. Maxillofacial Trauma

2. Anatomy

3. Anatomy

4. Maxillofacial Region 1. Fractures of the Nasal Pyramid
2. Fractures of the Central Midface
Le Fort Fractures

5. Maxillofacial Region 3. Fractures of the Lateral Midface
4. Fractures of the Frontal bone
5. Fractures of the Anterior Skull Base
Escher Classification

6. Maxillofacial Region
6. Fractures or dislocation of the mandible

7. Etiology Sports Vehicular Accidents Mauling
Women – consider the possibility of domestic violence

8. Etiology Patients with severe facial trauma: multisystem trauma
potential for airway compromise
concurrent brain injury
cervical spine injuries
blindness

9. Emergent Management Primary Survey Secondary Survey Airway Breathing
Circulation
Secondary Survey

10. Emergent Management 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

11. Emergent Management Avoid nasotracheal intubation  cricothyroidotomy
Adverse effects:
Nasocranial intubation
Nasal hemorrhage
 cricothyroidotomy
The cribiform plate may be disrupted- avoid nasotracheal intubation. Nasotracheal intubation can result in: 1) nasocranial intubation or 2) nasal hemorrhage. These include failure to intubate and subsequent failure to ventilate with a bag valve mask 2nd to facial distortion and should also be avoided.
Consider awake intubation and use Benzodiazepines or another induction agent that minimizes resp. depression. If paralytics are used, be prepared for immediate backup cricothyroidotomy.

12. Emergent Management Circulation: Direct pressure
Anterior and posterior nasal packing
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. Avoid blind clamping because it can lead to injury of 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, search for life threatening injuries to the chest, abdomen and pelvis.

13. History Place, Time, Date, Mechanism of injury
Detailed description of the circumstances surrounding the injury
Allergies, other medical problems, medications, tetanus immunizations

14. History
Questions:
Was there LOC, nausea/vomiting, headache? (Head Trauma related questions)
How is your vision?
Hearing problems?
Is there pain with eye movement?
Are there areas of numbness or tingling on your face?
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.

15. Physical Examination Inspection Open wounds for foreign bodies
Facial asymmetry
Nose for deviation, widening of bridge
Nasal septum for septal hematoma, CSF or blood
Ears for blood or CSF
Malocclusion
Inspection of the face for asymmetry. Ask the patient to smile, frown, whistle, raise their eyebrows, close their eyes. Inspect open wounds for foreign bodies.
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).
Note ecchymosis (Battle’s sign, Raccoon eyes)

16. Physical Examination Inspection Battle’s sign Raccoon eyes

17. Physical Examination Inspection
Not sensitive or specific but can be used as a preliminary test for CSF in blood
Dipstick
Beta transferrin
Battle’s sign, Raccoon eyes
Halo Sign
Otorrhea, Rhinorrhea

18. Physical Examination Palpation Palpate the entire face.
Supraorbital and Infraorbital rim
Zygomatic-frontal suture
Zygomatic arches
Nose - crepitus, deformity and subcutaneous air
Zygoma along its arch and its articulations with the maxilla, frontal and temporal bone
Mandible for tenderness, swelling
Palpate nose for crepitus, deformity and subcutaneous air.
Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.
Palpate the entire face.
Supraorbital and Infraorbital rim
Zygomatic-frontal suture
Zygomatic arches

19. Physical Examination Intraoral examination:
Inspect the teeth for malocclusions, bleeding
Manipulation of each tooth
Check for lacerations
Mandibular movements
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.)
Palpate the mandible for tenderness, swelling and step-off.

20. Physical Examination Ophthalmologic exam Visual acuity
Pupils for shape and reactivity
Eyelids for lacerations
Extra ocular muscles
Palpate around the 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 - nasoethmoidal fracture.)

21. Physical Examination Examine and palpate the exterior ears
Otoscopic examination
Look for lacerations
TM rupture
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.

22. Diagnostic Imaging Plain films CT scan
Confirm suspected clinical diagnosis
Determine extent of injury
Document fractures
CT scan

23. General Treatment ATS, TeAna Thorough evaluation of all wounds
All foreign bodies must be removed
Debridement
Suturing of lacerations as needed
Minimize scarring
Antibiotics

24. Nasal Fractures Most common bone injury in the face Open or closed
Signs
Depression or displacement of nasal bones
Edema of nose
Epistaxis
Fracture of septal cartilage with displacement or mobility
Crepitus on palpation

25. Nasal Fractures
All nasal injuries should be evaluated for septal hematoma
Note mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle nose deformity.
Untreated- result in septal necrosis and saddle nose deformity
Can become infected- result in a septal abscess

26. Nasal Fractures Treatment: Radiographs: Surgical
Lateral projection
Treatment:
Surgical
After reduction, nasal cavities should be packed – “internal splinting”
Note mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle nose deformity.

27. Maxillary Fractures Le Fort’s classification
Le Fort I (transverse maxillary)
Le Fort II (pyramidal)
Le Fort III (craniofacial dysjunction)

28. Le Fort I Low transverse fracture of maxilla involving palate
Facial edema
Mobility of hard palate and upper teeth
Malocclusion

29. Le Fort II Pyramidal fracture with detachment of maxilla Facial edema
Epistaxis
Bilateral periorbital edema and ecchymosis

30. Le Fort III
Complete disruption of attachments of facial skeleton to cranium
Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate
Open patient’s mouth and grasp the maxilla arch
Place the other hand on the forehead
Gently move back and forth, up and down - check for movement of maxilla

31. Le Fort III

32. Le Fort III
Massive edema with facial elongation, flattening – “Dish faced deformity”
Epistaxis and CSF rhinorrhea
Motion of the maxilla, nasal bones and zygoma

33. Management of Le Fort Fractures
Open reduction and intermaxillary fixation should be performed to establish correct occlusion
Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.

34. Zygoma Fractures The zygoma has 2 major components: Zygomatic arch
Zygomatic body
Two types of fractures can occur:
Isolated Arch fracture -most common
Tripod fracture - most serious
The zygoma has 2 major components, the zygomatic arch and the body. The arch forms the the inferior and lateral orbit, and the body forms the malar eminence of the face. Fractures to the zygoma are usually the result of blunt trauma. Direct blow to the arch can result in isolated arch fractures. These are the most common. While tripod fractures are more serious and are caused by more extensive trauma.

35. Zygoma Arch Fractures Palpable bony defect over the arch
Flattening of the cheek
Pain in cheek and jaw movement
Limited mandibular movement
Clinical findings:
Palpable bony defect over the arch
Depressed cheek with tenderness on palpation.
Pain in cheek and jaw movement and limited mandibular movement which is due to impingement of the coronoid process of the mandible on the arch during mouth opening or impingement of the temporalis muscle.
Picture: patient with blunt trauma to the zygoma. Flattening of the right malar eminence is evident.

36. Zygoma Arch Fractures Radiographic imaging: Treatment:
Submental view “bucket handle view”
- Arches may not be seen in usual views (anterior, lateral)
Treatment:
Symptomatic - surgical
X-ray: bucket handle view of the zygomatic arch demonstrating a depressed fracture.

37. Zygoma Tripod Fractures
Tripod fractures consist of fractures through:
Zygomatic arch
Zygomaticofrontal suture
Inferior orbital rim and floor
Symptoms
Periorbital edema
Sensory disturbances along the infraorbital nerve
Tripod fractures consist of fractures through:
Zygomatic arch
Zygomaticofrontal suture
Inferior orbital rim and floor
Picture: Diagram of a tripod fracture. Note the disruption of both the lateral orbital rim and the orbital floor, as well as the zygomatic arch.

38. Zygoma Tripod Fractures
Waters
Caldwell
Submental
Coronal CT
Treatment:
Symptomatic - surgical
Plain films including the waters, submental and caldwell views. Can demonstrate the fracture and evaluate the zygomaticomaxillary complex, but a Coronal CT of the facial bones will best show involvement and the degree of displacement.

39. Orbital Blow Out Fractures
Isolated fracture of the orbital floor with partial herniation of orbital contents
Facial asymmetry
Enophthalmos
Diplopia on upward gaze- impingement of inf. Rectus
Check for sensory disturbances – cheek, upper lip, lateral nasal wall

40. Orbital Blow Out Fractures
CT scan
Management:
Indicated for displaced fractures or for symptomatic fractures

41. Frontal Sinus Fracture
Uncommon
Depression of anterior table of frontal sinus
Intracranial injuries
Dural tears
Epistaxis
CSF rhinorrhea (disruption of posterior table of frontal sinus with dural rupture)

42. Frontal Sinus Fracture
Radiographs:
Facial views should include:
Waters
Caldwell
lateral projections
Caldwell view best evaluates the anterior wall fractures
Patients with a suggested mechanism or PE should get either skull films, or a caldwell view of the face. (Caldwell view is the best for anterior wall fx’s.).
Picture: Caldwell view

43. Frontal Sinus Fractures
Cranial CT with bone window
Frontal sinus fractures.
Orbital rim and nasoethmoidal fractures
R/O brain injuries or intracranial bleeds
CT scan of the head with bone windows should be done to r/o intracranial pathology, but also to r/o depressed or posterior fx’s.
Picture: CT of a patient which demonstrates a fracture of the anterior table of the frontal sinus.

44. Frontal Sinus Fractures
Patients with depressed skull fractures or with posterior wall involvement.
ENT or nuerosurgery consultation.
Admission.
IV antibiotics.
Tetanus.
Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.
Patients with depressed skull fractures or with posterior wall involvement require:
ENT or nuerosurgery consultation.
Admission.
IV antibiotics.
Tetanus.
Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

45. Frontal Sinus Fractures
Associated with intracranial injuries
Orbital roof fractures
Dural tears
Mucopyocoele
Epidural empyema
CSF leaks
Meningitis
Associated with with intracranial injuries:
Orbital roof fractures.
Dural tears.
Mucopyocoele.
Epidural empyema.
CSF leaks.
Meningitis.

46. Anterior Skull Base Fractures

47. Mandibular Fractures 2nd most commonly fractured facial bone
Signs and symptoms
Malocclusion of teeth
Tooth mobility
Intraoral lacerations
Pain on mastication
Bone deformity

48. Mandibular Fractures 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.

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

50. Mandibular Fractures Treatment: Nondisplaced fractures:
Analgesics
Soft diet
Dent/ORL surgery referral
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.