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

2. 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

3. Bones of the Facial Skeleton

4. Maxillofacial Trauma

5. Maxillofacial Trauma
Patient evaluation

6. Patient Evaluation History Physical exam Other systems: - Airway
- Circulation
- CNS (GCS)

7. Physical examination
Orbit
Nasal airway
Dental occlusion
Neurovascular

8. Soft tissue damage Contusion Avulsion Laceration
(loss of soft tissue – penetrating trauma)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Nasal bone

17. 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

19. 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

20. 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

21. 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

22. Nasal fracture Managements: (closed & open reduction) Complications:
- septal hematoma
- CSF leakage
- ophthalmologic compl.

24. Septal haematoma

25. closed reduction

26. 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

27. Tripod Fracture

28. 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

29. LeFort Fractures

31. 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.

32. Maxillofacial Trauma-Specific Fractures
Orbital Fractures
Usually through floor or medial wall
Enophthalmos
Anesthesia
Diplopia
Infraorbital stepoff deformity
Subcutaneous emphysema

33. 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.

34. 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).

35. 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

36. 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

37. 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.

38. Anatomic units of the mandible

39. 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)

40. Angle’s classification

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

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

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

49. 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.

50. 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)

51. 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

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

53. 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

54. Special Considerations
TMJ ank.
Pediatric
Dental root
Inf. Alveolar N.
airway

55. Special Considerations
Facial N.
Lacrimal ap.
Foreign body
Borders & margins injury
(Vermilion border- nasal ala- eyelids- helix)