This document provides an overview of maxillofacial injuries, including: - Causes such as road traffic accidents and violence - Principles of management including airway control, hemorrhage control, and imaging - Types of facial bone fractures like frontal sinus fractures, nasal-orbital fractures, zygomatic fractures, LeFort fractures, and mandible fractures - Guidelines for treatment including closed versus open reduction, fixation methods, and fracture-specific considerations.

1. Maxillo facial injuriesDepartment of dentistryTata Main HospitalDr K V Sebastian KVS

2. KVS Maxillofacial injuries

3. Learning Objectives To be able to recognize life threatening nature of facial injuries – Airway obstruction, associated head & spinal injuries. Method of examining facial injuries. Diagnosis & principles of management of facial injuries KVS 3

4. Anatomy KVS

5. Anatomy KVS

6. Causes Road traffic accidents Intentional violence Sporting activities KVS

7. Pathophysiology High 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 KVS

8. Severity @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% KVS

9. Assessment Based on Targeting care: Glasgow Coma Scale (GCS) Predicting outcome: Abbreviated Injury Scale (AIS) and Injury Severity Score(ISS) Assessing critically injured patients: APACHE II KVS

10. Initial hospital care Triage the causalities(sorting for prioritization) A: airway with cervical spine control B: breathing and ventilation C: circulation and hemorrhage control D: disability due to neurologic deficit E: exposure and environment control KVS

11. Clinical effects Injuries to facial skeleton -> Immediate airway obstruction delayed airway obstruction KVS

12. Immediate airway obstruction inhalation of tooth fragments accumulation of blood & secretions loss of control of tongue in unconscious/ semiconscious pt. -> KVS

13. Emergency ManagementAirway Control Control airway: Chin lift. Jaw thrust. Oropharyngeal suctioning. Manually move the tongue forward. Maintain cervical immobilization KVS

14. Emergency ManagementIntubation Considerations Avoid nasotracheal intubation: Nasocranial intubation Nasal hemorrhage Avoid Rapid Sequence Intubation: Failure to intubate or ventilate. Consider awake intubation. Sedate with benzodiazepines. KVS

15. Emergency ManagementIntubation Considerations Consider fiberoptic intubation if available. Alternatives include percutaneous transtracheal ventilation and retrograde intubation. Be prepared for cricothyroidotomy. KVS

16. Emergency ManagementHemorrhage Control Maxillofacial bleeding: Direct pressure. Avoid blind clamping in wounds. Nasal bleeding: Direct pressure. Anterior and posterior packing. Pharyngeal bleeding: Packing of the pharynx around ET tube. KVS

17. History Obtain a history from the patient, witnesses and or EMS Specific Questions: Was there LOC? If so, how long? How is your vision? Hearing problems? KVS

18. 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? KVS

19. Clinical examination ATLS standard approach Inspection Palpation Visual examination Eye movement Diplopia Pupil reaction 19

20. 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 KVS

21. 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. KVS

22. 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. KVS

23. Fractures of Facial Skeleton Upper third – above the eyebrows – involves frontal sinuses & supraorbital ridges Middle third – above the mouth Le Fort I , II , II Lower third -- Mandible

24. Imaging of Facial Trauma Frontal Sinus/ Bone FracturesDiagnosis Radiographs: Facial views should include Waters, Caldwell and lateral projections. Caldwell view best evaluates the anterior wall fractures. KVS

25. Frontal Sinus/ Bone FracturesDiagnosis CT Head with bone windows: Frontal sinus fractures. Orbital rim and nasoethmoidal fractures. R/O brain injuries or intracranial bleeds.

26. Naso-Ethmoidal-Orbital Fracture Fractures that extend into the nose through the ethmoid bones. Associated with lacrimal disruption and dural tears. Suspect if there is trauma to the nose or medial orbit. Patients complain of pain on eye movement.

27. Naso-Ethmoidal-Orbital Fracture Clinical findings: Flattened nasal bridge or a saddle-shaped deformity of the nose. Widening of the nasal bridge (telecanthus) CSF rhinorrhea or epistaxis. Tenderness, crepitus, and mobility of the nasal complex. Intranasal palpation reveals movement of the medial canthus.

28. 3D Reconstruction KVS

29. Nasoorbitalethmoidal(NOE)Fractures KVS Three types of NOE fractures – Type I: Large fragment of medial orbit, medial canthal insertion is intact – Type II: Comminution of bones, fracture line does not extend into area of medial canthal insertion – Type III: Comminution of bones, fracture line extends into area of medial canthal insertion

30. Management of nasal-orbital ethmoid fractures Examination for determination of the extent of the injury (surgical exploration) Nasal bone Orbital and ethmoidal Frontal bone Debridement and closure of open wounds Reduction and stabilization of bone fracture 30

31. Detached canthusTraumatic telecanthus Increase in inter-canthal distance secondary to canthus displacement or detachment Seen in association to: Nasal bone NEO Le Forts fractures 31

32. Surgical management of detached canthus Transnasal wiring technique (unilateral type) Canthopexy Identification of the ligament Liberation of the periorbital tissue Liberation of the lacrimal pathway Nasal transfixation Contralateral fixation 32

33. Zygomatic bone complex Anatomy Star-shape like with four processes Frontal process Temporal process Buttress Orbital floor (Maxilla and GWSB) Temporal fascia and muscle Masseter muscle 33

34. Zygomatic complex and arch fracture The malar bone represent a strong bone on fragile supports, and it is for this reason that, though the body of the bone is rarely broken, the four processes- frontal, orbital, maxillary and zygomatic are frequent sites of fracture. HD Gillies, TP Kilner and D Stone, 1927 34 Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent.

35. Signs and symptoms Periorbital ecchymosis and edema Flattening of the malar prominence Flattening over the zygomatic arch Pain and tenderness on palpation Ecchymosis of the maxillary buccal sulcus Deformity at the zygomatic buttress of the maxilla Deformity at the orbital margin 35

36. Trismus Abnormal nerve sensibility Epistaxis Subconjunctivalecchymosis Crepitation from air emphysema Displacement of palpebral fissure (pseudoptosis) Unequal pupillary levels Diplopia enophthalmos 36

37. Occipitomental view (Posterioanterior oblique) (water’s view) 37

38. submentovertex 38 Recommended for isolated zygomatic arch fracture

39. CT scan Coronal sections Axial sections 39

41. Restriction of mandibular movement

42. Restoration of normal contour

45. Infraorbial approach

46. Subciliary (blepharoplasty) incision

47. Mid-lower lid incision

49. Isolated Zygomatic Arch Fractures KVS

50. Maxillary FracturesLeFort 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.

51. Maxillary FracturesLeFort I Clinical findings: Facial edema Malocclusion of the teeth Motion of the maxilla while the nasal bridge remains stable

52. Maxillary FracturesLeFort II Definition: Pyramidal fracture Maxilla Nasal bones Medial aspect of the orbits

53. Maxillary FracturesLeFort II Clinical findings: Marked facial edema Nasal flattening Traumatic telecanthus Epistaxis or CSF rhinorrhea Movement of the upper jaw and the nose.

54. Maxillary FracturesLeFort III Definition: Fractures through: Maxilla Zygoma Nasal bones Ethmoid bones Base of the skull

55. Maxillary FracturesLeFort III Clinical findings: Dish faced deformity Epistaxis and CSF rhinorrhea Mobility of the maxilla, nasal bones and zygoma Severe airway obstruction

56. Le Fort fractures seldom confine to exactly to the original classification & combinations of any of the fractures may occur.

57. Coronal & Axial CT scan

58. Treatment closed reduction with inter maxillary fixation (unilateral fractures) open reduction. Open reduction – intra osseous wiring - by using micro or miniplates

59. Internal orbital fractures In conjunction with other facial fractures As isolated type (Blow out fracture) 54

60. Anatomy The floor is made of: Maxillary bone and part of zygoma bounded laterally by the inferior orbital fissure and small part of the ethmoid bone 55

61. Clinical and radiographical presentation Subconjunctival ecchymosis Crepitation from air emphysema Displacement of palpebral fissure Unequal pupillary levels Diplopia enophthalmos 56

62. Treatment Rational for intervention: Small defect with no clinical consequence may not warrant the surgical intervention. Large defect with handicapping symptoms should be operated. 57

63. Method of reconstruction Intra-sinus approach to the orbital floor External approach to the internal orbital floor 58

64. Materials in orbital reconstruction Autologous graft Bone (cranial, rib, iliac) Cartilage Allogenic materials Lyophilized dura Alloplastic materials Siliastic and proplast implants Teflon hydroxyapatite Titanium mish 59

65. Mandible FracturesPathophysiology 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 C-spine injuries – 0.2-6%.

66. KVS

67. Epidemiology Sites of weakness Third molar (esp. impacted) Socket of canine tooth Condylar neck

68. Haug et al

69. Favorable vs. Unfavorable Masseter, Medial and Lateral Pterygoid, and Temporalis tend to draw fractures medial and superior Almost all fractures of angle unfavorable

71. Physical Exam Complete Head and Neck exam Palpable step off Tenderness to palpation Malocclusion Trismus (35 mm or less) Sublingual hematoma Altered sensation of V3 Crepitus

72. Mandible FracturesClinical findings Mandibular pain. Malocclusion of the teeth Separation of teeth with intraoral bleeding Inability to fully open mouth. Preauricular pain with biting. .

73. Physical Exam Unilateral fractures of Condyle Decreased translational movement, functional height of condyle Deviation of chin away from fracture, open bite opposite side of fracture Bilateral fractures of condyle - Anterior open bite

75. Radiographic Evaluation Panorex (OPG) X ray skull Reverse towns view. X Ray mandible PA View, Lateral oblique views TMJ views

76. Radiographic Evaluation CT scan Not as diagnostic as plain films for nondisplaced fractures of mandible. Most useful for coronoid and condylar fractures, associated midface fractures KVS

77. Closed Reduction Favorable, non-displaced fractures Grossly comminuted fractures when adequate stabilization unlikely Severely atrophic edentulous mandible Children with developing dentition

78. Open Reduction Displaced unfavorable fractures Mandible fractures with associated midface fractures When MMF contraindicated or not possible Patient comfort Facilitate return to work

79. Open Reduction Associated condylar fracture Associated Midface fractures Psychiatric illness GI disorders involving severe N/V Severe malnutrition To avoid tracheostomy in patients who need postoperative intubation

80. Open Reduction Contraindications General Anesthetic risk too high Severe comminution and stabilization not possible No soft tissue to cover fracture site Bone at fracture site diffusely infected (controversial)

81. Closed Reduction Length of MMF Fracture at angle of mandible for adults : 4 wks Add 2 wks more for symphysis fracture Add 2 wks for geriatric patients (edentulous) Less 1 wk for peadiatricmandibular fractures. Less 1 wk for condylar fractures.

84. Open ReductionTechniques Rigid fixation Compression plates (DCP) Lag screws Semirigid fixation Miniplates Transosseous wiring External fixators

85. Rigid Fixation Compression plates Rigid fixation Allow primary bone healing Difficult to bend Operator dependent No need for MMF

87. Open Reduction Lag Screws Rigid fixation (Compression) Good for anterior mandible fractures, Oblique body fractures, mandible angle fractures Cheap Technically difficult Injury to inferior alveolar neurovascular bundle

88. Lag Screw Technique

89. Lag Screw Technique

90. Semi Rigid Fixation Miniplates Semi-rigid fixation Mono cortical screws Uses tension band principle Allows primary and secondary bone healing Easily bendable More forgiving Short period MMF Recommended

92. Champey’sminiplateosteosynthesis Areas of tension and compression 2 mm plates Monocortical screws. Placed in favourable positions on mandible. Micromovements possible favourable to healing. Technically not highly demanding. Plate removal is not routinely required. KVS

93. External Fixation Alternative form of rigid fixation Grossly comminuted fractures, contaminated fractures, non-union Often used when all else fails

94. Condylar and Subcondylar Lindhal and Hollender Closed reduction in children, teens, adults Intracapsular fractures Higher incidence of postoperative sequelae in adults Children and Teens with less sequelae, more remodeling

95. Condylar and Subcondylar ORIF, Absolute indications Displacement into middle cranial fossa Inability to achieve occlusion with closed reduction Foreign body in joint space

96. Condylar and Subcondylar Relative indications Bilateral condylar fractures to preserve vertical height Associated injuries that dictate earlier function Soft tissue swelling causing airway compromise with MMF Intracapsular fracture on opposite side where early mobilization important

98. Panfacial fractures Expose all fracture sites Reconstruct the AP projection of face, start from stable post area (temporal bone, proximal arch Reconstruct the width of the face across zygomatic arches (frontozygomatic suture) Recreate NOE area. Restore height (fix ramus fractures) Restore occlusion. Repair the fractures in maxilla and mandible closer to teeth bearing areas KVS

99. TMH statistics 2010-11 KVS

100. TMH statistics 2010-11 KVS

101. TMH statistics 2010-11 KVS

102. Thank you

103. KVS