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Maxillofacial Trauma

DR. RITESHSHIWAKOTI

MScD PROSTHODONTICS

S NO: 20130204556

Acute

Airway compromise

Exsanguination

Associated intracranial or cervical-spine injury

Delayed

Meningitis

Oropharyngeal infections

Causes of Mortality

Respiratory upper airway

Visual

Olfactory

Mastication

Cosmetic

Communication

Individual recognition

Functions of Face

Airway control / immobilize cervical spine

Bleeding control

Complete the primary survey

Secondary survey

Consider NG or OG tube placement

Management Sequence

Plain radiographs if fractures suspected

CT if suspect complex fractures

Management Sequence

Repair soft tissue immediately if no other injuries

Delay soft tissue repair until patient in OR , if surgery for other injuries necessary

Management Sequence

Step 1: Airway control

Oxygen for all patients

May need to keep patient sitting or prone

Stabilize C-spine early

Large bore (Yankauer) suction available

Initial Management

Step 1: Airway control

Orotracheal intubation preferred over nasotracheal if possible midfacial fracture and invasive airway needed

Combitube , retrograde wire, or cricothyroidostomy if unable to orotracheallyintubate

Initial Management

Step 2 : Bleeding control

Rapid nasal packing may be necessary

Be sure blood is not just running down posterior pharynx

Step 2 : Bleeding control

Rarely: emergent cutdown and ligation of external carotid artery needed to prevent exsanguination

Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury

Step 2 : Bleeding control

Rarely: emergent cutdown and ligation of external carotid artery needed to prevent exsanguination

Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury

Blood in airway

“Debris” in airway

Vomitus, avulsed tissue, teeth or dentures, foreign bodies

Pharyngeal or retropharyngeal tissue swelling

Posterior tongue displacement from mandible fractures

Airway Compromise

Scalp

Check for lacerations, hematomas, stepoffs, tenderness

Bleeding maybe brisk until sutured

Can use stapler for rapid closure

Secondary Survey

Ears

Examine pinnae, canal walls, tympanic membranes

Suction gently under direct vision if blood in canal

Put drop of canal fluid on filter paper for “ring sign” CSF leak

Assess hearing

Eyes

Pupils, anterior chamber, fundi, extraocularmovements

Conjunctivae for foreign bodies

Palpate orbital rims

No globe palpation if suspect penetration

Eyes

Lid injury can leave cornea exposed

Use artificial tears or cellulose gel

Overall facial appearance

Assess for symmetry, deformity, discoloration, nasal alignment

Palpate forehead & malar areas

Nose

Check septum for hematoma & position

Check airflow in both nares

Palpate nasal bridge for crepitus

Check fluid on filter paper for “ring sign” (for CSF leak)

Mouth

Check occlusion

Reflect upper & lower lips

Check Stenson's duct for blood

Palpate along mandibular and maxillary teeth

Major

Lefort I, II, III

Mandibular

Fracture Classification

ϕ Minor

ϕ Nasalϕ Sinus wallϕ Zygomaticϕ Orbital floorϕ Antral wallϕ Alveolar ridge

Lefort fractures can coexist with additional facial fractures

Patient may have different Lefort type fracture on each side of the face

Lefort Fractures

Pull forward on maxillary teeth

Lefort I: maxilla only moves

Lefort II: maxilla & base of nose move:

Lefort III: whole face moves:

Horizontal fracture extending through maxilla between maxillary sinus floor & orbital floor

Crepitus over maxilla

Ecchymosis in buccal vestibule

Epistaxis: can be bilateral

Malocclusion

Maxilla mobility

Lefort I: Nasomaxillary

Closed reduction

Intermaxillary fixation: secures maxilla to mandible

May need wiring or plating of maxillary wall and / or zygomatic arch

Antibiotics: anti-staphylococcal

Subzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of face

Lefort II: Pyramidal

Signs & symptoms

Midface crepitus

Face lengthening

Malocclusion

Bilateral epistaxis

Infraorbital paresthesia

Ecchymoses: buccal vestibule, periorbital, subconjunctival

Hemorrhage or airway obstruction may require emergent surgery

Treatment can often be delayed till edema decreased

Usually require

Intermaxillary fixation

Interosseous wiring or plating of infraorbitalrims, nasal-frontal area, & lateral maxillary walls

May need additional suspension wires

Antibiotics

Craniofacial dissociation

Bilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base

Lefort III

Signs and Symptoms

Face lengthening: “caved-in” or “donkey face”

Malocclusion: “open bite”

Lateral orbital rim defect

Ecchymoses: periorbital, subconjunctival

Signs and Symptoms

Bilateral epistaxis

Infraorbital paresthesia

Often medial canthal deformity

Often unequal pupil height

Usually associated with major soft tissue injury requiring emergent surgery for bleeding control

Surgery can be delayed till edema resolves

Intermaxillary fixation

Transosseous wiring or plating

Frontozygomatic suture

Nasofrontal suture

May need extracranial fixation if concurrent mandibular fracture

Antibiotics

Airway obstruction from loss of attachment at base of tongue

>50 % are multiple

Condylar fractures associated with ear canal lacerations & high cervical fractures

High infection potential if any violation of oral mucosa

Mandible Fractures

Signs and symptoms

Malocclusion

Decreased jaw range of motion

Trismus

Chin numbness

Ecchymosis in floor of mouth

Palpable step deformity

Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.

Treatment

Prompt fixation: intermaxillary fixation (arch bars), +/- body wiring or plating

Can occur from direct blow to mandible

Can occur “spontaneously” from yawning or laughing

Mandible dislocates forward & superiorly

Concurrent masseter & pterygoid spasm

TMJ Dislocation

Symptoms

Patient presents with mouth open, cannot close mouth or talk well

Can be misdiagnosed as psychiatric or dystonic reaction

Treatment

Manual reduction: place wrapped thumbs on molars & push downward, then backward

Be careful not to get bitten

Usually does not require procedural sedation or muscle relaxants

Often diagnosed clinically: x-ray not needed

Emergent reduction not necessary except to control epistaxis

Usually do not need antibiotics

Early reduction under local anesthesia useful if nares obstructed

Nasal Bone Fractures

Nasal septal hematoma: incise & drain, anterior pack, antibiotics, follow-up at 24 hours

Follow-up timing for recheck or reduction:

Children: 3 to 5 days

Adults: 7 days

Tripod (tri-malar) fracture

Depression of malar eminence

Fractures at temporal, frontal, and maxillary suture lines

Isolated arch fracture

Less common

Shows best on submental-vertex x-ray view

Painful mandible movement

Usually treat with fixation wire if arch depressed

Zygomatic Fractures

Tripod S & S

Unilateral epistaxis

Depressed malar prominence

Subcutaneous emphysema

Orbital rim step-off

Altered relative pupil position

Periorbitalecchymosis

Subconjunctivalhemorrhage

Infraorbitalhypoesthesia

Frontal sinus fracture

Often associated with intracranial injury

Often show depressed glabellar area

If posterior wall fracture, then dura is torn

Ethmoid fracture

Blow to bridge of nose

Often associated with cribiform plate fracture, CSF leak

Medial canthus ligament injury needs transnasal wiring repair to prevent telecanthus

Supraorbital Fractures

“Blow out” fracture of floor

Rule out globe injury

Visual acuity

Visual fields

Extraocular movement

Anterior chamber

Fundus

Fluorescein & slit lamp

Orbital Fractures

Symptoms and signs

Diplopia: double vision

Enophthalmos: sunken eyeball

Impaired EOM’s

Infraorbital hypesthesia

Maxillary sinus opacification

“Hanging drop” in maxillary sinus

Diplopia with upward gaze: 90%

Suggests inferior blowout

Entrapment of inferior rectus & inferior oblique

Diplopia with lateral gaze: 10%

Suggests medial fracture

Restriction of medial rectus muscle

Sometimes extraocular muscle dysfunction can be due to edema and will correct without surgery

Persistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.)

Before repair, rule out injury to:

Facial nerve

Trigeminal nerve

Parotid duct

Lacrimal duct

Medial canthal ligament

Remove embedded foreign material to prevent tattooing

Facial Soft Tissue Injuries

For lip lacerations, place first suture at vermillion border

Never shave an eyebrow: may not grow back

If debridement of eyebrow laceration needed, debride parallel to angle of hairs rather than vertically

Antibiotics for 3 to 5 days for any intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti-staphylococcal antibiotic) – no evidence

Remove sutures in 3 to 5 days to prevent cross-marks

Most face bite wounds can be sutured primarily

Clean facial wounds can be repaired up to 24 hours after injury

Place incisions or debridement lines parallel to the lines of least skin tension (Lines of Langer)

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Defect following surgical procedure

Cleft lip

Cleft palate

misaligned jaws.

Accident victims suffering facial injuries,

Dental implant surgery,

patients with tumors and cysts of the jaws and functional and esthetic conditions of the maxillofacial areas.

Condition requiring surgery

Surgery performed at outside institution without reconstruction after parotid surgery.

If cleft lip is present, its repair can precede palatoplasty. Although early repair seems to have an advantage in decreasing the chances of speech delays, the risk for facial growth abnormalities and other midface-related problems may be increased.

General Principles of Facial Reconstruction

Development of Facial Surgical Reconstruction

Replacing Tisssue Loss

Returning to Normal

Facial Reconstruction by Unit

Facial Function over Form

Invisible Scars

Facial Reconstruction following Trauma or Surgery

Our faces play a pivotal role in our daily social interactions, through expression of emotions, appearance and most importantly identity.

The face is our carte visite, the place where our individuality and our personality is manifested.

It is understandable then that permanent scarring of the face caused by severe trauma or surgery can be profoundly damaging for the person affected.

For this reason facial reconstruction is extremely important and there are a number of fundamental general principles that underpin the surgical techniques employed.

General principles

The first attempts at facial reconstruction took place several hundred years ago and are attributed to one of the forefathers of modern reconstructive surgery, the genius Gaspare Tagliacozzi. Tagliacozzi was Professor of Anatomy at the Medical School of Bologna in Italy in the late 16th century. He is credited with being the first surgeon to attempt reconstruction of the nose by using a flap of skin taken from the forearm. The flap, called a pedicle, was attached to the nose and the patient's arm was bandaged in a raised position until the skin of the arm had attached itself to the nose. The pedicle was then cut from the arm and the attached skin could then be shaped so that it resembled the nose.

The development

This in effect corresponds to a method that was later called "Robin Hood's tissue apportionment", where tissue from an area of abundance is used to make up for tissue deficiencies in another part of the body. This was achieved by using "advancement" or "rotational" flaps. The full development of this notion gave birth to modern ideas of "transfer" of flaps from other areas of the body and ultimately "transplantation" of flaps. The former requires the employment of "micro-vascular" techniques that involve the "transfer" of tissue together with their supporting arteries and veins, which then have to be connected to the recipient vessels in the neck.

Close collaboration with immunological manipulation techniques is also necessary as part of anti-rejection treatment of the "transplant". The reported success stories of total face transplants ultimately signify how advanced reconstructive surgery has become. However, surgical success would not be possible without close interaction between various medical disciplines including immunology, intensive care and post-surgery neurological and psychological rehabilitation.

Dr Ralph Millard, one of the founders of modern reconstructive surgery, summarisedthe main "executional principles" on which reconstruction of the face should be based by stating that "tissue losses should be replaced in kind.”

Replacing tissue

What this means in practice is that bone should be replaced with bone, muscle with muscle and skin with skin. Nevertheless, the 3-dimensional complexity of the anatomy of facial structures, including a multitude of small muscles attached to thin, sometimes hollow bones of irregular, complex shape makes such a principle difficult to apply successfully.

In particular, "transitional" areas between dry skin and moist mucosa, such as at the junction of the outer lip to vermillion border and inner lip and the junction of thin eyelid skin to the tarsal plate and the conjunctiva of the eye make reconstructive planning a daunting surgical task.

For the reason set out above, the further principle of "return what is normal to the normal position and retain it there" is of paramount importance. Displacement, or loss of structures, can occur as a direct result of trauma or planned surgical excision or even scar contraction. The surgical correction needs to take into account the normal appearance or in cases of long established deficit the aesthetic projection of what normal would have been for the missing facial structure.

Returning to normal

Nowadays, this can be facilitated with the use of technology, namely with the use of 3-dimensional images obtained by computer tomography. By using these radiological images and by utilising 3-dimensional "printers" it is possible to create custom-made plastic models, where the missing part has been recreated as a "mirror" image of the opposite healthy side. Obviously there are more complex defects or defects of a single structure, such as the nose, where the recreated missing part represents an estimate of the size and shape of the deficient organ. This assessment is based on data on size and shape depending on the gender, age and ethnic variation of the patient and ultimately on the anticipated symmetry of the new "organ" in relation to the surrounding structures.

Reconstruction by unit

This diagram* demonstrates how the face can be divided into "unit borders" that are demarcated by natural folds, creases and generally "transitional" anatomical areas. Respecting the boundaries of these "aesthetic units" during surgical procedures gives a more "natural" expression to the reconstructed area, concealing the differences in texture, thickness, composition, colour and light reflection between the native and the reconstructed tissues.

In addition, this breaking down of the face into aesthetic units provides the surgeon with an operative "road map" of the exact reconstructive needs caused by the defect. In this way, a complex 3-dimensional defect involving various anatomical borders can be divided into smaller anatomical units, which can then be considered almost independently during the planning of the surgical procedure.

There are a number of other principles that could be included but amongst them I would just like to underline the importance of "function over form”, especially applicable with patients being treated for major trauma or defects following major ablative surgery.

The functions of the face can be grouped into physiological, expressive and aesthetic. The face also plays a very important role in the patient's identity.

Importance of function over form

The physiological functions of the face include the crucial anatomical barrier that the skin of the face provides between the internal and external environments and the abundance of sensory cutaneous nerves that can be seen as the primary sensory organ of the body. The mouth forms part of the alimentary tract; and the nose (and secondarily mouth), the respiratory tract, whilst also hosting the olfactory nerve endings that provide the all-important sense of smell.

Finally the external parts of the eyelids protect the orbital globes from mechanical injury while the internal side together with the conjunctiva provides a pliable, thin layer protecting the cornea of the globe.

The expressive function of the face is underscored by its importance as the main instrument of non-verbal communication, allowing us to express and communicate our thoughts and feelings. Finally, the aesthetic function of the face allows social acceptance and integration.

The quest of modern facial reconstructive surgery techniques then is to provide, as far as possible, "invisible scars" in the face, which means concealing outside the most visible anatomical areas. Fortunately the face does offer such an opportunity. There is a vast array of operations that can be performed through the oral cavity including surgical procedures for the bones of the mid- and lower third of the face and their overlying soft tissues.

Invisible scars

Equally, surgery around the orbital globes can be performed through the conjunctiva, allowing access to the eye socket and the supportive bone with no need for skin incisions. Finally, the combination of facial incisions in conjunction with concealing incisions behind the ears or within the hairline can provide almost seamless, invisible access to the entire surface of the face and the facial skeleton. This allows not only cosmetic improvement of facial features, but primarily serves the ongoing need for social integration by minimising defects and scars and subsequently by minimising the indelible traces of previous illnesses