Faciomaxillary injuriesFaciomaxillary injuries

Learning ObjectivesLearning Objectives

To be able to recognize life threatening nature of To be able to recognize life threatening nature of facial injuries – Airway obstruction, associated head facial injuries – Airway obstruction, associated head & spinal injuries.& spinal injuries.

Method of examining facial injuriesMethod of examining facial injuries Classification of facial Classification of facial ## Diagnosis & principles of management of facial Diagnosis & principles of management of facial

injuriesinjuries To appreciate the importance of careful cleaning & To appreciate the importance of careful cleaning &

accurate suturing of facial lacerations.accurate suturing of facial lacerations.

CausesCauses

Sporting activitiesSporting activities

Road traffic accidentsRoad traffic accidents

Intentional violenceIntentional violence

Clinical effectsClinical effects

Injuries to facial skeleton Injuries to facial skeleton → →

Immediate airway obstructionImmediate airway obstruction

delayed airway obstructiondelayed airway obstruction

Immediate airway obstructionImmediate airway obstruction

inhalation of tooth fragmentsinhalation of tooth fragments

accumulation of blood & secretions accumulation of blood & secretions

loss of control of tongue in unconscious/ loss of control of tongue in unconscious/ semiconscious pt. →semiconscious pt. →

Nurse in semi prone positionNurse in semi prone position

delayed airway obstructiondelayed airway obstruction

edema of tongue edema of tongue

pharyngeal structurespharyngeal structures

Examination of the pt.Examination of the pt.

spinal & head injuries - Edema of face spinal & head injuries - Edema of face makes routine examination of face & head makes routine examination of face & head injuries observations difficult.injuries observations difficult.

Lacerations should be explored and cleansed,Lacerations should be explored and cleansed,

Whole head should be checked- occiput, Whole head should be checked- occiput, mastoidmastoid

Examination of the pt.Examination of the pt.

Facial asymmetry & displacements examined Facial asymmetry & displacements examined from the frontfrom the front

Gentle palpation wearing sterile gloves over Gentle palpation wearing sterile gloves over the face & inside the mouth will detect step the face & inside the mouth will detect step deformities, bone fragmentsdeformities, bone fragments

Middle third Middle third # → Epistaxis# → Epistaxis

Examination of the pt.Examination of the pt.

Le Fort II & III # may be associated with Le Fort II & III # may be associated with CSF rhinorrhoeaCSF rhinorrhoea

Zygoma # → subconjunctival hemorrhageZygoma # → subconjunctival hemorrhage

Cranial nervesCranial nerves

RadiologyRadiology

Posteroanterior Posteroanterior occipitomental (OM) occipitomental (OM) radiograph taken at 15radiograph taken at 1500 – 30– 300 0 → suitable to → suitable to illustrate the illustrate the displacement of displacement of middle1/3 #middle1/3 #

A panoramic oral A panoramic oral radiograph(orthopantoradiograph(orthopantomogram)mogram)

Coronal & Axial CT scanCoronal & Axial CT scan

#s #s Facial SkeletonFacial Skeleton

Upper third – above the Upper third – above the eyebrows – involves frontal eyebrows – involves frontal sinuses & supraorbital sinuses & supraorbital ridgesridges

Middle third – above the Middle third – above the mouthmouth

Le Fort I , II , IILe Fort I , II , II

Lower third -- MandibleLower third -- Mandible

Middle 1/3 Middle 1/3 #s#s

Le Fort I Le Fort I # .# .Separates the alveolus Separates the alveolus

and palate from the and palate from the facial skeleton above.facial skeleton above.

# line runs from the nasal # line runs from the nasal pyriform aperture → pyriform aperture → lateral &medial walls lateral &medial walls of max. antrum of max. antrum →posteriorly to include →posteriorly to include the lower part of the the lower part of the pterygoid platespterygoid plates

Diagnosis Diagnosis

suggested by the malocclusion suggested by the malocclusion

mobility of the fractured segment by doing mobility of the fractured segment by doing digital manipulation of the incisor teeth digital manipulation of the incisor teeth regionregion

TreatmentTreatment

closed reduction with inter maxillary fixationclosed reduction with inter maxillary fixation

open reduction. open reduction.

Open reduction – intra osseous wiring Open reduction – intra osseous wiring

- by using small plates - by using small plates

Le Fort II Le Fort II ## Pyramidal in shapePyramidal in shape Runs through the bridge of the Runs through the bridge of the

nose & ethmoidsnose & ethmoids→ medial part → medial part of the infraorbital rim & of the infraorbital rim & infraorbital foramen → infraorbital foramen → posteriorly through the lat wall posteriorly through the lat wall of the max. antrum at a higher of the max. antrum at a higher level than Le F.I to the pterygoid level than Le F.I to the pterygoid plates at the backplates at the back

Cribriform plate may be Cribriform plate may be fractured > CSF rhinorhhoeafractured > CSF rhinorhhoea

Treatment – Reduction of the Treatment – Reduction of the maxilla& internal fixation of the maxilla& internal fixation of the fragmentsfragments

Le Fort III Le Fort III ## Effectively separates facial Effectively separates facial

skeleton from the base of skeleton from the base of the skullthe skull

# → nasal bridge, septum # → nasal bridge, septum & ethmoids →irregularly & ethmoids →irregularly through the bones of orbit through the bones of orbit → frontozygomatic suture → frontozygomatic suture → lateral wall of the max. → lateral wall of the max. sinus at a higher level & sinus at a higher level & the pterygoid platesthe pterygoid plates

Crbriform plate #→CSF Crbriform plate #→CSF rhinorhoearhinorhoea

Clinical features & managementClinical features & management

Clinical features – facial elongation, massive Clinical features – facial elongation, massive facial edema & mobility entire middle third of facial edema & mobility entire middle third of the face.the face.

Treatment – Internal fixation by a Treatment – Internal fixation by a craniofacial approachcraniofacial approach

Le Fort Le Fort #s seldom confine to #s seldom confine to exactly to the original exactly to the original

classification & combinations classification & combinations of any of the #s may occur. of any of the #s may occur.

Zygomatic complexZygomatic complex Fractures occur through Fractures occur through

points of weakness – the points of weakness – the infra orbital margin, infra orbital margin,

frontozygomatic frontozygomatic suture, zygomatic suture, zygomatic arch, and ant. &lat. arch, and ant. &lat. walls of the max.walls of the max. sinus.sinus. Tears of antral Tears of antral mucosa mucosa → epistaxis→ epistaxis Injury to infraorbital Injury to infraorbital nerve → parasthesianerve → parasthesia

Zygomatic complexZygomatic complex

If the floor of the orbit is disrupted , orbital contents If the floor of the orbit is disrupted , orbital contents prolapse into the max. antrum prolapse into the max. antrum → entrapment of the → entrapment of the inferior oblique & inferior rectus → diplopiainferior oblique & inferior rectus → diplopia

Medial displacement of the arch impinches on the Medial displacement of the arch impinches on the coronoid process → difficulty in opening the jawcoronoid process → difficulty in opening the jaw

O/E – swelling of both upper & lower eyelid with O/E – swelling of both upper & lower eyelid with subconjuntival hemorrhage(post. Limit cannot be subconjuntival hemorrhage(post. Limit cannot be seen) seen)

Zygomatic complexZygomatic complex

Complications – flat cheek, Complications – flat cheek, enophthalmos,infraorbital anesthesia , enophthalmos,infraorbital anesthesia , restriction of jaw opening.restriction of jaw opening.

The fracture is visualized by a 30The fracture is visualized by a 300 0 occipto-occipto-mental view.mental view.

Treatment – open reduction & internal Treatment – open reduction & internal fixationfixation

Lower 1/3 of the faceLower 1/3 of the face

Sites of Mandible Sites of Mandible ##

1. Neck of the condyle1. Neck of the condyle

2. Angle of the mouth> 2. Angle of the mouth> last molar toothlast molar tooth

3. Anterior to the 3. Anterior to the mental foramen > mental foramen > canine tooth canine tooth

# Mandible# Mandible

Guardsman fracture – Guardsman fracture – Blow to the chin Blow to the chin → → # symphysis or parasymphysis # symphysis or parasymphysis

unilateral or bilateral condylar # (Indirect unilateral or bilateral condylar # (Indirect transmission of kinetic energy)transmission of kinetic energy)

C/FC/F

pain on moving the jawpain on moving the jaw

malocclusion, lacerations malocclusion, lacerations

ecchymosis of the floor of the mouth. ecchymosis of the floor of the mouth.

Palpation – fracture line, false motionPalpation – fracture line, false motion

# Mandible# Mandible

ManagementManagement:: Compound Compound # - broad spectrum antibiotics# - broad spectrum antibiotics

Intermaxillary fixation (IMF)Intermaxillary fixation (IMF)

Open reduction & internal fixation with Open reduction & internal fixation with stainless steel / titanium plates.stainless steel / titanium plates.

Soft tissue injuries of the faceSoft tissue injuries of the face

Facial soft tissues have an excellent blood supplyFacial soft tissues have an excellent blood supply→ → heals wellheals well

Suturing at the earliest after debridement under Suturing at the earliest after debridement under local anesthesia /GAlocal anesthesia /GA

Replace tissues accurately esp. vermilion borderReplace tissues accurately esp. vermilion border Hemostasis essential. Muscles & underlying tissues Hemostasis essential. Muscles & underlying tissues

should be sutured with absorbable suture materials. should be sutured with absorbable suture materials. Fine monofilament sutures to be used . Alt. sutures Fine monofilament sutures to be used . Alt. sutures to be removed on th3rd day, the remaining on the 5to be removed on th3rd day, the remaining on the 5 thth dayday