Download Maxillofacial

Maxillofacial Trauma
Maxillofacial Trauma
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Common as a result of blunt injury
Mandibular:Zygoma:Maxillary in ratio of 6:2:1
50% due to assaults
50% of which alcohol related
25% of women with facial trauma are victims of
domestic violence
Need ATLS approach
A. Main cause of death = airway obstruction
• May require surgical airway
• 10-15% have C-spine injury (if unconscious)
B. At risk of aspiration – missing teeth
C. Significant haemorrhage can be difficult to
control
D. Facial injury = head injury
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
General Examination
• Look for swelling/bruising/deformity etc.
• Palpate all bony margins for tenderness and
steps
• Intra-oral examination
• Facial stability
• Facial sensation
• Eye examination
Mandibular Injury
• Assaults and falls on the
chin account for most of
the injuries
• Often injured at site
distant from point of
impact
• Multiple fractures are
seen in greater then 50%
• Condyler fractures
commonly missed
• Usually open #’s
Clincial Features
• Occlusion of bite is the key point in history
• Parasthesia of mental nerve
• Intra-oral examination important (Sublingual
haematoma). Crepitus + mobility
• TMJ and ear examination
Mandible Imaging
• OPT (oral-pan-tomogram)
OPG (ortho-pan-tomogram)
• PA mandible ±
Lateral oblique
Mandibular Fracture Management
• Undisplaced fractures:
– Analgesics
– Soft diet
– Max-fax referral – usually outpatient
• Displaced fractures and those associated with dental
trauma
– Max-fax referral for inpatient care
• All fractures should be treated with antibiotics and
tetanus prophylaxis.
TMJ Dislocation
• Causes of mandibular dislocation are:
– Blunt trauma
– Excessive mouth opening – clinical diagnosis
• The mandible can be dislocated:
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Anterior 70%
Posterior
Lateral
Superior
• Mostly bilateral
Treatment:
• Analgesic
• Manual reduction
• ±Sedation
– Soft Diet
– Avoid Mouth opening
Zygoma Fractures
• Direct blunt trauma most common cause
• Two types of fractures can occur
– Arch fracture (most common)
– Tripod fracture (most serious)
• Zygomatic arch
• Zygomaticofrontal suture
• Inferior orbital rim and floor
Clinical Features
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Palpable bony defect over the arch
Depressed cheek with tenderness
Pain in cheek and jaw movement
Limited mandibular movement
Infra-orbital nerve parasthsia
in 80-90%
Midface fractures
High energy injury
• Le Fort I
– Low level maxilla fracture
– May have elongated face
– Movement of maxilla, but nose stable
• Le Fort II
– Pyramidal or nasomaxillary fracture
– Dished in face followed by evere facial swelling
– Movement of maxilla and nose
• Le Fort III
– Craniofacial dysjunction
– Mid face fractured off skull base - mobile
– Risk of severe pharyngeal bleeding
CSF leaks are common with Le Fort II & III fractures
These fractures may be asymmetrical
Orbital floor/Peri-orbital Injuries
• Consider associated eye injury with any facial
injury – thus all require eye exam
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Ophthalmoplegia & Diplopia
Hypoglobus
Enophthalmus
Proptosis
Visual loss
– Lid and lacrimal duct damage
Orbital Blowout Fractures
• Occur when the the globe sustains a direct
blunt force
• Imaging:
– Hanging tear drop sign
– Open bomb bay door
– Air fluid levels
– Orbital emphysema
Imaging
• Occipto-mental (OM) 15/30
views
• Submento-vertical view for
arch fractures
– Maxillary sinus opacification
– Follow McGrigors lines
OM Hotspots
Reviewing facial Xrays
Facial Fracture Management
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ABCDE approach
Protect airway if needed
Control Bleeding
If able, more comfortable sitting up
Max-fax review
Consider antibiotics
Management
• Surgery is indicated if –
– Impairment of function: ↓mouth opening
– Displaced fractures
– ?Cosmetic concern
– Often best performed when swelling settled
• Avoid nose blowing (surgical emphysema) and
pressurised environments
• Soft Diet
Others
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Dento-alveolar injury
Frontal sinus fracture
Naso-ethmoid fracture
Nasal fracture
Questions?
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Summary
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Commonly related to blunt trauma
Mandibular:Zygoma:Maxillary in ratio of 6:2:1
Often needs ATLS style approach
Thorough examination
Methodical approach to xray review
Consider antibiotics and tetanus
Involvement of Max-fax team