Download Facial Injuries

Facial Injuries
Yağmur AYDIN M.D.
Associate Proffessor
University of Istanbul, Cerrahpasa Medical Faculty
Department of Plastic, Aesthetic and Reconstructive
Surgery
soft tissue injuries
facial bone fractures
Emergency Treatment
Clear Airway and provide patent airway
Cleaning of blood, vomit and theet from inside of mouth with fingers
Aspiration of blood, saliva, and gastric contents
Early Intubation or Tracheostomy
Control Hemorrhage
Direct pressure on the wound
Tying of bleeding vessels(a. Facialis, a. Temporalis superfic., a.
Angularis, a. Carotis externa)
Angiographic demonstration and embolization of the bleeding point
Anterior-posterior nasal packing
Treat Shock
Evaluate Associated Injuries ( cervical vertebrea, skull base,
intracranial, thoracal, intraabdominal)
Diagnosis and treatment of facial injuries
Indications of Tracheostomy
Panfacial fracures(combined mandible, maxilla and
nasal fractures)
The multiply fractured mandible with significant swelling
of the neck and floor of the mouth
Patients who require prolonged intermaxillary fixation
who have significant head or chest injuries
Possibility of prolonged postop. airway problems
Severe facial and neck edema resulting from soft tissue
injuries such as severe facial burns
Unrelieved obstruction of airway in the region of larynx or
the hypopharynx
Clear Airway and provide patent airway
Control Hemorrhage
Nasal tamponage
Soft tissue Injuries
Laceration(most common form of facial injury)
Contusion (with or without hematoma)
Abrasion
Avulsion
Puncture
Accidental Tattoo
Retained Foreign Bodies
Treatment of Soft Tissue Injuries
Primary closure
Delayed primary closure
Secondary healing
Tertiary healing (skin grafts, flaps)
Wound Closure-I
The time lapse between injury and repair is
important in terms of the possibility of infection
and the choice of repair techniques
Primary closure is treatment of choice
It is applied immediately after the trauma if the
wound is sharp and clean
debridement, excision of a millimeter or two of
the wound edge
The wound edges is approximated with sutures
Wound Closure-II
The contused, dirty and heavy contamined
wounds are not closed by primaryly
Shotgun wounds, animal and human bites
are not closed primarly as well
Delayed Primary Closure
The wound must be prepared with
debridment and dressing
Cleaning
Irrigation
Debridment
The wound can be closed primarly after
24-48 hours, If it is clean and free of
devitalized tissue
Secondary Closure
If the wound is heavily contamined and
infected, contains necrotic and devital
tissues after 48 hours, The wound can be
closed after cleaning of the wound or can
be left to secondary healing
Secondary healing occurs with secondary
wound contracture and marginal
epithelization
Etiology of Facial Injuries
Traffic accidents
Interpersonel violence
Spor accidents
Home accidents
Occupational accidents
Shot-gun injuries
Symptom and Signs
Soft tissue Injury
Swelling
Pain or localized tenderness
Crepitation from areas of
underlying bone fracture
Hypostesia and paralysis in
the distribution of specific
nerve
Malocclusion
Class I :Normal oclusion
Class II :Retrognathi
Class III :Prognathi
Visual disturbance
Diplopia or decrease in vision
Facial asimmetry, deformity
Obstructed respiration
Lacerations inside of mouth
Ecchymosis
Bleeding
Clinical Examination-I
Evaluation for symmetry and deformity
Inspection of face ( comparing 2 sides)
Palpation of all bony surfaces in an orderly
manner (sup. and inf. orbital rims, nose, the
brows, the zygomatic arches, malar eminence,
border of mandible)
Inspection of intraoral area for lacerations and
abnormalities of the dentition
Palpation of dental arches for abnormal mobility
Clinical Examination-II
Maxillary and mandibular dental arches are
carefully visualized and palpated for bone
irregularity, bruise, hematoma, tenderness or
crepitus
Sensory and motor nerve functions in the facial
area evaluated
Extraocular movements and muscle of facial
expression must be examined
Globe functions (pupillary size and symmetry,
globe excursion, eyelid excursion, double vision
and visual loss) and fundoscopic examination
Facial Injuries
Midface Fractures
Le-Fort Maxillary Fractures
Lower Level fractures (Le-Fort I, Transverse, Guerin)
transverse fracture separating the maxillary alveolus from the
upper mid face
Upper Level Fractures
Le-Fort II(Pyramidal fracture) : separates a pyramid-shaped
central fragment containing the maxillary dentition from the
remainder of the orbits and upper craniofacial skeleton
Le-Fort III (craniofacial dysjunction) : separates the maxilla at
the level of the upper portion of the zygoma, orbital floor, and
nasoethmoid region from the remainder of the upper
craniofacial skeleton
Le-Fort Maxillary Fractures
Maxillary Fractures
Symptoms and Signs
Periorbital hematoma
Nasopharyngeal bleeding
Pain
Swelling on the face
Intraoral lacerations
Malocclusion
Elongation of the face
Maxillary retrusion
Anterior open bite
Abnormal mobility on the dental arc
Rinorea and pneumocephaly (% 25 in LeFort II and III)
Dental Occlusion
Normal occlusion
Mandibular retrognathia
Mandibular prognathia
Bimanual maxillary examination for abnormal movement
Imaging
Plain radiographs : Waters’ and lateral view
Axial and coronal CT scans of the midface
3 D CT
Waters’ radiograph
3D CT
Coronal CT
Dish-shaped face, loss of facial projection, bilateral conjunctival hemoraji
Vertical butresses of maxilla and mandible
Goals of treatment
restoration of the proper facial aesthetics including preservation of
midface width, height and projection
Treatment of Maxilla Fractures
Open reduction and intermaxillary fixation and spanning
each of the butresses with plate and screws
Orbital Fractures
Classification
Orbital floor blow-out fractures
Pure (nonfractured infraorbital rim)
Inpure (fractured infraorbital rim)
Orbital fractures (without blow-out)
Lineer fractures
Combined with maxillary fractures
Zygomatic fractures
A- small orbital blow-out fracture is
confined to the orbital floor
B- larger blow-out fracture extends to
involve to the lower medial orbit as well as
orbital floor
Bone graft for repair of medial blow-out
fracture
Symptom and Signs
palpebral and subconjunctival hematoma
Diplopia (most common looking superiorly or inferiorly)
Numbness in the inferior orbital nerve
distribution
Enophthalmos
Positive forced duction test
Radiological evidence of orbital floor fracture
and entrapment of soft tissues on the CT scans
with both axial and coronal views
Assessment of the visual system is essential
Coronal CT
Orbital Blow-out fracture
Treatment of Orbital Blow-out
Fracture
There are two major surgical indications for
orbital fracture repair
Muscle entrapment (confirmed by forced duction and CT scan)
volume increase (> 2cm2 defects enophthalmos and globe
dystopia developes)
Subciliar or transconjunctival approach
Entrapped soft tissues are brought back from maxiillary
sinus
Defect are bridged with bone grafts or alloplastic
materials(silicone, titanium mesh, medpor, proplast etc.)
The Superior Orbital Fissure and Orbital
Apex Syndrome
ptosis of the eyelid
proptosis of the globe
paralysis of cranial nerve III, IV, and VI
anesthesia in the distribution of the first
division of the trigeminal nerve
If blindness occurs in combination with the
superior orbital fissure syndrome, the
condition is termed the “orbital apex
syndrome.”
Nasoethmoidal Orbital Fractures
Symptoms and signs
Telecanthus
Decrease in the dorsal nasal projection
Rinorea
Treatment:open reduction with a
combination of interfragmentary wiring and
plate and screw fixation
Nasoethmoidal Orbital Fractures
and their treatment
Zygoma Fractures
Symptoms
periorbital and subconjunctival hematoma
numbness in the infraorbital nerve
distribution
epistaxis (ipsilateral or bilateral)
Disturbed occlusion and range of motion
of the mandible (inward displacement of the zygomatic arch)
Lack of prominence of the malar eminence
The Physical Signs
periorbital and subconjunctival hematoma,
loss of prominence of malar eminence,
numbness in the distribution of the infraorbital
nerve
inferior globe dystopia or enophthalmos
inferior displacement of the palpebral fissure.
Step or level discrepancies may be palpated
over fracture sites
tenderness at the sites of the fracture.
periorbital ecchymosis, edema, antimongoloid slant, and
subconjunctival hemorrhage.
Frontal
Worm’s-eye view.
Axial CT scan
isolated depressed left
zygomatic arch fracture.
The Radiographic Evaluation
Plain films of the Caldwell, Water’s, and
submental vertex
Axial and Coronal CT scan
TREATMENT
Treatment of zygomatic fracture with Gillies method
Open reduction and rigid fixation with plates and screws at
frontozygomatic suture, inferior orbital rim, and zygomaticomaxillary butress
Orbitazygomatic fracture- Repositon and rigid internal fixation
Axial CT
Zygomatic Fracture
Nasal Fractures
Various types of
fractures of nasal
bones
Hematoma of Septum
Symptoms
Pain
Swelling
Respiratory obstruction
Crepitation on palpation
Nasal deformity
Deviation of the septum
Mucosal lacerations intranasally
Septal hematoma
Reduction of nasal fracture with an Asch forceps
Mandibular Fractures
the second most common facial bone injury
Mandibular fractures are classified according to
the state of the dentition (dentulous, partially
dentulous, edentulous) or the region of the
mandible in which the fracture occurs (condyle,
condylar neck, ramus, coronoid, angle, body,
symphysis)
They are classified as either open or closed,
depending on whether or not they have a
communication with a skin laceration
•subcondylar area
•angle region weakened by the
presence of the third molar
tooth
•the parasymphysis weakened
by mental foramen and canine
where the long root of the
cuspid tooth
Anatomic regions and frequency of fractures in those regions
Symptoms and Signs
Pain
Swelling
Tenderness
Malocclusion
Frequently, the patient volunteers that the teeth
do not feel like they are “coming together
properly.”
Numbness in the distribution of the mental nerve
Fractured teeth, gaps, or level discrepancies in dentition,
asymmetries of the dental arch, the presence of intraoral
lacerations, loose teeth, and crepitance indicate the possibility of
a mandibular fracture
Radiographic Evaluation
Plain films: anteroposterior, lateral and oblique views
CT scan
Panorex examination
Panorex examination of mandible
Treatment
The treatment of mandibular fractures involves
establishing proper occlusal relationships and
then providing co-aptation of the edges of the
bone fracture with fixation
Closed reduction and Intermaxillary fixation
Open reduction and rigid internal fixation
Intermaxillary fixation
Treatment of mandibular fracture by application of an arch bar and
plating at the inferior border
Facial Fractures in Children
Facial fractures in children account for about 5% of all facial injuries
Most of these fractures occur in children > 5 years of age
Subcondylar fracture is seen most often
Children’s bones are soft, and frequently displace without fracture
In children, bone healing progresses rapidly. It may be difficult to
reduce a LeFort fracture properly, even after one week
children are able to provide some adjustment with growth such that
minor occlusal deformities
It is often more difficult to apply intermaxillary fixation devices in
patients with primary or mixed dentition because of the shape of the
teeth
The sinuses are small, and the pattern of the orbit and maxillary
fractures is different
Children have shallowly rooted teeth, and the shape of the crowns
may make the application of interdental wires more difficult
An acrylic splint may be used sometimes to align mandibular
fractures. Intermaxillary fixation is generally necessary for only 3
weeks.