You are in: eMedicine Specialties > Trauma > Trauma Management Initial Evaluation and Management of Maxillofacial InjuriesArticle Last Updated: Nov 2, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Tania Parsa, MD, Attending Physician, Eastern Maine Medical Center Tania Parsa is a member of the following medical societies: American Academy of Emergency Medicine Coauthor(s): Arthur K Adamo, DDS, Associate Clinical Professor, Department of Dentistry, Albert Einstein College of Medicine; Director of Oral and Maxillofacial Surgery, Jacobi Medical Center; Yvette Calderon, MD, Associate Program Director, Assistant Professor, Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine Editors: Alex Jacocks, MD, Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: frontal sinus fracture, orbital floor fracture, nasal fracture, nasoethmoidal fracture, NOE, zygoma fracture, zygomaticomaxillary complex fracture, ZMC, maxillary fracture, Le Fort fracture, mandibular fracture, alveolar fracture, panfacial fracture INTRODUCTIONSection 2 of 11
  Maxillofacial injuries are commonly encountered in the practice of emergency medicine. More than 50% of patients with these injuries have multisystem trauma requiring coordinated management between emergency physicians and surgical specialists in otolaryngology, trauma surgery, plastic surgery, ophthalmology, and oral and maxillofacial surgery. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center, Eye and Vision Center, and Teeth and Mouth Center. Also, see eMedicine's patient education articles Facial Fracture, Broken Nose, Broken Jaw, Black Eye, Eye Injuries, and Broken or Problem Trauma to the maxillofacial anatomy mandates special attention. Contained within the face are systems that control specialized functions including seeing, hearing, smelling, breathing, eating, and talking. Also, the vital structures in the head and neck region are intimately associated. Lastly, the psychological impact of disfigurement can be devastating. The maxillofacial region is divided into 3 parts. The first part is the upper face, where fractures involve the frontal bone and sinus. The second part is the midface. The midface is divided into upper and lower parts. The upper midface is where maxillary Le Fort II and Le Fort III fractures occur and/or where fractures of the nasal bones, nasoethmoidal or zygomaticomaxillary complex, and the orbital floor occur. Le Fort I fractures are in the lower part of the midface. The third part of the maxillofacial region is the lower face, where fractures are isolated to the mandible. Frequency More than 3 million facial injuries occur in the United States each year. Most are secondary to assaults and motor vehicle accidents. Information about the causes of facial fractures depends on the country and location of the trauma center; therefore, reported statistics vary widely. Etiology Facial trauma in an urban setting most often is caused by assaults, followed by motor vehicle and industrial accidents. The zygoma and mandible are the most commonly fractured bones during assaults. Facial trauma in the community setting most often is due to motor vehicle accidents, then to assaults and recreational activities. Motor vehicle accidents produce fractures that often involve the midface, especially in patients who were not wearing their seatbelts. Other important causes of facial trauma include penetrating trauma, domestic violence, and the abuse of children and elderly persons. Pathophysiology The kinetic energy present in a moving object is a function of the mass multiplied by the square of its velocity. The dispersion of this kinetic energy during deceleration produces the force that results in injury. High-impact and low-impact forces are defined as greater or lesser than 50 times the force of gravity. These parameters impact on the resultant injury because the amount of force required to cause damage to facial bones differs regionally. The supraorbital rim, mandible (symphysis and angle), and frontal bones require a high-impact force to be damaged. A low-impact force is all that is required to damage the zygoma and nasal bone. Frontal bone fractures: These result from a severe blow to the forehead. The anterior and/or posterior table of the frontal sinus may be involved. Assume a dural tear is present if the posterior wall of the frontal sinus is fractured. The nasofrontal duct often is disrupted. Orbital floor fractures: Injury to the orbital floor can result in an isolated fracture or can be accompanied by a medial wall fracture. When a force strikes the globe or orbital rim, the intraorbital pressure increases with transmission of this force and damages the weakest aspects of the orbit, the floor and medial wall. Herniation of the orbital contents into the maxillary sinus is possible. The incidence of ocular injury is high, but globe rupture is rare. Nasal fractures: These are the result of the forces transmitted during direct trauma. Nasoethmoidal fractures (NOEs): These extend from the nose to the ethmoid bones and can result in damage to the medial canthus, lacrimal apparatus, or nasofrontal duct. They also can result in a dural tear at the cribriform plate. Zygomatic arch fractures: A direct blow to the zygomatic arch can result in an isolated fracture involving the zygomaticotemporal suture. Zygomaticomaxillary complex fractures (ZMCs): These fractures result from direct trauma. Fracture lines extend through zygomaticotemporal, zygomaticofrontal, and zygomaticomaxillary sutures and the articulation with the sphenoid bone. The fracture lines usually extend through the infraorbital foramen and orbital floor. Concurrent ocular injuries are common. Maxillary fractures: These are classified as Le Fort I, II, or III.
Mandibular fractures: These can occur in multiple locations secondary to the U-shape of the jaw and the weak condylar neck. Fractures often occur bilaterally at sites apart from the site of direct trauma. Alveolar fractures: These can occur in isolation from a direct low-energy force or can result from extension of the fracture line through the alveolar portion of the maxilla or mandible. Panfacial fractures: These usually are secondary to a high-energy mechanism resulting in injury to the upper face, midface, and lower face. CLINICAL PRESENTATION AND APPROACH FOR PATIENTS WITH FACIAL TRAUMASection 3 of 11
Frontal bone fractures Presentation includes disruption or crepitus of the supraorbital rims, subcutaneous emphysema, and paresthesia of the supraorbital and supratrochlear nerves. Orbital floor fractures Periorbital edema, crepitus, ecchymosis, enophthalmos, and ocular injury can be present. Infraorbital nerve damage can cause paresthesia or anesthesia of the cheek and upper gum on the affected side. Lateral and upward gaze dysfunction may occur secondary to entrapment of the medial and inferior rectus muscles. Diplopia may be demonstrated upon the patient gazing upward, due to entrapment of the inferior rectus muscle. Nasal fractures The nose will be swollen and tender. Displacement, crepitus, and epistaxis also may be present. Nasoethmoidal fractures NOEs demonstrate telecanthus (ie, widened and flattened nasal bridge), epistaxis, cerebrospinal fluid rhinorrhea, and epiphora (ie, tears spilling over the lid) secondary to blockage of the nasolacrimal duct. Zygomatic arch fractures Fracture of the arch of the zygoma may exhibit a palpable defect over the area involved. Pain upon palpation and limitation of movement of the mandible resulting from interference with movement of the coronoid process may be found upon physical examination. Zygomaticomaxillary complex fractures Clinical findings of ZMCs may include a depressed malar eminence, resulting in flattening of the cheekbone and pain upon palpation of the zygomatic eminence. The "flame sign" may be present, due to disruption and depression of the lateral canthal tendon. Evidence of a lateral subconjunctival hemorrhage is present. A step defect often is palpated along the infraorbital rim or zygomaticomaxillary buttress. Paresthesia of the lateral side of the nose and upper lip may be present due to impingement of the infraorbital nerve. Diplopia may be demonstrated upon the patient gazing upward, due to entrapment of the inferior rectus muscle. Rarely, trismus occurs because of impingement of the coronoid process of the mandible. Intraoral ecchymosis or gingival disruption is possible. Maxillary fractures Potential findings of Le Fort I fractures are facial edema and mobility of the hard palate and upper teeth. Clinical presentations of Le Fort II fractures include facial edema, telecanthus, subconjunctival hemorrhage, mobility of the maxilla at the nasofrontal suture, epistaxis, and possible cerebrospinal fluid rhinorrhea. Characteristic findings of Le Fort III fractures include massive edema with facial elongation and flattening. An anterior open bite may be present due to posterior and inferior displacement of the facial skeleton. Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate, epistaxis, and cerebrospinal fluid rhinorrhea also may be found upon physical examination. Alveolar fractures Clinical findings include gingival bleeding, mobility of the alveolus, and loose or avulsed teeth. Mandibular fractures Condyle fractures are the most often overlooked. The area anterior to the meatus of the ear will be tender to palpation. The condyle on the fractured side will not move when the mandible is opened and closed. Common findings of mandibular fractures include painful jaw movement and malocclusion of the teeth, ie, an inability to open the mouth or bite down hard. Mobility and crepitus can be palpated along the symphysis, angles, or body. Intraoral edema, ecchymosis, gingival bleeding, or tears may be present. An anterior open bite can occur with bilateral condylar or angle fractures. Disruption of the inferior alveolar nerve, including the mental branch, may cause paresthesia or anesthesia of half of the lower lip and chin when the fracture involves the mandibular angle, body, or symphysis. Panfacial fractures Physical findings depend on the combination of fractures sustained. As in any trauma situation, initially address all life-threatening injuries. A systematic approach to the history and physical examination ensures adequate assessment of a maxillofacial trauma. Obtain information regarding allergies, medications, tetanus status, past medical and surgical history, most recent meal, and events surrounding the injury. Aspects to consider include the following:
A systematic approach to the physical examination ensures adequate assessment of maxillofacial trauma. The examination should include the following:
RELEVANT ANATOMY AND CONTRAINDICATIONSSection 4 of 11
Relevant anatomyBones The upper third of the face is comprised of the frontal bone and frontal sinus. The middle third of the face is comprised of the nasal, ethmoid, zygomatic, and maxillary bones. The mandible makes up the lower third of the face. It is subdivided into different areas, including the condyle, ramus, angle, body, symphysis, and alveolus. The frontal bone forms the superior orbital margin. The frontal process of the zygoma, the zygomatic process of the frontal bone, and the greater wing of the sphenoid form the lateral orbital margin. The zygoma and maxilla form the inferior orbital margin. The medial orbital margin is formed by the frontal process of the maxilla, lacrimal bone, the angular and orbital process of the frontal bone, and the ethmoid bone. The roof of the maxillary sinus forms the orbital floor. The orbital apex is formed by the lesser and greater wings of the sphenoid, palatine, and part of the ethmoid. Nerves The ophthalmic nerve is the first division of the trigeminal nerve. It is a sensory nerve supplying the skin of the forehead, the upper eyelid, and conjunctiva. Branches include lacrimal, supraorbital, supratrochlear, infratrochlear, external nasal, nasociliary, and frontal. The maxillary nerve is the second division of the trigeminal nerve. It also is a sensory nerve that supplies the skin on the posterior part of the side of the nose, lower eyelid, cheek, and upper lip. Branches include the anterior and posterior superior alveolar, infraorbital, zygomaticofacial, and zygomaticotemporal. The mandibular nerve is the third division of the trigeminal nerve. It is a sensory and motor nerve supplying the muscles of mastication and skin of the lower lip, chin, temporal region, and part of the auricle. Branches include the lingual, inferior alveolar, dental, mental, buccal, and auriculotemporal. The facial nerve supplies all of the muscles of facial expression. Branches include the temporal, zygomatic, buccal, mandibular, and cervical. The greater auricular nerve, a branch of the cervical plexus, supplies the angle of the mandible and skin over the parotid gland and mastoid process. Other cranial nerves (CN) include the following:
Blood supply The blood supply to the face is provided principally through the external carotid artery. Important branches are the lingual, facial, internal maxillary, and superficial temporal. Venous drainage is provided by the superficial temporal, pterygoid venous plexus, retromandibular, lingual, facial, and external jugular veins. They empty into a common trunk to the internal jugular vein. ContraindicationsDo not manipulate facial bones unless cervical spine injury has been excluded. Avoid nasotracheal intubation with patients with upper face or upper midface fractures. Nasotracheal intubation can result in nasocranial intubation or severe nasal hemorrhage. Avoid blind clamping to prevent injuries to vital structures. Do not perform closed reduction of mandibular fractures by intermaxillary fixation on patients who are alcoholics, mentally retarded, or have a seizure disorder. These patients usually require an open reduction. WORKUPSection 5 of 11
Lab studies
Imaging studies
TREATMENTSection 6 of 11
Prehospital care General airway: Administer oxygen and maintain a patent airway. Maintain an immobilized cervical spine at all times. Clear the mouth of any foreign body or debris, and suction any blood present. Intubation: Intubate if indicated. Have the cricothyroidotomy and tracheotomy tray set up prior to an initial attempt at intubation. Consider conscious sedation intubation if distortions of the mandible and maxilla exist because a tight seal with the mask may not be possible when bagging. Consider nasotracheal intubation if massive oropharyngeal edema is present. Consider orotracheal intubation if midface or upper face trauma is present. If unable to intubate the patient nasotracheally or endotracheally, cricothyroidotomy is the next procedure of choice. Breathing: Assess breath sounds. Check tube placement. Circulation: Do not remove impaled foreign bodies that can result in worsening of damage and bleeding. Control hemorrhage with direct pressure. Obtain large-bore intravenous access bilaterally. Disability: Assess the patient using the Glasgow coma scale. Perform a brief neurologic examination. Note any change in mental status. Exposure: Expose patients, but keep them warm. Remove all clothing and accessories. Recover all avulsed hard and soft tissue, and transport them in damp gauze with no ice and very little manual manipulation. Medical and surgical therapy General medical therapy: Administer oxygen and isotonic crystalloid fluids. Administer packed red blood cells if the patient is bleeding excessively. Tetanus prophylaxis is indicated. Antibiotics: For facial lacerations, use Kefzol. For oral cavity lacerations, use clindamycin. For fractures communicating with the sinus, use amoxicillin. For fractures with dural tears or cerebrospinal fluid leaks, use vancomycin and ceftazidime. Pain management: Use oral medications for minor injuries and parenteral medications if the patient cannot take oral medications (ie, nothing by mouth). For anti-inflammatory control, use ibuprofen, naproxen, or ketorolac. For central control, use narcotics (eg, codeine, oxycodone, hydrocodone, meperidine, morphine). Frontal bone fractures Of great concern is the patency of the nasofrontal duct. If this duct is blocked, surgery is indicated. Blockage may result in mucopyocele or abscess. Nondisplaced anterior sinus wall fractures are treated by observation. Displaced anterior sinus wall fractures with severe comminution and mucosal injury require otolaryngology, plastic surgery, or oral maxillofacial surgery for bone grafting and frontal sinus obliteration. Treatment of posterior sinus wall fractures is controversial and variable. Posterior sinus wall fractures are examined for displacement, dural tears, and cerebrospinal fluid leakage. Nondisplaced fractures with a cerebrospinal fluid leak may be observed for 5-7 days while undergoing treatment with intravenous antibiotics. Frontal sinus obliteration is indicated if a cerebrospinal fluid leak persists. Surgical treatment of displaced fractures with no cerebrospinal fluid leak is based on the severity of comminution. Mild comminution requires an osteoblastic flap and sinus obliteration. Comminution of greater than 30% of the posterior sinus wall requires the neurosurgeon to remove the posterior table allowing the brain to expand into the frontal sinus, this is known as cranialization. Displaced sinus wall fractures with a cerebrospinal fluid leak and minimal-to-mild comminution requires sinus obliteration. Moderate-to-severe comminution requires sinus cranialization. Orbital floor fractures Blowout fractures of the orbital floor require consultation with an ophthalmologist and maxillofacial trauma specialist (eg, otolaryngologist, oral and maxillofacial surgeon, or plastic surgeon). The indications and timing for fracture repair are debated; however, most literature supports a 2-week window for repair. The following are indications for surgery: a large defect in the orbital floor (>50%), enophthalmos (>2 mm) due to herniation of orbital contents into the maxillary sinus, diplopia on upward/downward gaze due to muscle entrapment and within 30° of primary gaze with a positive forced duction test, and CT scan confirmation of a fracture. Nasal fractures Patients with nasal fractures are discharged home and sent for follow-up with an otolaryngologist or plastic surgeon within 5-10 days, allowing time for resolution of the profuse edema of the tissues surrounding the nose. Nasoethmoidal fractures Fractures with suspected or detected dural tears require consultation with a neurosurgeon, and the patients should be admitted for observation and intravenous antibiotics. An ophthalmologist should be consulted for repair of the lacrimal apparatus. An oral and maxillofacial surgeon, plastic surgeon, or otolaryngologist should be consulted for repair of nasal bones, medial canthus, and the nasofrontal duct. Zygomatic arch fractures Patients with isolated fractures to the zygomatic arch can be discharged home, with follow-up from an otolaryngologist, an oral and maxillofacial surgeon, or a plastic surgeon if the displacement is minimal. Marked displacement and/or impingement of the coronoid process of the mandible requires open reduction. Zygomaticomaxillary complex fractures Consultations include an ophthalmologist and an otolaryngologist, plastic surgeon, or oral and maxillofacial surgeon. The standard of care is open reduction and internal fixation with miniplates and screws. The orbital floor frequently is explored and repaired if necessary. Maxillary fractures Consultations include an otolaryngologist, plastic surgeon, or oral and maxillofacial surgeon. Open reduction and intermaxillary fixation should be performed to establish correct occlusion, followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress. Mandibular fractures Management is provided by an otolaryngologist, plastic surgeon, or oral and maxillofacial surgeon. Temporary stabilization in the emergency department can be addressed with the application of a Barton bandage. Wrap the bandage around the crown of the head and jaw. A symphysis or body fracture can be reduced temporarily with a bridal wire (a 24-gauge wire wrapped around 2 teeth on either side of the fracture). This greatly helps control hemorrhage and pain and prevents infection because these are open compound fractures. Initially, the fracture is stabilized with intermaxillary fixation followed by open reduction and rigid fixation using titanium miniplates, mandibular plates, or reconstruction plates, depending on where the fracture is located. Nondisplaced fractures of the condyle require intermaxillary fixation for 10 days, followed by physiotherapy to help restore improved function. Ankylosis of the joint is extremely rare and is believed to be caused by an untreated intracapsular injury or fracture. Panfacial fractures At the time of surgery, tracheostomy or submandibular intubation is required. A submandibular intubation is performed by first intubating orally, and then surgically bringing the tube out through the submandibular space. Nasoendotracheal intubation is definitely contraindicated. Facial bones are repositioned beginning at the cranium. After the occlusion is established by intermaxillary fixation, the remaining facial bones are repaired with open reduction and internal fixation. COMPLICATIONS AND MEDICAL/LEGAL PITFALLSSection 7 of 11
Complications
Medical/legal pitfalls
OUTCOME AND PROGNOSISSection 8 of 11
Open reduction and internal fixation of facial fractures results in a patient with a satisfactory facial appearance and restoration of function. High-impact facial fractures often are associated with other bodily injuries that may be life threatening. Low-impact fractures rarely result in mortality if proper treatment is administered. Extensive soft tissue injuries or avulsions and comminuted fractures are much more difficult to treat and may have poor outcomes. Severe hemorrhage from massive midface injuries may result in death. Airway obstruction, if not properly treated or detected, is associated with high mortality. FUTURE AND CONTROVERSIESSection 9 of 11
A future development may be the use of bone morphogenic protein, which is a protein that stimulates stem cells to differentiate into osteoblasts. Use of this substance with a carrier such as a collagen sponge could be used to fill bony defects. The timing and indication for reconstruction of orbital floor fractures remain controversial. Another source of controversy is open reduction versus closed reduction of mandible condyle fractures. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Initial Evaluation and Management of Maxillofacial Injuries excerpt Article Last Updated: Nov 2, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
