1. Temple University School of Medicine
Maxillofacial Trauma
Joe Lex, MD, FACEP, FAAEM
Temple University School of Medicine
Philadelphia, PA USA

2. Lecture Outline Emergency management Facial exam Fractures FACE
Major
Minor
Soft tissue injuries
Unusual injuries
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3. Causes of Mortality Acute FACE Delayed Airway compromise
Exsanguination
Associated intracranial or cervical-spine injury
Delayed
Meningitis
Oropharyngeal infections
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4. Epidemiology Estimated 3,000,000 facial trauma cases per year in USA
Estimated 40 to 50% of motor vehicle victims have facial injury
No uniform reporting or registry of cases
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5. Functions of Face Respiratory  upper airway Visual Olfactory FACE
Mastication
Cosmetic
Communication
Individual recognition
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6. Management Sequence Airway control / immobilize cervical spine
Bleeding control
Complete the primary survey
Secondary survey
Consider NG or OG tube placement
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7. Management Sequence Plain radiographs if fractures suspected
CT if suspect complex fractures
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8. Management Sequence
Repair soft tissue immediately if no other injuries
Delay soft tissue repair until patient in OR if surgery for other injuries necessary
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9. Initial Management 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
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10. 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 orotracheally intubate
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11. Initial Management Step 2 : Bleeding control
Can be major threat to life
Use universal precautions
Direct pressure dressings initially
Contraindicated: blind vessel clamping
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12. Initial Management Step 2 : Bleeding control
Rapid nasal packing may be necessary
Be sure blood is not just running down posterior pharynx
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13. Initial Management 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
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14. Airway Compromise Blood in airway “Debris” in airway FACE
Vomitus, avulsed tissue, teeth or dentures, foreign bodies
Pharyngeal or retropharyngeal tissue swelling
Posterior tongue displacement from mandible fractures
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15. Secondary Survey Scalp
Check for lacerations, hematomas, stepoffs, tenderness
Bleeding maybe brisk until sutured
Can use stapler for rapid closure
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16. 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
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17. Secondary Survey
Eyes
Pupils, anterior chamber, fundi, extraocular movements
Conjunctivae for foreign bodies
Palpate orbital rims
No globe palpation if suspect penetration
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18. Secondary Survey Eyes Lid injury can leave cornea exposed FACE
Use artificial tears or cellulose gel
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19. Secondary Survey Overall facial appearance
Assess for symmetry, deformity, discoloration, nasal alignment
Palpate forehead & malar areas
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20. Secondary Survey Nose Check septum for hematoma & position FACE
Check airflow in both nares
Palpate nasal bridge for crepitus
Check fluid on filter paper for “ring sign” (for CSF leak)
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21. Secondary Survey Mouth Check occlusion Reflect upper & lower lips FACE
Check Stenson's duct for blood
Palpate along mandibular and maxillary teeth (be careful !)
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22. Secondary Survey Mouth Palpate along exterior of mandible
Pull forward on maxillary teeth
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23. Secondary Survey Neurologic Skin fold symmetry at rest
Motor: each division of CN-VII
Sensation: 3 divisions of CN-V
Sensation on tongue
Gag reflex
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24. Fracture Classification
Major
Lefort I, II, III
Mandibular
Minor
Nasal
Sinus wall
Zygomatic
Orbital floor
Antral wall
Alveolar ridge
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25. Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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26. Lefort Fractures
Lefort fractures can coexist with additional facial fractures
Patient may have different Lefort type fracture on each side of the face
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27. Differentiating Leforts
Pull forward on maxillary teeth
Lefort I: maxilla only moves
Lefort II: maxilla & base of nose move:
Lefort III: whole face moves:
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28. Lefort I: Nasomaxillary
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
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29. 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
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30. Lefort II: Pyramidal
Subzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of face
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31. Lefort II: Pyramidal Signs & symptoms Midface crepitus
Face lengthening
Malocclusion
Bilateral epistaxis
Infraorbital paresthesia
Ecchymoses: buccal vestibule, periorbital, subconjunctival
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32. Lefort II: Pyramidal
Hemorrhage or airway obstruction may require emergent surgery
Treatment can often be delayed till edema decreased
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33. Lefort II: Pyramidal Usually require Intermaxillary fixation
Interosseous wiring or plating of infraorbital rims, nasal-frontal area, & lateral maxillary walls
May need additional suspension wires
Antibiotics
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34. Lefort III Craniofacial dissociation
Bilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base
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35. Lefort III Signs and Symptoms
Face lengthening: “caved-in” or “donkey face”
Malocclusion: “open bite”
Lateral orbital rim defect
Ecchymoses: periorbital, subconjunctival
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36. Lefort III Signs and Symptoms Bilateral epistaxis
Infraorbital paresthesia
Often medial canthal deformity
Often unequal pupil height
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37. Lefort III
Usually associated with major soft tissue injury requiring emergent surgery for bleeding control
Surgery can be delayed till edema resolves
Intermaxillary fixation
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38. Lefort III Transosseous wiring or plating FACE Antibiotics
Frontozygomatic suture
Nasofrontal suture
May need extracranial fixation if concurrent mandibular fracture
Antibiotics
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39. Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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40. Mandible Fractures
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
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41. Mandible Fractures Signs and symptoms Malocclusion
Decreased jaw range of motion
Trismus
Chin numbness
Ecchymosis in floor of mouth
Palpable step deformity
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42. Mandible Fractures
Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.
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43. Mandible Fractures Treatment
Prompt fixation: intermaxillary fixation (arch bars), +/- body wiring or plating
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44. TMJ Dislocation Can occur from direct blow to mandible
Can occur “spontaneously” from yawning or laughing
Mandible dislocates forward & superiorly
Concurrent masseter & pterygoid spasm
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45. TMJ Dislocation Symptoms
Patient presents with mouth open, cannot close mouth or talk well
Can be misdiagnosed as psychiatric or dystonic reaction
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46. TMJ Dislocation 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
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47. Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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48. Nasal Bone Fractures 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
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49. 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
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50. Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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51. Zygomatic Fractures Tripod (tri-malar) fracture
Depression of malar eminence
Fractures at temporal, frontal, and maxillary suture lines
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52. Zygomatic Fractures Isolated arch fracture Less common
Shows best on submental-vertex x-ray view
Painful mandible movement
Usually treat with fixation wire if arch depressed
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53. Zygomatic Fractures FACE Tripod S & S Unilateral epistaxis
Depressed malar prominence
Subcutaneous emphysema
Orbital rim step-off
Altered relative pupil position
Periorbital ecchymosis
Subconjunctival hemorrhage
Infraorbital hypoesthesia
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54. Forces Required FACE Nasal fracture  30 g Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
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55. Supraorbital Fractures
Frontal sinus fracture
Often associated with intracranial injury
Often show depressed glabellar area
If posterior wall fracture, then dura is torn
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56. Supraorbital Fractures
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
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57. Orbital Fractures “Blow out” fracture of floor Rule out globe injury
Visual acuity
Visual fields
Extraocular movement
Anterior chamber
Fundus
Fluorescein & slit lamp
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58. Orbital Fractures Symptoms and signs Diplopia: double vision
Enophthalmos: sunken eyeball
Impaired EOM’s
Infraorbital hypesthesia
Maxillary sinus opacification
“Hanging drop” in maxillary sinus
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59. Orbital Fractures Diplopia with upward gaze: 90% FACE
Suggests inferior blowout
Entrapment of inferior rectus & inferior oblique
Diplopia with lateral gaze: 10%
Suggests medial fracture
Restriction of medial rectus muscle
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60. Orbital Fracture: Treatment
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.)
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61. Facial Soft Tissue Injuries
Before repair, rule out injury to:
Facial nerve
Trigeminal nerve
Parotid duct
Lacrimal duct
Medial canthal ligament
Remove embedded foreign material to prevent tattooing
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62. Facial Soft Tissue Rules
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
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63. Facial Soft Tissue Rules
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
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64. Facial Soft Tissue Rules
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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65. Questions??

66. Summary Assess ABC's first
Do complete exam as part of secondary survey
Obtain standard X-rays and / or CT scan as indicated
Decide if specialist referral and / or operative repair indicated
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67. Summary
Arrange followup after repair to assess for delayed complications or cosmetic problems
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