Facial trauma

Dr. Azher A. Auda

Oral and maxillofacial surgeon
BDS CABS
 INTRODUCTION

Injuries to the orofacial region are common, but the

majority are relatively minor in nature.

It must always be remembered that an intact and

unscarred face is important to the well-being of the
individual, and thus all injuries, however trivial, should be
treated thoughtfully and sympathetically.
 In addition, even trivial blows to the face may:
• cause injuries that compromise the airway;
• directly or indirectly cause a head injury;
• cause injuries to the cervical spine.
 Causes
 sporting activities,
accidents
and intentional violence.
 EXAMINATION OF THE PATIENT

 The examination of the patient should be under

a good light with consideration of the airway
and other collateral injuries in mind.

 The rapid onset of oedema may make

examination of the face and routine head injury
observations difficult.
 The face should be examined from the front.
 Lacerations should be explored first and, if
necessary, cleaned using sterile saline or
aqueous antiseptic solution.

 Then hard tissues examination. the whole head

should be examined visually and by palpation
starting with the vault of the skull.
Inspection
1\ bruising over the mastoid process, or Battle’s sign,
may be indicative of a middle cranial fossa fracture.
2\Any asymmetry and displacements should be noted.
3\ The majority of middle third injuries are
accompanied by some degree of epistaxis
4\ Le Fort II and III injuries frequently have a
cerebrospinal fluid (CSF) leak with anterior or
posterior CSF rhinorrhoea.
5\A useful sign in the fractured zygoma is the frequent
subconjunctival haemorrhage, which will often be
found to have no posterior limit when the patient is
asked to look to the other side .
Gentle palpation

1\Tenderness over sites of known weakness and

potential for fracture is a very good guide to the
possibility of there being an underlying
fracture.

2\ step deformity.
 Intra-oral examination
Inspection
1\ The occlusion of the teeth examined:
The maxillary and mandibular dentition
normally ‘fit’ together even if the occlusion is
naturally irregular – if they do not, a fracture of
the jaws may be suspected.
2\ Tearing of the gingivae and bleeding.
4\ Any missing or broken teeth and prostheses
should be carefully recorded.
5\Movement of the jaw should be tested –
deviation from the midline at rest or on
opening suggests a fracture of the side to
which the jaw is deviating.
Palpation
1\The maxillary dental arch should be grasped
between the index finger, middle finger and thumb
of one hand in the incisor region, while the other is
placed on the forehead, if the maxilla is fractured,
gentle movement forward and backward, or side to
side, will reveal movement between the examining
hands.

3\Confirmation of a fractured zygoma may be made

by palpating the fractured antral wall above the
upper molar teeth in the buccal sulcus.
5\Palatal lacerations tend to occur in young
children who fall onto objects held in the oral
cavity, especially pens and pencils, the
suspicion of retained foreign bodies must be
considered.
 Relevant cranial nerves.
1\ Anaesthesia or paraesthesia indicates a
fracture proximally along the course of the
nerve.
Thus, anaesthesia/ paraesthesia of the
cheek and upper lip suggests a fracture
involving the infraorbital foramen or floor of
the orbit, while anaesthesia/paraesthesia of
the lower lip suggests a fracture of the
mandibular body.
2\ Facial palsy may indicate severance of
branches of the facial nerve that are involved
in facial lacerations, particularly penetrating
wounds of the parotid gland.
In the absence of lacerations, facial palsy
may be suggestive of a fractured temporal
bone.
3\ It is important to confirm that the patient has sight in
both eyes.
This may be difficult in the very oedematous patient with
marked periorbital oedema, but a pen torch shone directly
through the lids will confirm gross optic nerve function.
 pupil size and reflexes to light should be observed and
recorded,
 eye movements.
 Diplopia should be checked for by asking the patient to
follow the light of a pen torch in both central and
extremes of gaze.
Diplopia may be indicative of damage to the III, IV or VI
cranial nerves or, more commonly, damage to the thin
orbital plates of bone, particularly the floor of the orbit.
Radiological investigations

 A chest radiograph is indicated if there is any

suggestion of inhalation of dental fragments or
dental prostheses.
 Posteroanterior occipitomental radiographs
taken at 15° and 30° are the optimum initial
radiographs to illustrate the site and
displacement of a middle third fracture.
 Coronal computerised tomography (CT)
scanning has superseded tomographic views
in the diagnosis of orbital floor fractures.
 FRACTURES OF THE FACIAL SKELETON

Fractures of the facial skeleton may be divided

into:
 Those of the upper third (above the eyebrows),
 The middle third (above the mouth)
 The lower third (the mandible).
 The middle third

In 1911, René Le Fort classified fractures

according to patterns which he created on
cadavers using varying degrees of force.
1\ The Le Fort I fracture effectively separates the
alveolus and palate from the facial skeleton
above.

The fracture line runs through points of weakness

from the nasal piriform aperture through the
lateral and medial walls of the maxillary sinus,
running posteriorly to include the lower part of
the pterygoid plates.
2\ The Le Fort II fracture is pyramidal in shape.

 The fracture involves the orbit, running through the

bridge of the nose and the ethmoids, whose
cribriform plate may be fractured, leading to a dural
tear and CSF rhinorrhoea.
 It continues to the medial part of the infraorbital
rim and often through the infraorbital foramen.
 It continues posteriorly through the lateral wall of
the maxillary antrum at a higher level than the Le
Fort I fracture to the pterygoid plates at the back.
3\ The Le Fort III fracture effectively separates the
facial skeleton from the base of the skull

 The fracture lines run high through the nasal

bridge, septum and ethmoids, again with the
potential for dural tear and CSF leak, and
irregularly through the bones of the orbit to the
frontozygomatic suture.
 The zygomatic arch fractures, and the facial
skeleton is separated from the bones above at a
high level through the lateral wall of the
maxillary sinus and the pterygoid plates.
 The zygomatic complex
 This is the most common fracture of the middle
third of the face, apart from the nose.

 The fractures occur through points of

weakness :
 infraorbital margin,
 the frontozygomatic suture,
 the zygomatic arch,
 the anterior and lateral wall of the maxillary
sinus.
 Blow-out fractures of the orbit

 Direct trauma to the globe of the eye may push

it back within the orbit.

 The globe is a fairly robust structure and, as it is

thrust backwards, the pressure increases within
the orbit, and the weaker plates of bone may
fracture, most commonly the orbital floor,
fractures, and the orbital contents herniate
down into the maxillary antrum.
 This soft-tissue herniation may lead to
muscular dysfunction, particularly the inferior
oblique and inferior rectus, leading to failure of
the eye to rotate upwards.
 Enophthalmos and diplopia can follow,
although both may initially be concealed by
oedema.
 Paraesthesia in the distribution of the
infraorbital nerve may be an important clue to
the blow-out fracture.
Naso-ethmoidal complex fractures

are usually comminuted fractures involving the

nasal bones, frontal processes of the maxilla,
medial and sometimes infraorbital rims and
the maxillary processes/anterior sinus wall of
the frontal bones.
Such injuries can cause significant deformity and,
because of disruption of the medial canthal
ligaments, may cause traumatic telecanthus
‫ تغير باتجاه العين‬.
 TREATMENT
Soft-tissue injuries
Facial soft tissues have an excellent blood supply and heal well.
They should be sutured as soon as possible following the
injury after careful exploration, debridement and cleaning,
particularly where foreign bodies may be embedded.
Many lacerations may be closed using local anaesthesia,
injecting into the edges of the wound. If the patient is due to
have a general anaesthetic and there is a delay, the wounds
should be temporarily closed in advance, using local
anaesthesia.
Tissue sufficiently traumatised to have lost its blood supply
should be removed with a sharp scalpel, and the edge to
which it is to be apposed trimmed to fit as appropriate.
 Great care should be taken to replace tissues
accurately, particularly in cosmetically
important landmarks such as the vermilion
border of the lips, the eyelids and nasal
contours.
 Haemostasis is important.
 Muscle and underlying tissues should be
brought together with absorbable sutures so
that the edges of the wound lie passively
within 2 mm of their final position. Then fine
monofilament sutures (5/0 or 6/0) are used to
bring the wound edges together
 Vacuum drains are used where there is
concern over dead space beneath the
wounds.
 The lacerations should be covered with
antibiotic ointment two or three times per
day, and broad spectrum antibiotics should be
prescribed.
 Ideally, alternate sutures should be removed
from the third day with the remaining sutures
removed on the fifth day.
Fractured nasal bones
The nasal bones are the most commonly
fractured bones of the facial skeleton.
Best results are obtained when soft-tissue
oedema has been allowed to settle so that
accurate reduction can be achieved.
Surgery should ideally be carried out within a
week of the injury as, if left any longer,
reduction may become difficult or impossible.
Reduction should be directed first to
repositioning the nasal bones, disimpacting
with Walsham’s forceps

The septum is then grasped with Asch’s forceps,

manipulated until it is straight

It should be remembered, however, that the

nasal septum often cannot be adequately
manipulated into position and may require
formal septoplasty at a later date.
 Fractures of the maxilla
The principle of treatment is to restore the fragments
to their original position. To achieve this, it is
usually necessary to reduce the maxilla first with
Rowe’s disimpaction forceps, which grasp the
palate between the nasal and palatal mucosa.

Considerable force is sometimes required in a series

of downwards, forwards and sideways movements
to mobilise it.

After 2–3 weeks, full disimpaction is often impossible.

The lower part of the maxilla is approached
through a gingival sulcus incision above the
maxillary teeth as far back as the second molar.

Fractures may be identified with ease through

this route and fixed with plates or wires.

The dental arch is restored to its original shape as

far as possible so that it matches the pre-
morbid occlusion with the mandibular arch.
The upper part of the midface is approached
through incisions in the lower eyelid
(blepharoplasty incision), lower conjunctival sac
or infraorbital region are used to explore
fractures of the infraorbital rim.

The fractured rim may be fixed using

mini/microplates or wires as above
Fractures of the zygomatic complex

Second to the fractured nasal bone, this is the

most common fracture of the middle third of
the facial skeleton.
Displacement is usually posteriorly, although it is
important to assess the actual displacement by
studying the occipitomental radiographs.
Most fractures may be reduced by the Gillies
temporal approach.
A Bristow’s or Rowe’s elevator is then inserted
beneath the body of the zygoma or arch,
according to the site of the fracture. Force is
then applied in the opposite direction to the
displacement of the fracture.
After reduction, the position of the zygoma can
be checked by palpating the bony prominences
of the zygomatic arch, and the lateral and
inferior orbital rims.
As all fractures of the zygoma, other than those
solely of the arch, involve the orbital floor, it is
essential to apply a forced duction test to ensure
no limitation of movement of the inferior oblique
and inferior rectus muscles.
For this to be done, the lower eyelid is retracted and
the inferior rectus grabbed in the lower fornix.
The globe can then be rotated upwards and
should move freely.
Any restriction in movement suggests entrapment of
the infraorbital soft tissues, and the floor of the
orbit should be explored as for a blow-out fracture
Should the fracture be unstable, open reduction
and fixation of the fracture may be necessary.

The frontozygomatic suture may be exposed by a

small incision just behind the lateral part of the
eyebrow and visualised. Displacements may be
reduced and fixed with intraosseous wires or
bone plates. Occasionally, it is necessary to
explore and fix fractures at the infraorbital rim
All patients who have had operations involving the
orbit should have formal eye observations in the
postoperative period.
The condition of the eye, pupil size and light
reaction should be recorded.
Occasional complications occur, the most serious
of hich is a developing retrobulbar haematoma
Increasing proptosis and loss of vision constitute a
postoperative emergency requiring immediate
action to reduce the pressure of the
haematoma.
Orbital blow-out fractures

These fractures are ideally treated within 10–14

days of the original injury.
The aim of treatment is to:
 reduce any soft-tissue herniation of the periorbita ,
restore the continuity of the orbital floor
restore any functional deficit of ocular function
caused by extraocular muscle dysfunction.
The floor of the orbit is approached either
through :
 ablepharoplasty incision in the lower eyelid
 or through the inferior fornix.
Defects of the orbital floor may be made up with
bone grafts from a variety of sources, titanium
mesh , reinforced silastic or resorbable materials.
These materials may be fixed in place with wires,
screws or plates.
If the fragments are very unstable owing to
comminution or the size of the blow-out is
excessively large, packing the antrum via a
Caldwell–Luc approach with ribbon gauze soaked
in Whitehead’s varnish may be necessary, taking
care not to overpack the antrum and so displace
the orbital contents. The pack should be removed
at 3 weeks
General
Fractures of the facial skeleton are almost always
compound, and prophylactic antibiotics are
important.
Penicillin/amoxicillin and metronidazole singly or
in combination are ideal for those patients who
are not allergic. The cephalosporins are an
alternative.
All patients with fractures of the facial skeleton
benefit from intraoperative and postoperative
dexamethasone to reduce facial oedema