Maxillofacial Trauma: Critical Aspects of Management
January 1, 2014 26 minutes read
Maxillofacial Trauma: Critical Aspects of Management
Authors:
Melissa H. Warta, MD, Adjunct Assistant Professor of Surgery, New York Medical College, Valhalla, NY; Attending Physician, Saint Joseph's Regional Medical Center, Department of Surgery, Division of Trauma and Critical Care, Paterson, NJ.
Abdulla Fakhro, MD, MRCSI, Plastic Surgery Resident, Cooper University Hospital at Rowan University, Camden, NJ.
Peer Reviewer:
Robert E. Falcone, MD, FACS, Clinical Professor of Surgery, The Ohio State University College of Medicine, Columbus.
Facial trauma is a common emergency department complaint with a diversity of injury patterns, including simple lacerations, complex soft-tissue loss, and simple to complex fractures. Clinicians need to be cognizant of associated injuries that may accompany facial trauma, including brain and cervical spine injuries. Early identification and aggressive management may significantly impact the eventual outcome.
— Ann M. Dietrich, MD, Editor
Executive Summary
- The risk of traumatic brain injury, ranging from a simple concussion to severe intracranial and extra-axial hemorrhages, increases in the setting of facial trauma.
- The incidence of blunt cerebrovascular injuries (BCVI), identified by the Denver screening criteria, found a significant association for BCVI with mandible fractures, Le Fort II and III fractures, as well as scalp degloving injuries.
- A broad-spectrum antibiotic and primary closure is indicated for all facial dog bites. Additionally, antibiotic coverage is highly suggested for all facial lacerations in patients who are immunocompromised, smokers, diabetic, steroid-dependent, or who have other causes for poor wound healing.
- Patients with a history of prior eye surgery are more likely to be at risk of globe rupture than those without surgery.
- Cerebrospinal fluid is normally clear without mucus, and it is usually amplified by prostrating forward or using the Valsalva maneuver. The fluid can always be sent for biochemical analysis for glucose (> 30 mg/dL) or B2 transferrin, which has now become pathognomonic of CSF leaks.
- There are five types of frontal sinus fractures, and the type of fracture will guide management. The main concerns lie with whether or not the dura is violated posteriorly, whether there is compromise of the nasoorbitoethmoidal (NOE) complex leading to a CSF leak, and if the nasofrontal outflow tract (NOFT) is affected.
Introduction
Facial trauma can range from simple lacerations to complex soft-tissue loss, with or without associated simple to complex fractures. These injuries often are accompanied by significant distortion of anatomy and can be, in and of themselves, life-threatening injuries. Additionally, it is imperative to treat every facial trauma patient with caution, not forgetting that many have concomitant brain and cervical spine injuries.1,2 In our current society, motor vehicle collisions are still the leading cause of facial fractures in most individuals ages 15-50 years, and depending on the sample pooled, are followed by sports and violence as causes of facial fractures.1 In a study of 3385 cases of pediatric craniomaxillofacial injuries during a 10-year period, the authors found that most injuries were a result of play (58.2%), followed by sports (31.8%), traffic accidents (5%), and violence (3.9%).2 Facial trauma is a daily entity in emergency departments, and the aim of this report is to aid the general emergency department staff to understand the etiology and assist in stratification of emergent, urgent, and non-urgent management of facial trauma. Furthermore, this review article will provide the reader a better understanding of the additional risks of concomitant injuries and the ability to relay the pertinent information to the subspecialist. Each subsection will focus on the management of specific injuries, taking into account the vast majority of these injuries do not occur in isolation.
Initial Evaluation
The goals of treatment for all craniomaxillofacial traumas are several-fold. First and foremost, the principles of Advanced Trauma and Life Support (ATLS) apply to all traumatic evaluations. As with any trauma, airway protection and stabilization are paramount and can be quite challenging in the setting of maxillofacial trauma. Furthermore, significant blood loss may result from injuries elsewhere, with co-existing blunt or penetrating trauma including abdominal, thoracic, pelvic, and long bone fractures. Once the patient is stabilized, the goals of management are guided by restoration of occlusion, prevention of loss of function such as vision, and, ultimately, restoration of pre-injury appearance.
It is important to emphasize that ATLS protocols take precedence, beginning with the airway. The primary survey is a mainstay in early identification of life-threatening injuries and initiation of immediate life-preserving therapy. The survey should assess the patency and safety of the airway while analyzing the risk of deleterious compromise due to injury of the facial skeleton. Injury of the facial skeleton may affect ventilation, either directly by fracture displacement of tissue or indirectly by sequelae of ongoing hemorrhage. The indications to establish an airway are related to the extent of injury that may obstruct or has obstructed the airway. Significant mandible and midface fractures are likely to lead to airway edema and obstruction, and it is safer to establish a definitive airway when in doubt. Active hemorrhage compromising the airway, significantly decreased mental status precluding the ability to protect one's airway, or a patient in shock are all additional indications for establishing a definitive airway. It is preferable to orally intubate via direct laryngoscopy, taking care to maintain cervical spine precautions. One should always be prepared for an emergent, surgical airway in the presence of massive facial trauma. This is followed by assessment of the adequacy of breathing, oxygenation, ventilation, circulation, and any other major disabilities.3 Once a definitive airway is established, if significant hemorrhage accompanies the facial fractures, initial control can be established with compression via intranasal, nasopharyngeal, and oropharyngeal packing. If not, there are several options for definitive management, which will be discussed in detail in the section on management of specific injuries. However, packing will at least temporize the bleeding to allow for completion of the primary survey.
Once the primary survey is completed, the secondary survey is conducted to take note of the remainder of the injuries. Assessment of facial symmetry, deformity, discoloration, and facial alignment can be sought efficiently and expeditiously in the emergency department. Palpation of the face for tenderness can often localize a site of fracture. Further, identify lacerations, areas of edema and ecchymosis, or palpable crepitus to assess for craniomaxillofacial trauma. If the patient is cooperative, a thorough cranial nerve and ocular exam will also help to delineate injuries. It is useful to know if the patient has any preexisting motor, sensory, or visual deficits. Finally, do not neglect to look in the oral cavity for missing dentition, evidence of alveolar ridge fractures, and signs of malocclusion.
In the presence of significant craniofacial injuries, the likelihood of several concomitant injuries that may be a priority over the craniofacial trauma increases. The risk of traumatic brain injury, ranging from a simple concussion to severe intracranial and extra-axial hemorrhages, increases in the setting of facial trauma. In one study of 3,385 cases of pediatric craniomaxillofacial trauma, the authors found a 6.3% rate of concomitant injuries, and of those, 80.5% were craniocerebral.2 Cervical spine fractures range anywhere from 0.3%-24% in the presence of facial fractures, with the risk increasing with the number of fractures.4 At the University of Colorado in Denver, the trauma group evaluated the incidence of blunt cerebrovascular injuries (BCVI) identified by the Denver screening criteria. In 2012, they reported that there was a significant association for BCVI with mandible fractures, LeFort II and III fractures, as well as scalp degloving injuries.5 The remainder of this article will address the management of facial trauma and will elude to the concomitant injuries; the focus will be on the specific management of the craniomaxillofacial aspects of the treatment and management.
Specific Injuries
Soft-tissue Trauma. Soft-tissue trauma can occur in isolation or with fractures. This section will focus on isolated soft-tissue injuries without the added complexity of fractures. However, if there is extensive soft-tissue injury, the physician should have a high suspicion for underlying fractures and should obtain a computed tomography (CT) scan of the underlying maxillofacial structures. Facial soft-tissue injury accounts for about 10% of all emergency room visits, and knowing which injuries require a more complex approach will be helpful to the patient as well as the emergency room physician and the consultants.1
It is generally accepted that most facial lacerations do not require antibiotics, but antibiotics are indicated in a few situations. Dog bites have a higher incidence of infection when no antibiotic prophylaxis is given (6-8%), as demonstrated by Chen et al in 2012. In a study by Paschos et al, there was a 0% infection rate for patients with facial bite wounds who received antibiotics.6,7 Furthermore, both of these studies evaluated primary versus non-closure of dog bite wounds. They both demonstrated that primary closure had better cosmetic results and did not alter wound infection rates. The Paschos study included all dog bites and, thus, had an overall infection rate of 8.3%; in the isolated facial injuries, there were no infections in the primary closure group. The Chen group did not give antibiotics initially and had an infection rate of 6-8%, which was not statistically different in primary versus secondary closure of the wound. Thus, a broad-spectrum antibiotic and primary closure is indicated for all facial dog bites, and this can be expanded to any animal bite. Additionally, antibiotic coverage is highly suggested for all facial lacerations in patients who are immunocompromised, smokers, diabetic, steroid-dependent, or who have other causes for poor wound healing.1
Ideally, all wounds are closed primarily within eight hours of injury. For simple and relatively small lacerations of the face, the first step is to provide a local anesthetic and proceed with a thorough cleansing of the wound. If the deeper tissue and muscle units are involved, they should be approximated with a 40 absorbable suture such as non-dyed polyglactin. The skin should be approximated with a nonabsorbable 50 or 60 monofilament suture such as nylon or polypropylene. If the laceration involves the lips, it is critical to align the vermillion border for the best cosmetic outcome. If the injury is full thickness involving the oral mucosa, it should be closed in layers. Contraindications for ED management of facial lacerations include wounds that have sustained too much tissue loss and preclude a tension-free closure, those that require flap construction for coverage, or in cases of other injuries that require operative intervention and are of higher priority. Finally, if the wound is such that hemostasis or adequate visualization and assessment of the damaged tissue cannot be achieved in the emergency department setting, the operating room is needed. Aside from the tissue injury requiring repair in the operating room, other indications for a consultation with a maxillofacial surgeon may include lacerations that are complex, eyelid lacerations, full or partial thickness lacerations involving the vermillion border or philtrum of the lip, those with a concern for a parotid duct injury, or wounds with associated facial nerve deficits. In the case of a wound that is not repaired in the emergency room, keep the tissue protected with antibiotic ointment and a non-adherent dressing over the tissue. In the case of exposed cartilage, cover the exposed cartilage with sulfamylon until the specialist is able to repair the cartilage.
Isolated scalp wounds also fall under the category of facial trauma. Most scalp wounds can be closed primarily without the need for a specialist. The scalp can bleed profusely, so this is an area in which obtaining hemostasis is critical, and closure of the laceration will assist with this. Additionally, if a patient has a significant scalp laceration, a CT scan of the head and cervical spine are warranted. If it is a degloving injury, strongly consider CT angiography of the neck. Scalp lacerations with less than 2-3 cm of tissue loss can easily be approximated without the need to raise any flaps. As with any open wound, provide local anesthetic, then irrigate and debride the wound of necrotic tissue and debris. Approximate the wound with 30 monofilament non-absorbable suture or skin staples. The staples or suture can be removed in 10 to 14 days.
Nasal and ear lacerations deserve special mention, as they both have cartilaginous components. Exposed ear cartilage must be assessed for viability. Any that is questionable or frankly necrotic must be debrided. If it is a laceration and there is minimal to no tissue loss, the skin along with the perichondrium can be closed in a single layer with a non-absorbable monofilament suture such as poliglecaprone. If there are significant skin and cartilage defects, a consultant should be notified so that a graft can be performed within 12 hours of injury.1 If there is a complete avulsion but the ear has the potential to be salvaged, the patient requires immediate surgical intervention.
In terms of the nose, the tip and alar rim are more challenging to repair, as the tissues are relatively stiff and unforgiving. If the laceration requires the specialist to aid in closure, keep the tissue covered and moist with a non-adherent dressing such as gauze impregnated with 3% bismuth tribromophenate and petrolatum blend or antibiotic ointment and a non-adherent gauze while awaiting the consultant's assistance. Small lacerations are easily repaired primarily, but, again, seek out both bony and cartilaginous fractures in the appropriate setting. A thin cut maxillofacial CT can be done with reconstructed images to best assess for the facial skeleton involvement.
Facial soft-tissue injuries run the gamut from those that require a simple suture repair that can easily be performed in the emergency department without a consultant's assistance, to large amounts of tissue loss requiring complex reconstruction. If the injury is to the eyelid, the globe should be closely evaluated and visual acuity tested. If lacerations are near either canthus, the lacrimal ducts must be interrogated for injuries. When in doubt, seek out the appropriate consultant covering craniomaxillofacial injuries for advice on how to proceed with repairs or temporizing measures until the arrival of the consultant.
Isolated Orbital and Ocular Injuries
All patients with facial trauma, especially around the orbit, warrant a thorough visual assessment with attention to visual acuity, light perception, field of vision, and evaluation of extra-ocular muscle movements. Patients with a history of prior eye surgery are more likely to be at risk of globe rupture than those without surgery.8 It is important to ascertain if there is any change from pre-injury vision. The Snellen chart is a useful adjunct, and there are now smartphone apps that allow a quick portable version to test for acuity.
A neuromotor cranial nerve examination should be conducted to rule out extra-ocular muscle entrapment, paresthesias resulting from nerve damage, and impingement. It is imperative that comparison to the contralateral side for symmetry is conducted and documented. Looking for gross derangements such as visible corneal wounds, missing iris sectors, an abnormally shaped iris or pupil, or blood layering in the anterior chamber are all suggestive of significant ophthalmic injury and require an emergent consultation. A fluorescein/slit-lamp examination may also be useful in identifying additional injury to the cornea.9 These steps are critical, as in one retrospective review over a 13-year period, the authors found that all patients who had persistent visual impairments had ocular findings on the initial exam.10 When ocular injury is suspected, it is most useful to have a CT of the orbits to assess for fractures and soft-tissue injury. One can identify emergent issues such as abnormal globe contour, intra-ocular hemorrhage, retrobulbar hemorrhage, or intra-ocular air — all of which require an emergent ophthalmology consult.9
Soft-tissue injury, such as lid injuries, can also indicate the potential for underlying globe injury. Not only do full-thickness lid injuries have the potential to leave the cornea exposed, but they can also be a harbinger of a more significant injury. It is imperative to protect the cornea and globe from further injury with early application of artificial tears or cellulose gel. If the lacrimal ducts are spared, then closure of the laceration by a facial surgeon should not be delayed for the ophthalmologist's more formal exam. If there is a concern for globe rupture or laceration, avoid palpating the globe and place a metal or plastic shield to protect the eyes from unwanted pressure or further trauma. Lacerations of the lid margins should be managed by an ocular specialist, as the lacrimal ducts will require probing and possibly stenting if involved. Corneal injuries are generally abrasions and will heal in 24-48 hours. A ruptured cornea or significant laceration, however, will require emergent evaluation and treatment by a specialist. Most conjunctiva injuries can heal by secondary intention, but this should be determined in consultation with an ophthalmologist.
The orbit is comprised of several bones, and the contents include the globe, optic nerve, optic artery, and rectus muscles. Orbital blowout fractures (see Figure 1) are characterized by downward displacement of the orbital floor with protrusion of orbital contents into the maxillary sinus. They are most often a result of direct or transferred forces applied to the eye causing an increased intraorbital pressure, fracturing the orbit at its weakest point, which is the posterior medial floor. These most commonly present with periorbital ecchymosis and are most frequently the result of motor vehicle collisions.11 Index treatment of orbital fractures is supportive, with ensuring strict head elevation, ice, cessation of forceful nose blowing, and pain relief. Diplopia with upward gaze may be present with inferior blowout fractures. This is due to entrapment of the inferior rectus and inferior oblique muscles. Diplopia with lateral gaze is present in 10% of fractures, usually suggesting a medial wall fracture and restriction of the medial rectus muscle.
Figure 1. Bilateral Orbital Blowout Fractures
Image courtesy of Melissa H. Warta, MD.
Surgical intervention and timing of the intervention in orbital floor fractures remains a topic of controversy. Surgery is generally reserved for fractures with defects greater than 1 cm on the coronal view on computerized tomography, acute enophthalmos, or mechanical muscle entrapment.12-15 Rhim et al suggests immediate repair in the setting of diplopia and CT findings of an entrapped rectus muscle and non-resolving oculocardiac reflex, or in a young patient (younger than 18 years old) with a blowout fracture, diminished vertical motility, and CT exam demonstrating entrapped muscle or perimuscular soft tissue. If there is minimal diplopia, not in the primary or downgaze, with good ocular motility and no significant enophthalmos, then observation is sufficient. The remainder of fractures are likely to be repaired in two weeks after the edema diminishes.11 The importance of early specialist involvement by consultation of an ophthalmologist, oral-maxillofacial surgeon, or plastic surgeon is critical in the setting of inferior rectus muscle entrapment, inferior orbital nerve entrapment, enophthalmos, or orbital dystopia. These injuries have significant potential to result in both functional impairment and cosmetic disfigurement.
Injuries to the Mandible and Dentition
Mandible fractures are a common occurrence and often are the result of blunt force. Penetrating injuries can also cause mandible fractures, but are often associated with massive soft-tissue destruction. As with all injuries, securing the airway is followed by hemorrhage control. Mandible fractures can range from simple ones that do not require any interventions other than a soft diet, to extremely complex and comminuted fractures that require extensive operative reconstruction. An astute physical exam will provide the necessary clues to the presence of a mandible fracture. Any malocclusion, difficulty in maintaining a firm bite, or significant pain with jaw opening should raise concern about a mandibular fracture.
Trismus is the inability to open the jaw due to spasm of jaw muscles. It is assessed by measuring the distance between the upper and lower incisors; any distance less than 35 mm is considered to be trismus. Numbness in the mandibular distribution of the trigeminal nerve should be investigated. The patient should be able to feel the touch of a sterile sharp object on the jaw, cheek, oral mucosa, lower lip, and gums. Intraoral evaluation is essential so that an alveolar ridge or open mandibular fracture is not missed.
The floor of the mouth should be assessed for any hematomas, particularly sublingual hematomas. Loose and fractured teeth should be evaluated and counted. If teeth are missing, a chest radiograph may be taken to rule out aspiration. Prophylactic antibiotics are recommended for all compound or open mandibular fractures. In one study, patients who received either penicillin or clindamycin had a 30% reduction in the incidence of infection in such a setting.16 A plain X-ray will often show the fractures; however, CT scans are also useful adjuncts to determining the degree of injury. Fractures that involve the angle or ramus of the mandible (see Figure 2) also warrant a CT angiogram of the neck to assess for BCVI.5 (See Figures 3 and 4.)
|
Figure 2. Rami Fracture of the Mandible 
Image courtesy of Abdulla Fakhro, MD. |
Figure 3. Fracture of the Right Ramus 
Fracture of the right ramus and the left paraphyseal portions of the mandible. These fractures warrant a CT-angiogram of the neck. Image courtesy of Abdulla Fakhro, MD. |
Figure 4. Isolated Fracture of the Body of the Mandible 
This isolated injury does not require a CT-angiogram of the neck. Image courtesy of Abdulla Fakhro, MD. |
Once the presence of a mandible fracture is encountered, the management is at the discretion of the specialist. In general, there are three approaches that are based on the extent of fracture and whether the dentition is involved. Some fractures can be managed nonoperatively if there is minimal displacement and the patient is placed on a soft, no-chew diet. More extensive or unstable fractures are addressed by either open or closed reduction with internal versus external fixation. The goal of the treatment is to reduce pain and restore occlusion, facial contour, and function.17
Le Fort Fractures or Midface Fractures
When assessing fractures of the midface, it is important to ascertain if there is involvement of the pterygoid plate. The pterygoid plates are two vertical plates making up the pterygoid process of the sphenoid bone. Any combination of fractures to these structures can occur. In a treatise published in 1901, French surgeon René Le Fort published his work on cadaver skulls that were subjected to blunt forces of various magnitudes and directions.18 Le Fort fractures, defined by his work, are fractures of the midface, which collectively involve separation of all or a portion of the maxilla from the skull base. Le Fort concluded that there are three predominant types of mid-face fractures:
- Type I: horizontal maxillary fracture separating the teeth from the upper face; fracture line passes through the alveolar ridge, lateral nose, and inferior wall of maxillary sinus;
- Type II: pyramidal fracture, with the teeth at the pyramid base and nasofrontal suture at its apex; fracture arch passes through posterior alveolar ridge, lateral walls of maxillary sinuses, inferior orbital rim, and nasal bones;
- Type III: craniofacial disjunction; fracture line passes through nasofrontal suture, maxillofrontal suture, orbital wall, and zygomatic arch. (See Table 1.)
Table 1. Le Fort Fracture Types
Le Fort Fracture Type |
Description |
|
Type I |
|
|
Type II |
|
|
Type III |
|
In Le Fort I fractures, there is marked swelling and edema of the upper lip, with mobility of the alveolar segment of the mandible. The patient often has pain and tenderness while trying to speak or articulate. The pain is more pronounced when the patient is asked to clench his or her jaw. On exam, one sees an area of ecchymosis or laceration in the labia or buccal vestibule. Guerin's sign is ecchymosis at the greater palatine foramen alongside the distribution of the greater palatine vessels. Bruising of the palatal tissues is frequently observed. Additional physical exam findings and signs include bilateral epistaxis and malocclusion.
In Le Fort II fractures, there is widespread edema of the face, often described as moon face, usually with paresthesias of the cheek. Frequently, these fractures are accompanied by circumorbital ecchymosis, subconjunctival hemorrhage, and epistaxis. Cerebrospinal fluid (CSF) rhinorrhea can occur, as well as diplopia and maloclussion. Trismus is also common to such fractures, with mobility of the fractured fragment at the nasal bridge and the inferior orbital margin.
Le Fort III fractures produce craniofacial dysjunction, classically associated with widespread edema of the face and bilateral periorbital ecchymosis (i.e., panda facies with raccoon eyes). The conjunctiva are generally suffused with subconjunctival hemorrhages. The nose is routinely depressed or flattened, usually with epistaxis and/or CSF rhinorrhea. The clinical exam demonstrates limited ocular movements, with diplopia and enophthalmos. There is hemotympanum, and CSF otorrhea is usually present. The jaw is most certainly in maloclussion with trismus. The moving fragments are at the nasofrontal and frontozygomatic sutures. There is an accompanying ecchymosis at the mastoid process, seen posterior to the lobe of the ear, known commonly as the Battle sign.
Care of Le Fort fractures once again follows the principles of ATLS. Airway control is always a priority, ensuring first that the airway is patent. Maintain cervical spine precautions, which can lead to challenges in airway management. If there is suspicion of facial fractures, the key imaging includes CT scans of the head, and maxillofacial imaging with thin 3-5 mm axial cuts that allow for three-dimensional reconstruction.
The ideal choice of airway varies with each fracture when considering the operative repair of each; however, keep in mind that emergent intubations will be orotracheal or surgical. Le Fort I fractures are better suited to a nasal airway, especially if accompanied by a mandibular fracture, but this is reserved for the stable patient and done by one skilled at nasotracheal intubation. Often a patient with a LeFort I fracture does not need an emergent airway if the fracture is an isolated injury. The airway of choice in Le Fort II or III fractures depends on the dentition status of the patient. Edentulous patients are better suited to an oral airway, usually through a portal cut in Gunning splints or dentures. Dentulous patients can be intubated by guided nasal intubation or a surgical airway. In the emergent setting, if orotracheal intubation cannot be accomplished, an emergent cricothyroidotomy will be required and can later be transitioned to a tracheotomy.
Management of bleeding is crucial, especially with ongoing epistaxis. There can be significant hemorrhage from the greater palatine, maxillary artery, and its branches. Nasal packing is undertaken with caution, given the likely disruption of the cribriform plate and possible exacerbation of cerebral injury. Once an airway is established, one can pack the oropharynx and place anterior and posterior nasal packing.19 Once the patient is stabilized, at the time of imaging a CT angiogram should be obtained, and if there are signs of continued hemorrhage, either with physical exam or active contrast extravasation, angioembolization should ensue.6, 20-23
A thorough examination of the facial skeleton is always mandated in the trauma bay, with particular attention to the facial skin, deformities, asymmetry, and nasal or ear discharge. The distinction between rhinorrhea and CSF rhinorrhea is of utmost importance. Cerebrospinal fluid is normally clear without mucus, and it is usually amplified by prostrating forward or using the Valsalva maneuver. Patients will often report the fluid as having a sweet taste. The fluid can always be sent for biochemical analysis for glucose (> 30 mg/dL) or B2 transferrin, which has now become pathognomonic of CSF leaks. Periorbital examination for edema, ecchymosis, diplopia on extreme gaze, papillary diameter, proptosis, and visual acuity should be documented. An intraoral examination should also be conducted to assess for lacerations, fragments, and stability of the skeleton. Dental occlusion should be noted in all patients with facial trauma.
After addressing all life-threatening emergencies, definitive treatment of Le Fort fractures is aimed at restoration of stability, form, and function of the facial skeleton. It is imperative to achieve premorbid dental occlusion in addition to alleviating the pain burden on the patient. The ideal time for reduction of midface fractures is either immediately after repair of any cranial or dural injuries and as soon as possible;19 otherwise it is best at one week post-injury.24 Delaying treatment beyond a week makes reduction and disimpaction difficult and warrants open reduction techniques.
A more invasive reduction technique, the open reduction with internal fixation, is required in Le Fort III fractures and some Le Fort I and II fractures. In Le Fort III fractures, the fracture is panfacial, and fixation to the nasal bones, orbital rims, or zygomaticofrontal sutures is often necessary. This method of repair permits the resetting of bony fragments and fractures to their premorbid alignment and placement of implants to aid in repair of the bones. Maxilloplating systems are widely available, with different manufacturers on the market. Open reduction, internal fixation is necessary for severely displaced fractures, multiple fractures, the edentulous patient, and patients undergoing a delayed repair.
In many circumstances, a closed reduction technique, which is less invasive, can be performed. This technique is applied to stable, nondisplaced Le Fort I and II fractures. The closed reduction involves immobilization by maxillomandibular fixation (MMF) and fastening together of the maxillary and mandibular teeth. MMF can be maintained using wires, arch bars, or plates. Alignment often can be achieved and sufficient to allow for the fractures to heal. These patients are maintained on a "wired-jaw" diet, which is a full liquid diet, and will need wire cutters at home to release the jaw in case of choking or any other airway emergency.
In both techniques, care must be taken to meticulously disimpact bony fragments, expose the fracture, and ensure adequate reduction ahead of fixation. Various interplay of struts, plates, and screws can be used to aid stability in Le Fort fractures. Regardless of the fracture, a specialist's input and services are required to reduce and stabilize the fracture.
Frontal Sinus Fractures
Frontal sinus fractures deserve a special mention, not only because of the potential immediate threats to the integrity of the cerebrum, but also because there is a lifelong risk of delayed complications.25 Interestingly, the frontal sinus is absent in approximately 4% of the population, and in 12% of adults it is rudimentary or lacks pneumatization.26 As with the majority of facial injuries, the majority of these injuries are due to blunt trauma, most commonly from motor vehicle collisions.
There are five types of fractures, and the type of fracture will guide management. The main concerns lie with whether or not the dura is violated posteriorly, whether there is compromise of the nasoorbitoethmoidal (NOE) complex leading to a CSF leak, and if the nasofrontal outflow tract (NOFT) is affected.25 A CT scan of the head and brain are critical to evaluation, as well as the cervical spine. The consultation of a neurosurgeon and facial surgeon are critical. The five types are as follows: type 1: isolated anterior table fracture with or without displacement and no orbital fractures of NOE involvement; type 2: comminuted anterior wall fracture with possible orbital fractures or extension into NOE; type 3: anterior and posterior table fractures without significant displacement or dural involvement; type 4: anterior and posterior wall fractures with dural violation and CSF leak; type 5: anterior and posterior wall fractures, with dural injury, CSF leak, soft tissue or bone loss, and/or severe disruption of the anterior cranial fossa. (See Table 2.) The mainstay in management of these fractures is to prevent CSF leaks, prevent infection, and ensure that there is separation between the sinonasal tract and the brain.
Table 2. Types of Frontal Sinus Fractures
Frontal Sinus Fracture Type |
Description |
|
Type 1 |
Isolated anterior table fracture with or without displacement and no orbital fractures of nasoorbitoethmoidal (NOE) involvement |
|
Type 2 |
Comminuted anterior wall fracture with possible orbital fractures or extension into NOE |
|
Type 3 |
Anterior and posterior table fractures without significant displacement or dural involvement |
|
Type 4 |
Anterior and posterior wall fractures with dural violation and CSF leak |
|
Type 5 |
Anterior and posterior wall fractures, with dural injury, CSF leak, soft tissue or bone loss, and/or severe disruption of the anterior cranial fossa |
Summary
Facial trauma can range from a simple laceration that is easily repaired in the emergency department, to significant fractures and soft-tissue loss that leave the patient unrecognizable. As stated, stabilization of the airway and patient are paramount. This end is best served by following ATLS guidelines and protocols. Note that there is limited to no role for plain films in the era of CT scans, with the exception of a patient suspected to have a cervical spine injury that is unstable; a portable lateral cervical spine image can be immediately obtained to assess for a compromising cervical spine injury resulting in neurogenic shock. Once the patient is stabilized, appropriate imaging (see Table 3), consultations if needed, and definitive management of specific injuries can occur. The involvement of subspecialists early is key in the complex injuries, as is the thorough evaluation for the more common concomitant injuries, especially those that may be more life-threatening, such as an intracerebral hemorrhage and cervical spine injury. If the facility does not have the required specialists or capabilities to care for the injured patient, then stabilizing the patient for transfer to another facility that can provide the necessary treatment is critical to management.
Table 3. Imaging and Specialists for Maxillofacial Injuries
Injury |
Imaging |
Specialist |
|
Soft-tissue injury |
|
|
|
Orbital injury |
|
|
|
Mandible fracture |
|
|
|
Le Fort fractures |
|
|
|
Frontal sinus fracture |
|
|
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- Burlew CC, et al. Blunt cerebrovascular injuries: Redefining screening criteria in the era of noninvasive diagnosis. J Trauma Acute Care Surg 2012;72(2):330-335; discussion 336-337, quiz 539.
- Chen YF, et al. Transcatheter arterial embolization in the treatment of maxillofacial trauma induced life-threatening hemorrhages. J Trauma 2009;66(5):1425-1430.
- Paschos NK, et al. Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury 2013.
- Marx JA, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 7th ed.Philadelphia: Mosby/Elsevier; 2010.
- Blice JP. Ocular injuries, triage, and management in maxillofacial trauma. Atlas Oral Maxillofac Surg Clin North Am 2013;21(1):97-103.
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