Facial InjuriesFacial Injuries

Yağmur AYDIN M.D.Yağmur AYDIN M.D.Associate ProffessorAssociate Proffessor

University of Istanbul, Cerrahpasa Medical FacultyUniversity of Istanbul, Cerrahpasa Medical FacultyDepartment of Plastic, Aesthetic and Reconstructive Department of Plastic, Aesthetic and Reconstructive

SurgerySurgery

soft tissue injuries soft tissue injuries

facial bone fracturesfacial bone fractures

Emergency TreatmentEmergency Treatment

Clear Airway and provide patent airwayClear Airway and provide patent airwayCleaning of blood, vomit and theet from inside of mouth with fingersCleaning of blood, vomit and theet from inside of mouth with fingersAspiration of blood, saliva, and gastric contents Aspiration of blood, saliva, and gastric contents Early Intubation or TracheostomyEarly Intubation or Tracheostomy

Control HemorrhageControl HemorrhageDirect pressure on the woundDirect pressure on the woundTying of bleeding vessels(a. Facialis, a. Temporalis superfic., a. Tying of bleeding vessels(a. Facialis, a. Temporalis superfic., a. Angularis, a. Carotis externa)Angularis, a. Carotis externa)Angiographic demonstration and embolization of the bleeding pointAngiographic demonstration and embolization of the bleeding pointAnterior-posterior nasal packingAnterior-posterior nasal packing

Treat Shock Treat Shock Evaluate Associated Injuries Evaluate Associated Injuries ( cervical vertebrea, skull base, ( cervical vertebrea, skull base, intracranial, thoracal, intraabdominal)intracranial, thoracal, intraabdominal)

Diagnosis and treatment of facial injuriesDiagnosis and treatment of facial injuries

Indications of TracheostomyIndications of Tracheostomy

Panfacial fracures(combined mandible, maxilla and nasal Panfacial fracures(combined mandible, maxilla and nasal fractures)fractures)TThe multiply fractured mandible with significant swelling he multiply fractured mandible with significant swelling of the neck and floor of the mouthof the neck and floor of the mouthPatients who require prolonged intermaxillary fixation Patients who require prolonged intermaxillary fixation who have significant head or chest injurieswho have significant head or chest injuriesPossibility of prolonged postop. airway problemsPossibility of prolonged postop. airway problemsSevere facial and neck edema resulting from soft tissue Severe facial and neck edema resulting from soft tissue injuries such as severe facial burnsinjuries such as severe facial burnsUnrelieved obstruction of airway in the region of larynx or Unrelieved obstruction of airway in the region of larynx or the hypopharynxthe hypopharynx

Clear Airway and provide patent airwayClear Airway and provide patent airway

Control HemorrhageControl Hemorrhage

Nasal tamponage

Soft tissue InjuriesSoft tissue Injuries

LacerationLaceration(most common form of facial injury)(most common form of facial injury)

Contusion (with or without hematoma) Contusion (with or without hematoma)

Abrasion Abrasion

Avulsion Avulsion

PuncturePuncture

Accidental Tattoo Accidental Tattoo

Retained Foreign Bodies Retained Foreign Bodies

Treatment of Soft Tissue Treatment of Soft Tissue InjuriesInjuries

Primary closurePrimary closure

Delayed primary closureDelayed primary closure

Secondary healingSecondary healing

Tertiary healing (skin grafts, flaps)Tertiary healing (skin grafts, flaps)

Wound Closure-IWound Closure-I

The time lapse between injury and repair is The time lapse between injury and repair is important in terms of the possibility of infection important in terms of the possibility of infection and the choice of repair techniquesand the choice of repair techniques

Primary closure is treatment of choicePrimary closure is treatment of choice

It is applied immediately after the trauma if the It is applied immediately after the trauma if the wound is sharp and cleanwound is sharp and clean

debridement, excision of a millimeter or two of debridement, excision of a millimeter or two of the wound edgethe wound edge

The wound edges is approximated with suturesThe wound edges is approximated with sutures

Wound Closure-IIWound Closure-II

The contused, dirty and heavy contamined The contused, dirty and heavy contamined wounds are not closed by primarylywounds are not closed by primaryly

Shotgun wounds, animal and human bites Shotgun wounds, animal and human bites are not closed primarly as wellare not closed primarly as well

Delayed Primary ClosureDelayed Primary Closure

The wound must be prepared with The wound must be prepared with debridment and dressingdebridment and dressing

CleaningCleaning

IrrigationIrrigation

DebridmentDebridment

The wound can be closed primarly after The wound can be closed primarly after 24-48 hours, If it is clean and free of 24-48 hours, If it is clean and free of devitalized tissuedevitalized tissue

Secondary ClosureSecondary Closure

If the wound is heavily contamined and If the wound is heavily contamined and infected, contains necrotic and devital infected, contains necrotic and devital tissues after 48 hours, The wound can be tissues after 48 hours, The wound can be closed after cleaning of the wound or can closed after cleaning of the wound or can be left to secondary healingbe left to secondary healing

Secondary healing occurs with secondary Secondary healing occurs with secondary wound contracture and marginal wound contracture and marginal epithelizationepithelization

Etiology of Facial Injuriesof Facial Injuries

Traffic accidentsTraffic accidents

Interpersonel violenceInterpersonel violence

Spor accidentsSpor accidents

Home accidentsHome accidents

Occupational accidentsOccupational accidents

Shot-gun injuriesShot-gun injuries

Symptom and Signs Symptom and Signs

Soft tissue InjurySoft tissue InjurySwellingSwellingPain or localized tendernessPain or localized tendernessCrepitation from areas of Crepitation from areas of underlying bone fractureunderlying bone fractureHypostesia and paralysis in Hypostesia and paralysis in the distribution of specific the distribution of specific nervenerveMalocclusionMalocclusion

Class I :Normal oclusionClass I :Normal oclusion

Class II :RetrognathiClass II :Retrognathi Class III :PrognathiClass III :Prognathi

Visual disturbanceVisual disturbanceDiplopia or decrease in visionDiplopia or decrease in vision

Facial asimmetry, deformityFacial asimmetry, deformityObstructed respirationObstructed respirationLacerations inside of mouthLacerations inside of mouthEcchymosisEcchymosisBleedingBleeding

Clinical Examination-IClinical Examination-I

Evaluation for symmetry and deformityEvaluation for symmetry and deformityInspection of face ( comparing 2 sides)Inspection of face ( comparing 2 sides)Palpation of all bony surfaces in an orderly Palpation of all bony surfaces in an orderly manner (sup. and inf. orbital rims, nose, the manner (sup. and inf. orbital rims, nose, the brows, the zygomatic arches, malar eminence, brows, the zygomatic arches, malar eminence, border of mandible)border of mandible)Inspection of intraoral area for lacerations and Inspection of intraoral area for lacerations and abnormalities of the dentitionabnormalities of the dentitionPalpation of dental arches for abnormal mobilityPalpation of dental arches for abnormal mobility

Clinical Examination-IIClinical Examination-II

Maxillary and mandibular dental arches are Maxillary and mandibular dental arches are carefully visualized and palpated for bone carefully visualized and palpated for bone irregularity, bruise, hematoma, tenderness or irregularity, bruise, hematoma, tenderness or crepituscrepitusSensory and motor nerve functions in the facial Sensory and motor nerve functions in the facial area evaluatedarea evaluatedExtraocular movements and muscle of facial Extraocular movements and muscle of facial expression must be examinedexpression must be examinedGlobe functions (pupillary size and symmetry, Globe functions (pupillary size and symmetry, globe excursion, eyelid excursion, double vision globe excursion, eyelid excursion, double vision and visual loss) and fundoscopic examination and visual loss) and fundoscopic examination

Facial InjuriesFacial Injuries

Lower Level fractures (Le-Fort I, Lower Level fractures (Le-Fort I, TransverseTransverse, Guerin), Guerin)transverse fracture separating the maxillary alveolus from the transverse fracture separating the maxillary alveolus from the upper mid faceupper mid face

Upper Level FracturesUpper Level FracturesLe-Fort II(Le-Fort II(Pyramidal Pyramidal fracture) : fracture) : separates a pyramid-shaped separates a pyramid-shaped central fragment containing the maxillary dentition from the central fragment containing the maxillary dentition from the remainder of the orbits and upper craniofacial skeletonremainder of the orbits and upper craniofacial skeleton

Le-Fort III (Le-Fort III (craniofacial dysjunctioncraniofacial dysjunction) : ) : separates the maxilla at separates the maxilla at the level of the upper portion of the zygoma, orbital floor, and the level of the upper portion of the zygoma, orbital floor, and nasoethmoid region from the remainder of the upper nasoethmoid region from the remainder of the upper craniofacial skeletoncraniofacial skeleton

Midface Fractures

Le-Fort Maxillary Fractures

Le-Fort Maxillary Fractures

Maxillary FracturesMaxillary FracturesSymptoms and SignsSymptoms and Signs

Periorbital hematomaPeriorbital hematomaNasopharyngeal bleedingNasopharyngeal bleedingPainPainSwelling on the faceSwelling on the faceIntraoral lacerationsIntraoral lacerationsMalocclusionMalocclusionElongation of the faceElongation of the faceMaxillary retrusionMaxillary retrusionAnterior open biteAnterior open biteAbnormal mobility on the dental arcAbnormal mobility on the dental arcRinorea and pneumocephaly (% 25 in LeFort II and III)Rinorea and pneumocephaly (% 25 in LeFort II and III)

Dental Occlusion

Normal occlusion Mandibular retrognathia Mandibular prognathia

Bimanual maxillary examination for abnormal movement

ImagingImagingPlain radiographs : Waters’ and lateral view

Axial and coronal CT scans of the midface

3 D CT

Waters’ radiograph Coronal CT3D CT

Dish-shaped face, loss of facial projection, bilateral conjunctival hemoraji

Vertical butresses of maxilla and mandible

restoration of the proper facial aesthetics including preservation of midface width, height and projection

Goals of treatment

Treatment of Maxilla Fractures

Open reduction and intermaxillary fixation and spanning each of the butresses with plate and screws

Orbital FracturesOrbital Fractures

ClassificationClassificationOrbital floor blow-out fracturesOrbital floor blow-out fractures

Pure (nonfractured infraorbital rim)Pure (nonfractured infraorbital rim)

Inpure (fractured infraorbital rim)Inpure (fractured infraorbital rim)

Orbital fractures (without blow-out)Orbital fractures (without blow-out)Lineer fracturesLineer fractures

Combined with maxillary fracturesCombined with maxillary fractures

Zygomatic fracturesZygomatic 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 Symptom and Signs

palpebral and subconjunctival hematomapalpebral and subconjunctival hematomaDiplopia (Diplopia (most common looking superiorly or inferiorlymost common looking superiorly or inferiorly))

Numbness in the inferior orbital nerve Numbness in the inferior orbital nerve distributiondistributionEnophthalmosEnophthalmosPositive forced duction testPositive forced duction testRadiological evidence of orbital floor fracture Radiological evidence of orbital floor fracture and entrapment of soft tissues on the and entrapment of soft tissues on the CT scans CT scans with both axial and coronal viewswith both axial and coronal viewsAssessment of the visual system Assessment of the visual system is essentialis essential

Orbital Blow-out fracture

Coronal CT

Treatment of Orbital Blow-out Treatment of Orbital Blow-out FractureFracture

There are two major surgical indications for There are two major surgical indications for orbital fracture repairorbital fracture repair

Muscle entrapment Muscle entrapment ((confirmed by forced duction and CT scanconfirmed by forced duction and CT scan))

volume increasevolume increase (> 2cm(> 2cm2 2 defects enophthalmos and globe defects enophthalmos and globe dystopia developes)dystopia developes)

Subciliar or transconjunctival approachSubciliar or transconjunctival approach

Entrapped soft tissues are brought back from maxiillary Entrapped soft tissues are brought back from maxiillary sinussinus

Defect are bridged with bone grafts or alloplastic Defect are bridged with bone grafts or alloplastic materials(silicone, titanium mesh, medpor, proplast etc.)materials(silicone, titanium mesh, medpor, proplast etc.)

The Superior Orbital Fissure and Orbital The Superior Orbital Fissure and Orbital Apex SyndromeApex Syndrome

ptosis of the eyelidptosis of the eyelid proptosis of the globeproptosis of the globe paralysis of cranial nerve III, IV, and VIparalysis of cranial nerve III, IV, and VI anesthesia in the distribution of the first anesthesia in the distribution of the first division of the trigeminal nervedivision of the trigeminal nerveIf blindness occurs in combination with the If blindness occurs in combination with the superior orbital fissure syndrome, the superior orbital fissure syndrome, the condition is termed the “orbital apex condition is termed the “orbital apex syndrome.”syndrome.”

Nasoethmoidal Orbital Fractures Nasoethmoidal Orbital Fractures

Symptoms and signsSymptoms and signsTelecanthusTelecanthus

Decrease in the dorsal nasal projectionDecrease in the dorsal nasal projection

RinoreaRinorea

Treatment:Treatment:open reduction with a open reduction with a combination of interfragmentary wiring and combination of interfragmentary wiring and plate and screw fixationplate and screw fixation

Nasoethmoidal Orbital Fractures Nasoethmoidal Orbital Fractures and their treatmentand their treatment

Zygoma FracturesZygoma Fractures

SymptomsSymptoms

periorbital and subconjunctival hematoma periorbital and subconjunctival hematoma

numbness in the infraorbital nerve numbness in the infraorbital nerve distributiondistribution

epistaxis epistaxis ((ipsilateral ipsilateral or bilateralor bilateral))

Disturbed Disturbed occlusion and range of motion occlusion and range of motion of the mandible of the mandible ((inward displacement of the zygomatic archinward displacement of the zygomatic arch))

Lack of prominence of the malar eminence Lack of prominence of the malar eminence

The The PPhysical hysical SSignsigns

periorbital and subconjunctival hematoma, periorbital and subconjunctival hematoma,

loss of prominence of malar eminence, loss of prominence of malar eminence,

numbness in the distribution of the infraorbital numbness in the distribution of the infraorbital nervenerve

inferior globe dystopia or enophthalmosinferior globe dystopia or enophthalmos

inferior displacement of the palpebral fissure. inferior displacement of the palpebral fissure.

Step or level discrepancies may be palpated Step or level discrepancies may be palpated over fracture sitesover fracture sites

tenderness at the sites of the fracture. tenderness at the sites of the fracture.

periorbital ecchymosis, edema, antimongoloid slant, and subconjunctival hemorrhage.

FrontalWorm’s-eye view.

Axial CT scan

isolated depressed left zygomatic arch fracture.

The The RRadiographic adiographic EEvaluation valuation

Plain films of the Caldwell, Water’s, and Plain films of the Caldwell, Water’s, and submental vertex submental vertex

AAxial and xial and CCoronal CT scanoronal CT scan

Treatment of zygomatic fracture with Gillies method

TREATMENT

Open reduction and rigid fixation with plates and screws at frontozygomatic suture, inferior orbital rim, and zygomatico-

maxillary butress

Orbitazygomatic fracture- Repositon and rigid internal fixation

Axial CT

Zygomatic Fracture

Nasal FracturesNasal Fractures

Various types of fractures of nasal

bones

Hematoma of Septum

SymptomsSymptoms

PainPainSwelling Swelling Respiratory obstructionRespiratory obstructionCrepitation on palpationCrepitation on palpation Nasal deformityNasal deformityDeviation of the septumDeviation of the septumMucosal lacerations intranasally Mucosal lacerations intranasally Septal hematoma Septal hematoma

Reduction of nasal fracture with an Asch forceps

Mandibular FracturesMandibular Fractures

the second most common facial bone injurythe second most common facial bone injuryMandibular fractures are classified according to Mandibular fractures are classified according to the state of the dentition (dentulous, partially the state of the dentition (dentulous, partially dentulous, edentulous) dentulous, edentulous) or or the region of the the region of the mandible in which the fracture occurs (condyle, mandible in which the fracture occurs (condyle, condylar neck, ramus, coronoid, angle, body, condylar neck, ramus, coronoid, angle, body, symphysis)symphysis)TThey are classified as either open or closed, hey are classified as either open or closed, depending on whether or not they have a depending on whether or not they have a communication with a skin lacerationcommunication with a skin laceration

Anatomic regions and frequency of fractures in those regions

•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

Symptoms and SignsSymptoms and Signs

PainPainSwellingSwellingTTendernessendernessMalocclusionMalocclusionFrequently, the patient volunteers that the teeth Frequently, the patient volunteers that the teeth do not feel like they are “coming together do not feel like they are “coming together properly.” properly.” Numbness in the distribution of the mental nerveNumbness in the distribution of the mental nerve

Fractured teeth, gaps, or level discrepancies in dentition, Fractured teeth, gaps, or level discrepancies in dentition, asymmetries of the dental arch, the presence of intraoral asymmetries of the dental arch, the presence of intraoral lacerations, loose teeth, and crepitance indicate the possibility of lacerations, loose teeth, and crepitance indicate the possibility of a mandibular fracturea mandibular fracture

RRadiographic adiographic EEvaluationvaluation

PPlain filmslain films: : anteroposterior, lateral and oblique viewsanteroposterior, lateral and oblique views

CT scanCT scan

Panorex examinationPanorex examination

Panorex examinationPanorex examination of mandible of mandible

TreatmentTreatment

The treatment of mandibular fractures involves The treatment of mandibular fractures involves establishing proper occlusal relationships and establishing proper occlusal relationships and then providing co-aptation of the edges of the then providing co-aptation of the edges of the bone fracture with fixationbone fracture with fixation

Closed reduction and Intermaxillary fixationClosed reduction and Intermaxillary fixation

Open reduction and rigid internal fixationOpen 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 ChildrenFacial Fractures in Children

Facial fractures in children account for about 5% of all facial injuriesFacial fractures in children account for about 5% of all facial injuriesMost of these fractures occur in children > 5 years of ageMost of these fractures occur in children > 5 years of ageSubcondylar fracture is seen most often Subcondylar fracture is seen most often Children’s bones are soft, and frequently displace without fractureChildren’s bones are soft, and frequently displace without fractureIn children, bone healing progresses rapidlyIn children, bone healing progresses rapidly. . It may be difficult to It may be difficult to reduce a LeFort fracture properly, even after one weekreduce a LeFort fracture properly, even after one weekchildren are able to provide some adjustment with growth such that children are able to provide some adjustment with growth such that minor occlusal deformitiesminor occlusal deformitiesIt is often more difficult to apply intermaxillary fixation devices in It is often more difficult to apply intermaxillary fixation devices in patients with primary or mixed dentition because of the shape of the patients with primary or mixed dentition because of the shape of the teethteethThe sinuses are small, and the pattern of the orbit and maxillary The sinuses are small, and the pattern of the orbit and maxillary fractures is different fractures is different Children have shallowly rooted teeth, and the shape of the crowns Children have shallowly rooted teeth, and the shape of the crowns may make the application of interdental wires more difficult may make the application of interdental wires more difficult An acrylic splint may be used sometimes to align mandibular fractures. An acrylic splint may be used sometimes to align mandibular fractures. Intermaxillary fixation is generally necessary for only 3 weeks. Intermaxillary fixation is generally necessary for only 3 weeks.