MAXILLOFACIAL INJURY

This injury can present with an apparently frightening clinical picture. Do not panic! Traumatic injuries to the facial structures may be classified as:

  • Soft tissue injuries ± tissue loss
  • Hard tissue injuries ± bone loss
  • Combined soft and hard tissue injuries

Management

The management principles of maxillofacial injuries are:

  • Advanced trauma life support (ATLS) principles (ABCDE)
  • Restore occlusion
  • Restore function
  • Restore aesthetics
  • A thorough history and examination is paramount to the management of maxillofacial injuries.

Patients with maxillofacial injury require immediate referral to higher levels for appropriate management.

ATLS

Primary Survey
  • Airway + cervical spine control: Note that maxillofacial injuries both soft tissue
    and hard tissue may compromise the airway.

    • If palate is collapsed on roof of mouth, scoop with finger and try to elevate.
    • If tongue is pushed back in direction of pharynx, pull forward with forceps.
    • Apply suture to hold in place if need be. Lay patient on the side.
    • With severe nose injury, suck to clear the blood and insert nasopharyngeal
      tube if need be. Take precautions as above for possible neck injuries.
    • If needed in very severe injury, perform tracheostomy with cuffed tube.
    • Apply local pressure or nasal packs soaked in liquid paraffin.
    • Perform direct suture of spurting bleeders.
  • Breathing
    • Rule out other injuries such as head injury or chest injury that may impair breathing; relevant radiographs such as chest radiograph and CT scan of the head should be taken.
    • If the patient is not breathing or oxygen saturations are low, intubate and ventilate.
    • For chest injury management, refer to Section 49.2, on chest injuries.
  • Circulation
    • Monitor vitals such as BP and pulse, which are pointers to impending or established shock; also monitor urine (insert a urinary catheter if the patient is unconscious).
    • Give benzyl penicillin 2.4g IM 8 hourly + metronidazol 500mg IV 8 hourly until the situation is managed.
    • Administer fluids to maintain haemodynamic stability.
    • Monitor fluid management as above.
    • Give tetanus toxoid 0.5ml IM stat.
  • Disability
  • Check for consciousness and other neurological deficits (Glasgow Coma Scale – GCS – and examination of all cranial nerves).

Table 49.1: Glasgow Coma Scale

Serial No. Category Specific function Score
l Eye opening (E) Spontaneous 4
To voice 3
To pain 2
Nil 1
2 Best verbal response (V) Oriented, converses 5
Converses but confused 4
Inappropriate words 3
Incomprehensible words 2
Nil 1
3 Best motor response (M) Obeys 5
Localizes pain 4
Flexion withdrawal 3
Flexion abnormal 3
Extension 2
Nil 1

Glasgow Coma Score

Score = E + M + V ( the higher the score the better the prognosis).
Note: Trend is more important than present level of consciousness.

Resuscitation

  • Arrange transport with adequate resuscitation equipment. Ensure communication with receiving facility has been made.

Definitive Management

SOFT TISSUE INJURIES

As above plus:

  • Tetanus toxoid 0.5ml IM STAT.
  • Rabies vaccine in case of animal bites
  • Antibiotic therapy
  • Thorough debridement of necrotic tissues and surgical toilet; all vital
    structures that are injured such as the parotid duct, facial nerve, and nasolacrimal
    duct should be repaired.
  • Primary closure if there is adequate tissue for approximation; plan for wound
    cover with skin graft or flaps if there is tissue loss.

Always rule out underlying bone injury by taking appropriate
radiographs.

HARD TISSUE INJURIES

  • These may be classified as:
    • Dentoalveolar
    • Mandibular fractures
    • Midface fractures (Le Forte I, II and III)
    • Panfacial fractures
    • The bones of the mid face tend to stick out and are thus prone to being
      injured. The nose, zygoma, and mandible are the most prone to injury, with
      maxillary bone injuries being relatively less common and more complicated.

DENTOALVEOLAR FRACTURES

This is more common in children but can occur in adults.

  • Check for missing teeth/fragments/fillings to rule out inhalation (take chest xray,
    abdominal x-ray).
  • For mobile teeth, rule out fractures of the root using radiographs such as intraoral
    periapical (IOPA), upper or lower standard occlusal or an
    orthopantomograms (OPG). Then reposition and splint. Teeth that have very
    poor support or are infected should be extracted.
  • For alveolar fractures, reduce and splint with composite resin, dental wires
    (figure of 8), arch bar, or acrylic resin splints. Fixation should be maintained for
    4–6 weeks in adults and 2–3 weeks in children. (Stainless steel wire 0.5mm)
  • Put the patient on a soft diet.
  • Clean and repair associated soft tissue injuries of the gingivae and lips.
  • Give antibiotic cover (refer to Section 51.2, on management of orofacial
    fractures in dental and orofacial conditions), analgesics, and oral mouth wash.

MANDIBULAR FRACTURES

  • These may involve any part of the mandible – the symphysis, parasymphysis,
    body, angle, ramus, condyle, and coronoid.
  • They may also be displaced or undisplaced, depending on the pull of the
    muscles attached to the mandible.
  • Plain radiographs demonstrate these fractures well – OPG, PA mandible (to
    assess linguo-buccal displacement), lower standard occlusal, lateral views.
Management
  • Closed reduction – Indications (these are not absolute indications)
    • Undisplaced fractures involving the dentate mandible, children in developing dentition and
    • severely atrophic edentulous mandible.
  • Maxillo-mandibular fixation (MMF) for 6 weeks; 10–14 days for children. This is done using arch bars, eyelets, or Ivy loops (stainless steel wire 0.5mm)
  • Lingual-labial occlusal splints
  • Circum-mandibular wiring
    • Gunning splints
    • Antibiotic cover syrup amoxicillin 500mg 8 hourly orally and metronidazole
      400mg 8 hourly orally.
    • Normal saline rinse or chlorhexidine 0.2% mouthwash.
  • Open reduction and internal fixation (ORIF)
Indications:
  • Displaced unstable fracture segments;
  • Associated midface fractures;
  • When MMF is contraindicated such as in epileptics, mentally handicapped.
Treatment
  • Semi-rigid fixation with trans-osseous wires (osteosynthesis)
  • Lag screws
  • Plates and screws; load sharing plates or load bearing plates (for edentulous atrophic mandible, comminuted and defect fractures).
MIDFACE FRACTURES
  • Investigations include plain radiographs: Occipito-mental view (OMV), PA skull, OPG), CT scan
Treatment
  • MMF + suspension wires
  • ORIF – -semi-rigid fixation with trans-osseous wires – rigid plating with mini plates (1.5 and 2.0mm plates)
ZYGOMATIC COMPLEX FRACTURES
  • Investigations include OMV, submental vertex (for zygomatic arch fractures), CT scan (axial, coronal cuts + 3D reconstruction)
Treatment
  • Limited access treatment (reduction without fixation) for medially displaced fractures without comminution
    • Gilles technique (through temporal region)
    • Keen technique (intra-oral approach)
    • Dingman technique (lateral eyebrow approach)
  • ORIF for laterally displaced fractures and those with comminutions
    • Semi-rigid fixation with trans-osseous wires
    • Rigid fixation with miniplates (1.5 and 2.0mm plates)
  • Orbital fractures
    • Eye examination is mandatory.
    • If no ophthalmoplegia and fracture is minimally displaced, no treatment.
    • If there is entrapment of orbital contents or muscles, ORIF is done.
    • Miniplates are used for the orbital rims.
    • Consult ophthalmic surgeon.