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Maxillofacial Trauma. Anatomy. Anatomy. Maxillofacial Region. 1. Fractures of the Nasal Pyramid 2. Fractures of the Central Midface Le Fort Fractures. Maxillofacial Region. 3. Fractures of the Lateral Midface 4. Fractures of the Frontal bone 5. Fractures of the Anterior Skull Base

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Maxillofacial region
Maxillofacial Region

1. Fractures of the Nasal Pyramid

2. Fractures of the Central Midface

  • Le Fort Fractures

Maxillofacial region1
Maxillofacial Region

3. Fractures of the Lateral Midface

4. Fractures of the Frontal bone

5. Fractures of the Anterior Skull Base

  • Escher Classification

Maxillofacial region2
Maxillofacial Region

6. Fractures or dislocation of the mandible


  • Sports

  • Vehicular Accidents

  • Mauling

  • Women – consider the possibility of domestic violence


  • Patients with severe facial trauma:

    • multisystem trauma

    • potential for airway compromise

    • concurrent brain injury

    • cervical spine injuries

    • blindness

Emergent management
Emergent Management

  • Primary Survey

    • Airway

    • Breathing

    • Circulation

  • Secondary Survey

Emergent management1
Emergent Management


  • Chin lift.

  • Jaw thrust.

  • Oropharyngeal suctioning

  • Manually move the tongue forward

  • Maintain cervical immobilization

Emergent management2
Emergent Management

  • Avoid nasotracheal intubation

    • Adverse effects:

      • Nasocranial intubation

      • Nasal hemorrhage

  •  cricothyroidotomy

Emergent management3
Emergent Management


  • Direct pressure

    • Anterior and posterior nasal packing

  • Packing of the pharynx around ET tube


  • Place, Time, Date, Mechanism of injury

  • Detailed description of the circumstances surrounding the injury

  • Allergies, other medical problems, medications, tetanus immunizations


  • Questions:

    • Was there LOC, nausea/vomiting, headache? (Head Trauma related questions)

    • How is your vision?

    • Hearing problems?

    • Is there pain with eye movement?

    • Are there areas of numbness or tingling on your face?

    • Able to bite down without any pain?

    • Is there pain with moving the jaw?

Physical examination
Physical Examination


  • Open wounds for foreign bodies

  • Facial asymmetry

  • Nose for deviation, widening of bridge

  • Nasal septum for septalhematoma, CSF or blood

  • Ears for blood or CSF

  • Malocclusion

Physical examination1
Physical Examination


  • Raccoon eyes

  • Battle’s sign

Physical examination2
Physical Examination


  • Halo Sign

  • Not sensitive or specific but can be used as a preliminary test for CSF in blood

  • Dipstick

  • Beta transferrin

  • Otorrhea, Rhinorrhea

Physical examination3
Physical Examination


  • Palpate the entire face.

    • Supraorbital and Infraorbital rim

    • Zygomatic-frontal suture

    • Zygomatic arches

  • Nose - crepitus, deformity and subcutaneous air

  • Zygoma along its arch and its articulations with the maxilla, frontal and temporal bone

  • Mandible for tenderness, swelling

Physical examination4
Physical Examination

  • Intraoral examination:

    • Inspect the teeth for malocclusions, bleeding

    • Manipulation of each tooth

    • Check for lacerations

    • Mandibular movements

Physical examination5
Physical Examination

Ophthalmologic exam

  • Visual acuity

  • Pupils for shape and reactivity

  • Eyelids for lacerations

  • Extra ocular muscles

  • Palpate around the orbits

Physical examination6
Physical Examination

  • Examine and palpate the exterior ears

  • Otoscopic examination

    • Look for lacerations

    • TM rupture

Diagnostic imaging
Diagnostic Imaging

  • Plain films

    • Confirm suspected clinical diagnosis

    • Determine extent of injury

    • Document fractures

  • CT scan

General treatment
General Treatment

  • ATS, TeAna

  • Thorough evaluation of all wounds

  • All foreign bodies must be removed

  • Debridement

    • Suturing of lacerations as needed

    • Minimize scarring

  • Antibiotics

Nasal fractures
Nasal Fractures

  • Most common bone injury in the face

  • Open or closed

  • Signs

    • Depression or displacement of nasal bones

    • Edema of nose

    • Epistaxis

    • Fracture of septal cartilage with displacement or mobility

    • Crepitus on palpation

Nasal fractures1
Nasal Fractures

  • All nasal injuries should be evaluated for septal hematoma

  • Untreated- result in septal necrosis and saddle nose deformity

  • Can become infected- result in a septal abscess

Nasal fractures2
Nasal Fractures

  • Radiographs:

    • Lateral projection

  • Treatment:

    • Surgical

    • After reduction, nasal cavities should be packed – “internal splinting”

Maxillary fractures
Maxillary Fractures

  • Le Fort’s classification

    • Le Fort I (transverse maxillary)

    • Le Fort II (pyramidal)

    • Le Fort III (craniofacial dysjunction)

Le fort i
Le Fort I

  • Low transverse fracture of maxilla involving palate

  • Facial edema

  • Mobility of hard palate and upper teeth

  • Malocclusion

Le fort ii
Le Fort II

  • Pyramidal fracture with detachment of maxilla

  • Facial edema

  • Epistaxis

  • Bilateral periorbital edema and ecchymosis

Le fort iii
Le Fort III

  • Complete disruption of attachments of facial skeleton to cranium

  • Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate

    • Open patient’s mouth and grasp the maxilla arch

    • Place the other hand on the forehead

    • Gently move back and forth, up and down - check for movement of maxilla

Le fort iii2
Le Fort III

  • Massive edema with facial elongation, flattening – “Dish faced deformity”

  • Epistaxis and CSF rhinorrhea

  • Motion of the maxilla, nasal bones and zygoma

Management of le fort fractures
Management of Le Fort Fractures

  • Open reduction and intermaxillary fixation should be performed to establish correct occlusion

  • Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.

Zygoma fractures
Zygoma Fractures

  • The zygoma has 2 major components:

    • Zygomatic arch

    • Zygomatic body

  • Two types of fractures can occur:

    • Isolated Arch fracture -most common

    • Tripod fracture - most serious

Zygoma arch fractures
Zygoma Arch Fractures

  • Palpable bony defect over the arch

  • Flattening of the cheek

  • Pain in cheek and jaw movement

  • Limited mandibular movement

Zygoma arch fractures1
Zygoma Arch Fractures

  • Radiographic imaging:

    • Submental view “bucket handle view”

      - Arches may not be seen in usual views (anterior, lateral)

  • Treatment:

    • Symptomatic - surgical

Zygoma tripod fractures
Zygoma Tripod Fractures

  • Tripod fractures consist of fractures through:

    • Zygomatic arch

    • Zygomaticofrontal suture

    • Inferior orbital rim and floor

  • Symptoms

    • Periorbital edema

    • Sensory disturbances along the infraorbital nerve

Zygoma tripod fractures1
Zygoma Tripod Fractures

  • Waters

  • Caldwell

  • Submental

  • Coronal CT

  • Treatment:

    • Symptomatic - surgical

Orbital blow out fractures
Orbital Blow Out Fractures

  • Isolated fracture of the orbital floor with partial herniation of orbital contents

  • Facial asymmetry

  • Enophthalmos

  • Diplopia on upward gaze- impingement of inf. Rectus

  • Check for sensory disturbances – cheek, upper lip, lateral nasal wall

Orbital blow out fractures1
Orbital Blow Out Fractures

  • CT scan

  • Management:

  • Indicated for displaced fractures or for symptomatic fractures

Frontal sinus fracture
Frontal Sinus Fracture

  • Uncommon

  • Depression of anterior table of frontal sinus

  • Intracranial injuries

  • Dural tears

  • Epistaxis

  • CSF rhinorrhea (disruption of posterior table of frontal sinus with dural rupture)

Frontal sinus fracture1
Frontal Sinus Fracture

  • Radiographs:

    • Facial views should include:

      • Waters

      • Caldwell

      • lateral projections

    • Caldwell view best evaluates the anterior wall fractures

Frontal sinus fractures
Frontal Sinus Fractures

  • Cranial CT with bone window

    • Frontal sinus fractures.

    • Orbital rim and nasoethmoidalfractures

    • R/O brain injuries or intracranial bleeds

Frontal sinus fractures1
Frontal Sinus Fractures

  • Patients with depressed skull fractures or with posterior wall involvement.

    • ENT or nuerosurgery consultation.

    • Admission.

    • IV antibiotics.

    • Tetanus.

  • Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

Frontal sinus fractures2
Frontal Sinus Fractures

  • Associated with intracranial injuries

    • Orbital roof fractures

    • Dural tears

    • Mucopyocoele

    • Epidural empyema

    • CSF leaks

    • Meningitis

Mandibular fractures
Mandibular Fractures

  • 2nd most commonly fractured facial bone

  • Signs and symptoms

    • Malocclusion of teeth

    • Tooth mobility

    • Intraoral lacerations

    • Pain on mastication

    • Bone deformity

Mandibular fractures1
Mandibular Fractures

  • Mandibularpain

  • Malocclusion of the teeth

  • Separation of teeth with intraoral bleeding

  • Inability to fully open mouth

  • Preauricular pain with biting

  • Positive tongue blade test

Mandibular fractures2

  • Radiographs:

    • Panorex

    • Plain view: PA, Lateral and a Townes view

Mandibular fractures3


  • Nondisplacedfractures:

    • Analgesics

    • Soft diet

    • Dent/ORL surgery referral

  • Displaced fractures, open fractures and fractures with associated dental trauma

    • Urgent oral surgery consultation

  • All fractures should be treated with antibiotics and tetanus prophylaxis.