Maxillofacial Injury - Investigation, Treatment

If a patient has severe maxillofacial injury- Place the patient in the semi-prone position. This position will allow secretions, blood and foreign bodies to fall from the mouth. If significant bleeding from central midface, this indicates that injuries usually from pterygoid venous plexus and/or rich blood supply of nose.

Classification Of Facial Injuries

Facial skeleton can be divided into thirds vertically.   1.Upper face (from level of canthi upwards) 2. Mid face (from maxillary teeth to canthi) 3. Lower face (mandible and mandibular teeth). When we classify the facial injury, we divide face into 3 zones- Central (Maso-orbital-ethmoidal complex) and, Lateral portions (includes check bones, malar bones, zygomatic bones, zygomatic-maxillary complex). Orbital fracture can occur as a part or in isolation of multiple fractures.

Investigations

CT Scans which tells severity or degree of injury. If the clinical picture suggests an isolated mandibular fracture, plain radiographs at right angles to each other. Rotational tomography, Orthopantomogram and a posteroanterior (PA) mandible would be sufficient.

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Mandibular Fractures

Mandibular fractures are diagnosed clinically, often because of deranged dental occlusion. On examination- Numbness over the distribution of the mental nerve is common. 3 patterns of the fracture of the mandible are- SubCondylar, angle of mandible, ramus of mandible.

Treatment

• There are 2 treatment options for the patients with mandibular fracture

1. Intermaxillary fixation (IMF)- or the wiring of the teeth together.

This treatment was done earlier when the treatment started to evolve.

2. Open Reduction and Internal Fixation (ORIF)- undisplaced fractures are those treated with ORIF heals after about 4 weeks.

Open Reduction and Internal Fixation is more preferred over Intermaxillary fixation because Intermaxillary fixation requires liquid diet and Open Reduction and Internal Fixation procedure includes very soft sloppy diet for some period of time. To fix any kind of fracture (bones or plates),we need screws. Screws can be big enough to involve both the cortex of the bone or they can involve only a single cortex of bone.  If we use the smallest screws, i.e2mm diameter screws, they engage a single bone cortex and are called monocortical. These screws are said to be load-sharing. If we use the bigger screws, i.e.; around 2.7mm diameter screws, which are sometimes needed in complex or comminuted fractures, screws go deeper and involve both inner and outer cortex. This is called bicortical fixation. These screws are called load-bearing, as the entire weight is on screws. The optimal time to treat mandible fracture is 24-48 hours.

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Fractures Of The Zygomatico- Orbital Complex (ZMC)-

• Zygomatico orbital complex is a four-legged stool model including, Zygomatic arch anteroposteriorly, Zygomatic process vertically, Infraorbital rim horizontally, Maxillary buttress vertically, Any one or more out of these can get fractured to cause a Zygomatico orbital complex injury .

Altered sensation over the distribution of the infraorbital nerve is common (commonly injured nerve). Eye injuries should be actively excluded because they’re in close proximity with the bony orbit. We need to be vigilant about it. Subconjunctival hemorrhage with no posterior limit is often seen, this indicates fracture of Zygomatico orbital complex. No posterior border to the hemorrhage as the patient looks away from the site of the fracture.

• Investigation - CT scans to find the severity of injury.
• Treatment- ORIF with fixation at one of the 4 legs of stool, namely frontozygomatic suture. Uncomplicated Zygomatico orbital complex fractures are generally treated within 10 days of injury.

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Maxillary Fractures

In the Maxillary fracture we have- Le fort I, II and III. Le Fort I fracture being involved inferior to the maxilla and le fort III being involved superiorly. A characteristic finding is a mobile maxilla which tends to be displaced backwards and inferiorly. This can compromise the airway and result in an anterior open bite, that is, inability to close the front teeth together. Treatment includes ORIF.

Orbital Fractures

Order of frequency of occurrence of orbital fracture is:  Floor,  medial wall,  lateral wall, roof. If the patient has- Binocular diplopia, which indicates motility issues with the eyeball. Monocular diplopia, indicates probability within the globe such as a dislocated lens or retinal detachment. Inferior rectus entrapment is more common in children, this needs to be treated as an emergency because muscle necrosis can occur, leading to irreversible damage. This can result in 2 things, Dropping of globe (Hypoglobus) or, Sinking of the globe (Enophthalmos). Retrobulbar hemorrhage is a surgical emergency because when left untreated it can lead to blindness. Mechanism- typically they are caused by a blow to the bridge of the nose leading to “piggy nose”. Treatment – ORIF to be done within 7-10 days post injury.

CSF Rhinorrhoea-

Fracture of cranial cavity and facial bones in continuity ? involving the frontal and ethmoidal sinuses combined with a Dural tear. Antibiotics are not indicated. Most common site of injury is the posterior wall of the frontal sinus. Persistent leaks lasting for 10 days are treated with open anterior fossa repair also called frontal craniotomy. This treatment is usually delayed for 7 to 14 days.

Parotid Duct Injury

Saliva leaking into the wound. The buccal branch of the facial nerve is often injured. Repaired over a cannula inserted into the parotid papilla.

Facial Nerve Injury

Best repaired primarily. Injuries that lie behind a line from lateral canthus of the eye to the angle of the mouth are repairable and this should be attempted. Animal and human bites.  All bites should be debrided carefully and then should be closed.

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