OVERVIEW TRAUMA

MAXILLOFACIAL
Rosadi Seswandhana
Div. of Plastic Surgery, Dept. of Surgery Faculty of
Medicine, Universitas Gadjah Mada
Dr. Sardjito General Hospital
Introduction
• Soft tissues and bones of the face give anterior protection to the
cranium
• Facial appearance is a major factor in “appearance“
• Multi function of daily life :
• Sight, smell, eating , breathing and talking
à significant impairment
à potentially serious effect of life style and quality of life
• Injury can involve the skin and soft tissues as well as resulting in
fractures
• Facial injuries themselves are rarely life-threatening, but are
indicators of the energy of injury.
• Facial injuries should alert the examiner to the possibility of airway
compromise, cervical spine injuries, central nervous system injuries,
or other organ injury
Other organ injured associated to maxillofacial trauma

Incidence Percent
Head 243 53,9
Eyeball 25 7,4
Chest 13 2,9
Abdominal 8 2,4
Upper Extremity 37 10,6
Lower Extremity 26 7,6
Vertebrae 5 1,5

(Seswandhana, 2006)
Epidemiology
• Age mean :
26,675 (SD+10,0522) year
• Male : Female = 89,6 :10,4
• Onset on admission :
1,885 (SD+ 0,3194) hour
Facial Fracture Incidence
200
118
91 73
100 62 59 48

0
2001 2002 2003 2004 2005 2006

Incidence 91 73 62 59 48 118

(Seswandhana, 2006)
Aetiology
Maxillofacial trauma is usually caused by:
• Assault (most common; domestic violence is an
important cause; alcohol may be involved)
• Road traffic accidents (midface fractures can
occur)
• Falls
• Sporting accidents

• The fracture ratio mandibular:zygoma:maxillary is 6:2:1

Aetiology
Mostly caused by motorcycle accident

1,

4,
3,

0,
3,

8
4

7
5,

4
4
4,
8

76
Pedestrian Bicycle ,2
Motorcycle
Car Train Occupational
Fall Domestic
(Seswandhana, 2006)
Anatomy of the face
 Anatomy of the bone
• The maxillofacial region can be divided into three parts:
• The upper face : the frontal bone and frontal sinus
• The mid face : the nasal, ethmoid, zygomatic and maxillary bones
• The lower face : the mandible

3D Skeleton Frame
Vertical
(red)
buttresses

transverse (yellow) buttresses

Blood and sensory supply
• Branches of the external carotid artery supply
blood to the face.
• The facial nerve supplies the muscles of facial
expression.
• The ophthalmic, maxillary and mandibular
branches of the trigeminal nerve supply sensation
to the skin of the face.
Airway related structure
Ocular related structure
Stensen’s duct
Mastication related structure
General assessment
• First look for associated life-threatening injuries. There
may be associated cervical spine and significant head
injury.
• Assess Airway, Breathing and Circulation and manage
appropriately.

OR=1,143; 95%CI (0,927-2,206)

More severe facial fracture

indicates more severe head
injury

(Seswandhana, 2006)
Mechanism of injury
Velocity and area of victim
• K = MV2
(tenaga/dampak energi yg dihasilkan lebih tergantung
pada velocity daripada massanya)
• Posisi daerah yang terkena
Daerah yang terkena pukulan/hantaman, makin lebar à
makin kecil akibat dampak energinya
• Posisi penerima apa dalam keadaan diam atau bergerak.
• Sudut pukulan
INITIAL ASSESSMENT

Primary survey and

resuscitation of vital
functions are done
simultaneously using
a team approach
 INITIAL ASSESSMENT
P
R
I
Airway with c-spine protection
M
A Breathing / ventilation / oxygenation
R
Y
Circulation: stop the bleeding!
S
U
R
Disability / neurological status
V
E Expose / Environment / body temperature
Y
Maxillofacial Trauma and Airway Injuries
Specific situations associated with maxillofacial trauma,
which may adversely affect the airway
1. Posteroinferior displacement of a fractured maxilla parallel
to the inclined plane of the skull base may block the
nasopharyngeal airway.
2. A bilateral fracture of the anterior mandible may cause
the fractured symphysis to slide posteriorly along with the
tongue attached to it via its anterior insertion. In the supine
patient, the base of the tongue may drop back, thus blocking
the oropharynx.
3. Fractured or exfoliated teeth, bone fragments, vomitus
and blood as well as foreign bodies – dentures, debris,
shrapnel etc. – may block the airway anywhere along the
upper aerodigestive tract.
4. Hemorrhage, either from distinct vessels in open wounds or
severe nasal bleeding from complex blood supply of the
nose, may also contribute to airway obstruction.
History
Allergic – Medication – Past illnest – Last meal – Event
• Mechanism of injury
• Any loss of consciousness?
• Any visual disturbance, including disturbance of eye
movement?
• Any problems with hearing, including vertigo and tinnitus?
• Any discharge from the ears or nose, including blood or
cerebrospinal fluid (CSF)?
• Any problems with breathing through the nose?
• Ability to bite down without pain and feeling of whether
the teeth come together normally?
• Any numbness or tingling on the face?
Examination

• Look for facial asymmetry

• Inspect for bruising, swelling, lacerations, missing tissue,
foreign bodies and bleeding
• Palpate for bony injury and crepitus systematically
• Inspect the eyes. Examine eye movements. Assess pupils
• Check for foreign bodies and lacerations
Forced duction testing
• Inspect the nose, looking for dislocation and telecanthus
(widening and flattening of the nasal bridge). Palpate for
tenderness and crepitus. Look for lacerations and CSF
• Ears: look for lacerations and CSF in the canal Assess the
tympanic membrane
• Inspect the tongue and mouth
• Assessment for Le Fort fractures (see below): put one
hand on the anterior maxillary teeth, the other on the
nasal bridge. Only the teeth will move in a Le Fort I
fracture. If the nasal bridge moves, a Le Fort II or III
fracture is present
Intra-oral examination
• Occlusion and avulsion of the teeth
• Laceration of oral mucous , ginggiva and hematoma floor
of the mouth
• Step off deformity of the bone
• Mobility of maxilla bone
• Open bite or disability to open the mouth
• Split of the palatal bone
Type of teeth oclussion
Class Occlusion I Class Occlusion II Class Occlusion III

Other type of malocclusion

• Open bite
• Premature bite
• Cross bite
 Type of teeth oclussion

Class I Angles’ occlusion

Mandible examination
• Palpate the mandible and temporomandibular joint,
looking for mobility or crepitus

• Assess the teeth. Look for avulsed or mobile teeth. Look

for jaw malocclusion

• Place a finger in the patient's ear canal to palpate the

mandibular condyle. Ask the patient to open and close the
mouth. If there is pain or lack of movement, this indicates
a condylar fracture

• Tongue blade test

Facial danger Zone
Parotic duct injury
Investigations
• X-ray and CT scanning provide the mainstay of fracture
investigation.
• Specific X-ray views are needed depending on the
fracture suspected.
Specific fractures

• Frontal bone fractures

• Orbital floor fractures
• Nasal fractures
• Nasoethmoidal fractures
• Zigoma fracture
• Maxillary fractures
• Mandibular fractures
• DentoAlveolar fractures
• Panfacial fractures
Frontal bone
Fraktur Impresi
 CT scan
Impresi Fraktur
TINDAKAN OPERATIF FRAKTUR DEPRESI
Orbital floor fractures
• Can occur alone or with medial wall fracture.
• May be herniation of orbital contents into maxillary sinus.
Nasal Fracture

% of Total
Frontonasoethmoid Region
nasal nasoethmoid frontonasal Total
1 site fracture 25,5% 2,1% 27,6%
2 site fracture 15,9% 15,9%
3 site fracture 17,9% 1,4% 2,8% 22,1%
more than 3 site fracture 29,7% 4,1% ,7% 34,5%
Total 89,0% 7,6% 3,4% 100,0%
Incidence : 32% from overall facial fracture
Mostly be a part of multiple facial fracture

(Seswandhana, 2006)
Nasal Bone Fracture
Nasoethmoidal fractures
• Extend from nose to involve ethmoid bones.
• Can lead to damage of lacrimal apparatus,
canthus, nasofrontal duct or dural tear at cribiform
plate.
• If a dural tear is suspected, referral to a
neurosurgeon is required.
 Mid-Face Facial Fracture
% of Total
Mid-Face Facial Region
maxilla maxilla
sagital sagital zygoma ZMC ZMC zygoma
unilateral bilateral unilateral unilateral bilateral bilatera Total
1 site fracture 5,0% ,4% 19,1% 1,7% 26,1%
2 site fracture 3,7% ,8% 15,8% 3,7% ,4% 24,5%
3 site fracture 2,5% ,4% ,4% 9,1% 9,5% 1,7% 23,7%
more than 3 site fracture ,4% 1,2% 4,6% 18,7% ,8% 25,7%
Total 11,6% 2,5% ,8% 48,5% 32,0% 4,6% 100,0%

Incidence : 53,4% from overall facial fracture

Unilateral ZMC fracture was the most
frequent in mid-face facial region

(Seswandhana, 2006)
Zygoma fracture

Pre Operasi Post Operasi

Zygoma fracture
Zygoma fracture
Zygoma fracture
Diagnosis

Waters view Dolan Line - Waters

Maxillary fractures
• Anatomy: the two maxillae form the upper jaw, the
anterior part of the hard palate, part of the lateral walls of
the nasal cavities, and part of the floors of the orbital
cavities. They meet in the midline at the intermaxillary
suture and form the lower margin of the nasal aperture.
Maxillary Bone Facture
Diagnosis
Maxillary Bone Fracture
Klasifikasi

1. Lefort I 4. Sagital

2. Lefort II

3. Lefort III
Classic Le Fort Fracture

% of Total
Le Fort Fracture
Le Fort 1 Le Fort 2 Le Fort 3 Total
2 site fracture 2,7% 2,7%
3 site fracture 24,3% 5,4% 29,7%
more than 3 site fracture 51,4% 16,2% 67,6%
Total 2,7% 75,7% 21,6% 100,0%

Incidence : 8,2% from overall facial fracture

The common Le Fort Fracture is type 2

(Seswandhana, 2006)
Wise sayings about facial fractures
• Look at the orbits carefully, since 60 - 70 % of all facial
fractures involve the orbit in some way.
• Bilateral symmetry can be very helpful.
• Carefully trace along the lines of Dolan.
• Use CT liberally in working up facial fractures.
 Mandible Fracture

% of Total
Mandible Region
parasim condyle / segmen gun shoot
Simphisis phisis corpus angle ramus coronoid subcondyle tal wound bone loss Total
1 site fracture 4,4% 13,1% 6,8% 2,4% ,8% 1,6% ,4% ,4% ,4% 30,3%
2 site fracture 2,0% 6,8% 2,4% 1,2% ,4% ,4% ,8% 23,1% 37,1%
3 site fracture ,8% 2,8% ,8% 1,2% ,8% 8,0% 14,3%
more than 3 site fracture 2,0% 2,8% 2,4% ,4% 10,8% 18,3%
Total 9,2% 25,5% 12,4% 5,2% 2,0% ,4% 2,4% 42,2% ,4% ,4% 100,0%

Incidence : 55,7% from overall facial fracture

Segmental fracture is frequent especially in
simphyseal region

(Seswandhana, 2006)
literature
Anatomy
Mandible Fracture
Fracture site
Fraktur Mandibula
Musculature
Fraktur Mandibula
Diagnosis
Tn. B, 28 th
Waters, AP, Lateral
Alveolar fractures
• Injuries of the tooth bearing portion of the mandible
are common.
• They can occur after relatively low impact trauma. The
alveolus (tooth bearing portion of bone) and/or the
tooth can be damaged. Segmental fractures that
involve multiple teeth can occur.
• Can present with loose or lost teeth and bleeding
gums.
Panoramix - OPG
Panfacial fracture
• Usually result from high-energy trauma to the face.
• Panfacial injuries involve trauma to the upper, middle, and
lower facial bones.
• Multisystem injury or polytrauma is commonly associated
with these injuries; thus, treatment often requires a team
approach.
• After stabilization of the patient, early and total restoration
of facial form and function should be the goal of the
maxillofacial surgeon.
Complications of maxillofacial injuries

• Immediate
• Airway compromise
• Aspiration
• Haemorrhage
• Infection
• Longer-term
• Scars and permanent facial deformity
• Chronic sinusitis
• Nerve damage leading to loss of facial sensation, movement, smell,
taste or vision
• Malocclusion
• Non-union/malunion of fractures
Prevention of maxillofacial injuries

• Full-face helmets may offer some protection against maxillofacial

injury
• Airbags, non-lacerating windscreens and seatbelts in cars
• Safety measures in high-risk occupations
• Gumshields in sports, although it is unclear which offers the best
protection for which sport
Timing of Surgery
• Soft tissue injury: Max 24 hours after trauma

• Facial bone fracture’s

Depend on patient condition
Ideally couple days after trauma or directly after trauma
Max 2 weeks
Transfer of patient
Preparation of surgery
• Oral hygiene (mouth wash gurgle)
• Oral intake, Liquid diet
• Naso gastric tube
• Anti tetanus
• Pain killer
• Antibiotic
Treatment
• Initial
• Primary survey and stabilization
• Immobilization à barton sling

• Definitive
• Open Reduction vs Close Reduction
• Alignment parameter : Occlusal plane
• Internal Fixation vs External Fixation

• Wire
• interdental wiring,
• intermaxillary wiring ~ maxillo-mandibular fixation
• Miniplate & Screw
• Rubber
Post op follow up
• Oral hygiene
• Evaluation of occlusion
• Tightness of archbar or
other MM fixation
• X ray post op
Longterm follow up
• Removal (take out)
fixatur
• Asymetri
• Disturbance of face
function
Conclusion

• A-B-C treatment at the first chance is the most important

for saving patient’s life
• The knowledge and physical examination skills in the
maxillofacial trauma are essential to be able to make the
right diagnosis,
• Facial bone fractures in particular sites should be more
aware because it is often overlooked
• so as to determine appropriate treatment
• Post-operative evaluation is important for assessing the
success of achieving surgical goals and monitoring the
likelihood of early and late complications
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