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Management of Maxillofacial Soft tissue injuries. Management of Fractures of the Zygomatic bone and Orbit. Management of Fractures of the Maxilla.
Table of contents

Acute and long-term psychological problems can result from maxillofacial trauma and disfigurement. Separate articles entitled Examination of the Cranial Nerves and Cranial Nerve Lesions discuss the cranial nerves in more detail. 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.

J Oral Maxillofac Surg. J Trauma. Angelopoulos C ; Anatomy of the maxillofacial region in the three planes of section. Dent Clin North Am. Part 1: Advanced trauma life support. Emerg Med J. Coulthard P, Yong S, Adamson L, et al ; Domestic violence screening and intervention programmes for adults with dental or facial injury.

Cochrane Database Syst Rev. Strong EB ; Frontal sinus fractures: current concepts. Craniomaxillofac Trauma Reconstr. Natl J Maxillofac Surg. Part 5: Dentoalveolar injuries.

Maxillofacial Injuries : George Dimitroulis :

Brookes CN ; Maxillofacial and ocular injuries in motor vehicle crashes. Ann R Coll Surg Engl. Br J Sports Med. I have this horrid poo smell from my mouth. I brush my teeth twice a day, floss, use Dentyl PH mouthwash, I have the best oral hygeine of anyone I know but I still have this smell. As with any open wound, provide local anesthetic, then irrigate and debride the wound of necrotic tissue and debris.

The staples or suture can be removed in 10 to 14 days. Nasal and ear lacerations deserve special mention, as they both have cartilaginous components. Exposed ear cartilage must be assessed for viability. Any that is questionable or frankly necrotic must be debrided. If it is a laceration and there is minimal to no tissue loss, the skin along with the perichondrium can be closed in a single layer with a non-absorbable monofilament suture such as poliglecaprone.

Management of maxillofacial trauma in emergency: An update of challenges and controversies

If there are significant skin and cartilage defects, a consultant should be notified so that a graft can be performed within 12 hours of injury. In terms of the nose, the tip and alar rim are more challenging to repair, as the tissues are relatively stiff and unforgiving. Small lacerations are easily repaired primarily, but, again, seek out both bony and cartilaginous fractures in the appropriate setting.

A thin cut maxillofacial CT can be done with reconstructed images to best assess for the facial skeleton involvement. Facial soft-tissue injuries run the gamut from those that require a simple suture repair that can easily be performed in the emergency department without a consultant's assistance, to large amounts of tissue loss requiring complex reconstruction. If the injury is to the eyelid, the globe should be closely evaluated and visual acuity tested.

If lacerations are near either canthus, the lacrimal ducts must be interrogated for injuries. When in doubt, seek out the appropriate consultant covering craniomaxillofacial injuries for advice on how to proceed with repairs or temporizing measures until the arrival of the consultant. All patients with facial trauma, especially around the orbit, warrant a thorough visual assessment with attention to visual acuity, light perception, field of vision, and evaluation of extra-ocular muscle movements. Patients with a history of prior eye surgery are more likely to be at risk of globe rupture than those without surgery.

General assessment of maxillofacial injuries

The Snellen chart is a useful adjunct, and there are now smartphone apps that allow a quick portable version to test for acuity. A neuromotor cranial nerve examination should be conducted to rule out extra-ocular muscle entrapment, paresthesias resulting from nerve damage, and impingement. It is imperative that comparison to the contralateral side for symmetry is conducted and documented.

Looking for gross derangements such as visible corneal wounds, missing iris sectors, an abnormally shaped iris or pupil, or blood layering in the anterior chamber are all suggestive of significant ophthalmic injury and require an emergent consultation. One can identify emergent issues such as abnormal globe contour, intra-ocular hemorrhage, retrobulbar hemorrhage, or intra-ocular air — all of which require an emergent ophthalmology consult. Soft-tissue injury, such as lid injuries, can also indicate the potential for underlying globe injury. Not only do full-thickness lid injuries have the potential to leave the cornea exposed, but they can also be a harbinger of a more significant injury.

It is imperative to protect the cornea and globe from further injury with early application of artificial tears or cellulose gel. If the lacrimal ducts are spared, then closure of the laceration by a facial surgeon should not be delayed for the ophthalmologist's more formal exam. If there is a concern for globe rupture or laceration, avoid palpating the globe and place a metal or plastic shield to protect the eyes from unwanted pressure or further trauma. Lacerations of the lid margins should be managed by an ocular specialist, as the lacrimal ducts will require probing and possibly stenting if involved.

Corneal injuries are generally abrasions and will heal in hours. A ruptured cornea or significant laceration, however, will require emergent evaluation and treatment by a specialist. Most conjunctiva injuries can heal by secondary intention, but this should be determined in consultation with an ophthalmologist. The orbit is comprised of several bones, and the contents include the globe, optic nerve, optic artery, and rectus muscles. Orbital blowout fractures see Figure 1 are characterized by downward displacement of the orbital floor with protrusion of orbital contents into the maxillary sinus.

They are most often a result of direct or transferred forces applied to the eye causing an increased intraorbital pressure, fracturing the orbit at its weakest point, which is the posterior medial floor.

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These most commonly present with periorbital ecchymosis and are most frequently the result of motor vehicle collisions. Diplopia with upward gaze may be present with inferior blowout fractures. This is due to entrapment of the inferior rectus and inferior oblique muscles. Figure 1. Bilateral Orbital Blowout Fractures. Image courtesy of Melissa H. Warta, MD. Surgical intervention and timing of the intervention in orbital floor fractures remains a topic of controversy.

Surgery is generally reserved for fractures with defects greater than 1 cm on the coronal view on computerized tomography, acute enophthalmos, or mechanical muscle entrapment. If there is minimal diplopia, not in the primary or downgaze, with good ocular motility and no significant enophthalmos, then observation is sufficient.

The remainder of fractures are likely to be repaired in two weeks after the edema diminishes. These injuries have significant potential to result in both functional impairment and cosmetic disfigurement. Mandible fractures are a common occurrence and often are the result of blunt force. Penetrating injuries can also cause mandible fractures, but are often associated with massive soft-tissue destruction. As with all injuries, securing the airway is followed by hemorrhage control.

Synopsis of Management of Maxillofacial Trauma

Mandible fractures can range from simple ones that do not require any interventions other than a soft diet, to extremely complex and comminuted fractures that require extensive operative reconstruction. An astute physical exam will provide the necessary clues to the presence of a mandible fracture. Any malocclusion, difficulty in maintaining a firm bite, or significant pain with jaw opening should raise concern about a mandibular fracture. Trismus is the inability to open the jaw due to spasm of jaw muscles. It is assessed by measuring the distance between the upper and lower incisors; any distance less than 35 mm is considered to be trismus.

Numbness in the mandibular distribution of the trigeminal nerve should be investigated.

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The patient should be able to feel the touch of a sterile sharp object on the jaw, cheek, oral mucosa, lower lip, and gums. Intraoral evaluation is essential so that an alveolar ridge or open mandibular fracture is not missed. The floor of the mouth should be assessed for any hematomas, particularly sublingual hematomas. Loose and fractured teeth should be evaluated and counted.

If teeth are missing, a chest radiograph may be taken to rule out aspiration. Prophylactic antibiotics are recommended for all compound or open mandibular fractures. Figure 2. Rami Fracture of the Mandible.


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Image courtesy of Abdulla Fakhro, MD. Figure 3.

Fracture of the Right Ramus. Fracture of the right ramus and the left paraphyseal portions of the mandible. These fractures warrant a CT-angiogram of the neck. Figure 4. Isolated Fracture of the Body of the Mandible. This isolated injury does not require a CT-angiogram of the neck. Once the presence of a mandible fracture is encountered, the management is at the discretion of the specialist. In general, there are three approaches that are based on the extent of fracture and whether the dentition is involved.