Maxillofacial injuries are commonly encountered in the practice of emergency

medicine. More than 50% of patients with these injuries have multisystem trauma requiring
coordinated management between emergency physicians and surgical specialists in
otolaryngology, trauma surgery, plastic surgery, ophthalmology, and oral and maxillofacial
surgery
Problem
Trauma to the maxillofacial anatomy mandates special attention. Contained within the face
are systems that control specialized functions including seeing, hearing, smelling, breathing,
eating, and talking. Also, the vital structures in the head and neck region are intimately
associated. Lastly, the psychological impact of disfigurement can be devastating.
The maxillofacial region is divided into 3 parts.
1. the upper face, where fractures involve the frontal bone and sinus
2. the midface. The midface is divided into upper and lower parts. The upper midface is
where maxillary Le Fort II and Le Fort III fractures occur and/or where fractures of the
nasal bones, nasoethmoidal or zygomaticomaxillary complex, and the orbital floor
occur. Le Fort I fractures are in the lower part of the midface
3. the lower face, where fractures are isolated to the mandible
Frequency
Most are secondary to assaults and motor vehicle accidents. Information about the causes of
facial fractures depends on the country and location of the trauma center
Etiology
Facial trauma in an urban setting most often is caused by assaults, followed by motor
vehicle and industrial accidents. The zygoma and mandible are the most commonly
fractured bones during assaults. Facial trauma in the community setting most often is due to
motor vehicle accidents, then to assaults and recreational activities. Motor vehicle accidents
produce fractures that often involve the midface, especially in patients who were not
wearing their seatbelts. Other important causes of facial trauma include penetrating trauma,
domestic violence, and the abuse of children and elderly persons.
A systematic approach to the physical examination ensures adequate assessment of
maxillofacial trauma. The examination should include the following:

Inspect the face for asymmetry. Check cheekbones by looking down from the head of
the bed (ie, bird's-eye view). The width of the nasal bridge should be half of the
interpupillary distance.

Inspect the head and the face for abrasions, swelling, ecchymosis, missing tissue,
lacerations, and hemorrhage. Inspect open wounds for foreign bodies.

Inspect the teeth for mobility, fracture, or malocclusion. If teeth are avulsed, rule out
aspiration.

Palpate for bony injury, crepitus, and step-off, especially in the areas of the
supraorbital and infraorbital rims, frontal bone, zygomatic arches, and at the
articulation of the zygoma with the frontal, temporal, and maxillary bones.

Inspect the eyes for the presence of exophthalmos or enophthalmos; fat protruding
from the globe; visual acuity, abnormality of ocular movements; interpupillary

distance; and pupillary size, shape, and reactivity to light, both direct and
consensual.

Watch for superior orbital fissure syndrome, ophthalmoplegia, ptosis of the upper lid,
proptosis, and a fixed dilated pupil.

Watch for orbital apex syndrome, blindness, decreased visual acuity, and symptoms
of superior orbital fissure syndrome.

Evert eyelids and check for foreign bodies or lacerations.

Examine the anterior chamber for the presence of blood, flaring on slit-lamp
examination, or hyphema (ie, blood layering in the inferior aspect of the anterior
chamber).

Check the cornea. Use fluorescein staining to distinguish between an abrasion (ie,
uptake of dye) and laceration (ie, streaming of fluid in dye).
Perform a forced duction test. Anesthetize the sclera, grab the inferior aspect with
forceps, and tug upwards. The eye remains fixed if entrapped.
Palpate the medial orbital area. Tenderness may signify damage to the
nasoethmoidal complex.
Perform a bimanual nasal palpation test. Anesthetize and press intranasally against
medial orbital rim. Simultaneously press the medial canthus. If the bone moves, the
nasoethmoidal complex is fractured.
Assess the status of the medial canthus ligament and its attachment to the frontal
process of the maxilla.
Perform the traction test. Grasp the edge of the lower eyelid, and pull against its
medial attachment. If an obvious "give" of the tendon occurs, suspect a disruption of
the medial canthus.
Inspect the nose for telecanthus (ie, widening and flattening of the nasal bridge) or
dislocation. Palpate for tenderness and crepitus.
Inspect the nasal septum for a hematoma; bluish bulging mass; widening mucosal
laceration, fracture, or dislocation; and cerebrospinal fluid rhinorrhea.
Inspect for ear canal lacerations, cerebrospinal fluid leaks, integrity of the tympanic
membrane, hemotympanum, perforation, or mastoid area ecchymosis (ie, Battle
sign).
Inspect the tongue and look for intraoral lacerations, ecchymosis, or swelling.
Bimanually palpate the mandible, and examine for signs of crepitus or mobility.
Place one hand on the anterior maxillary teeth and the other on the nasal bridge.
Movement of only the teeth indicates a Le Fort I fracture. Movement at the nasal
bridge indicates a Le Fort II or III fracture.
Manipulate each tooth individually for movement, pain, gingival and intraoral
bleeding, tears, or crepitus.
Perform a tongue blade test. Ask the patient to bite down hard on a tongue blade. If
the jaw is fractured, the patient cannot do this and will experience pain.
Palpate the entire length of the mandible and the temporomandibular joint for pain,
deformity, or ecchymosis.
Palpate the mandibular condyle by placing a finger in the external ear canal while the
patient opens and closes the mouth. Pain or lack of movement of the condyle
indicates fracture.
Check for paresthesia or anesthesia of nerves.
Perform a thorough cranial nerve examination

Treatment protocol for Maxillofacial Injuries

1. Stabilize patient
2. Identify injuries

3.
4.
5.
6.
7.

Obtain radiographic studies and stereolithographic models

Initiate consultations (eg, psychiatry, physical therapy, speech therapy)
Initiate cultures/sensitivities (infectious disease consultations)
Unidertake serial debridement (days 310) to remove necrotic tissues
Stabilize hard tissue base to support soft tissue envelope and prevent scar
contracture before primary reconstruction
8. Conduct comprehensive review of stereolithographic models and radiographs and
determination of
9. treatment goals
10. Replace missing soft tissue component (if necessary)
11. Perform primary reconstruction and fracture management
12. Incorporate aggressive physical/ occupational therapy
13. Perform secondary reconstruction (eg, implants, vestibuloplasty)
14. Perform tertiary reconstruction (eg, cosmetic issues, scar revisions)
Initial Evaluation and Management
Initial Care Is dependent upon the severity of injury. Maxillofacial and laryngeal injury
may range from the simplest nasal fracture without significant epistaxis and only minor
nasal deformity to the most massive facial crush injury with extensive involvement of the
patients vital signs and the institution of basic life support measures is appropriate.
Maintenance of airway is the 1 st priority and may involve suctioning of the oral and
nasal cavity to remove blood or other debris. If the patient is comatose or if mandibular
fracture has resultedin instability of the floor of the mouth with prolapsed of the tongue into
the pharynx an oral airway may be required. If, for whatever reason, an oral airway is
unsatisfactory abd tracheal ventilation is necessary, endotracheal intubation is the
method of choice. Emergency tracheostomy is to be avoided if at all possible since the
procedure is fraught with hazard if operator is not intimately familiar with the anatomy and
experienced in the surgical technique. Emergency tracheostomy should be resorted to only
if all other measures have failed or if laryngeal injury is suspected.
The second priority is the maintenance of cardiac output in the trauma patient is
Hypovolemic Shock. This usually responds to volume replacement and appropriate
hemostatic measures. When stability has been obtained, following initial resuscitive
measures, an orderly head and neck examination is carried out.
1.
2.
3.
4.

Treatment Priorities
Evaluation and therapy of any central nervous injury
Evaluation and therapy of any abdominal or thoracic injury
Treatment of soft tissue, facial , and extremity trauma
Reduction and fixation of both facial and extremity fractures
Treatment & Management
Prehospital care
General airway: Administer oxygen and maintain a patent airway. Maintain an immobilized
cervical spine at all times. Clear the mouth of any foreign body or debris, and suction any
blood present.
Intubation: Intubate if indicated. Have the cricothyroidotomy and tracheotomy tray set up
prior to an initial attempt at intubation. Consider conscious sedation intubation if distortions
of the mandible and maxilla exist because a tight seal with the mask may not be possible
when bagging. Consider nasotracheal intubation if massive oropharyngeal edema is present.
Consider orotracheal intubation if midface or upper face trauma is present. If unable to

intubate the patient nasotracheally or endotracheally, cricothyroidotomy is the next

procedure of choice.
Breathing: Assess breath sounds. Check tube placement.
Circulation: Do not remove impaled foreign bodies that can result in worsening of damage
and bleeding. Control hemorrhage with direct pressure. Obtain large-bore intravenous
access bilaterally.
Disability: Assess the patient using the Glasgow coma scale. Perform a brief neurologic
examination. Note any change in mental status.
Exposure: Expose patients, but keep them warm. Remove all clothing and accessories.
Recover all avulsed hard and soft tissue, and transport them in damp gauze with no ice and
very little manual manipulation.
Medical and surgical therapy
General medical therapy: Administer oxygen and isotonic crystalloid fluids. Administer
packed red blood cells if the patient is bleeding excessively. Tetanus prophylaxis is indicated.
Antibiotics: For facial lacerations, use Kefzol. For oral cavity lacerations, use clindamycin. For
fractures communicating with the sinus, use amoxicillin. For fractures with dural tears or
cerebrospinal fluid leaks, use vancomycin and ceftazidime.
Pain management: Use oral medications for minor injuries and parenteral medications if the
patient cannot take oral medications (ie, nothing by mouth). For anti-inflammatory control,
use ibuprofen, naproxen, or ketorolac. For central control, use narcotics (eg, codeine,
oxycodone, hydrocodone, meperidine, morphine).
Frontal bone fractures
Of great concern is the patency of the nasofrontal duct. If this duct is blocked,
surgery is indicated. Blockage may result in mucopyocele or abscess. Nondisplaced anterior
sinus wall fractures are treated by observation. Displaced anterior sinus wall fractures with
severe comminution and mucosal injury require otolaryngology, plastic surgery, or oral
maxillofacial surgery for bone grafting and frontal sinus obliteration.
Treatment of posterior sinus wall fractures is controversial and variable. Posterior
sinus wall fractures are examined for displacement, dural tears, and cerebrospinal fluid
leakage. Nondisplaced fractures with a cerebrospinal fluid leak may be observed for 5-7 days
while undergoing treatment with intravenous antibiotics. Frontal sinus obliteration is
indicated if a cerebrospinal fluid leak persists. Surgical treatment of displaced fractures with
no cerebrospinal fluid leak is based on the severity of comminution. Mild comminution
requires an osteoblastic flap and sinus obliteration. Comminution of greater than 30% of the
posterior sinus wall requires the neurosurgeon to remove the posterior table allowing the
brain to expand into the frontal sinus, this is known as cranialization. Displaced sinus wall
fractures with a cerebrospinal fluid leak and minimal-to-mild comminution requires sinus
obliteration. Moderate-to-severe comminution requires sinus cranialization.
Orbital floor fractures
Blowout fractures of the orbital floor require consultation with an ophthalmologist and
maxillofacial trauma specialist (eg, otolaryngologist, oral and maxillofacial surgeon, or
plastic surgeon).
In a retrospective study, Salgarelli et al compared the aesthetic results,
complications, and surgical indications in 274 patients treated for orbital trauma (without
soft-tissue lacerations of the orbital region) via a subciliary (n = 219), transconjunctival (n =
32), or transconjunctival with lateral canthotomy (n = 23) approach. [3] Overall, 50 (18.2%)

patients had complications: 41 patients in the subciliary approach group, 1 patient in the
transconjunctival approach group, and 8 patients in the transconjunctival approach with
lateral canthotomy group -- the investigators also noted a higher rate of lower eyelid
malposition in patients with the last surgical approach. [3]
Salgarelli et al concluded that transconjunctival incision without canthotomy was the
most successful surgical approach for the treatment of isolated fracture of the orbital floor;
however, when major surgical exposure is necessary, subciliary incision is recommended. [3]
The indications and timing for fracture repair are debated; however, most literature
supports a 2-week window for repair. The following are indications for surgery: a large defect
in the orbital floor (>50%), enophthalmos (>2 mm) due to herniation of orbital contents into
the maxillary sinus, diplopia on upward/downward gaze due to muscle entrapment and
within 30 of primary gaze with a positive forced duction test, and CT scan confirmation of a
fracture.
Nasal fractures
Patients with nasal fractures are discharged home and sent for follow-up with an
otolaryngologist or plastic surgeon within 5-10 days, allowing time for resolution of the
profuse edema of the tissues surrounding the nose.
Nasoethmoidal fractures
Fractures with suspected or detected dural tears require consultation with a
neurosurgeon, and the patients should be admitted for observation and intravenous
antibiotics. An ophthalmologist should be consulted for repair of the lacrimal apparatus. An
oral and maxillofacial surgeon, plastic surgeon, or otolaryngologist should be consulted for
repair of nasal bones, medial canthus, and the nasofrontal duct.
Zygomatic arch fractures
Patients with isolated fractures to the zygomatic arch can be discharged home, with
follow-up from an otolaryngologist, an oral and maxillofacial surgeon, or a plastic surgeon if
the displacement is minimal. Marked displacement and/or impingement of the coronoid
process of the mandible requires open reduction.
Zygomaticomaxillary complex fractures
Consultations include an ophthalmologist and an otolaryngologist, plastic surgeon, or
oral and maxillofacial surgeon. The standard of care is open reduction and internal fixation
with miniplates and screws. The orbital floor frequently is explored and repaired if necessary.
Maxillary fractures
Consultations include an otolaryngologist, plastic surgeon, or oral and maxillofacial
surgeon. Open reduction and intermaxillary fixation should be performed to establish correct
occlusion, followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.
Mandibular fractures
Management is provided by an otolaryngologist, plastic surgeon, or oral and
maxillofacial surgeon. Temporary stabilization in the emergency department can be
addressed with the application of a Barton bandage. Wrap the bandage around the crown of
the head and jaw.
A symphysis or body fracture can be reduced temporarily with a bridal wire (a 24gauge wire wrapped around 2 teeth on either side of the fracture). This greatly helps control
hemorrhage and pain and prevents infection because these are open compound fractures.

Initially, the fracture is stabilized with intermaxillary fixation followed by open

reduction and rigid fixation using titanium miniplates, mandibular plates, or reconstruction
plates, depending on where the fracture is located. Nondisplaced fractures of the condyle
require intermaxillary fixation for 10 days, followed by physiotherapy to help restore
improved function. Ankylosis of the joint is extremely rare and is believed to be caused by an
untreated intracapsular injury or fracture.
Panfacial fractures
At the time of surgery, tracheostomy or submandibular intubation is required. A
submandibular intubation is performed by first intubating orally, and then surgically bringing
the tube out through the submandibular space. Nasoendotracheal intubation is definitely
contraindicated.
Facial bones are repositioned beginning at the cranium. After the occlusion is established by
intermaxillary fixation, the remaining facial bones are repaired with open reduction and
internal fixation.
Lab studies

CBC every 4 hours to follow hemoglobin and hematocrit when excessive bleeding
occurs
Sequential Multiple Analysis of 20 chemical constituents (SMA-20)
Blood type and cross match
Coagulation studies
Beta human chorionic gonadotropin (bhCG) studies

Imaging studies

Upper face: Study of choice is the axial and coronal CT scan. Alternative diagnostic
studies include a skull series and Waters view radiograph.
Middle face: Study of choice is the axial and coronal CT scan. Alternative diagnostic
studies include a Waters view radiograph and posteroanterior, submental vertex (jughandle), and occlusal views.
Lower face: Study of choice is a panographic x-ray. Alternative diagnostic studies
include a posteroanterior view, right and left lateral oblique view of the mandible,
elongated Towne projection radiograph, and occlusal views.
A CT scan of the condyle is indicated if a fracture is strongly suspected but
accompanying radiographic findings are negative.

Summary
The management of complex maxillofacial injuries sustained in modern warfare or
terrorist attack has presented military surgeons with a new form of injury pattern previously
not discussed in the medical literature. The unique wounding characteristics of the IED, the
portability of the weapon platform, and the relative low cost of development make it an ideal
weapon for potential terrorist attacks. If potential future terrorist attacks in the United States
follow the same pattern as the incidents currently unfolding in the Middle East, civilian
practitioners will be required to manage these wounds early for primary surgical intervention
and late for secondary and tertiary reconstructive efforts. The use of stereolithographic
models in presurgical planning of complex maxillofacial injuries is critical and should be
considered the standard of care. These models can be manufactured during the initial 48- to
72-hour period of serial debridement and surgical washouts. They are invaluable in
visualizing the bony architecture of the skeletal framework. if inadequate projection of the
soft tissue envelope is not maintained. The treating surgeon should not fall victim to the

mistake of rushing these patients to the operating room for definitive treatment before
gathering the appropriate preoperative data. Projection and support of the soft tissue
envelope is critical to the success of any surgical treatment initially performed. We also have
used this treatment protocol on civilian panfacial trauma casualties, such as victims of
automobile accidents or isolated gunshot wounds, and have found it to be successful.