26. Maxillofacial injuries

1. Definition

• Maxillofacial injuries → injuries of the soft tissues and bones of the face, jaws, teeth and oral cavity
• Causes → road traffic accidents, assault, falls, sports, gunshot
• Associated injuries → head injury, cervical spine injury (up to 10%), eye injury

2. Classification

By skin and mucosa integrity

• Closed → contusion, haematoma, closed fractures
• Open → wounds of the face, open fractures (all fractures through teeth-bearing bone are open into the mouth)

By tissue

• Soft tissue injuries
• Dental and alveolar injuries
• Bone injuries:
  • Mandible
  • Midface → maxilla (Le Fort), zygoma, nasal bones, naso-orbito-ethmoid complex
  • Orbit
  • Frontal sinus
• Combined

3. Pathogenesis

• Face → rich blood supply; heavy bleeding, fast healing, low infection rate
• Mandible → U-shaped bone; weak points fracture, often 2 fractures (ring principle)
• Midface → buttresses absorb force; protect brain and orbit
• Muscle pull → displaces fragments (masseter, pterygoids, suprahyoid muscles)

4. Clinical picture

Soft tissue injuries

• Heavy bleeding, swelling, early oedema
• Wounds of lips, eyelids, nose, ears
• Facial nerve injury → weakness of facial muscles; repair if lateral to the lateral canthus
• Parotid (Stensen's) duct injury → line from tragus to mid upper lip; saliva leak

Mandible fractures

• Sites → condyle, angle, body, symphysis, ramus, coronoid
• Signs:
  • Malocclusion → teeth do not meet normally
  • Step deformity, abnormal mobility, crepitus
  • Sublingual haematoma → pathognomonic of mandible fracture
  • Numb lower lip and chin → inferior alveolar nerve
  • Trismus, pain on chewing
  • Bilateral condyle fractures → anterior open bite
• Bilateral body fractures → tongue falls back, airway obstruction

Midface fractures (Le Fort)

1. Le Fort I → horizontal, above the teeth roots; mobile tooth-bearing maxilla (floating palate)
2. Le Fort II → pyramidal, through nasal bones, medial orbit, infraorbital rim; mobile nose and maxilla
3. Le Fort III → craniofacial dysjunction through zygomatic arches and orbits; whole midface mobile
4. Signs → dish face (flattened midface), periorbital oedema, bilateral black eyes, malocclusion
5. Cerebrospinal fluid (CSF) rhinorrhoea → Le Fort II and III, anterior cranial fossa fracture

Zygomatic complex fracture

• Flattened cheek, step in the infraorbital rim
• Infraorbital nerve numbness (cheek, upper lip)
• Trismus → depressed arch presses on coronoid process
• Subconjunctival haemorrhage without posterior limit

Orbital blow-out fracture

• Orbital floor fracture with entrapment of inferior rectus
• Diplopia on upward gaze, enophthalmos, infraorbital numbness

Nasal fractures

• Deformity, epistaxis
• Septal haematoma → drain urgently; otherwise septal necrosis and saddle nose

5. Diagnosis

• Inspection and palpation → symmetry, steps, occlusion, mobility, sensation, eye movements
• CT of the face with 3D reconstruction → standard for midface and orbit
• Orthopantomogram (OPG) and posteroanterior mandible view → mandible fractures
• CT of head and cervical spine

6. Treatment

Emergency (ATLS)

• Airway → clear blood, teeth, dentures; pull tongue forward; jaw thrust
• Intubation or surgical airway (cricothyroidotomy, tracheostomy) when needed
• Cervical spine protection
• Haemorrhage control → pressure, packing (anterior and posterior nasal packs), ligation, embolisation
• Exclude head injury, eye injury

Soft tissue

• Irrigation, minimal debridement → face tolerates delay up to 24 h
• Primary closure in layers; align landmarks first (vermilion border, eyebrow, eyelid margin)
• Repair facial nerve and parotid duct primarily
• Tetanus prophylaxis, antibiotics for bites and open fractures

Fractures

• Timing → within days, after swelling settles; airway and life-threatening injuries first
• Open reduction and internal fixation (ORIF) with titanium miniplates → standard
• Intermaxillary fixation (IMF) → restores occlusion; wires or arch bars
• Condyle fractures → often conservative (soft diet, elastics) or ORIF
• Orbital floor → repair with plate or mesh for entrapment, enophthalmos
• Nasal fracture → closed reduction at 5–10 days

7. Complications

• Airway obstruction, aspiration
• Haemorrhage
• Infection, osteomyelitis of the mandible
• Malunion, non-union, malocclusion
• Diplopia, enophthalmos, blindness
• CSF leak, meningitis
• Facial nerve palsy, sensory loss
• Ankylosis of the temporomandibular joint
• Facial asymmetry, scarring