- The facio-maxillary injury is usually obvious clinically.
- Haemorrhage and upper airway obstruction are the most important aspects of
- Take out dentures.
- Loose teeth should be re-implanted ASAP
- Head down position.
- Maintenance of the airway with proper suction technique, particularly if the patient is
intubated. Keep the tube patent.
Examination Equipment Requested
- Oral/nasopharyngeal airway.
- Tongue suture
- Yankeur sucker
- Good lighting and an assistant for the examining Doctor.
- ENT tray for packing.
Intra oral examination requires a good light and two pairs of hands.
- Check for chest injures.
- Check patients overall clinical state - if shocked, then there are other injuries apart
from facio-maxillary trauma.
- Facio-maxillary injuries obscure other injures.
NO NOT FORGET TO LOOK FOR CONTACT LENSES.
Most common fracture site is the subcondylar region. It is a ring of
bone somewhat like the Pelvis, so if you see one fracture look for others elsewhere.
Isolated fractures of the subcondylar region are common and treated conservatively.
Other common sites
- Body of the Mandible - numb lower lip if nerve affected.
- Guardsmans Fracture - fracture of the chin and both condyles.
- Coronoid Fracture
- Usually associated with fracture of the Zygomatic arch.
- It is important, because if it is missed, can lead to a rigid trismus of the mouth some
months later. This is an anaesthetic hazard for corrective surgery.
- Fractures of edentureless mandible - bucket handle fracture are plated early because of
difficulty with eating. Can be repaired under local anaesthetic.
X-RAYS in two planes:
- Lateral oblique
- AP mandible including Odontoid Process
- OPG - Orthopantomogram - view of the whole mandible on one film.
PLATING - INTERNAL FIXATION - Patients can resume eating quite easily and can resume
work in two weeks.
INFECTION CONCERN - any fractures of the tooth bearing region should be admitted. Avoid
abscess formation, Osteomyelitis of the jaw. By admission to Hospital proper antibiotic
regime and oral hygiene can be given.
lateral middle third Zygomatic bone, i.e. cheek bone eminence.
- usually black eye (tense tissues)
- bleeding into white of eye.
- surgical emphysema around eyelids.
- numb upper lip, nose and teeth.
- diplopia (not always).
- sometimes the eye is dropped down and back if the orbital floor is blown out
- the malar prominence is flat.
- limited opening/closing of mouth if malar pushed back onto mandible.
- looked at from above the patient, it is flat.
- occipito mentals x 2.
- Lateral view shows opaque antrum, and a step is sometimes seen.
- X-rays are not essential for diagnosis.
Blow Out Fracture
- treated ten days to two weeks later when swelling has subsided.
- get Ophthalmology opinion also.
Middle Third Fracture
- Pushes face back and down the incline plane "Dish Face".
- Jacks the patients mouth open as far as it will go which can cause respiratory problems.
- Finger in the mouth, hooked behind the soft palate. Lift the middle face up and out and
then a naso-pharyngeal tube usually passed.
- The nasopharyngeal haematoma of the pre-vertebral fascia be careful and wary of this
when passing the tube.
- Facial views - OPG if available.
- R & L lateral oblique.
- AP of the jaws.
- Towns view for the Occiput (shows condyle very well).
- OM and lateral face views (same as for malar).
More useful than x-rays, take instead of x rays if high clinical suspicion.
Le Fort Fractures
Tested by putting hand under the occiput, fingers on the R & L molar teeth and NOT
on the palate.
Le Fort 1
- moves across the nasal base.
Le Fort 2
- moves through the cribiform plate (base of the brain) i.e. across the nasal bridge.
- Leaks C.S.F. rhinorrhoea (indicates a need for antibiotic cover).
- The C.S.F. leak dries up once the facial bones are repositioned.
Le Fort 3
- moves across the floor of the orbit and out the Zygomatic frontal suture, i.e. involves
the lateral aspect of the face. (Very rare as an isolated case.)
Marked swelling - dished in appearance.
- for surgical emphysema
- numbness sensory deficit
- facial lacerations
- the patients bite
- rhinorrhoea, otorrhoea
- bony tissues - orbits, zygomatic arches, nose, temporo-mandibular joints, mandible.
- Restore functional oral anatomy - talking, eating, swallowing
- Functional dental occlusion
- Normal jaw movement
- Normal facial contour restored
- Minimise and alleviate pain
- Minimise the need for secondary procedures.
Adapted from Box
Hill Emergency Manual