Maxillofacial injuries Lectures - Copie.pptx

Presentation on maxillofacial trauma, emergency diagnosis and management.

1. Maxillofacial injuries Dr Philippe-Albert LINGO Emergency Medicine Resident 1st Year Supervised by Dr NCHOFFOR

2. Plan G eneralities Definition Interest Epidemiologic data Anatomic recall Injury Mechanisms Diagnosis : Clinical and radiologic Complications Emergency management Conclusion

3. Generalities Facial trauma or maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw as well as eye injuries. Facial injuries have the potential to cause disfigurement and loss of function; for example, blindness or difficulty moving the jaw can result.

4. Interest Facial injuries have the potential to cause disfigurement and loss of function; for example, blindness or difficulty moving the jaw can result. Although it is seldom life-threatening, facial trauma can also be deadly because it can cause severe bleeding or interference with the airway; thus a primary concern in treatment is ensuring that the airway is open and not threatened so that the patient can breathe

5. Epidemiology In most developed countries, violence from other people has replaced vehicle collisions as the main cause of maxillofacial trauma. Increased use of seat belts and airbags has been credited with a reduction in the incidence of maxillofacial trauma, but fractures of the mandible (the jawbone) are not decreased by these protective measures. Prevalence of 69.7% in Yaounde-Cameroon with males being affected the most and the main cause being RTA followed by interpersonal violence Generally Facial fractures occur with peak incidence between ages 20 and 40, and children under 12 have only 5–10% of all facial fractures. Most facial trauma in children involves lacerations and soft tissue injuries.

6. Anatomic R ecall Face = Anterior part of the head which extends from the superior margin of the forehead to the chin and from one ear to another . Face consists of skin, sensorial organs ( eye,nose,tongue , ear ), muscles, bones and teeth including vessels and cranial nerves It has a great role in body aesthetics , communication and expression of mood and emotions . The basic shape of the human face is determined by the underlying facial skeleton (i.e.  viscerocranium ), the  facial muscles  and the amount of subcutaneous tissue present.

7. Definition Most anterior part of the human head Parts and regions Superior : Frontal region , orbital region , temporal region Middle : Nasal region , infraorbital region , zygomatic region , auricular region Inferior : Oral region , mental region , buccal region , parotideomasseteric region Bones of face Paired bones : Nasal conchae , nasal bones , maxillae , palatine bones , lacrimal bones , zygomatic bones Unpaired bones : Mandible , vomer Muscles of face Buccolabial group:   Levator labii superioris , levator labii superioris alaeque nasi , risorius, levator anguli oris , zygomaticus major, zygomaticus minor , depressor labii inferioris , depressor anguli oris , mentalis , orbicularis oris and buccinator Nasal group:   Nasalis , procerus Orbital group:   Orbicularis oculi, corrugator supercilii , depressor supercilii Epicranial group:  Occipitofrontalis , platysma Auricular group :   Auricularis anterior , auricularis posterior , auricularis superior Function Communication, emotion expression, identity

8. Face muscles

9. Vasculature of the face

10. Mechanisms of Injury Direct blow or shock from a blunt object Direct blow from a sharp object This will lead to injuries such as   abrasions ,  lacerations ,  avulsions ,  bruises , burns and  cold injuries for soft tissues or fractures and dislocations for bones and articulations Commonly injured facial bones include the  nasal bone  (the nose), the  maxilla  (the bone that forms the upper jaw), and the  mandible  (the lower jaw). The mandible may be fractured at its symphysis , body, angle, ramus, and condyle .  The  zygoma  (cheekbone) and the  frontal bone  (forehead) are other sites for fractures .  Fractures may also occur in the bones of the palate and those that come together to form the orbit of the eye.

11. Diagnosis A- Clinical : History : context of trauma System review and exam: Bone injury : deformities , sweelling , bruising , asymetric movements of the face, sunken cheek bone , tooth avulsion, inability to move e.g limitation of mouth opening Skin and muscle injury : swelling , wound ( from abrasion to laceration or tear ), bleeding Vascular injury : exteriorised superficial bleeding Nerve injury : facial asymetry

12. Diagnosis B- Radiologic X-ray of face: show break in integrity of continuity of facial bon(e)s Limited by complexity of facial bones and soft tissues CT scan of face: Permits detection of fractures and soft tissue injuries Establishes clear indications of surgery limit:Too expensive

13. Diagnosis Lefort’s Radiologic Classification of Maxillofacial trauma: Lefort I :   they are horizontal maxillary fractures which   separate the maxilla from the palate .

14. Lefort II: Also called pyramidal fractures of the maxilla, these fractures cross the nasal bones and the orbital rim

15. Lefort III Most serious  They are also called craniofacial disjunction and transverse facial fractures,  they cross the front of the maxilla and involve the  lacrimal bone , the  lamina papyracea , and the  orbital floor , and often involve the  ethmoid bone .

16. Complications Airway osytruction from bleeding , swelling of surrounding tissues, damaged tissues and bone fragments Bleeding which may lead to hemorragic shock in about 1-11% of cases Aspiration of blood from face and mouth Disfigurement +/- emotional sequela Disability e.g limitation of mouth opening Eyesight compromise Infections from debris trapped in a wound or in case of bites Association with other traumas or polytrauma

17. Emergency Management Follows the A B C principle ; they are however aadapted to each clinical scenario due to the complexity of facial injuries and their possible association with cranial or cervical injuries A- Airway management: Main challenge in management of maxillofacial trauma Remove any solid or liquid material in the mouth and nose either manually or with a suction device Reduce and reposition any fracture that may interfere with airways Maintain airaway patency by canula or endotracheal tube In worst cases : surgical management for airway e.g cricothyrotomy or tracheostomy NB: Always anticipate the possibility of late airway obstruction

18. Algorithm of Airaway Management in Maxillofacial trauma

19. Emergency Management B- Bleeding Management Packing of nose bleeds or ballon tamponnade Drainage of any nasal septum haematoma Compressive dressing H emostatic suture of bleeding laceration C- Circulation Management: An IV (or 2) access must be obtained Fluid resuscitation beginning with NS may be done if bleeding is massive

20. Emergency Management Algorithm for Bleeding in Maxillofacial trauma

21. Emergency Management D – Wound Management Washing and debridement with clean water, NS and Povidone iodine Dressing Suture of lacerations Antitetanus toxoid and eventual Antitetanus immunization E- Pain control Analgesics pallier 1 and 2: paracetamol and tramadol preferably parenteral route . NSAIDs may also be used F - Cervical Spine Precaution Measures Taken if signs of sub-lesional syndrome or unconscious patient or extreme neck pain Done by cervical immobilization though C- Spine collar

22. Emergency Management G- F racture management Mainly as directed by Maxilofacial surgeon Non- surgical : careful manual reduction Surgical : metal plates and screws , bone grafts or wires The earlier the management the better the outcomes Monitoring: Vital signs : RR, HR, BP, Temp °, Conscience (GCS) , SaO2, coloration Patency of airways Level of pain control

23. Conclusion Maxillofacial injuries are public health issues due to their relatively increasing frequencies in context of increasing prevalence of road traffic accidents and insecurity with violent assaults in our community and country. Though most are not life- threatening , they do carry the vital risks mainly due to the potential of upper airway obstruction and possible injury of deep vessel injury leading to moderate or massive bleeding . Thus , early appropriate diagnosis and management is important to ensure better vital, functional and esthetic outcomes .

24. References Kenhub Anatomy and Physiology 2023 Perry M (March 2008). "Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 1: dilemmas in the management of the multiply injured patient with coexisting facial injuries".  International Journal of Oral and Maxillofacial Surgery .  37  (3): 209–14 Abena et al: An Injury Profile of Maxillofacial Trauma in Yaoundé: An Obsservational Study ; Journal of Dental Health and Oral Research Anson et al:Management of maxillofacial trauma in emergency: An update of challenges and controversies J Emerg Trauma Shock .  2016 Apr -Jun; 9(2): 73–80.

25. Thanks for your kind attention