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Maxillo-facial injuries

The maxilla is bounded by the base of the cranium above and the dental occlusal plane below. Its proximity to the oral cavity, the nasal cavity and the orbits makes it very important from both a cosmetic and functional perspective.

Maxillary fractures usually result from high energy blunt force. This may be a road traffic accident, an assault or an industrial or sporting injury.

Epidemiology: Seat belts in cars appear to have reduced chest injuries at the expense of facial injuries but possibly because more people survive to have their facial injuries repaired. The relative contribution of road traffic accidents, assaults, especially with alcohol as an aggravating factor, sports injuries, industrial accidents and firearms injuries varies enormously between different countries.

Classification: In 1901 a Frenchman called René Le Fort published his work on inflicting trauma on cadavers and noting the types of injury from various directions of force. The Le Fort classification is still the basis of nomenclature although experts complain that it is too simplistic and some injuries are not within the Le Fort classification.

Le Fort I: Le Fort I is a horizontal fracture that may result from a force directed low on the maxillary alveolar rim in a downward direction. The fracture starts at the nasal septum and travels horizontally above the teeth, crossing below the zygomaticomaxillary junction, and crosses the pterygomaxillary junction to fracture the pterygoid plates.

Le Fort II: Le Fort II fractures are pyramidal in shape. They may result from a blow to the lower or mid maxilla. The fracture extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus. It then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates.

Le Fort III: Le Fort III fractures are transverse, also called craniofacial dysjunctions. They may follow a blow to the nasal bridge or upper maxilla. They start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the ethmoid bones. The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. The fracture continues along the floor of the orbit and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. In the nose, a branch of the fracture extends through the base of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid.

In reality, fractures may be a combination of Le Fort fractures or deviate from the described lines. Muscles attached to the maxilla tend to have the other end to skin and therefore do not contribute to distortion at the fracture as with most other parts of the body.

History: Try to obtain an idea of the degree of force and its direction and other information such as loss of consciousness that may lead to other concerns. Ask about problems with airways, sight, hearing or dental occlusion.

Examination: It may be necessary to postpone examination of the maxilla and facial bones until after matters such as airways and head injury have been addressed.

The shape and structure of the face is often obscured by soft tissue swelling, bruising, blood, and haematoma. Simple observation may still be valuable. Localized areas of swelling or haematoma may overlie a fracture. Periorbital swelling may indicate Le Fort II or III fractures. A posterior retrusion of the mid face creates a flattened appearance called a dish-face or pan-face deformity. It may occur after a large Le Fort II or Le Fort III fracture. The maxillary segment is displaced backwards and downwards. This may cause premature contact of the molar teeth, with an anterior open bite deformity. In severe cases, the upper airway may be impaired. It may even be necessary to disimpact the nasal floor and hard palate to pull the bony segment forward to restore the airway.

Palpate the face and cranium for any bony irregularities, steps, crepitus or sensory loss. Examine the nose and mouth. The nasal bones are typically quite mobile in Le Fort II fractures, along with the rest of the pyramidal free-floating segment. There may be fresh or old blood in the nose, septal haematoma, or CSF rhinorrhoea. Examine the mouth for dental occlusion, overall dentition, stability of the alveolar ridge and palate, and soft tissue.

Check the integrity of the orbital rims, orbital floor, vision, extraocular motion, position of the globe, and intercanthal distance. Le Fort III fractures have lateral rim and zygomatic breaks. Visual changes may suggest damage to the optic canal, problems within the globe or retina, or other neurological problems. Impaired eye movement or enophthalmos may signify a blowout in the orbital floor. An increased intercanthal distance implies displacement of the frontomaxillary or lacrimal bones or avulsion of the medial canthal ligament.

Early photographs may be helpful both to plan treatment and to counsel the patient.

Investigations:

• Plain x-ray is the first investigation. They include submental vertical views and lateral films, including checking the cervical spine. Sinus films include the zygomatic arch and nasal bones. It is important to compare films from different directions to get an idea of 3-dimensional anatomy and distortion.
• The advent of CT has greatly improved the imaging of injuries .They give far more detail than plain films and help with planning treatment.

Management:

• The first part of management is to ascertain that the airway is adequate and to attend to any neurological features. If there is difficulty securing the airway it may be necessary to disimpact fractures. If this cannot be achieved then tracheostomy may be required.
• Surgical treatment is based on trying to trying to correct anatomical abnormalities and fixing unstable parts to fixed parts. Normal dental occlusion and masticatory function are important aims. Maxillo-mandibular fixation (MMF) may be required and so nasogastric feeding will be required during this period. The technical details of operative fixation are not considered here but may be found in the Internet section at the end. Fixation plates or suspension wires may be used. Skin closure in 2 layers gives the best cosmetic results.
• The goals of surgery are:¹
  • Obliteration of any defect
  • Restoration of such functions as mastication and speech
  • Adequate structural support of the facial unit
  • Aesthetic reconstruction of external features
• Skin sutures are removed at about 5 days but it is 3 to 8 weeks before the MMF is removed. This requires a liquid or puréed diet to give adequate calories, protein and vitamins to aid healing.

Complications:

• "Before and after" pictures tend to show remarkably good results but there are many opportunities for adverse events. Adherence to protocols improves outcome.²
• Incisions in the mouth may dehisce in part or completely, especially if poor oral hygiene permits infection.
• Neurovascular bundles may have been damaged in the incident but care must be taken at operation when flaps are raised. The supraorital nerve, the infraorbital nerve and the frontal branch of the facial nerve are all at risk.
• Extensive soft tissue injury, haematoma, open fractures and comminuted fractures all predispose to subsequent infection.
• Malunion is commoner than non-union but bone grafts may be required.
• Early and meticulous surgery offers a better prospect of good functional and cosmetic result.³ Early firm fixation allow the MMF to be removed at an earlier stage but less rigid fixation permits adjustment to improve the anatomical alignment is necessary. Rigid fixation is better but only if correct alignment is achieved at the outset.¹

Prevention: Airbags and non-lacerating windscreens in cars are thought to reduce facial injuries.² Better airbags can reduce injuries from the bags but wearing of seatbelts is essential.³ Gumshields in sport are thought to reduce injuries but there is lack of information about the best type for particular sports.¹

References:

1. Muzaffar AR, Adams WP Jr, Hartog JM, et al; Maxillary reconstruction: functional and aesthetic considerations.;Plast Reconstr Surg. 1999 Dec;104(7):2172-83; quiz 2184.[abstract]
2. Markowitz BL, Manson PN; Panfacial fractures: organization of treatment.;Clin Plast Surg. 1989 Jan;16(1):105-14.[abstract]
3. Marciani RD, Gonty AA; Principles of management of complex craniofacial trauma.;J Oral Maxillofac Surg. 1993 May;51(5):535-42.[abstract]
4. Duckert LG; Management of middle third facial fractures.;Otolaryngol Clin North Am. 1991 Feb;24(1):103-18.[abstract]
5. Karlson TA; The incidence of hospital-treated facial injuries from vehicles.;J Trauma. 1982 Apr;22(4):303-10.[abstract]
6. Brookes CN; Maxillofacial and ocular injuries in motor vehicle crashes.;Ann R Coll Surg Engl. 2004 May;86(3):149-55.[abstract]
7. Patrick DG, van Noort R, Found MS; Scale of protection and the various types of sports mouthguard.;Br J Sports Med. 2005 May;39(5):278-81.[abstract]

Internet:

• Kim DW Facial trauma; maxillary and Le Fort fractures; eMedicine; January 2005
• Garza JR Facial trauma; sports related injury; eMedicine; October 2004
• Lee S Facial soft tissue trauma; eMedicine; October 2004
• www.savingfaces.co.uk/ Facial surgery research foundation

History: Hippocrates described a variety of facial injuries around 400 BC. René Le Fort was a French surgeon who was born in 1869 and died in 1951. He studied the results of trauma on cadavers and published his seminal paper in 1901 in which he described 3 basic types of fracture. Endotracheal anaesthesia and radiology were developed during the First World War and led to a better understanding and treatment of facial fractures.

During the Second World War, a multidisciplinary approach to treatment of facial fractures continued to improve the outcomes of severely injured servicemen. The introduction of CT along with reconstruction of facial bones and new surgical techniques dramatically improved the final appearance of patients with bony injuries.

During the early 20th century, Sir Harold Gilles, who is regarded as the father of plastic surgery, taught army personnel about breathing problems in patients with facial injuries and to place them supine to maintain an airway. We now call it the recovery position.

Acknowledgements EMIS is grateful to the Mentor authoring team for writing this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2006.

Last issued 05 Jul 2006