Comprehensive Management of Maxillofacial Injuries: From Prehospital Care to Surgical Interventions

• 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.
• Intub ation: Intubate, if indicated. Have the cricothyroidotomy and tracheotomy tray set up before 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 nasotracheal 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.

“Temporary Measures For Facial Bleeding Control”

Read And Learn More: Maxillofacial Fractures, Disorders, and Treatments

Medical And Surgical Therapy

• Generalmedical therapy: Administeroxygenand, isotonicity stalled flids.
  Administer packed red blood cells if the patient is bleeding excessively. Tetanus prophylaxis is indicated.
• Antibiotics: For facial lacerations, use cefazolin (Ancef,Kefzol).
  • For oral cavity lacerations, use clindamycin or penicillin.
  • For fractures communicating with the sinus, use amoxicillin. For fractures with dural tears or CSF leaks, use vancomycin and a third-generation cephalosporin.
• Pain management: Use oral medications for minor injuries and parenteral medications if the patient cannot take oral medications (i.e., anything by mouth [NPO]).
  For antiinflammatory control, use ibuprofen, naproxen, or ketorolac (Toradol). For central control, use narcotics (e.g., codeine, oxycodone, hydrocodone, meperidine, morphine).

“Reconstructive Surgery Options For Facial Trauma”

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 mucocele or abscess.
• Non-displaced anterior sinus wall fractures are treated by observation.
• Displaced anterior sinus wall fractures with severe comminution and mucosal injury require neurosurgery, oral and maxillofacial surgery, otolaryngology, or plastic 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.
• Non-displaced 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 osteoblastic flu 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 require sinus obliteration.
• Moderate-to-severe comminution requires sinus cranialization.

“Open Reduction Internal Fixation For Mandibular Fractures”

Orbital Floor Fractures

• Blow-out fractures of the orbital floor require consultation with an ophthalmologist and maxillofacial trauma specialist (e.g., oral and maxillofacial surgeon, otolaryngologist, or plastic surgeon).
• Several approaches are available including subsidiary, subtarsal, transconjunctival, and transconjunctival with lateral canthotomy. The subsidiary approach has the most complications (e.g., ectropion), and the transconjunctival approach has the least complications.
• However, when major surgical exposure is necessary, a transconjunctival approach with or without a lateral canthotomy incision is recommended.
• Orbital flor repair via sub-tarsal approach.

• Nasal fractures should be managed between days 2–10.
• This allows time for the resolution of the edema and therefore assists in obtaining the best reduction possible.
• After 10 days, achieving good closed reduction results may be difficult and it may be necessary to wait for as long as 6 months to obtain satisfactory good results via an open reduction technique.

• 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 if disrupted.
• An oral and maxillofacial surgeon, plastic surgeon, or otolaryngologist should be consulted for the repair of nasal bones, medial canthus, and the nasofrontal duct.

Zygomatic Arch Fractures

• Patients with isolated minimally displaced fractures to the zygomatic arch usually do not require treatment, unless it caused a facial asymmetry.
• Marked displacement and/or impingement ofthe coronoid process of the mandible, preventing the patient from opening their mouth, requires admission and an open reduction via transoral (Keen) or temporal (Gillies) approach.
• In cases of a severe comminuted fracture, an open reduction with internal fixation (ORIF) may be required.

• When the impact is sufficient to sustain a fracture of the ZMC consultation with an ophthalmologist is warranted to rule out ocular injury. Like the zygomatic arch fracture, surgical treatment of a ZMC fracture is indicated when a cosmetic deformity or functional loss is noted.
• Waiting 4–5 days for the edema to be reduced is helpful to properly assess the situation.
• The standard of care is open reduction and internal fixation with mini plates and screws. The orbital floor is frequently explored and repaired, if necessary.

• When the impact is severe enough to cause mobility of the maxilla or to a part of it, the patient should be placed in intermaxillary fixation and open reduction with internal fixation should be performed at the piriform rim and zygomaticomaxillary buttress.
• Patients with a maxillary fracture should be placed on sinus precautions, and if they have subcutaneous emphysema, they should be placed on antibiotics because some of the bacterial flares could have been forced by the air into the subcutaneous planes.

“Evidence-Based Guidelines For Maxillofacial Fracture Repair”

Mandibular Fractures

• Management is provided by an oral and maxillofacial surgeon, otolaryngologist or plastic surgeon.
• Temporary stabilization in the emergency department can be addressed with the application of a Barton bandage.
• Bring the teeth into occlusion and wrap the bandage around the crown of the head and jaw. This stabilizes the jaw and greatly reduces pain and hemorrhage.
• A symphysis or body fracture can be reduced temporarily with a bridal wire (a 24-gauge wire wrapped around 2 teeth on either side of the fracture). This greatly reduces hemorrhage, pain and infection.
• Nondisplaced mandibular fractures may be treated by closed reduction and intermaxillary fixation for 5–6 weeks.
• However many patients do not want to be closed down for that length of time and prefer open reduction.
• Initially, the fracture is stabilized with intermaxillary fixation followed by open reduction and rigid fixation using
• titanium mini plates, 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.

“Emergency Maxillofacial Care In Rural Areas”

Panfacial Fractures

• At the time of surgery, tracheostomy or submandibular intubation is required.
• A submandibular intubation, which avoids a tracheostomy, is performed by first intubating orally, and then surgically bringing the tube out through the submandibular space.
• Nasoendotracheal intubation is 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.