Maxillofacial Trauma Management

Oral and Maxillofacial surgeons are uniquely qualified by training in Dentistry and the surgical arts to treat injuries to the facial bones and nearby structures. Throughout history, fractures of the jaw have been managed by dentists because they involve the bite and function of the teeth. Many methods of repairing fractures require the knowledge, experience, and capabilities of a dentist to reduce and stabilize jaw fractures. Our doctor is trained in the surgical arts to safely perform the newest techniques in repairing injuries to the face. Dr. Brindley is a contributing author to an internationally recognized textbook of Maxillofacial Trauma.

Injuries to the facial structures can occur for a variety of reasons:

Falls of all types

Work related injuries

Interpersonal violence involving blunt trauma and penetrating injuries.

Sports injuries

Explosions, bomb blasts, improvised explosive devices {IED}and artillery rounds.

Gun shot wounds

Traumatic injuries can involve both soft tissues and hard tissues. Patients seek treatment following traumatic injury at the emergency room or our office. Severe trauma is usually transported by EMS personnel to the hospital. Thorough initial evaluation is accomplished in the emergency department involving physical and radiographic examination. Following a period of stabilization and observation, definitive treatment is begun. Minor injuries can often be managed in the office as an outpatient procedure.

FACIAL LACERATIONS 

Despite the use of seat belts, lacerations are still common in facial trauma following motor vehicle accidents. Many uncomplicated lacerations are closed by the ER physicians on call. However, if the lacerations are extensive, involve other structures which must be repaired or are associated with underlying facial bone fractures, the repair of lacerations is accomplished as a part of our treatment. Our doctor has extensive experience and training in the management of facial laceration repair including complex lacerations involving inside the mouth and on the face. Proper attention is paid to details of wound cleaning and debridement before suturing begins. Wounds are closed with stitches reattaching the various layers of tissues. Care is taken to reattach muscles to avoid alterations in facial expression. The goal in soft tissue repair is to attempt to return the soft tissues to the functional and esthetic optimum before injury.

HARD TISSUE INJURIES OF THE FACE

The facial bones serve to hold the teeth and also serve to support and protect vital structures such as the eyes and brain from injury. Facial bones absorb much of the kinetic energy of impact, folding up like the bumper and front end of an automobile in a collision. The more severe the impact is, the more damage to the facial bones. The midface is comprised of two cheek bones {zygomas}, the upper jaw bone {maxillae} and nasal bones. A fracture of the cheekbone is called a ZMC fracture {zygomaticomaxillary complex fracture}and involves the zygoma, the maxillae, and Sphenoid bones. Fractures of the maxillae or midface are called Lefort fractures and are graded by the severity and height of the fracture lines on the face. A Lefort I fracture is a horizontal fracture above the teeth through the maxillary sinus. A Lefort II fracture{pyramidal fracture} angles in a pyramid fashion from the back of the upper jaw through the lower rims of the eyes and through the bridge of the nose. A Lefort III fracture{total facial disjunction} separates from the cheekbone arches through the rim of the eye near the outer eyebrow and terminates at the bridge of the nose. Generally, the higher the midfacial fracture the higher the energy of impact. It is also common for there to be combinations of these categories {Lefort I,II,III}which indicates total separation of all the bones of the midface. Disruption of the thin bone under the eye{orbital blow-out fracture} can result in the eye falling into the sinus below the eye. Signs of a midfacial fracture include inability to get the teeth to bite properly, motion in the face with biting or swallowing, copious bleeding from the nose, and facial asymmetry. There is often numbness of the teeth, upper lip and nose. The eyes often are black and blue, frequently swollen shut with red blood under the white of the eyes and exhibit double vision and inability to look upward.

Fractures of the lower jaw {mandible} frequently occur where it is weakest. The direction of impact also affects the stresses applied. The stalk below the joint {subcondylar} on either side is frequently broken in falls where a laceration of the chin exists. If the blow is to one side of the chin, the opposite neck of the head of the condyle{joint} is usually fractured. Leaving impacted teeth in the mouth without removing them weakens the angle of the jaw by displacing as much as 60% of the bony strength in the structurally weak “L” shaped angle. This translates into three times the risk of a fracture through the angle of the mandible if an impact occurs. The tooth bearing area of the jaw is also an area of frequent fracture. Signs of a lower jaw fracture include inability to bite normally, facial asymmetry, bleeding from the mouth, inability to open widely or straight, steps or gaps between the teeth, numbness of the lower lip and chin, and pain on biting.

Principles of repair facial bone fractures are the same as for other bones in the body. If bones are to heal, they must be held still with the fractured ends of the bones contacting each other. Bones in the extremities are often placed in a cast to hold them still for the 6 weeks it takes to heal. The head can’t be placed in a cast or the patient wouldn’t be able to breathe, see, or eat. Facial bones are repaired by anatomical realignment and stabilization in open or closed fashion using the teeth as a primary guide. Specialized brace-like devices are fastened to the upper and lower teeth and then the teeth are placed and held together with wires or rubber bands. Open procedures, usually done inside the mouth or through small minimally noticeable locations, expose and visualize the reduction of the fractures allowing for “rigid fixation” of the bone with plates and screws. Reattaching the facial fractures in this rigid fashion often allows for the mouth not to be wired shut, greatly improving the ease of recovery, a better diet, and early return to normal function.

DENTOALVEOLAR INJURIES 

Restoration or a normal smile following teeth being broken or knocked out is a cooperative effort involving the Oral and Maxillofacial surgeon, the Endodontist, and the patient’s restorative dentist. Injuries to soft tissues and bones when properly managed will heal quickly and predictably. However, injuries to teeth are usually more costly and take longer to repair. During the eruption of the incisors or front teeth, often they are spaced, protrude and are very prominent. Blows to the face frequently involve injuries to the incisors, knocking them out, displacing them, or fracturing the tooth itself. More severe blows can fracture the bone holding the teeth or segments of teeth causing them to be displaced. Incisors can be driven up into the bone through the socket {intrusion injury}, partial knocked out {subluxation or partial avulsion}, or totally knocked out {total avulsion}. The living tissue inside the tooth {dental pulp}often loses its blood supply following injuries and will require a root canal filling to prevent the tooth from abscessing. A specialized root canal may also be necessary in teeth knocked out of the mouth to help prevent the root of the tooth from melting away.

Teeth that are knocked completely out of the mouth should be found and placed in milk or salt water. If teeth are reimplanted and stabilized with bonding or wires within 24 hours of the accident, there is an excellent chance they will reattach. Reimplanted teeth with mature roots will require a root canal to remove the dead tissue inside the tooth to prevent the tooth from turning a dark color, abscessing, or the roots melting away. Reimplanted teeth can survive the rest of a person’s life or may be lost due to progressive root resorption. If the teeth survive into adulthood, they will maintain normal development of the alveolar ridge and allow for an esthetic implant replacement which would not have been an option during growth and development.