Facial trauma

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Facial trauma
Civil War facial wound.jpg
1865 illustration of a private injured in the American Civil War by a shell two years previously
Specialty Oral and maxillofacial surgery   OOjs UI icon edit-ltr-progressive.svg

Facial trauma, also called 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 trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures.

Contents

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. Depending on the type of facial injury, treatment may include bandaging and suturing of open wounds, administration of ice, antibiotics and pain killers, moving bones back into place, and surgery. When fractures are suspected, radiography is used for diagnosis. Treatment may also be necessary for other injuries such as traumatic brain injury, which commonly accompany severe facial trauma.

In developed countries, the leading cause of facial trauma used to be motor vehicle accidents, but this mechanism has been replaced by interpersonal violence; however auto accidents still predominate as the cause in developing countries and are still a major cause elsewhere. Thus prevention efforts include awareness campaigns to educate the public about safety measures such as seat belts and motorcycle helmets, and laws to prevent drunk and unsafe driving. Other causes of facial trauma include falls, industrial accidents, and sports injuries.

Signs and symptoms

Bruising, a common symptom in facial trauma Black eye 2.jpg
Bruising, a common symptom in facial trauma

Fractures of facial bones, like other fractures, may be associated with pain, bruising, and swelling of the surrounding tissues (such symptoms can occur in the absence of fractures as well). Fractures of the nose, base of the skull, or maxilla may be associated with profuse nosebleeds. [1] Nasal fractures may be associated with deformity of the nose, as well as swelling and bruising. [2] Deformity in the face, for example a sunken cheekbone or teeth which do not align properly, suggests the presence of fractures. Asymmetry can suggest facial fractures or damage to nerves. [3] People with mandibular fractures often have pain and difficulty opening their mouths and may have numbness in the lip and chin. [4] With Le Fort fractures, the midface may move relative to the rest of the face or skull. [5]

Cause

Injury mechanisms such as falls, assaults, sports injuries, and vehicle crashes are common causes of facial trauma in children [6] [4] as well as adults. [7] Blunt assaults, blows from fists or objects, are a common cause of facial injury. [8] [1] Facial trauma can also result from wartime injuries such as gunshots and blasts. Animal attacks and work-related injuries such as industrial accidents are other causes. [9] Vehicular trauma is one of the leading causes of facial injuries. Trauma commonly occurs when the face strikes a part of the vehicle's interior, such as the steering wheel. [10] In addition, airbags can cause corneal abrasions and lacerations (cuts) to the face when they deploy. [10]

Diagnosis

Left orbital floor fracture FractLeftOrbitFloorMark.png
Left orbital floor fracture

Radiography, imaging of tissues using X-rays, is used to rule out facial fractures. [2] Angiography (X-rays taken of the inside of blood vessels) can be used to locate the source of bleeding. [11] However the complex bones and tissues of the face can make it difficult to interpret plain radiographs; CT scanning is better for detecting fractures and examining soft tissues, and is often needed to determine whether surgery is necessary, but it is more expensive and difficult to obtain. [4] CT scanning is usually considered to be more definitive and better at detecting facial injuries than X-ray. [3] CT scanning is especially likely to be used in people with multiple injuries who need CT scans to assess for other injuries anyway. [12]

Classification

LeFort1e.png LeFort1a.png
Le Fort I fractures
LeFort2b.png LeFort2a.png
Le Fort II fractures
LeFort3b.png LeFort3a.png
Le Fort III fractures

Soft tissue injuries include abrasions, lacerations, avulsions, bruises, burns and cold injuries. [3]

The facial bones Human skull front bones.svg
The facial bones

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. [4] The zygoma (cheekbone) and the frontal bone (forehead) are other sites for fractures. [13] Fractures may also occur in the bones of the palate and those that come together to form the orbit of the eye.

At the beginning of the 20th century, René Le Fort mapped typical locations for facial fractures; these are now known as Le Fort I, II, and III fractures (right). [7] Le Fort I fractures, also called Guérin or horizontal maxillary fractures, [14] involve the maxilla, separating it from the palate. [15] Le Fort II fractures, also called pyramidal fractures of the maxilla, [16] cross the nasal bones and the orbital rim. [15] Le Fort III fractures, also called craniofacial disjunction and transverse facial fractures, [17] cross the front of the maxilla and involve the lacrimal bone, the lamina papyracea, and the orbital floor, and often involve the ethmoid bone, [15] are the most serious. [18] Le Fort fractures, which account for 10–20% of facial fractures, are often associated with other serious injuries. [15] Le Fort made his classifications based on work with cadaver skulls, and the classification system has been criticized as imprecise and simplistic since most midface fractures involve a combination of Le Fort fractures. [15] Although most facial fractures do not follow the patterns described by Le Fort precisely, the system is still used to categorize injuries. [5]

Prevention

Measures to reduce facial trauma include laws enforcing seat belt use and public education to increase awareness about the importance of seat belts [8] and motorcycle helmets. [9] Efforts to reduce drunk driving are other preventative measures; changes to laws and their enforcement have been proposed, as well as changes to societal attitudes toward the activity. [8] Information obtained from biomechanics studies can be used to design automobiles with a view toward preventing facial injuries. [7] While seat belts reduce the number and severity of facial injuries that occur in crashes, [8] airbags alone are not very effective at preventing the injuries. [3] In sports, safety devices including helmets have been found to reduce the risk of severe facial injury. [19] Additional attachments such as face guards may be added to sports helmets to prevent orofacial injury (injury to the mouth or face); [19] mouth guards also used. In addition to factors listed above, correction of dental features that are associated with receiving more dental trauma also helps, such as increased overjet, Class II malocclusions, or correction of detofacal deformities with small mandible [20] [21]

Treatment

Cas de traumatisme maxillo-facial 438 (7).jpg
Cas de traumatisme maxillo-facial 438 (9).jpg
Woman with a prosthesis for facial trauma, 1900-1950

An immediate need in treatment is to ensure that the airway is open and not threatened (for example by tissues or foreign objects), because airway compromisation can occur rapidly and insidiously, and is potentially deadly. [22] Material in the mouth that threatens the airway can be removed manually or using a suction tool for that purpose, and supplemental oxygen can be provided. [22] Facial fractures that threaten to interfere with the airway can be reduced by moving the bones back into place; this both reduces bleeding and moves the bone out of the way of the airway. Tracheal intubation (inserting a tube into the airway to assist breathing) may be difficult or impossible due to swelling. [1] Nasal intubation, inserting an endotracheal tube through the nose, may be contraindicated in the presence of facial trauma because if there is an undiscovered fracture at the base of the skull, the tube could be forced through it and into the brain. [1] If facial injuries prevent orotracheal or nasotracheal intubation, a surgical airway can be placed to provide an adequate airway. [1] Although cricothyrotomy and tracheostomy can secure an airway when other methods fail, they are used only as a last resort because of potential complications and the difficulty of the procedures. [4]

Sutures may be used to close wounds. Hamatom und Naht.jpg
Sutures may be used to close wounds.

A dressing can be placed over wounds to keep them clean and to facilitate healing, and antibiotics may be used in cases where infection is likely. [13] People with contaminated wounds who have not been immunized against tetanus within five years may be given a tetanus vaccination. [3] Lacerations may require stitches to stop bleeding and facilitate wound healing with as little scarring as possible. [4] Although it is not common for bleeding from the maxillofacial region to be profuse enough to be life-threatening, it is still necessary to control such bleeding. [23] Severe bleeding occurs as the result of facial trauma in 1–11% of patients, and the origin of this bleeding can be difficult to locate. [11] Nasal packing can be used to control nose bleeds and hematomas that may form on the septum between the nostrils. [2] Such hematomas need to be drained. [2] Mild nasal fractures need nothing more than ice and pain killers, while breaks with severe deformities or associated lacerations may need further treatment, such as moving the bones back into alignment and antibiotic treatment. [2]

Treatment aims to repair the face's natural bony architecture and to leave as little apparent trace of the injury as possible. [1] Fractures may be repaired with metal plates and screws commonly made from Titanium. [1] Resorbable materials are also available; these are biologically degraded and removed over time but there is no evidence supporting their use over conventional Titanium plates. [24] Fractures may also be wired into place. Bone grafting is another option to repair the bone's architecture, to fill out missing sections, and to provide structural support. [1] Medical literature suggests that early repair of facial injuries, within hours or days, results in better outcomes for function and appearance. [12]

Surgical specialists who commonly treat specific aspects of facial trauma are oral and maxillofacial surgeons, otolaryngologists, and plastic surgeons. [4] These surgeons are trained in the comprehensive management of trauma to the lower, middle and upper face and have to take written and oral board examinations covering the management of facial injuries.

Prognosis and complications

Diagram of lateral view of face showing the imaginary line between the tragus of the ear and the middle of the upper lip. The middle third of this line is the approximate location of the course of the parotid duct. If facial lacerations cross this line, there is a risk that the parotid duct is damaged. Trauma to parotid duct.jpg
Diagram of lateral view of face showing the imaginary line between the tragus of the ear and the middle of the upper lip. The middle third of this line is the approximate location of the course of the parotid duct. If facial lacerations cross this line, there is a risk that the parotid duct is damaged.

By itself, facial trauma rarely presents a threat to life; however it is often associated with dangerous injuries, and life-threatening complications such as blockage of the airway may occur. [4] The airway can be blocked due to bleeding, swelling of surrounding tissues, or damage to structures. [25] Burns to the face can cause swelling of tissues and thereby lead to airway blockage. [25] Broken bones such as combinations of nasal, maxillary, and mandibular fractures can interfere with the airway. [1] Blood from the face or mouth, if swallowed, can cause vomiting, which can itself present a threat to the airway because it has the potential to be aspirated. [26] Since airway problems can occur late after the initial injury, it is necessary for healthcare providers to monitor the airway regularly. [26]

Even when facial injuries are not life-threatening, they have the potential to cause disfigurement and disability, with long-term physical and emotional results. [7] Facial injuries can cause problems with eye, nose, or jaw function [1] and can threaten eyesight. [12] As early as 400 BC, Hippocrates is thought to have recorded a relationship between blunt facial trauma and blindness. [12] Injuries involving the eye or eyelid, such as retrobulbar hemorrhage, can threaten eyesight; however, blindness following facial trauma is not common. [27]

Incising wounds of the face may involve the parotid duct. This is more likely if the wound crosses a line drawn between the tragus of the ear to the upper lip. The approximate location of the course of the duct is the middle third of this line. [28]

Nerves and muscles may be trapped by broken bones; in these cases the bones need to be put back into their proper places quickly. [4] For example, fractures of the orbital floor or medial orbital wall of the eye can entrap the medial rectus or inferior rectus muscles. [29] In facial wounds, tear ducts and nerves of the face may be damaged. [3] Fractures of the frontal bone can interfere with the drainage of the frontal sinus and can cause sinusitis. [30]

Infection is another potential complication, for example when debris is ground into an abrasion and remains there. [4] Injuries resulting from bites carry a high infection risk. [3]

Epidemiology

As many as 50–70% of people who survive traffic accidents have facial trauma. [3] In most developed countries, violence from other people has replaced vehicle collisions as the main cause of maxillofacial trauma; however in many developing countries traffic accidents remain the major cause. [9] 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. [10] The risk of maxillofacial trauma is decreased by a factor of two with use of motorcycle helmets. [10] A decline in facial bone fractures due to vehicle accidents is thought to be due to seat belt and drunk driving laws, strictly enforced speed limits and use of airbags. [8] In vehicle accidents, drivers and front seat passengers are at highest risk for facial trauma. [10]

Facial fractures are distributed in a fairly normal curve by age, with a peak incidence occurring between ages 20 and 40, and children under 12 have only 5–10% of all facial fractures. [31] Most facial trauma in children involves lacerations and soft tissue injuries. [4] There are several reasons for the lower incidence of facial fractures in children: the face is smaller in relation to the rest of the head, children are less often in some situations associated with facial fractures such as occupational and motor vehicle hazards, there is a lower proportion of cortical bone to cancellous bone in children's faces, poorly developed sinuses make the bones stronger, and fat pads provide protection for the facial bones. [4]

Head and brain injuries are commonly associated with facial trauma, particularly that of the upper face; brain injury occurs in 15–48% of people with maxillofacial trauma. [32] Coexisting injuries can affect treatment of facial trauma; for example they may be emergent and need to be treated before facial injuries. [12] People with trauma above the level of the collar bones are considered to be at high risk for cervical spine injuries (spinal injuries in the neck) and special precautions must be taken to avoid movement of the spine, which could worsen a spinal injury. [26]

Related Research Articles

<span class="mw-page-title-main">Injury in humans</span> Physiological wound caused by an external source

An injury is any physiological damage to living tissue caused by immediate physical stress. Injuries to humans can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or overexertion. Injuries can occur in any part of the body, and different symptoms are associated with different injuries.

Oral and maxillofacial surgery is a surgical specialty focusing on reconstructive surgery of the face, facial trauma surgery, the mouth, head and neck, and jaws, as well as facial plastic surgery including cleft lip and cleft palate surgery.

<span class="mw-page-title-main">Orthognathic surgery</span> Surgery of the jaw

Orthognathic surgery, also known as corrective jaw surgery or simply jaw surgery, is surgery designed to correct conditions of the jaw and lower face related to structure, growth, airway issues including sleep apnea, TMJ disorders, malocclusion problems primarily arising from skeletal disharmonies, and other orthodontic dental bite problems that cannot be treated easily with braces, as well as the broad range of facial imbalances, disharmonies, asymmetries, and malproportions where correction may be considered to improve facial aesthetics and self-esteem.

<span class="mw-page-title-main">Dental extraction</span> Operation to remove a tooth

A dental extraction is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed. In orthodontics, if the teeth are crowded, healthy teeth may be extracted to create space so the rest of the teeth can be straightened.

<span class="mw-page-title-main">Skull fracture</span> Medical condition

A skull fracture is a break in one or more of the eight bones that form the cranial portion of the skull, usually occurring as a result of blunt force trauma. If the force of the impact is excessive, the bone may fracture at or near the site of the impact and cause damage to the underlying structures within the skull such as the membranes, blood vessels, and brain.

<span class="mw-page-title-main">Pericoronitis</span> Inflammation of the soft tissues surrounding the crown of a partially erupted tooth

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an operculum, an area which can be difficult to access with normal oral hygiene methods. The hyponym operculitis technically refers to inflammation of the operculum alone.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, and sports-related injuries, and are notably common among the elderly who experience falls.

A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source. Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency.

Cheek augmentation is a cosmetic surgical procedure that is intended to emphasize the cheeks on a person's face. To augment the cheeks, a plastic surgeon may place a solid implant over the cheekbone. Injections with the patients' own fat or a soft tissue filler, like Restylane, are also popular. Rarely, various cuts to the zygomatic bone (cheekbone) may be performed. Cheek augmentation is commonly combined with other procedures, such as a face lift or chin augmentation.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

<span class="mw-page-title-main">Le Fort fracture of skull</span> Type of head injury

The Le Fortfractures are a pattern of midface fractures originally described by the French surgeon, René Le Fort, in the early 1900s. He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning. Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat. Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.

<span class="mw-page-title-main">René Le Fort</span> French surgeon

René Le Fort was a French surgeon from Lille known for creating a classification for fractures of the face.

<span class="mw-page-title-main">Nasal fracture</span> Medical condition

A nasal fracture, commonly referred to as a broken nose, is a fracture of one of the bones of the nose. Symptoms may include bleeding, swelling, bruising, and an inability to breathe through the nose. They may be complicated by other facial fractures or a septal hematoma.

<span class="mw-page-title-main">Mandibular fracture</span> Medical condition

Mandibular fracture, also known as fracture of the jaw, is a break through the mandibular bone. In about 60% of cases the break occurs in two places. It may result in a decreased ability to fully open the mouth. Often the teeth will not feel properly aligned or there may be bleeding of the gums. Mandibular fractures occur most commonly among males in their 30s.

<span class="mw-page-title-main">Dental trauma</span> Medical condition

Dental trauma refers to trauma (injury) to the teeth and/or periodontium, and nearby soft tissues such as the lips, tongue, etc. The study of dental trauma is called dental traumatology.

<span class="mw-page-title-main">Dislocation of jaw</span> Medical condition

Dislocations occur when two bones that originally met at the joint detach. Dislocations should not be confused with subluxation. Subluxation is when the joint is still partially attached to the bone.

Osteomyelitis of the jaws is osteomyelitis which occurs in the bones of the jaws. Historically, osteomyelitis of the jaws was a common complication of odontogenic infection. Before the antibiotic era, it was frequently a fatal condition.

<span class="mw-page-title-main">Zygomaticomaxillary complex fracture</span> Medical condition

The zygomaticomaxillary complex fracture, also known as a quadripod fracture, quadramalar fracture, and formerly referred to as a tripod fracture or trimalar fracture, has four components, three of which are directly related to connections between the zygoma and the face, and the fourth being the orbital floor. Its specific locations are the lateral orbital wall, separation of the maxilla and zygoma at the anterior maxilla, the zygomatic arch, and the orbital floor near the infraorbital canal.

The hyoid bone fracture is a very rare fracture of the hyoid bone, accounting for 0.002% of all fractures in humans. It is commonly associated with strangulation and rarely occurs in isolation. The fracture may be associated with gunshot injury, car accidents or induced vomiting. In 50% of strangulations and 27% of hangings, hyoid fractures occur.

<span class="mw-page-title-main">Orbital emphysema</span> Medical condition

Orbital emphysema is a medical condition that refers to the trapping of air within the loose subcutaneous around the orbit that is generally characterized by sudden onset swelling and bruising at the impacted eye, with or without deterioration of vision, which the severity depends on the density of air trapped under the orbital soft tissue spaces.

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