Surgery chapters
Maxillofacial trauma
Airway and bleeding threats in facial injury, systematic examination, and the diagnosis and treatment of mandibular, zygomatic, Le Fort, orbital, naso-orbito-ethmoid, dental and facial soft tissue injuries.
- In facial injury the airway is the first threat: a fractured maxilla falls back and a comminuted anterior mandible lets the tongue fall back; sit the patient forward, clear, pull the tongue and maxilla forward, and intubate or perform a surgical airway if needed.
- Mandible fractures show as malocclusion and numb lower lip; zygomatic fractures as flat cheek, numb cheek and subconjunctival haemorrhage without a posterior limit; Le Fort fractures as a mobile maxilla and anterior open bite.
- Orbital blow-out causes upgaze limitation and enophthalmos; retrobulbar haemorrhage threatens sight and needs lateral canthotomy at once.
On this page
Overview
Facial injuries come from road crashes (especially motorcyclists without helmets), assaults, falls, sports and firearm or blast injuries. They look dramatic and bleed a lot, but the real dangers are airway obstruction, hidden bleeding, and associated head and cervical spine injuries.
Follow ATLS: airway with cervical spine protection, breathing, circulation, then the detailed facial examination.
Emergency care
Airway
Why the airway is at risk:
- A blow from the front drives the midface backwards and downwards along the skull base, narrowing the nasopharynx.
- A comminuted or bilateral anterior mandible fracture (for example both parasymphyseal regions) loses tongue support, so the tongue falls back.
- Blood, broken teeth, dentures and vomit block the pharynx.
- Soft palate and tongue swelling can close the airway a few hours after injury.
What to do:
- Sit the conscious patient up and forward, or lay the unconscious one semi-prone (if spine allows), so blood drains out of the mouth.
- Suction with good light; remove loose teeth and fragments.
- Disimpact the maxilla by hand (pull it forwards) and pull the tongue forward with a stitch or towel clip.
- Intubate early if obstruction threatens; if intubation fails, perform a surgical airway (cricothyroidotomy or tracheostomy).
Nasotracheal intubation and nasal tubes are relatively contraindicated in midface, frontal sinus, skull base and cribriform plate fractures. Pass gastric tubes orally.
Bleeding
- Severe bleeding comes from the nose and the pterygoid venous plexus in central midface fractures; it can be occult (swallowed).
- Control: secure the airway, then anterior and posterior nasal packs; inflatable nasal balloons or Foley catheters can be used. Reduction of the fracture also helps.
Dramatic facial wounds must not distract you from head, cervical spine, chest and abdominal injuries. Any patient with significant facial injury is managed as having a cervical spine injury.
Classification
The face is divided into thirds:
| Third | Extent | Main fractures |
|---|---|---|
| Upper | Above the level of the eye corners (canthi) | Frontal bone and frontal sinus |
| Middle | Canthi to the upper teeth | Central: naso-orbito-ethmoid (NOE) and Le Fort; lateral: zygomatic (cheekbone) complex |
| Lower | Mandible and lower teeth | Mandibular fractures |
The orbit is assessed separately. Craniofacial fractures involve both skull and facial bones; panfacial fractures involve all three levels and imply very high energy.
Examination
- History: mechanism, loss of consciousness, vision, bite, numbness.
- Inspect the whole scalp, face and back of the neck; record wound size, site and depth.
- Cranial nerves II, III, IV, V, VI and VII before any local anaesthetic or intubation.
- Eyes: acuity, pupils, movement in all directions, diplopia, globe position (proptosis or enophthalmos). Open swollen lids gently with cotton buds.
- Mouth: missing or loose teeth, mucosal tears, sublingual haematoma (mandible fracture), and occlusion: patients notice even small changes in their bite.
- Palpate systematically: supraorbital rims, infraorbital rims, zygomatic arches, condyles, lower border of the mandible; feel for steps, tenderness and asymmetry.
- Check midface mobility: hold the upper teeth and gently rock the maxilla.
Investigations
- CT with fine cuts is now the standard for most facial fractures.
- Isolated mandible fracture: two views at right angles: orthopantomogram (OPG) and PA mandible.
- Chest X-ray if teeth or fragments are unaccounted for (aspiration).
Mandibular fractures
Common sites (Bailey & Love): the condylar neck is the commonest, then the angle (through the last molar or a wisdom tooth), then the canine region (long canine root weakens the bone).
Some books name the angle as the commonest site. In a single-best-answer question, the condylar neck is Bailey & Love's answer. A blow to the chin often breaks the chin region on one side and the condyle on the other: always look for a second fracture.
Features:
- Pain, swelling, difficulty opening or closing the mouth
- Deranged occlusion (the key sign)
- Step in the teeth line or lower border, gum tear, sublingual haematoma
- Numb lower lip and chin (inferior alveolar nerve, ending as the mental nerve)
- Bleeding into the mouth (mandible fractures through teeth are open (compound) fractures)
Treatment:
- Principles: reduce, fix, immobilise, rehabilitate.
- Open reduction and internal fixation (ORIF) with titanium miniplates and monocortical screws is now standard; larger reconstruction plates for comminuted fractures.
- Intermaxillary fixation (IMF), wiring the teeth together, is used less often now; undisplaced condylar fractures may be treated with soft diet or elastic IMF.
- Ideally treat within 24–48 hours; give antibiotics for open fractures.
- Healing takes about 4 weeks; soft diet meanwhile.
Zygomatic (zygomatico-orbital) complex fractures
- The commonest facial fracture (Bailey & Love). The cheekbone is like a four-legged stool: the zygomatic arch, the frontozygomatic suture, the infraorbital rim and the zygomatic (maxillary) buttress. Most fractures break all four legs ("tripod/tetrapod" fracture).
Features:
- Flattened cheek (often hidden by swelling at first), periorbital bruising
- Subconjunctival haemorrhage with no posterior limit
- Numbness of the cheek, side of nose and upper lip (infraorbital nerve)
- Step at the infraorbital rim or frontozygomatic suture
- Diplopia and globe displacement (the orbit is involved)
- Trismus when a depressed arch presses on the coronoid process
Investigation: CT. Treatment: ORIF at one or more of the four "legs", usually within about 10 days; isolated arch fractures can be elevated.
Maxillary (Le Fort) fractures
Le Fort described three levels in cadavers; in practice fractures are often mixed and comminuted.
| Type | Level | Line of fracture | Clinical clue |
|---|---|---|---|
| Le Fort I (low, horizontal) | Above the teeth roots | Through the lower maxilla, floor of nose and lower part of pterygoid plates; tooth-bearing segment separates | "Floating palate": upper teeth and palate move together |
| Le Fort II (pyramidal) | Mid-level | Through the nasal bones, frontal process of maxilla, medial orbital wall and orbital floor, infraorbital rim, down the maxilla to the pterygoid plates | Nose and maxilla move together; infraorbital numbness; CSF leak possible |
| Le Fort III (craniofacial dysjunction) | High | Through the nasal root, medial and lateral orbital walls, frontozygomatic sutures and zygomatic arches; the whole face separates from the skull base | "Dish face", whole midface moves; CSF rhinorrhoea common |
Shared features: marked facial swelling, mobile maxilla, backward and downward displacement causing an anterior open bite (front teeth cannot meet), bilateral periorbital bruising ("raccoon eyes") in higher fractures, and airway risk.
Treatment: ORIF with mini- and microplates along the facial buttresses, after the patient is stable.
A Le Fort fracture means high energy: look for brain, cervical spine and other injuries. Bleeding from the pterygoid plexus may be hidden.
Le Fort numbers go up the face: I is lowest (palate), II is the pyramid (nose), III takes the whole face off the skull.
Orbital fractures
- The orbital floor breaks most often, then the medial wall, lateral wall and roof.
- Blow-out fracture: a sudden rise in orbital pressure (fist, ball) bursts the thin floor or medial wall while the rim stays intact.
Features of floor fracture:
- Diplopia, especially on upgaze (orbital fat or the inferior rectus/inferior oblique trapped)
- Enophthalmos and a lower globe (hypoglobus), often hidden by swelling at first
- Numb cheek (infraorbital nerve runs in the floor)
- CT: herniation of orbital contents into the maxillary sinus
Management: most are repaired after 7–10 days once swelling settles, using bone grafts or titanium implants.
In children, a "trapdoor" floor fracture can snap shut on the inferior rectus with an almost normal-looking CT. This is an emergency because the muscle can die; operate early.
Binocular diplopia = muscle or movement problem. Monocular diplopia = problem inside the globe (lens dislocation, retinal detachment).
Retrobulbar haemorrhage
- Bleeding behind the globe raises orbital pressure and can cause blindness.
- Signs: increasing pain, tense proptosis, falling visual acuity, loss of pupil response.
- Treatment: urgent lateral canthotomy and cantholysis at the bedside; medical support with acetazolamide, mannitol and steroids. Treat before CT if suspected.
Naso-orbito-ethmoid (NOE) and craniofacial fractures
- Blow to the bridge of the nose. Flattened nasal bridge, upturned tip, periorbital bruising, nosebleed.
- Traumatic telecanthus (wide gap between the eyes) from displacement of the medial canthal attachment.
- Look for a septal haematoma and CSF leak.
- CSF rhinorrhoea: clear or salty nasal fluid from a dural tear (often the posterior wall of the frontal sinus or the ethmoid roof). Bailey & Love notes antibiotics are not indicated; most surgeons repair leaks persisting about 10 days.
- CT; repair usually after 7–10 days with ORIF and canthopexy.
Dental injuries
- Primary teeth are fully erupted by about 2.5 years; the first permanent teeth appear at about 6 years.
- Avulsed permanent tooth: rinse gently in saline and reimplant as quickly as possible, then splint and refer to a dentist. Do not reimplant primary (milk) teeth.
- Fractures through enamel, dentine or pulp; exposed dentine or pulp is very painful and needs urgent dental care.
- Account for every missing tooth; if not found, get a chest X-ray to exclude aspiration.
Facial soft tissue injuries
- Excellent blood supply: wounds heal well, so debride only clearly dead tissue.
- Scrub out ground-in dirt early to prevent traumatic tattooing.
- Close in layers; take special care at the eyelid margin and lip vermilion border.
- Parotid duct: saliva in the wound; often with injury to the buccal branch of the facial nerve; repair over a cannula.
- Facial nerve: test before local anaesthetic; Bailey & Love advises primary repair under magnification for cuts lying behind a line joining the lateral canthus to the angle of the mouth; branches in front of it are small and recover better.
- Facial bites (animal or human): debride and close primarily (unlike bites elsewhere), with antibiotics.
Expect: airway management in facial trauma with stridor (intubation or a surgical airway), why nasal tubes are avoided, commonest facial fracture and commonest mandible fracture site, signs of mandibular and zygomatic fractures (malocclusion, numb lip, numb cheek, subconjunctival haemorrhage without a posterior limit), Le Fort levels, signs and emergencies of orbital floor fracture, retrobulbar haemorrhage treatment, CSF rhinorrhoea, reimplantation of avulsed teeth, and repair of parotid duct and facial nerve.
Quick revision
- Airway first: sit forward, suction, pull maxilla and tongue forward, intubate or cut a surgical airway.
- Facial injury = assume C-spine injury; no nasal tubes if skull base fracture possible.
- Commonest facial fracture: zygomatic complex. Commonest mandible site: condylar neck (Bailey & Love).
- Mandible: malocclusion, sublingual haematoma, numb lower lip; ORIF with miniplates.
- Zygoma: flat cheek, numb cheek, subconjunctival haemorrhage without posterior limit, trismus.
- Le Fort I palate, II pyramid, III craniofacial dysjunction; mobile maxilla, open bite.
- Orbital floor: upgaze diplopia, enophthalmos; child trapdoor = emergency.
- Retrobulbar haemorrhage: lateral canthotomy now.
- Avulsed adult tooth: reimplant; milk tooth: do not.
Written by The House Job from standard references (Bailey & Love's Short Practice of Surgery, 27th edition; ATLS Student Course Manual, 10th edition).
FAQ
Why can a Le Fort fracture block the airway?
The broken midface slides backwards and downwards along the skull base, narrowing the nasopharynx, and swelling, blood and an unsupported tongue add to the obstruction.
What is the commonest site of a mandibular fracture?
Bailey & Love gives the condylar neck as the commonest site, followed by the angle and the canine region; always look for a second fracture.
What does subconjunctival haemorrhage without a posterior border mean?
Blood tracking forward from a fracture of the orbital wall, typical of a zygomatic complex fracture.
What is the emergency treatment of retrobulbar haemorrhage?
Immediate lateral canthotomy and cantholysis to relieve orbital pressure, supported by acetazolamide, mannitol and steroids, without waiting for a scan.