Trauma Maxillofacial

Epidemiologi

• Di USA kejadian trauma facial ada +/- 3 jt kasus

pertahun
• Hampir 40-50% trauma facial disebabkan kecelakaan
kendaraan bermotor
 Penyebab kematian

 Masalah airway
 Perdarahan hebat
 Adanya intracranial dan cervical-spine injury
 Meningitis
 Oropharyngeal infections
 Penanganan Trauma
• Jika terindikasi fraktur  rontgen
• Fraktur komplex  CT
 Penanganan Trauma
• Trauma jar lunak diperbaiki segera bila tidak ada
trauma lain
• Perbaikan jar lunak ditunda apabila ada trauma lain
yang harus ditanggulangi terlebih dahulu
 Initial Management

Step 1: Airway control

• Stabilisasi dengan c-spine
• Oxygen
• Posisikan pasien
• Suction dan bersihkan jalan nafas
 Initial Management

Step 1: Airway control

• Pada midfacial fracture  intubasi orotracheal
• Cricothyroidostomy jika intubasi Orotracheal tidak
bisa dilakukan
 Gangguan airway

• Blood in airway
• “Debris” in airway
• Vomitus, avulsed tissue, teeth or dentures, foreign bodies
• Pembengkakan Pharyngeal atau retropharyngeal
• Jatuhnya lidah ke bagian belakang karena fraktur
mandibula
 Initial Management

Step 2 : Bleeding control

• Penekanan secara langsung
• Hindari perdarahan ke arah belakang pharynx
• Facial bleeding  syok
 Secondary Survey

Scalp
• Cek lacerasi, hematoma, oedem, krepitasi, step pada
tulang
• Rembesan perdarahan
 Secondary Survey

Telinga
• Periksa dari luar  dalam
• Bila terhalang darah, bersihkan dan suction
• Cek “halo test”
• Periksa pendengaran
 Secondary Survey

Mata
• Periksa Pupil, ukuran,dan pergerakan bola mata
• Benda asing di konjungtiva
• Palpasi rima orbita
• Luka pada kelopak  expose kornea  artificial
tears
 Secondary Survey

Hidung
• Lihat septum nasal, hematom dan perdarahan
• Aliran udara di kedua lubang hidung
• Palpasi  krepitasi +/-
• Cek “halo test”
 Secondary Survey

Mulut
• Oklusi
• Reflek upper & lower lips
• Check Stenson's duct
• Palpasi mandibula and maxilla
 Secondary Survey
Pemeriksaan facial secara menyeluruh
• Simetri, deformitas, diskolorisasi, keesimetrisan hidung
• Palpasi semua tulang muka
 Fracture Classification

Major Minor
• Lefort I, II, III • Nasal
• Mandibular • Sinus wall
• Zygomatic
• Orbital floor
• Alveolar ridge
 Leforts

• Lefort I: maxilla only moves

• Lefort II: maxilla & base of nose move:
• Lefort III: whole face moves:
 Lefort I: Nasomaxillary

• Horizontal fracture
• Krepitasi maksila
• Ekimosis pada vestibulum
• Epistaxis: can be bilateral
• Malocclusion
• Floating maxilla
 Lefort I: Nasomaxillary

• Closed reduction
• Intermaxillary fixation: secures maxilla to mandible
• May need wiring or plating of maxillary wall and / or
zygomatic arch
 Lefort II: Pyramidal

• Fraktur midfacial subzygomatic dengan bentuk

piramida terpisah dari cranium dan aspek lateral
wajah
 Lefort II: Pyramidal

Signs & symptoms

• Midface crepitus
• Face lengthening
• Malocclusion
• Bilateral epistaxis
• Infraorbital paresthesia
• Ecchymoses: buccal vestibule, periorbital,
subconjunctival
 Lefort II: Pyramidal

• Hemorrhage or airway obstruction may require

emergent surgery
• Treatment can often be delayed till edema decreased
 Lefort II: Pyramidal

Usually require
• Intermaxillary fixation
• Interosseous wiring or plating of infraorbital rims,
nasal-frontal area, & lateral maxillary walls
 Lefort III

• Craniofacial disjunction
• Bilateral suprazygomatic fracture floating fragment
of mid-facial bones  totally separated from the
cranial base
 Lefort III

Signs and Symptoms

• Face lengthening: “caved-in” or “donkey face”
• Malocclusion: “open bite”
• Lateral orbital rim defect
• Ecchymoses: periorbital, subconjunctival
 Lefort III

Signs and Symptoms

• Bilateral epistaxis
• Infraorbital paresthesia
• Often medial canthal deformity
• Often unequal pupil height
 Lefort III

• Usually associated with major soft tissue injury

requiring emergent surgery for bleeding control
• Surgery can be delayed till edema resolves
• Intermaxillary fixation
 Lefort III

• Transosseous wiring or plating

• Frontozygomatic suture
• Nasofrontal suture
• May need extracranial fixation if concurrent mandibular
fracture
 Mandible Fractures

• Airway obstruction
• >50 % multiple fracture
• Fracture condyle  ear canal lacerations & high
cervical fractures
 Mandible Fractures

Signs and symptoms

• Malocclusion
• Decreased jaw range of motion
• Trismus
• Chin numbness
• Ecchymosis in floor of mouth
• Palpable step deformity
 Mandible Fractures

Treatment
• Fixation: intermaxillary fixation (arch bars), +/- body
wiring or plating
 Nasal Bone Fractures

• Often diagnosed clinically

• Emergent reduction not necessary except to control
epistaxis
• Early reduction under local anesthesia useful if nares
obstructed
 Nasal Bone Fractures

• Nasal septal hematoma: incise & drain, anterior pack

• Follow-up timing for recheck or reduction:
• Children: 3 to 5 days
• Adults: 7 days
 Zygomatic Fractures

Tripod (tri-malar) fracture

• Depression of malar eminence
• Fractures at temporal, frontal, and maxillary suture
lines
 Zygomatic Fractures

• Painful mandible movement

• Water’s xray
• Usually treat with fixation wire if arch depressed
 Supraorbital Fractures

Frontal sinus fracture

• Often associated with intracranial injury
• Often show depressed glabellar area
 Supraorbital Fractures

Ethmoid fracture
• Often associated with cribiform plate fracture, CSF
leak
• Medial canthus ligament injury needs transnasal
wiring repair to prevent telecanthus
 Orbital Fractures

• Diplopia with upward gaze: 90%

• Suggests inferior blowout
• Entrapment of inferior rectus & inferior oblique
• Diplopia with lateral gaze: 10%
• Suggests medial fracture
• Restriction of medial rectus muscle
Orbital Fracture: Treatment
• Sometimes extraocular muscle dysfunction can be
due to edema and will correct without surgery
• Persistent or high grade muscle entrapment requires
surgical repair of orbital floor (bone grafts, Teflon,
plating, etc.)
 Facial Soft Tissue Injuries
• Before repair, rule out injury to:
• Facial nerve
• Trigeminal nerve
• Parotid duct
• Lacrimal duct
• Medial canthal ligament
• Remove embedded foreign material to prevent
tattooing
 Facial Soft Tissue Rules

• For lip lacerations, place first suture at vermillion

border
• Never shave an eyebrow: may not grow back
 Facial Soft Tissue Rules

• Antibiotics for 3 to 5 days for any intraoral laceration

(penicillin VK or erythromycin) and if any exposed
ear cartilage (anti-staphylococcal antibiotic) – no
evidence
• Remove sutures in 3 to 5 days to prevent cross-marks
 Facial Soft Tissue Rules

• Clean facial wounds can be repaired up to 24 hours

after injury
• Place incisions or debridement lines parallel to the
lines of least skin tension (Lines of Langer)
 Summary

• Assess ABC's first

• Do complete exam as part of secondary survey
• Obtain standard X-rays and / or CT scan as
indicated
 Summary

• Arrange followup after repair to assess for delayed

complications or cosmetic problems