CRANIOMAXILLOFACIAL TRAUMA

Tutorial of Basic Surgery

Tutor:
dr. Prasetyanugraheni Kreshanti, SpBP-RE(K)
Plastic Surgery Division, Department of Surgery
Dr. Cipto Mangunkusumo Hospital
 ANATOMY

European Journal of Radiology Volume 48, Issue 1, October 2003, Pages 17-32
 THE CLINICAL APPROACH
• Complies with the ATLS protocol.
• Presence of overt facial injuries is indicative of:
• The forces of the injury
• Possibility of airway compromise, cervical spine injury, and CNS injury.
• Address and manage these problems first!
• Airway compromise: e.c. excessive bleeding from upper airway source, foreign
body, or direct laryngeal injury.
• Bleeding in head and neck area: secure airway!
• CNS injury: stabilized first before continuing to facial fracture repair.

Hollier LH, Kelley P, Koshy JC. Soft-tissue and skeletal injuries of the face. In: Grabb and Smith’s Plastic Surgery. 7th ed.
 THE CLINICAL APPROACH
• After primary survey  secondary NV1 + NVII
Frontal sinus
survey, consisting of a thorough Skin laceration Upper third
head and neck examination. Eyes, NIII, NIV, NVI, NVII
Bony fragment: os. zygoma,
• Skin nasal, lacrimal, maxillary
• Soft tissue Dentition, NV2 Middle third

• Neurovascular structures: especially Malocclusion

Oral mucosa
N.V and N.VII of cranial nerves
NV3 Lower third
• Bone
• A systematic examination:

Additional examination: otoscopy

Hollier LH, Kelley P, Koshy JC. Soft-tissue and skeletal injuries of the face. In: Grabb and
Smith’s Plastic Surgery. 7th ed.
Resident Manual of the Trauma to the Face, Head, and Neck
 THE CLINICAL APPROACH
• Imaging:
• Ct-scan: with axial cut, < 3mm apart, from top of cranium to inferior border of the mandible.
• May not be sufficient for the mandible  regarding dental structure.
• Additional panoramic radiograph with posteroanterior film.
• Soft tissue injury:
• Wound cleansing  painful, need to do regional nerve/field block.
• Debridement when there is devitalized tissue.
• Early wound closure: importance of subdermal suture to maintain tensile strength.
• Special facial region: eyelids, ears, nose, lips, and parotid gland.

Hollier LH, Kelley P, Koshy JC. Soft-tissue and skeletal injuries of the face. In: Grabb and Smith’s Plastic Surgery. 7th ed.
Resident Manual of the Trauma to the Face, Head, and Neck
THE CLINICAL APPROACH

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CRANIOMAXILLOFACIAL
FRACTURES
1. Palatoalveolar Fracture
2. LeFort Fracture
3. Nasal Fracture
4. Nasoorbitoethmoid Fracture
5. Orbital Fracture
6. Zygoma Fracture

1. Tooth Fracture
2. Tooth Luxation
3. Alveolar Fracture

1. Parasymphisis and symphysis Fracture

2. Body Fracture
3. Angle and ramus Fracture
4. Condylar process and head Fracture
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 SIMPLE PALATOALVEOLAR FRACTURE
• Rare as an isolated fracture
• Mostly occurs in combination with other midfacial or
panfacial fractures.
• Clinical examination: malocclusion.
• Left untreated: malocclusions and widened maxilla.
• Supporting examination: CT Scan axial and coronal.

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 SIMPLE PALATOALVEOLAR FRACTURE
• Treatment options:

Observation Closed treatment ORIF

• Compliant patient • CT: fracture line with • MMF alone is

no splaying unable to prevent
• Fracture line • Possible instability
without splaying
displacement on • Palatal splint
the CT unavailable
• Stable fracture
• Normal occlusion

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 SIMPLE PALATOALVEOLAR FRACTURE
• ORIF:

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 COMPLEX PALATOALVEOLAR FRACTURE
• Commonly associated with panfacial fractures.
• Clinical examination:
• Malocclusion.
• Mucosal tears including the nasal mucosa
• Left untreated: malocclusions and widened maxilla.
• Supporting examination: CT Scan axial and coronal.
• Treatment option:
• Observation: risk of fistula formation.
• Splint application & closed reduction
• ORIF: controversial
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LE FORT FRACTURE

• Pure Le Fort I, II, and III fractures rare  associated

with multiple other midface fractures.
• Le Fort I: Horizontal maxillary fracture
• Le Fort II: Pyramidal maxillary fracture
• Le Fort III: Craniofacial dysjunction because the entire mass
of facial bones is separated from the cranial base

Hollier LH, Kelley P, Koshy JC. Soft-tissue and skeletal injuries of the face. In: Grabb and Smith’s Plastic Surgery. 7th ed
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LE FORT I FRACTURE

Linear Fracture Bilateral comminution

Unilateral comminution Edentulous patient

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LE FORT I FRACTURE
Observation Closed reduction ORIF

Non- or Minor malocclusion Mobile maxillae

minimally Not grossly mobile after Malocclusion
Linear mobile repositioning Restoration of vertical buttresses.
Need additional
stabilization method
Unilateral - Method of choice
comminution Restoration of vertical buttresses

- - Method of choice
Bilateral Vertical buttresses restoration,
comminution using bone graft

Standard - Malposition causing inadequate

Edentulous
treatment support to wear prosthesis
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LE FORT II FRACTURE
• Extends from the pterygoid, through maxilla, nasal orbital ethmoid area, and
nasofrontal bone.
• It has to go through the pterygoid plate.
• Clinical features:
• Unconscious and intubated.
• Severe bleeding and/or CSF leakage.
• Involving the orbit  visual acuity or afferent pupillary defect test
LE FORT II FRACTURE
• Aim: Reestablish the midfacial
buttresses.
• Additionally: establish the premorbid
dental occlusion

• Treatment:
• Observation.
• Closed treatment: can be as an
emergency treatment to reduce bleeding
and CSF leakage.
• ORIF: method of choice for any
displaced Le Fort II
LE FORT III FRACTURE
• Clinical features:
• Unconscious and intubated.
• Severe bleeding and/or CSF leakage.
• Involving the orbit  visual acuity or afferent pupillary
defect test
• Treatment option:
• Similar with Le Fort II

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NASAL FRACTURE
• Involving nasal bones
• May include nasal cartilage and/or nasal septum.
• In association with NOE or frontal sinus fracture.
• Classification based on clinical findings:

Disarticulation of
Laterally displaced fracture Posteriorly displaced
upper lateral cartilage
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NASAL FRACTURE
• Diagnosis:
• History, physical examination  including
intranasal space, possibility of septal
hematoma.
• Imaging: plain films  usually unhelpful
• Treatment options:
• Observation
• Closed reduction: 10-14 d post injury
• Open reduction
• Additional treatment: septorhinoplasty
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NASOORBITOETHMOIDAL (NOE)
FRACTURE
• Involving area of confluence of the:
• Nose
• Medial orbit
• Ethmoid
• Base of frontal sinus
• Floor of the anterior cranial base

• Three subtypes of NOE fracture (Markowitz):

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NASOORBITOETHMOIDAL (NOE)
FRACTURE

• Clinical findings:
• Swelling in the medial canthal area with
crepitation during palpation
• Retruded/impacted nose at the nasofrontal
suture
• Increased intercanthal distance
• Lack of resistance in medial canthal area

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NASOORBITOETHMOIDAL (NOE)
FRACTURE

Observation Closed reduction Open reduction

Non- or minimally - Significant displacement

displaced without Telecanthus or medial canthal
Type I telecanthus ligament malposition

- Using transnasal wire

Type II

- - Using internal fixation

Type III

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ORBITAL FRACTURE

• Clinical findings:
• Decreasing visual acuity and/or visual field
• Nerve injury (NII, NIII, NIV, and NVI)
• Occulomotor muscles entrapment
• Radiographic findings:

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ZYGOMA FRACTURE

• Two types:
• Isolated zygomatic arch fracture
• Zygomatic complex
• Clinical findings
• Pain
• Swelling
• Palpable step-off
• Trismus
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ZYGOMA FRACTURE

• Treatment options (isolated zygomatic arch fracture)

• Closed treatment
• Open reduction with or without fixation
• Treatment options (zygomatic complex fracture)
• Closed treatment (rarely)
• ORIF with/without orbital reconstruction

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 BIOMECHANICS OF THE MANDIBLE

• The mandible is a hoop of bone that deforms with movement based on the origin and
insertion of the muscles of mastication
• The superior border of the mandible is the tension zone and the inferior border is the
compression zone.

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 MANDIBLE FRACTURE
Anamnesis:
• Complaint of malocclusion after trauma is a reliable indication of a mandible fracture
• Obtain complete history of trauma mechanism
• Because of the constant motion of the lower jaw in normal daily function, mandible
fractures tend to be painful until stabilized
• Patient may complain paresthesia or numbness on the lower lip and chin

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 MANDIBLE FRACTURE
Physical examination:

• ABCD primary survey

• Abnormal mandibular movement
• Malocclusion
• Tenderness on palpation
• Edema
• Laceration
• Hematoma
• Ecchymosis
• Bony step off

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 MANDIBLE FRACTURE
Radiological examination:

• Plain x-ray  Caldwell position, oblique and reverse Towne

• Panoramic x-ray
• Occlusal x-ray
• CT Scan
• MRI is only beneficial to assess TMJ

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 SYMPHYSIS AND PARASYMPHYSIS FRACTURE

• Located at anterior mandible between canines

• Classified as simple and complex fracture
• Clinical features:
• Sublingual hematoma
• crepitation
• ecchymosis
• Plain posteroanterior x-ray, CT scan

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 SYMPHYSIS AND PARASYMPHYSIS FRACTURE
• Treatment of simple mandibular fracture:
1. Closed treatment (MMF)
• MMF is indicated for non- or minimally displaced simple fractures in compliant patients with good
dentition.
• Open reduction internal fixation (ORIF) is usually the method of choice for simple symphyseal
fractures in order to avoid the drawbacks and inconveniences of MMF in the majority of patients.
2. ORIF
• Open reduction internal fixation (ORIF) is usually the method of choice for simple symphyseal
fractures in order to avoid the drawbacks and inconveniences of MMF in the majority of patients.
• It is recommended in all unstable fractures and noncompliant patients.

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 SYMPHYSIS AND PARASYMPHYSIS FRACTURE

Treatment of complex mandibular fracture:

1. Closed treatment (MMF)
2. ORIF is the recommended method for complex symphyseal fractures to assure
adequate stability in the fracture site
3. External fixation, temporary stabilization of complex fractures simultaneously affecting
several anatomic mandibular subunits.

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 BODY /CORPUS FRACTURE

• Located between canine and the last molar

• Clinical features:
• face asymmetry
• crepitation
• ecchymosis
• pain
• malocclusion

• Radiological exam : CT scan with 3D reconstruction

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 CORPUS FRACTURE
• Treatment of simple fracture of the corpus:
1. Observation (seldom, only in favorable fractures)
2. Closed treatment (MMF)
• Non- or minimally displaced simple fractures in compliant patients with good dentition
amenable to MMF.
3. ORIF
• sagittal/oblique fractures
• rapid application with high level of stability

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 CORPUS FRACTURE
• Treatment of complex fracture of the corpus:
1. Closed treatment (MMF) : rare cases, in compliant patients with good dentition and
non- or minimally displaced fractures
2. ORIF
• Standard method of treatment of a comminuted fracture.
3. External fixator

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 ANGLE AND RAMUS FRACTURE
• Located distal to second molar
• Fracture line often passes through the area of impacted third
molar teeth
• Clinical features:
• Face asymmetry
• Crepitation
• Pain
• Malocclusion
• Paresthesia

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 ANGLE AND RAMUS FRACTURE
• Treatment of simple fracture of the angulus and ramus
1. Observation (seldom, usually for incomplete, non-displaced, non-mobile fractures in a
compliant patient with undisturbed occlusion).
2. Closed treatment (Non- or minimally displaced favorable fractures)
3. ORIF

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 ANGLE AND RAMUS FRACTURE

• Treatment of complex fracture of the angulus and ramus

1. closed treatment (rare cases)
2. ORIF is the recommended method for complex angle fractures to assure adequate
stability in the fracture site
3. External fixator

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CONDYLE FRACTURE

• is classified intracapsular, condylar neck, and

subcondyle.
• Clinical features:
• face asymmetry and preauricular swelling
• deviated mandible towards the fracture side while
mouth opening \open bite deformity
• malocclusion
• pain

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 CONDYLE FRACTURE
• Treatment of simple fracture of the angle and ramus
1. Observation
• Minimally or nondisplaced fracture
• Dentate patients should have a stable occlusion over time
• Acceptable level of pain
• Patient compliance

2. Closed treatment : Closed treatment results in a functional adaptation by the patient to

achieve a repeatable occlusion
3. ORIF

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DENTOALVEOLAR TRAUMA
• Segmental alveolar fracture is defined as a fracture of the alveolar process
which may or may not involve the socket of the teeth
• typical clinical appearance is a segment containing two or more teeth being
displaced axially
• The majority of cases may be treated with closed repositioning and non-
internal fixation (closed treatment) or laterally,

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DENTOALVEOLAR TRAUMA

• Treatment of simple fracture of the dentoalveolar trauma

1. Closed treatment
2. ORIF

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