MAXILLOFACIAL TRAUMA AND DEFORMITIES
Many injuries occur as a result of various traumas on the face and skull, which are open to various effects and do not have protective features. Jaw and facial injuries can take many forms, from simple abrasions and cuts to complex injuries characterized by soft tissue crushes and losses, and various bone fractures.
The importance of treatment in facial injuries is not only to save the life of the injured person. It is of great importance to prevent secondary changes and bad appearances that will occur in the individual as a result of this injury.
Purpose of Treatment in Maxillofacial Injuries:
1. To ensure optimal occlusion of the teeth
2. To ensure full functionality of the jaw joint
3. It is to bring the facial appearance, contours and symmetry into normal dimensions as much as possible. For this, soft tissues should be repaired by atraumatic methods as well as the repair of bone structures.
In addition, one of the goals should be to treat wounds specific to the skin and soft tissues with minimal sequelae in burns and frostbite of the maxillofacial region, injuries caused by physical and chemical agents.
While maxillofacial injuries only concern the skin and soft tissues, with the sensitivity of these tissues, they can be large enough to injure the underlying bone tissues and vital organs. Sometimes traumas to the face and skull may be accompanied by many fractures and injuries in other parts of the body. Concentrate only on the maxillofacial region.
Emergency care and treatment
The procedure to be followed in maxillofacial injuries should be as follows.
1. Keeping the Airway Open :
Facial bones can be fractured causing posterior displacement. The airway can be obstructed by the movement of bone fragments and soft tissue. As time progresses, large-scale hematoma and intra-tissue hemorrhages leading to progressive edema are another important cause of respiratory obstruction.
Especially if there is a bilateral lower fracture of the mandibular symphysis in patients in confusion, the backward slip of the fragment in the middle causes the tongue to run backwards. The jaw should be repositioned forward, if this is not possible, the tongue should be pulled forward by holding it with a forceps. 1.5 cm from the tip of the tongue pulled forward. When one move from the distance, a suture should be pulled and the tongue should be pulled out and the tip of the suture should be tied to the button of the casualty’s dress to prevent the tongue from escaping. If there are foreign objects such as teeth, blood clots, broken dental prosthesis pieces, rags that may have entered the oral cavity or nose, the index finger should be inserted into the patient’s mouth and removed.
Such casualties are often in a state of bewilderment and fear, sometimes they feel suffocated, and their consciousness may be clouded.
Maxillary bone fractures should be repositioned anteriorly. It is important to block the nasal and oral airway. The upper jaw should be temporarily supported by placing gas buffers between the posterior teeth. If these measures are insufficient, an endotracheal tube should be placed urgently and even an emergency tracheostomy should be performed.
2. Control of Hemorrhage :
A quick and careful examination should be performed to save life. Active bleeding should be brought under control immediately. More serious arterial bleeding can be stopped initially with finger pressure. Finger pressure should be continued until the methods of stopping bleeding are applied. Bleeding caused by dangerous injuries in the extremities can be controlled by applying a tourniquet. However, face and neck wounds require another procedure. The person should stop the bleeding with finger compression. Pressure is applied on some areas with bandages and gas pads. Thus, the bleeding is controlled until a clamp or ligation is applied. It is possible. In hemorrhagic traumas of A.carotis externa or one of its branches, applying finger pressure along the anterior edge of the sternocleidomastoid muscle stops the bleeding. In maxillary branch and superficial temporal artery hemorrhages, bleeding can be prevented by keeping the arteries under pressure at the points where they pass over the bones. Blind clamping should be done. In summary, control of bleeding can be achieved by dressings, local pressure, clamping of vessels, ligation of vessels, and ligation of soft tissues by suturing. In some special bleedings, posterior nasal packings and sinus packings may be required. These packings can be left for 2-3 days or even until the patient’s condition allows surgery. Another importance of bleeding is that it prevents breathing by forming a hematoma in the orolarengeal region.
3. Treatment of Shock :
If there is no excessive bleeding, shock picture usually does not occur after soft tissue trauma. Shock with circulatory failure is characterized by hemoconcentration and hypovolemia.
4. Relief of Pain :
The patient’s pain should be relieved with analgesics. If there is breathing difficulty, morphine is not used. If CNS injuries are also present, all analgesics should be avoided except acetylsalicylic acid.
Physical examination and surgical treatment principles should be completed as quickly as possible after trauma. Neurological examinations of patients should be performed. If Cheyn-Stokes breathing is present, it indicates diffuse bilateral hemispheric trauma. Trauma to the midbrain tegmentum leads to Kusmaul breathing. Hypotension and tachycardia are important symptoms of intracranial pressure. There is usually a moderate headache. The presence of acute epidural hematoma causes severe headaches. This type of headache is also seen in foramen magnum fractures. The presence of vomiting is usually seen in these traumas.
In revealing the location of the trauma, revealing whether the individual is getting enough oxygen plays a role in the detection of cyanosis.
Head and Neck Examination:
If there is a simple laceration or abrasion, penetrating cranial injury may be encountered at the bottom. It should be requested in the cervical X-ray.
Examination of the Eyes:
While periorbital ecchymoses occur due to local traumas, they should also suggest anterior fossa trauma. Rhinorhea ethmoid fractures, presence of pupillary edema indicates increased intracranial pressure.
Ears : Blood and cerebrospinal fluid coming from the ear canal suggests skull base fracture.
Nose : If cerebrospinal fluid comes out, ethmoid fracture should be considered. Different pupil levels suggest orbital or zygoma fractures.
- Soft tissue injuries
- Only bone tissue injuries
- Complicated injuries involving both bone and soft tissue
Wound Treatment: Planning the treatment and repair time, and treatment of soft tissues very rarely play a life-saving role. Repair and treatment of these tissues can be left behind until important problems are corrected. Successful results have been obtained even in cases where soft tissue treatment is delayed for 24 hours. This period, known as the golden period, covers a longer time for this area. The blood supply to this forehead continues to expand the boundaries of this golden period. In late closure, the underlying approximation sutures should be avoided. It should be closed postoperatively with wet dressings.
- Gentle wound care
- Full investigation and evaluation of the wound
- Precise debridement
- A very ingenious reconstruction
- Good postoperative wound care
If local anesthesia is to be applied, anesthesia is applied before cleaning the wound. After removing the clots and foreign bodies from the wound, the wound is washed with plenty of physiological saline. Cleanliness should be ensured by washing foreign objects and paints with a brush. If there is any indication of nerve and tendon cuts, it should be thoroughly explored. Lacrimal duct and stenon duct incisions should also be investigated.
Vital tissues that have not necrosis should be strictly preserved. Crushed necrotic tissue should be debrided. Massive hematomas of the forehead and cheek should be aspirated using aseptic techniques. Wound areas are closed with gasses impregnated with antibiotic ointment.
If the patient’s condition does not allow primary soft tissue repair, it should be closed temporarily and covered with wet dressings until the time of primary or secondary closure. If there are large tissue losses in the soft tissues and open areas in the bones, the wound should be turned into a closed wound.
GENERAL RULES FOR FACE FRACTURES
As a general rule, causes that may endanger life (bleeding, airway obstruction, etc.) in patients presenting with facial injuries are urgently eliminated. Then, the displaced ends as a result of the fracture are reduced and brought to their normal anatomical position and fixation is applied when necessary. Although the reduction process can be done manually, in cases where it fails, fractures are treated by open reduction with surgical interventions.
Either the extraoral or intraoral route is used to reach the fracture site. The scar on the face in extraoral procedures, the risk of infection in intraoral procedures should be discussed and evaluated, and the most appropriate method should be selected.
Today, wide-open reduction, rigid fixation with plates and screws, and repair with bone grafts when necessary are the most appropriate treatment methods for maxillofacial fractures.
If the soft tissue relations of the broken bone parts are not disturbed during the surgical interventions, these parts must be replaced and the broken bone parts must be covered with healthy soft tissues.
Simple fractures should be repaired under local anesthesia, complicated fractures should be repaired under general anesthesia and in the operating room.
The time factor is also important in facial bone fractures. Early treatment should be done within the first 48 hours after injury.