1. Maxillofacial injuries: types, diagnosis and treatment

Maxillofacial injuries: types, diagnosis and treatment

Maxillofacial trauma involves injury to the facial skeleton, dentoalveolar structures and associated soft tissues.
It ranges from isolated nasal or mandibular fractures to complex panfacial injuries.
The first priority is always life-threatening trauma: airway obstruction, haemorrhage, cervical-spine injury, intracranial injury and ocular injury may coexist.
Use an ATLS-style primary survey before detailed facial assessment.

The facial skeleton is divided into upper, middle and lower thirds.
The midface is formed by the maxilla, zygoma, nasal bones, lacrimal bones, palatine bones and parts of the sphenoid and ethmoid.
The mandible is a mobile U-shaped bone with symphysis, body, angle, ramus, condyle and coronoid process.
Important structures include the infraorbital and inferior alveolar nerves, facial nerve branches, parotid duct, orbit, nasal airway, maxillary sinus and teeth.
Thin buttresses transmit force; fracture displacement can alter occlusion, orbital volume and facial projection.

Common mechanisms are road-traffic collisions, interpersonal violence, falls, sports injuries and occupational trauma.
Fractures may be open or closed, displaced or undisplaced, simple or comminuted.
Midface fractures are often described by the Le Fort patterns: I (horizontal maxillary separation), II (pyramidal), and III (craniofacial dysjunction).
Other important patterns include zygomaticomaxillary complex, orbital floor, nasal, frontal sinus and mandibular fractures.
Mandibular fractures are classified by site and may be unilateral, bilateral, favourable/unfavourable, or associated with dental-alveolar injury.

Direct force causes bone failure; transmitted force may produce fractures away from the impact site.
Haematoma, oedema and soft-tissue disruption produce pain, deformity and airway risk.
Malalignment of the dental arches causes malocclusion.
Orbital fractures can entrap extraocular muscles or increase orbital volume, producing diplopia or enophthalmos.
Contamination from the oral cavity or sinuses increases infection risk.

Begin with airway, breathing and circulation.
Look for blood, teeth, vomitus, loose fragments, tongue displacement, expanding haematoma, stridor or inability to handle secretions.
Suction, jaw thrust and early expert airway support may be needed; avoid blind nasal instrumentation when a basal skull or severe midface fracture is suspected.
Control external bleeding with direct pressure and evaluate shock.
Maintain cervical-spine precautions until cleared.

Establish mechanism, time, loss of consciousness, amnesia, visual symptoms, diplopia, altered bite, numbness, epistaxis, nasal obstruction and dental injury.
Inspect facial symmetry, wounds, bruising, step deformity, swelling and CSF rhinorrhoea.
Palpate facial buttresses and mandibular borders gently.
Assess occlusion, mouth opening, teeth, intraoral lacerations and mobility.