Trauma to the face and head can be caused by a number of events: explosions, gunshot, road traffic accidents, falling masonry, flying glass, sports injuries, and blunt force trauma. Soft tissue injury comprises lacerations, abrasions and avulsions.
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| Maxillofacial Injuries |
There can be:
Bony damage - fractures can occur in any of the bones of the head and face, but are particularly common in the mandible and nose - and also soft tissue injury. CT scanning is essential for diagnosis as this shows fractures of facial bones more reliably than plain X-ray, and also shows soft tissue injury.
Facial Nerve or the Trigeminal Nerve damage may occur with facial and head trauma.
Direct damage to the eye: It is important to be aware that a number of patients who suffer trauma to the face also suffer from brain injury, and some have co-existing cervical spine injury.
Initial repair following serious facial trauma is performed by surgeons: fractured bones will be plated or wired; skin and soft tissue lacerations will be stitched; large areas of severe soft tissue damage may require grafting.
The physiotherapy rehabilitation of these patients is thus largely post-operative rehabilitation.
Epidemiology
The main causes of facial trauma are road traffic accidents (RTAs), falls, assaults and sports injuries. Many studies from different countries show that world-wide the prevalence of facial trauma is considerably higher in men than women, It is clear that the causes of maxillofacial injuries vary from one country to another, and even within the same country as a result of environmental, socioeconomic and cultural factors.
Developing Countries: In developing countries which have a high usage of motorised vehicles, RTAs account for up to 93% of facial injuries, with a high proportion of these involving motorcycles. One study reports that as many as 50 to 70% of RTA survivors suffer from facial trauma. In countries where motorcycles are a major form of transport, such as Malaysia, RTAs involving motorcycles, are the biggest single cause of facial trauma.
Developed Countries: One large study in Austria found that the causes of maxillofacial injury were: in 38% of cases, an activity of daily life, in 31% sports, in 12% violence, 12% RTA, 5% work accidents, 2% other causes.
Soft Tissue Injury: In areas of thin skin (eg. the eyelids) sutures can normally be removed after just 3-4 days, and elsewhere on the face, they are often removed after 6 days. Sutures in cartilage, for example, the ear or the nose, are often left in situ for 10-14 days.
Lacerations are frequently treated with sutures, but if large areas of skin and muscle have been severely damaged, skin graft surgery will be required.
Bony Injury
Specific fractures
Frontal bone fractures
- These usually follow a severe blow to the forehead.
- A dural tear should be considered if the posterior wall of the frontal sinus is fractured.
- There may be tenderness, crepitus or disruption of the supraorbital rim. Look for subcutaneous emphysema and reduced sensation of supraorbital and supratrochlear nerves.
- Surgery is needed if the nasofrontal duct is blocked.
- Non-displaced fractures are sometimes managed by observation.
Orbital floor fractures
- These can occur alone or with medial wall fracture.
- There may be herniation of orbital contents into the maxillary sinus.
- There are separate articles entitled Zygomatic Arch and Orbital Fractures and Eye Trauma.
Nasal fractures
There is a separate article entitled Nasal Injury and Nasal Foreign Bodies.
Nasoethmoidal fractures
- These extend from the nose to involve the ethmoid bones.
- They can lead to damage of the lacrimal apparatus, canthus, nasofrontal duct or dural tear at the cribiform plate.
- If a dural tear is suspected, referral to a neurosurgeon is required.
- Ophthalmology, ear, nose and throat, maxillofacial or plastic surgery referral is required to manage other injuries.
- Maxillary fractures
Anatomy
The two maxillae form the upper jaw, the anterior part of the hard palate, part of the lateral walls of the nasal cavities, and part of the floors of the orbital cavities. They meet in the midline at the intermaxillary suture and form the lower margin of the nasal aperture.
Classification
Le Fort I - a horizontal fracture across the inferior aspect of the maxilla. May result from a direct blow on the maxillary alveolar rim in a downward direction. The alveolar process and hard palate become separated from the rest of the maxilla. The fracture extends through the lower nasal septum, the lateral maxillary sinus wall and into the palatine bones and pterygoid plates. It can present with facial oedema, loose teeth and a mobile hard palate.
Le Fort II- a pyramidal-shaped fracture. It may result from a blow to the lower or mid-maxilla. The fracture extends from the nasal bridge through the frontal processes of the maxilla, through the lacrimal bones and inferior orbital floor and rim, through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus. It then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates. It can present with facial oedema, epistaxis, subconjunctival haemorrhage, CSF rhinorrhoea, a mobile maxilla and telecanthus (widening and flattening of the nasal bridge).
Le Fort III- a transverse fracture, also known as craniofacial dysjunction. It may follow a blow to the nasal bridge or upper maxilla. There is separation of all of the facial bones from the cranial base with simultaneous fracture of the zygoma, maxilla, and nasal bones. The fracture line extends through the ethmoid bones, orbits, and pterygomaxillary suture into the sphenopalatine fossa. It presents with massive facial oedema and facial flattening. There may be movement of all of the facial bones in relation to the cranial base.
Management
Maxillary fractures are usually managed by open reduction and fixation.
Patients with higher Le Fort injuries have more severe injuries and more frequently need a surgical airway. Those with Le Fort III injuries have a higher chance of needing neurosurgical intervention or experiencing vision-threatening trauma.
Mandibular fractures
- There is a separate article entitled Mandibular Fractures.
- Alveolar fractures
- Injuries of the tooth-bearing portion of the mandible are common.
- They can occur after relatively low-impact trauma. The alveolus (tooth-bearing portion of bone) and/or the tooth can be damaged. Segmental fractures that involve multiple teeth can occur.
- They can present with loose or lost teeth and bleeding gums.
Panfacial fractures
These usually result from high-energy trauma to the face.
Open reduction with repositioning and internal fixation is needed.
Complications of maxillofacial injuries
Immediate
- Airway compromise.
- Aspiration.
- Haemorrhage.
- Infection.
Longer-term
- Scars and permanent facial deformity.
- Chronic sinusitis.
- Nerve damage leading to loss of facial sensation, movement, smell, taste or vision.
- Malocclusion.
- Non-union/malunion of fractures.
- Malnutrition and weight loss.
Prevention of maxillofacial injuries
Full-face helmets may offer some protection against maxillofacial injury.
Airbags, non-lacerating windscreens and seatbelts in cars.
Safety measures in high-risk occupations (eg, farm and forestry workers).
Gumshields in sports, although it is unclear which offers the best protection for which sport.
Treatment
Treatment of maxillofacial trauma varies according to the type and extent of the injury.
Jaw
Dislocation of the jaw can be treated by a primary care physician by exerting pressure in the proper manner. If muscle spasm prevents the jaw from moving back into alignment, a sedative is administered intravenously (IV) to relax the muscles. Afterward, the child must avoid opening the jaw wide to minimize the risk of another dislocation.
A jaw fracture may be minor enough to heal with simple limitation of movement and time. More serious fractures require complicated multistep treatment. The jaw must be surgically immobilized by a qualified oral or maxillofacial surgeon or an otolaryngologist. The jaw is properly aligned and secured with metal pins and wires. Proper alignment is necessary to ensure that the bite is correct. If the bite is off, the patient may develop a painful disorder called temporomandibular joint syndrome.
During the weeks of healing the patient is limited to a liquid diet sipped through a straw and must be careful not to choke or vomit since he cannot open his mouth to expel the vomitus. The surgeon will prescribe pain relievers and perhaps muscle relaxants. The recovery time varies according to the patient's overall health but takes at least several weeks.
Nose
Another common maxillofacial fracture is a broken nose. The bones that form the bridge of the nose may be fractured, but cartilage may also be damaged, particularly the nasal septum that separates the two nostrils. If the child's nose is hit from the side, the bones and cartilage are displaced to the side, but if hit from the front, they are splayed out. Severe swelling can inhibit diagnosis and treatment. Mild trauma to the nose can sometimes heal without the person being aware of the fracture unless there is an obvious deformity. The nose will be tender for at least three weeks.
Either before the swelling begins or after it subsides, some ten days after the injury, the doctor can assess the extent of the damage. Physical examination of the inside using a speculum and the outside, in addition to a detailed history of how the injury occurred, determines appropriate treatment. The doctor should be informed of any previous nasal fractures, nasal surgery, or such chronic diseases as diabetes or bleeding disorders. Sometimes an x-ray is useful for diagnosis, but it is not always required.
A primary care physician may treat a nasal fracture himself, but if there is extensive damage or the air passage is blocked, he will refer the patient to an otolaryngologist or a plastic surgeon for treatment. Initially the nose may be packed to control bleeding and hold the shape. It is reset under anesthesia. A protective shield or bandage may be placed over it while the fracture heals.
Eyes
In the case of orbital fractures, there is great danger of permanent damage to vision. Double vision and decreased mobility of the eye are common complications of facial trauma. Surgical reconstruction may be required if the fracture changes the position of the eye or there is other facial deformity. Proper treatment of these injuries requires a maxillofacial surgeon.
When the eyes have been exposed to chemicals, they must be washed out for 15 minutes with clear water. Contact lenses may be removed only after rinsing the eyes. The eyes should then be kept covered until the person can be evaluated by a primary care physician or ophthalmologist.
When a foreign object is lodged in the eye, the person should not rub the eye or put pressure on it which would further injure the eyeball. The eye should be covered to protect it until medical attention can be obtained.
Mouth and teeth
Several kinds of traumatic injuries can occur to the mouth. A person can suffer a laceration (cut) to the lips or tongue or loosening of teeth or have teeth knocked out. Such injuries often accompany a jaw fracture or other facial injury. Wounds to the soft tissues of the mouth bleed freely, but the plentiful blood supply that leads to this heavy bleeding also helps healing. It is important to clean mouth wounds thoroughly with salt water or a hydrogen peroxide rinse to prevent infection. Large cuts may require sutures and should be done by a maxillofacial surgeon for a good cosmetic result, particularly when the laceration is on the edge of the lip line (vermilion). The doctor will prescribe an antibiotic because there is normally a large amount of bacteria present in the mouth.
Any injury to the teeth should be evaluated by a dentist for treatment and prevention of infection. Implantation of a tooth is sometimes possible if it has been handled carefully and protected. The tooth should be held by the crown, not the root, and kept in milk, saline, or contact lens fluid. The child's dentist can refer him to a specialist in this field.
Facial burns
For first-degree burns, the child's parent can put a cold-water compress on the area or run cold water on it and cover it with a clean bandage for protection. Second- and third-degree burn victims must be taken to the hospital for treatment.
In the hospital, the child will be given replacement fluids through an IV. This treatment is vital since a patient in shock will die unless those lost fluids are replaced quickly. Antibiotics are given to combat infection since the burns make the body vulnerable to infection.
Head injuries
Treatment for a head injury requires examination by a primary care physician unless the child's symptoms point to a more serious injury. In that case, the victim must seek emergency care. A concussion is treated with rest and avoidance of contact sports. Very often athletes who have suffered a concussion are allowed to play again too soon, perhaps in the mistaken impression that the injury is not so bad if the player did not lose consciousness. Anyone who has had one concussion is at increased risk of another one.
Danger signs that a head injury is more serious include worsening headaches, vomiting, weakness, numbness, unsteadiness, change in the appearance of the eyes, seizures, slurred speech, confusion, agitation, or a change in mental status. These signs require immediate transport to the hospital. A neurologist will evaluate the situation, usually with a CT scan. A stay in a rehabilitation facility may be necessary.
In the case of animal bites on the face or head, the child may be given passive or active immunization against rabies if there is a chance that the animal is rabid. This precaution is particularly important, as the incubation period of the rabies virus is much shorter for bites on the head and neck than for bites elsewhere on the body.
Alternative treatment
Fractures, burns, and deep lacerations require treatment by a doctor but alternative treatments can help the body withstand injury and assist the healing process. Calcium, minerals , vitamins , all part of a balanced and nutrient-rich diet, as well as regular exercise , build strong bones that can withstand force well. After an injury, craniosacral therapy may help healing and ease the headaches that follow a concussion or other head trauma. A physical therapist can offer ultrasound treatment, which raises skin temperature to ease pain, or biofeedback, a technique in which the patient learns how to tense and relax muscles to relieve pain. Hydrotherapy may ease the emotional stress of recovering from trauma. Traditional Chinese medicine seeks to reconnect the chi (energy flow) along the body's meridians and thus aid healing. Homeopathic physicians may prescribe such remedies as Arnica or Symphytum to enhance healing.
Prognosis
When appropriate treatment is obtained quickly after a facial injury, the prognosis can be excellent. If the child or adolescent has a weakened immune system or a debilitating chronic disease, healing is more problematic. Healing also depends upon the extent of the injury. An automobile accident or a gunshot wound, for example, can cause severe facial trauma that may require multiple surgical procedures and a considerable amount of time to heal. Burns and lacerations cause scarring that might be improved by plastic surgery.
Prevention
Safety equipment is vital for preventing maxillofacial trauma from automobile accidents and sports. Here is a partial list of equipment people should always use:
- seatbelts
- automobile air bags
- approved child safety seats
- helmets for riding motorcycles or bicycles, skateboarding, snowboarding, and other sports
- safety glasses for yard work and sports
- such other approved safety equipment for sports as mouthguards, masks, and goggles
KEY TERMS
Corneal abrasion —A scratch on the surface of the cornea.
Crepitus —A crackling sound.
Hematoma —A localized collection of blood, often clotted, in body tissue or an organ, usually due to a break or tear in the wall of blood vessel.
Mandible —The lower jaw, a U-shaped bone attached to the skull at the temporomandibular joints.
Maxilla —The bone of the upper jaw which serves as a foundation of the face and supports the orbits.
Nasal septum —The partition that separates the nostrils.
Orbit —The eye socket which contains the eyeball, muscles, nerves, and blood vessels that serve the eye.
Otolaryngologist —A doctor who is trained to treat injuries, defects, diseases, or conditions of the ear, nose, and throat. Also sometimes known as an otorhinolaryngologist.
Shock —A medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen and allows the build-up of waste products. Shock can be caused by certain diseases, serious injury, or blood loss.
Temporomandibular joint disorder —Inflammation, irritation, and pain of the jaw caused by improper opening and closing of the temporomandibular joint. Other symptoms include clicking of the jaw and a limited range of motion. Also called temporomandibular joint syndrome.
Temporomandibular joint (TMJ) —One of a pair of joints that attaches the mandible of the jaw to the temporal bone of the skull. It is a combination of a hinge and a gliding joint.
Vermilion border —The line between the lip and the skin.
Surgical repair is often required for a bony injury, which may involve wiring or plating, or more substantial surgical techniques to rebuild the damaged bone, such as bone grafting.
Surgical Interventions
Maxillary Repair
The maxilla bone forms the upper jaw and houses the upper teeth. It forms the hard palate, as well as the floor of the eye socket. Fractures of the maxilla may require surgical intervention, plating or wiring.
Mandibular Repair
The mandible, AKA jaw bone, is frequently injured in facial trauma. It is the only moving bone in the face, and it houses the lower teeth.
In some cases, Mandibular Maxilla Fixation, MMF, may be required - this involves wiring the jaws closed while the bony healing occurs.
Later Stages
Once the surgical repair techniques have been completed, the body continues the healing, producing scar tissue.
The proliferation phase (AKA fibroblastic phase) of scar tissue lasts for 2-3 weeks, and it is in this phase that the majority of the scar tissue, collagen, is laid down; after this time there is a slowing of proliferation for the next 4-6 months.
This is followed by the remodelling (AKA maturation) phase, when the scar tissue continues to rebuild and remodel, becoming more organised and functional, and more similar to the tissue it is repairing. This process continues for up to a year.
Please see the Soft Tissue Healing page for more details on scar tissue formation.
Characteristics of Facial Muscles
The facial muscles have different characteristics compared to muscles in the trunk and limbs:
- They have a more complex pattern of innervation of extrafusal fibres
- They have a larger percentage of slow-type nerve fibres
- Many facial muscles insert not into bone or fascia, but into the skin
- Many facial muscles are very thin in structure and are poorly differentiated, merging with other facial muscles
Physiotherapy following Facial Trauma
Rehabilitation should begin as soon as the surgeons permit it.
The aim of physiotherapy is to restore as much facial range of movement as possible, which will result in the restoration of facial function.
Clinical Presentation
Any of the following may occur, often several in combination:
- Reduced facial range of movement
- Inability or reduced ability to close the eye
- Inability or reduced ability to move the lips eg. into a smile, pucker
- Inability to bite or chew
- Asymmetry of the facial structures
- Difficulties keeping food in the mouth when eating
- Difficulties forming a lip seal on a vessel when drinking
- Dry eye
- Dry mouth
- Reduction in non-verbal communication through facial expression
- Rehabilitation
Manual Techniques
Manual techniques to the soft tissues are frequently utilised, with the aim of restoring the flexibility of the soft tissues. The nature of scar tissue means that as it heals there is a tendency for loss of both elasticity and length, and this can result in a reduced range of movement.
Gentle passive stretching techniques can be used to lengthen the tissues.
Injury to the eye and the surrounding area can be problematic: if the eyelid is injured, as it heals and shortens, it may result in insufficient passive length resulting in incomplete eye closure. This in turn means that the eye itself is at risk of being damaged. The tissues of the eyelid are extremely thin, and with careful, gentle stretching techniques the length can be restored.
Active Exercises
Once tissue length is established, the patient should be encouraged to move the affected area of the face actively through the newly gained range.
Electrotherapy
While several electrotherapeutic techniques are known to improve soft tissue healing, the face is such a vascular area that in the majority of cases these are not required as the tissue spontaneously heals swiftly and well.
Temporomandibular Joint [TMJ] Rehabilitation
- Active and passive joint movements are considered to be an important part of post-operative exercise rehabilitation
- Active exercises to increase TMJ range of movement. These should include all TMJ movements:
- depression of the mandible - mouth opening
- elevation of the mandible - mouth closing
- lateral movement of the mandible - these actions are used in chewing
- protraction of the mandible
- There are 4 muscles of mastication which act on the TMJ:
- Masseter, Temporalis, Lateral Pterygoid and Medial Pterygoid
- Of the 4 muscles which act on the TMJ, the masseter is the strongest, its action is to close the mouth. If the temporomandibular joint and/or the masseter is injured, the patient will initially have marked weakness of the chewing action.
- There is only one muscle which produces opening of the mouth/mandible depression: Lateral Pterygoid. Injuries to this muscle produce difficulty and weakness in closing the mouth
- Learn more about TMJ Disorders, assessment, and management
- Rehabilitation for injured facial muscles
- Injury to the muscles of the upper face can result in difficulties closing the eye; protection of the eye is of paramount importance. The sphincter muscle of which closes the eye is called orbicularis oculi, so if this muscle is damaged they eye may remain open and be unable to close.
Trauma to the lower facial muscles frequently causes difficulties in eating and drinking. The orbicularis oris muscle controls the movement of the lips, and if injured the person may struggle to drink out of a cup or glass without spilling the fluid, as well as having problems with keeping food in the mouth when eating.
Nerve Injury Rehabilitation - Trigeminal Nerve
Damage to the Trigeminal Nerve results in loss of sensation to the skin of the face. Of the three branches of the Trigeminal Nerve, the 3rd branch, V3 known as the Mandibular nerve, is the only one which carries motor fibres; the other two branches, V1 Ophthalmic Nerve and V2 Ophthalmic Nerve, carry only sensory fibres. Thus if the Mandibular nerve is damaged, the power of the chewing function is affected.
Active exercises, and in some cases even Trophic Electrical Stimulation, will be required to restore function and improve ease of eating.
Nerve Injury Rehabilitation - Facial Nerve
Trauma to the cheek region can easily result in damage to the facial nerve. Surgical exploration is required to evaluate the condition of the nerve: if it is completely transected, surgical repair or even nerve graft will be performed, and the recovery of active movement will be delayed as the axons grow through the repaired nerve at a rate of approximately 1mm per day.
There are a series of pages on this topic; the main one to consult is the Facial Palsy page.
Very often, if the facial nerve is damaged, the orbicularis oculi muscle is unable to contract, which results in the patient being unable to close the eye, and the eye will not produce tears as this function is also supplied by the facial nerve. The person will need to be taught appropriate eye care (see the Dry Eye page for more detail) including use of artificial lubrication products and how to tape the eye closed at night.
Psychological Effects of Facial Trauma Injury
The disfigurement caused by facial injuries can lead to psychological difficulties, ranging from depression, anxiety, a tendency to become socially isolated and in some cases increased hostility. A number of patients report they experience social stigma.
Post-traumatic stress disorder PTSD, can occur following facial trauma. One study found that 23% of patients continued to suffer from PTSD one year after the incident
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