Maxillofacial trauma refers to any injury to the face or jaw caused by physical force, foreign objects, or burns.
Maxillofacial trauma includes injuries to any of the bony or fleshy structures of the face.
Any part of the face may be affected. Teeth may be knocked out or loosened. The eyes and their muscles, nerves, and blood vessels may be injured as well as the eye socket (orbit), which can be fractured by a forceful blow. The lower jaw (mandible) may be dislocated by force. Although anchored by strong muscles for chewing, the jaw is unstable in comparison with other bones and is easily dislocated from the temporomandibular joints that attach it to the skull. A fractured nose or jaw may affect the ability to breathe or eat. Any maxillofacial trauma may also prevent the passage of air or be severe enough to cause a concussion or more serious brain injury.
Athletes are particularly at risk of maxillofacial injuries. Boxers suffer repeated blows to the face and occasional knockouts (traumatic brain injury). Football, basketball, hockey, and soccer players, and many other athletes are at risk for milder forms of brain injury called concussions. There are an estimated 300,000 cases every year. Overall, there are one million new traumatic brain injuries every year, causing 50,000 deaths. Of the rest, 7-9% are left with long-term disability.
Burns to the face are also categorized as maxillofacial trauma.
Causes and symptoms
There are no reliable statistics on the incidence of maxillofacial trauma because there are so many types and many are not reported. Automobile accidents are a major cause, as well as participation in sports, fights, and other violent acts, and being hit by an object accidentally, for instance being hit by a baseball while watching a game. People most at risk are athletes, anyone who drives a vehicle or rides in one, and those who do dangerous work or engage in aggressive types of behavior.
One study reported in August 2000 that 42% of all facial fractures resulted from sports activity.
The major symptoms of most facial injuries are pain, swelling, bleeding, and bruising, although a fractured jaw also prevents the person from working his jaw properly, and symptoms of a fractured nose also include black eyes and possible blockage of the airway due to swelling and bleeding.
Symptoms of eye injury or orbital fracture can include blurred or double vision, decreased mobility of the eye, and numbness in the area of the eye. In severe injuries there can be temporary or permanent loss of vision.
Burn symptoms are pain, redness, and possibly blisters, fever, and headache. Extensive burns can cause the victim to go into shock. In that situation, he will have low blood pressure and a rapid pulse.
Symptoms of traumatic brain injury include problems with thinking, memory, and judgement as well as mood swings, and difficulty with coordination and balance. These symptoms linger for weeks or months, and in severe cases can be permanent. Double vision for months after the injury is not uncommon.
Trauma is usually diagnosed in an emergency room or physician's office by physical examination and/or x ray. Some injuries require diagnosis by a specialist. A detailed report of how the injury occurred is also taken. In some cases, diagnosis cannot be made until swelling subsides.
Treatment varies, depending on the type and extent of the injury.
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 patient must avoid opening the jaw wide as he will be prone to repeat dislocations.
A jaw fracture may be minor enough to heal with simple limitation of movement and time. More serious fractures require complicated, multi-step 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. Healing time varies according to the patient's overall health, but will take at least several weeks.
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 which divides the nose. If 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 obvious deformity. The nose will be tender for at least three weeks.
Either before the swelling begins or after it subsides, some 10 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 will determine appropriate treatment. The doctor should be informed of any previous nasal fractures, nasal surgery, or chronic disease such as osteoporosis. Sometimes an x ray is useful, 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.
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. Surgical reconstruction may be required if the fracture changes the position of the eye or there is other facial deformity. Treatment 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.
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 the wound thoroughly with salt water or 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 patient's dentist can refer him to a specialist in this field.
For first degree burns, put a cold-water compress on the area or run cold water on it. Put a clean bandage on it for protection. Second and third degree burn victims must be taken to the hospital for treatment.
Fluids are replaced there through an IV. This 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.
Treatment for a head injury requires examination by a primary care physician unless 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 the injury is more serious include worsening headaches, vomiting, weakness, numbness, unsteadiness, change in the appearance of the eyes, seizures, slurred speech, confusion, agitation, or the victim won't wake up. 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 become necessary.
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 that raises temperature to ease pain, or biofeedback in which the patient learns how to tense and relax muscles to relieve pain. Hydrotherapy may ease the stress of recovering from trauma. Chinese medicine seeks to reconnect the chi along the body's meridians and thus aid healing. Homeopathic physicians may prescribe natural medicines such as Arnica or Symphytum to enhance healing.
When appropriate treatment is obtained quickly after an injury, the prognosis can be excellent. However, if the victim of trauma has osteoporosis 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.
Safety equipment is vital to preventing maxillofacial trauma from automobile accidents and sports. Here is a partial list of equipment people should always use:
- automobile air bags
- approved child safety seats
- helmets for riding motorcycles or bicycles, skate-boarding, snowboarding, and other sports
- safety glasses for the job, yard work, sports
- other approved safety equipment for sports such as mouthguards, masks, and goggles
Corneal abrasion — A scratch on the surface of the eyeball.
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 cartilage which divides the nose in half.
Orbit — The eye socket which contains the eyeball, muscles, nerves, and blood vessels that serve the eye.
Otolaryngologist — Ear, nose and throat specialist.
Shock — A reduction of blood flow in the body caused by loss of blood and/or fluids. Can be fatal if not treated quickly.
Temporomandibular joint — The mandible attaches to the temporal bone of the skull and works like a hinge.
Temporomandibular joint syndrome — TMJ Syndrome refers to an incorrect alignment of the lower jaw to the skull which causes the bite to be off line. It causes chronic headaches, nausea, and other symtoms.
Vermilion border — The line between the lip and the skin.
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American Association of Oral & Maxillofacial Surgeons. 9700 W. Bryn Mawr Ave., Rosemont, IL 60018. (847) 678-6200.
Brain Injury Association, Inc. 105 N. Alfred St., Alexandria, VA 22314. (703) 236-6000. http://www.biausa.org..
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injury to the jaw and face. Fractures requiring reconstructive surgery tend to occur most frequently in motor vehicle collisions and short falls.