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 injury may also prevent the passage of air or be severe enough to cause a concussion or more serious brain damage.
Athletes are particularly at risk of maxillofacial injuries; one researcher estimates that 10.4 percent of all fractures of the facial bones are related to sports. 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. Burns to the face are also categorized as
.
Demographics
About 3 million injuries to the face and jaw occur in the United States each year. Falls account for 78 percent of facial injuries in preschoolers and 47 percent of such injuries in children between the ages of six and 15. In older adolescents and adults, violent crime or other personal assaults account for almost 50 percent of facial injuries, with automobile accidents accounting for 29 percent and sports-related accidents for another 11 percent. One researcher estimates that about 2 percent of all children or adolescents who participate in sports eventually suffer a facial injury severe enough to require medical attention. Patients between the ages of 17 and 30 are more likely to suffer facial injuries from gunshot wounds, while older adults are more likely to be injured by attacks with blunt objects. About 10 percent of facial injuries in young children are caused by parental abuse.
Children who grow up on farms are at significant risk for injury by animals. Of one group of 96 children who required inpatient treatment for head or facial injuries, 39 had been kicked or bitten by horses or other farm animals. Another 37 children had been injured by farm machinery, most commonly a tractor.
Causes
Automobile accidents are a major cause of maxillofacial trauma, as well as participation in sports, fights, and other violent acts. Athletes may sustain facial injuries from colliding with other players (as in football or rugby), from direct contact with equipment (baseball bats, hockey sticks, goal posts, parallel bars, etc.), or from contact with other objects related to the sport (baseballs, hockey pucks, lacrosse balls, skis, etc.) People most at risk are athletes, anyone who drives a vehicle or rides in one, and those who live on farms, do dangerous work, or engage in aggressive types of behavior.
Animals are a common cause of maxillofacial trauma. Horses and other large farm animals can cause severe injury to the face and jaw from kicks or bites. In addition, some large pet dogs can bite hard enough to fracture a small child's facial bones.
Domestic violence and abuse is also a common cause of facial injuries in children and adolescents.
Symptoms
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. Symptoms of a fractured nose 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 include pain, redness, and possibly blisters, fever, and headache. Extensive burns can cause the victim to go into shock. In that situation, the person will have low blood pressure and a rapid pulse.
Symptoms of traumatic brain injury include problems with thinking, memory, and judgment as well as mood swings and difficulty with coordination and balance. These symptoms may linger for weeks or months and in severe cases can be permanent. Double vision for months after the injury is not uncommon.
When to call the doctor
Parents should call 911 or take their child to an emergency room at once in the event of a facial injury. The following describe emergency situations that require immediate medical care:
The child or adolescent is bleeding profusely.
The patient is having difficulty breathing normally.
The child or adolescent has lost consciousness or is comatose.
The patient is nauseated and vomiting.
There are penetrating injuries of the skin, ear, or eye.
The injury involves a gun, blunt instrument, or animal or human bites.
The child is seeing double, has other visual disturbances, or staggers when trying to walk.
Blood or watery fluid is leaking from the child's nose or ears.
Diagnosis
Maxillofacial trauma is often diagnosed and treated by specialists in emergency medicine. About 50 percent of patients with facial injuries have suffered trauma to other organ systems or other parts of the body, however, and may need care from specialists in ophthalmology, plastic surgery, otolaryngology, trauma surgery, oral surgery, and psychiatry as well as from doctors with specialized training in emergency medicine. Injuries to the face and jaw area require special attention because they involve the senses of sight, hearing, taste, and smell as well as such vital functions as breathing. From a psychological perspective, maxillofacial trauma can be additionally upsetting if the patient's appearance is permanently affected.
The doctor will begin by taking a history, either from the patient if he is able to talk or from the parents or other witnesses. In the case of a known accident, sports injury, or assault, the doctor begin with the ABCs, which means that he or she will check the child or adolescent's airway, breathing, and circulation. The doctor will usually have the patient sit upright or lie on one side and will remove blood clots, broken teeth, vomitus, or other foreign bodies from the nose or throat. He or she will then carry out a systematic examination of the patient's face and head. The most common pattern of examination moves from the inside of the nose and mouth to the outside of the face, and from the bottom of the face to the top.
The doctor looks for signs of bruising and tissue swelling as well as bleeding and gently palpates, or touches, the various facial bones for movement and stability. If the doctor suspects that the nose is fractured, he or she will listen for crepitus (a crackling sound) when the nose is gently moved and will look for evidence of a dislocated septum or a septal hematoma, which appears as a bluish bulging mass within the nasal septum. The child's teeth will be examined for looseness, and the muscles and nerves of the face will be evaluated. If there is a discharge from the nose, the doctor will look at it to see whether it contains cerebrospinal fluid, which would indicate damage to the bones of the skull as well as the nasal bones. Lastly, the doctor examines the patient's eyes to make sure that the pupils are responding normally to light and that the patient is not seeing double or having other visual problems that might indicate nerve damage or damage to the eye itself.
In cases involving animal kicks, bites, or other tearing or crushing injuries to the skin and external tissues of the face and jaw, the doctor carefully cleanses the broken skin with soap and water or benzalkonium chloride and checks for fractured facial bones.
Emergency room doctors are required by law to report to local law enforcement authorities cases of suspected family abuse.
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.
Parental concerns
Parental concerns regarding maxillofacial trauma depend on the cause and severity of the injury. Minor bruises and uncomplicated fractures caused by accidents generally heal without problems and are quickly absorbed into the family's routine. Complex fractures or
other injuries requiring a second operation may require explanation or discussion with the child. Facial injuries, particularly repeated injuries related to the neighborhood or farm setting, lifestyle choices, or family violence, however, suggest the importance of professional counseling and changes in the family's structure, geographical location, or level of functioning. Children or adolescents who are severely disfigured by facial injuries may require extra reassurance from family members as well as professional counseling in order to cope with their changed appearance.
BOOKS
"Fractures of the Nose." Section 7, Chapter 86 in The MerckManual of Diagnosis and Therapy, edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck Research Laboratories, 2002.
PERIODICALS
Alvi, A., T. Doherty, and G. Lewen. "Facial Fractures and Concomitant Injuries in Trauma Patients." Laryngoscope 113 (January 2003): 102–6.
Delilbasi, C., et al. "Maxillofacial Fractures Sustained During Sports Played with a Ball." Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 97 (January 2004): 23–7.
Gordy, F. M., N. P. Eklund, and S. DeBall. "Oral Trauma in an Urban Emergency Department." Journal of Dentistry for Children (Chicago) 71 (January–April 2004): 14–6.
Haug, R. H., L. L. Cunningham, and M. T. Brandt. "Plates, Screws, and Children: Their Relationship in Craniomaxillofacial Trauma." Journal of Long-Term Effects of Medical Implants 13 (2003): 271–87.
King, R. E., J. M. Scianna, and G. J. Petruzzelli. "Mandible Fracture Patterns: A Suburban Trauma Center Experience." American Journal of Otolaryngology 25 (September–October 2004): 301–7.
Smith, G. A., et al. "Pediatric Farm-Related Injuries: A Series of 96 Hospitalized Patients." Clinical Pediatrics 43 (May 2004): 335–42.
Tu, A. H., et al. "Facial Fractures from Dog Bite Injuries." Plastic and Reconstructive Surgery 109 (April 1, 2002): 1259–65.
ORGANIZATIONS
American Academy of Family Physicians (AAFP). 11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site: <www.aafp.org>.
American Academy of Otolaryngology—Head and NeckSurgery. One Prince Street, Alexandria, VA 22314–3357. Web site: <www.entnet.org>.
American Association of Oral & Maxillofacial Surgeons. 9700 W. Bryn Mawr Ave., Rosemont, IL 60018. Web site: <www.acoms.org>.
American College of Sports Medicine (ACSM). 401 West Michigan Street, Indianapolis, IN 46202–3233. Web site: <www.acsm.org>.
Brain Injury Association Inc. 105 N. Alfred St., Alexandria, VA 22314. Web site: <www.biausa.org>.
WEB SITES
Parsa, Tatiana, et al. "Initial Evaluation and Management of Maxillofacial Injuries." eMedicine, August 17, 2004. Available online at <www.emedicine.com/med/topic3222.htm> (accessed November 11, 2004).
Ross, Adam T., and Daniel G. Becker. "Fractures, Nasal and Septal." eMedicine, July 13, 2004. Available online at <www.emedicine.com/ent/topic159.htm> (accessed November 11, 2004).
Rupp, Timothy J., Marian Bednar, and Stephen Karageanes. "Facial Fractures." eMedicine, August 29, 2004. Available online at <www.emedicine.com/sports/topic33.htm> (accessed November 11, 2004).
