Maxillofacial trauma refers to any injury to the face or jaw caused by
physical force, the presence of
, animal or human
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
or more serious brain damage.
Athletes are particularly at risk of maxillofacial injuries; one
researcher estimates that 10.4 percent of all
of the facial bones are related to
. 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
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
, 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 and symptoms
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.
The major symptoms of most facial injuries are
, 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
Symptoms of eye injury or orbital fracture can include blurred or double
vision, decreased mobility of the eye, and
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,
. 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
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:
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
. 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
Treatment of maxillofacial trauma varies according to 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 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.
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.
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
When the eyes have been exposed to chemicals, they must be washed out for
15 minutes with clear water.
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
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 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.
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.
are given to combat infection since the burns make the body vulnerable to
Treatment for a
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
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
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.
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,
, all part of a balanced and nutrient-rich diet, as well as regular
, 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
to enhance healing.
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.
—A scratch on the surface of the cornea.
—A crackling sound.
—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.
—The lower jaw, a U-shaped bone attached to the skull at the
—The bone of the upper jaw which serves as a foundation of the
face and supports the orbits.
—The partition that separates the nostrils.
—The eye socket which contains the eyeball, muscles, nerves, and
blood vessels that serve the eye.
—A doctor who is trained to treat injuries, defects, diseases, or
conditions of the ear, nose, and throat. Also sometimes known as an
—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
—The line between the lip and the skin.
Parental concerns regarding maxillofacial trauma depend on the cause and
severity of the injury. Minor
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.
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11400 Tomahawk Creek Parkway, Leawood, KS 66211–2672. Web site:
American Academy of Otolaryngology—Head and Neck
One Prince Street, Alexandria, VA 22314–3357. Web site:
American Association of Oral & Maxillofacial Surgeons.
9700 W. Bryn Mawr Ave., Rosemont, IL 60018. Web site:
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401 West Michigan Street, Indianapolis, IN 46202–3233. Web site:
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