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Facial Trauma

Facial trauma can be a devastating outcome of accidents, assault and sporting incidents. It has the possibility of causing lifelong issues with function (chewing, speech, and breathing), cosmetic appearance and a patient’s psychology.

The Oral & Maxillofacial Surgeons in this practice are some of the most experienced facial trauma surgeons in the country, including paediatric facial trauma. Their medical and dental knowledge along with their significant experience, means they are capable of repairing and reconstructing not only the facial soft tissues and facial skeleton, but also re-establishing the bite and subsequent replacement of any missing teeth.

The goals of repairing the facial skeleton are to return the patient as close as possible to their pre injury state with regards to form and function. This is ideally done with minimal to no evidence of access on the face. Ideally it is done in cuts hidden in areas not visible externally such as the mouth, skin creases and places such as within the eye lids.

Your facial trauma will often have been diagnosed before seeing your Oral & Maxillofacial Surgeon. Whether you have been seen in an emergency department or by your general practitioner, appropriate imaging (x-rays, CT scan) is usually performed to diagnose the problem.

Not all facial fractures require immediate repair. In fact, it is occasionally appropriate to permit swelling to resolve before deciding if surgery is required. This may be on the day of injury to enable prompt surgery, or possibly even several days later assuming pain control is coordinated. Your Maxillofacial Surgeon will provide you with the best advice on the treatment schedule.

You will be reassured to know that wiring of jaws is seldom employed any more, and most facial fractures are repaired using small titanium plates and screws buried below the tissues. Such plates and screws are often left in place permanently, although may be removed at a later date in growing patients or where further surgery is anticipated in the future (i.e. implant surgery or wisdom teeth removal).

Following your surgery, you will often be referred for postoperative imaging (x-ray, CT scan) to confirm the position of the bones, plates and screws as a result of the surgery. All trauma patients, whether treated or not are usually reviewed at least once. This may to check on healing once swelling has resolved, remove sutures, review the function of tissues such as the eye and check the bite, and numerous other reasons. In paediatric patients, long term growth may be reviewed as this can be influenced by the trauma and surgery.

 

Mandibular or lower jaw fractures can be divided into those of the jaw joint, and those of the tooth bearing areas. Such fractures can lead to changes in biting ability, jaw joint troubles, limited mouth opening, numbness of the lower lip and chin and cosmetic concerns.

 

Fractures of the jaw in areas where teeth lie are usually treated via incisions done within the mouth, and then secured with small titanium mini-plates and screws. Such treatment permits immediate function and avoids the need to ‘wire the jaws’. In saying this, a soft diet is appropriate for several weeks, and it is usually not appropriate to resume contact sport for a minimum of four weeks.

Jaw joint fractures are often observed for a short period prior to any intervention. In many situations, these fractures are not amenable to modern plating techniques, and require ‘surgical braces’ or arch bars to be applied. These wires are secured to the teeth in both upper and lower jaws, and elastics bands are placed between the upper and lower jaws to guide the bit whilst it heals. If the fracture is minimal, small metal screws may be placed in the gums, instead of the archbars, and the elastics are placed between these screws. Your maxillofacial surgeon will show you how to apply these elastics at your review. If your jaw joint fracture includes a larger fragment of bone, your surgeon may surgically reposition and plate the fracture via a small incision behind your lower jaw.

 

Maxillary fractures or those of the top jaw, are classified by a 100 year old classification by ‘Lefort’. They are often in combination with other facial fractures. These sorts of injuries can influence your bite, appearance, nasal breathing and sensation of the cheeks.   There is usually accompanying paraesthesia (numbness) of the cheeks, upper lip and teeth which usually resolves after several weeks to months. Maxillary fractures are usually treated with a combination of archbars or ‘surgical braces’, in addition to miniplates and screws placed via oral incisions.

 

Nasal fractures may be simple fractures of the external nasal bones altering ones appearance, to fractures involving the inner nasal septum or adjacent top jaw (nasomaxillary fracture). They can result in deformity, impaired nasal breathing, and chronic sinusitis. Depending on the extent of the fracture, treatment may involve simple manipulation of the bones without the need for any incisions or open surgery. If adjacent bones are involved, occasionally intraoral incisions are required to reposition and then secure the fracture with mini-plates and screws. You will usually awaken with a splint on your nose which you may be instructed to avoid taking off until your first review.

 

Zygomatic fractures are those of the cheek bone and often involves the adjacent maxilla (top jaw) and orbit (eye socket). Such fractures have the potential to significantly influence your appearance, hinder the ability of the mandible (lower jaw) to open, and alter the position and function of the globe (‘eye ball’). Such a fracture usually is associated with paraesthesia (numbness) of the cheeks, upper lip and chin which will resolve over weeks to months. Depending on the location of the cheek bone fracture surgery may require a less invasive lift via a cut in the hairline, or require miniplates and screws to hold the fracture after repositioning. Access to cheek bone fractures that require open fixation, includes via incisions in the oral cavity, and upper and lower eye lids which are conspicuously hidden.   You will likely remain in hospital overnight after such surgery.

 

Orbital (eye socket) fractures require a site specific blow to the eye. They can result in long term cosmetic and functional issues with the eye. This can include a sunken eye or one that is not at the same level as the non-injured orbit. It can also lead to permanent and troubling double vision. The numbness accompanying such fractures usually resolves after a few months with or without surgery. A particular complexity with orbital fractures is that symptoms may begin to develop several weeks after injury, which is why you will often be reviewed for some time after the injury to monitor for delayed complications. Your surgery may direct you to see a specialist eye doctor or ophthalmologist who will review the globe or eyeball itself. Surgery for such fractures is usually done via a cut inside the lower eye lid or on creases on the face, and it is infrequent for such surgical access to be evident after recovery. The orbital bones are very thin and are not usually amenable to being repositioned and ‘reused’. Therefore they are often ‘replaced’ by other materials to support the eyeball, and these include artificial materials such as plastics and titanium, or even bone from other sites. You will likely be in hospital overnight as nursing staff monitor your eye post operatively. Your surgeon will give you specific post-operative instructions including to avoid nose blowing for at least 2 weeks after injury to avoid facial swelling.

 

Frontal sinus fractures involve the bones of the forehead and have the potential to cause significant cosmetic deformity, in addition to problems with drainage of the frontal sinus which sits behind this bone. You will usually have accompanying numbness of the forehead after such injury. The exact timing of the surgery is often delayed until swelling has resolved, and this may be anywhere from several days to 2 weeks. Surgery for such fractures is complicated and your Maxillofacial Surgeon will explain access for such a fracture. Such injuries are usually repaired with metal plates and screws which cannot be felt or seen after the surgery. You will usually remain in hospital for 1-2 days and a drain may be in place postoperatively but will be removed before you leave hospital. The drain permits removal of swelling from the surgical site. The surgical access for such an injury is usually through incisions in the hair.

 

Injuries of the teeth and tooth supporting structures often accompany such facial fractures. Your Maxillofacial Surgeon is highly trained and capable of managing all aspects of facial trauma including that of the oral cavity. Holistic care will be coordinated with your general dentist, and any other clinicians involved in your care.