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The maxillofacial specialist performs the proper treatment of facial injuries.  These professionals must be well versed in emergency care, acute treatment and long term reconstruction and rehabilitation – not just for physical reasons but emotional as well.  Oral and Maxillofacial Surgeons are trained, skilled and uniquely qualified to manage and treat Facial Trauma. Injuries to the face, by their very nature, impart a high degree of emotional, as well as physical trauma to patients.  The science and art of treating these injuries requires special training involving a “hands on” experience and an understanding of how the treatment provided will influence the patient’s long term function and appearance. 

Dr Matouk meets and exceeds these modern standards.  He is on staff at local hospitals and delivers emergency room coverage for facial injuries, which include the following conditions:

     
 
  • Facial lacerations
  • Intra oral lacerations
  • Avulsed (knocked out) teeth
  • Fractured facial bones (cheek, nose or eye socket)
  • Fractured jaws (upper and lower jaw)
 
     

The Nature of Maxillofacial Trauma

There are a number of possible causes of facial trauma such as motor vehicle accidents, accidental falls, sports injuries, interpersonal violence and work related injuries. Types of facial injuries can range from injuries of teeth to extremely severe injuries of the skin and bones of the face. Typically, facial injuries are classified as either soft tissue injuries (skin and gums), bone injuries (fractures), or injuries to special regions (such as the eyes, facial nerves or the salivary glands).

The proper treatment of facial injuries is now the realm of specialists who are well versed in emergency care, acute treatment, long term reconstruction and rehabilitation of the patient.

Types of Injuries

     
 

Soft Tissue Injuries of the Maxillofacial Region

When soft tissue injuries such as lacerations occur on the face, they are repaired by suturing. In addition to the obvious concern of providing a repair that yields the best cosmetic result possible, care is taken to inspect for and treat injuries to structures such as facial nerves, salivary glands and salivary ducts (or outflow channels). Dr. Matouk is proficient at diagnosing and treating all types of facial lacerations.

 
     

Bone Injuries of the Maxillofacial Region

Fractures of the bones of the face are treated in a manner similar to the fractures in other parts of the body. The specific form of treatment is determined by various factors, which include the location of the fracture, the severity of the fracture, the age and general health of the patient. When an arm or a leg is fractured, a cast is often applied to stabilize the bone to allow for proper healing. Since a cast cannot be placed on the face, other means have been developed to stabilize facial fractures.

One of these options involves wiring the jaws together for certain fractures of the upper and/or lower jaw. Certain other types of fractures of the jaw are best treated and stabilized by the surgical placement of small plates and screws at the involved site. This technique of treatment can often allow for healing and obviates the necessity of having the jaws wired together. This technique is called "rigid fixation" of a fracture. The relatively recent development and use of rigid fixation has profoundly improved the recovery period for many patients, allowing them to return to normal function more quickly.

The treatment of facial fractures should be accomplished in a thorough and predictable manner. More importantly, the patient's facial appearance should be minimally affected. An attempt at accessing the facial bones through the fewest incisions necessary is always made. At the same time, the incisions that become necessary, are designed to be small and, whenever possible, are placed so that the resultant scar is hidden.

     
 

Soft Tissue Injuries of the Maxillofacial Region

When soft tissue injuries such as lacerations occur on the face, they are repaired by suturing. In addition to the obvious concern of providing a repair that yields the best cosmetic result possible, care is taken to inspect for and treat injuries to structures such as facial nerves, salivary glands and salivary ducts (or outflow channels). Dr. Matouk is proficient at diagnosing and treating all types of facial lacerations.

 
     

Injuries to the Teeth and Surrounding Dental Structures

Dentoalveolar traumas involve injuries to the teeth and the surrounding bone. Isolated injuries to the teeth are quite common and are usually treated by your general dentist. Sometimes these injuries require the expertise of various dental specialists. Oral surgeons usually are involved in treating fractures in the supporting bone or in replanting teeth that have been displaced or knocked out. Teeth that have been "knocked out " (avulsed) can be saved if replaced and properly splinted in an timely fashion.

In the event of an avulsed tooth one should:

Find the tooth and rinse it gently in cool water. (Do not scrub it or clean it with soap - just use water). Never attempt to wipe the tooth off, since remnants of the ligament that hold the tooth in the jaw are attached and are vital to the success of replanting the tooth.  If possible, replace the tooth in the socket and hold it there with clean gauze or a washcloth. If you can’t put the tooth back in the socket, place the tooth in a clean container with milk, saliva, or water. Call your dentist immediately to have the tooth replaced and splinted. Time is of the utmost importance, the faster you act, the better chance of saving the tooth. Dentoalveolar fractures involve the teeth and its surrounding bony housing. These injuries usually require the expertise of oral and maxillofacial surgeons. Treatment involves reducing the fracture (placing the involved segment in the proper anatomic position) along with stabilization and immobilization of the bony segments. This requires splinting, bonding or wiring the segment to the adjacent uninvolved teeth.

Other dental specialists may be called upon such as endodontists, who may be asked to perform root canal therapy, and/or restorative dentists who may need to repair or rebuild fractured teeth. In the event that injured teeth cannot be saved or repaired, dental implants are often now utilized as replacements for missing teeth.

Some dentoaveolar trauma cannot be anticipated or prevented but if you or your child is involved in sports where collisions can occur an athletic mouth guard should be used. The athletic mouth guard is clearly one of the most effective pieces of equipment available with documented effectiveness against dental trauma and concussion. There are several types of mouth guards available but the custom-fitted mouth guard is much more desirable in sports with continuous activity such as basketball and soccer.

Figure 1. Dentoalveolar Trauma

Mandible Fractures

Mandible fractures are lower jaw fractures. The specific anatomic location of the fracture is dependent on the mechanism of injury and direction of the traumatic blow. For instance, an impact of the chin region (symphysis) may result in a fracture in that location but the force may also result in a fracture at a distant sight. Patients commonly present with fractures of both the symphysis and subcondylar area (just below the jaw joint) region. Another common sight for fractures to occur is in the angle region of the mandible through impacted wisdom teeth that have not been previously removed.

One of the most important aspects of surgical correction of mandible fractures is restoration of the pre-injury occlusal relationship. The teeth are first aligned and then the upper and lower jaws are temporarily wired together establishing the proper occlusion. The devices used to wire the teeth together are termed arch bars and are similar to braces. Once the occlusion has been established, depending on the nature of the fracture, a bone plate is surgically placed across the fracture site (open reduction) aiding in stabilization of the fracture. At this point, the teeth are unwired, and the occlusion is checked for accuracy. When an open reduction is performed most patients do not have to have their teeth wired together (termed intermaxillary fixation) after the operation. There are some fractures that do not require an open reduction and are best treated with placement of arch bars and a period of post-operative intermaxillary fixation. The surgeon will determine which is the best treatment on a case-by-case basis. Post operative care for mandible fractures is similar to that described in the section on orthognathic surgery.

Figure 2. Subcondylar Fracture, left; Angle of Mandible Fracture, right.

LeFort I, II, and III Fractures

The diagram in figure 3 demonstrates the location of LeFort I, II and III fractures. All LeFort fractures affect the occlusal relationship. Therefore, a primary goal in the treatment of these fractures is the restoration of the occlusal relationship. Principles of treatment are similar to those in the treatment of mandible fractures. All LeFort II and III level fractures involve the bony orbit and can therefore result damage to the eye. Fractures of this type all require careful ophthalmologic evaluation as well. As a general rule, all midface fractures should have an ophthalmologic evaluation prior to surgical intervention.

Figure 3a. LeFort I Fracture, frontal view on the left, lateral view on the right.

Figure 3b. LeFort II Fracture, frontal view on the left, lateral view on the right.

Figure 3c. Lefort III Fracture, frontal view on the left, lateral view on the right.

Zygoma Fractures

Patients with fractures of the zygoma often present with pain, difficulty opening, visual changes and cosmetic defects. Displaced zygoma fractures can mechanically obstruct the normal movement of the mandible, resulting in limited opening. Zygoma fractures involve the orbit and the bony fracture segments can impinge the muscles responsible for movement of the eye resulting in diplopia (double vision) and other visual changes. It is therefore extremely important to obtain precise realignment of the fractured bone to prevent long-term visual changes. Noticeable flattening of the cheekbone occurs with displaced zygoma fractures and can be prevented with precise reduction and fixation of the fracture. Isolated zygoma fractures do not directly involve the occlusion and patients may resume a normal diet after they have been repaired.

Figure 4. Zygoma Fractures (cheekbone fractures)

Figure 5. Nasal-Orbital-Ethmoid Fractures

Nasal-Orbital-Ethmoid Fractures

     
 

The nasal-orbital-ethmoid area is bordered by the orbital cavities laterally. Anteriorly, the space is demarcated by the frontal process of the maxilla, the nasal bones, and the frontal process of the frontal bone. Posteriorly, the boundary is the anterior aspect of the sphenoid bones and the roof is formed by the cribriform plate of the ethmoid bone. Injuries to this region of the facial skeleton generally occur from a direct frontal force. The diagnosis of fractures in this region is usually made by physical findings aided by a CT scan.

Routine films often fail to demonstrate the degree and location of the disruption. Special considerations of fractures in this region involve assessment of the lacrimal apparatus (tear duct system) and injury to the canthal ligaments. Disruption of the canthal ligaments can result in traumatic telecanthus (apparent widening of distance between the eyes). Treatment of nasal-orbital-ethmoid injuries must be directed toward the proper reduction of the nasal fractures, the correction of the medial canthal ligament disruption, and the correction of traumatically induced lacrimal system abnormalities.

 
     

Orbital Floor Fracture

The classic orbital blowout fracture, by definition, implies an intact orbital rim and a disruption of one of the walls or floor of the orbit. If the floor or the orbit is fractured and displaced one may experience prolapse of the orbital tissues into the maxillary sinus. Diplopia, entrapment of infraorbital tissues (resulting in inability to move the eye) and enophthalmos ("sunken eye") can result when these fractures occur. Again, treatment involves reduction of the fractures, which usually requires an open reduction and repair of the defect with a graft material. The reason for repairing a defect with a graft is to support the orbital contents in the correct anatomical position. There have been many different materials used to repair orbital blowout fractures. Alloplasts are frequently used to reconstruct the orbital floor. Among then have been methyl methacrylate, Teflon, Silastic and titanium. Autogenous bone grafts are also used for orbital reconstruction but are generally for more complex reconstructions. There are a variety of graft sites available to obtain autogenous bone. If a large quantity of bone is needed hipbone is often used. Other sites include the cranium, tibia, rib and intraoral sites as well.

Figure 6. Orbital Floor Fractures (orbital blowout fractures)