18.3 Maxillofacial Trauma
Key Takeaways
- Trauma priorities are airway, breathing, circulation, and cervical-spine precautions before definitive dental repair; bilateral mandible fractures and severe midface injuries can threaten the airway.
- Le Fort I is a low floating maxilla pattern; Le Fort II is pyramidal through the nasal/infraorbital region; Le Fort III is craniofacial disjunction with the face mobile relative to the skull base.
- Mandible fractures commonly involve condyle, angle, body, and symphysis/parasymphysis sites and are often multiple; malocclusion, step defects, and V3 numbness are key clinical clues.
- Dental trauma is classified into hard-tissue fractures and luxation injuries; avulsed permanent teeth should be replanted as soon as possible and stored in physiologic media if delayed, whereas primary teeth are not replanted.
- Orbital floor blowout presents with diplopia, restricted extraocular motion, and possible enophthalmos—these signs demand urgent specialty evaluation.
18.3 Maxillofacial Trauma
Quick Answer: Trauma care prioritizes ABC (airway, breathing, circulation) and cervical spine precautions before dental details. Classify midface injuries with Le Fort I–III, map mandible fracture sites (condyle, angle, body, symphysis, etc.), and use dental trauma classifications (fracture, luxation, avulsion) to drive urgent vs delayed care. AFK expects pattern recognition and first-response logic more than OR plating recipes.
Primary Survey Mindset (Dentist as First Responder)
Even in a dental office or ER consult:
- Airway — bleeding, foreign teeth/fragments, bilateral mandible fractures with tongue fall-back, midface instability
- Breathing / C-spine — assume cervical injury in high-energy trauma until cleared
- Circulation — hemorrhage control with pressure; facial vessels can bleed briskly
- Neurologic / baseline — consciousness, cranial nerves, pupil checks as appropriate
- Then facial exam, occlusion check, imaging
Never manipulate the neck or delay airway for a perfect dental charting sequence in life-threatening injury.
Soft-Tissue Facial Trauma Basics
- Cleanse, explore for foreign bodies (tooth fragments in lip lacerations—radiograph soft tissue if missing tooth structure)
- Layered closure concepts; tetanus status
- Through-and-through cheek lacerations: consider parotid duct (Stensen) injury near mid-cheek line from tragus to mid-upper lip
- Tongue lacerations: large gaping or bleeding wounds may need suture; small ones often heal well
Le Fort Midface Fractures
Le Fort fractures are classic patterns of maxillary separation from the skull base/craniofacial buttresses (often high-energy).
| Type | Level / pattern | Clinical clues |
|---|---|---|
| Le Fort I | Low horizontal maxillary fracture (floating maxilla / palate-maxilla segment) | Mobility of maxilla/teeth relative to rest of face; malocclusion; maxillary mobility on rocking |
| Le Fort II | Pyramidal fracture through nasal bridge, lacrimal, inferior orbital rim/maxilla | Midface mobility including nose; periorbital ecchymosis; possible CSF rhinorrhea risk in higher patterns |
| Le Fort III | Craniofacial disjunction (zygomaticofrontal, nasofrontal, etc.) | Entire face mobile relative to cranium; dish face deformity; severe edema; airway risk; CSF leak possible |
Shared midface findings to remember
- Malocclusion, midface mobility, maxillary vestibular ecchymosis
- Epistaxis, flattened midface, infraorbital nerve paresthesia
- Battle’s sign/raccoon eyes more associated with basilar/orbital injuries—integrate with full trauma exam
- Imaging: CT face is standard in modern trauma; plain films limited
Management concept: stabilize airway, ophthalmology/ENT/OMFS pathways, avoid nasal tubes if midface/basilar concerns dictate alternative airway strategies in emergency settings, definitive fixation by specialists.
Zygomatic and Orbital Injuries (Exam Adjuncts)
| Injury | Key signs |
|---|---|
| Zygomaticomaxillary complex (ZMC) | Flattened cheekbone, step-off, trismus (masseter/temporalis interference), infraorbital nerve numbness |
| Orbital floor blowout | Diplopia, restricted upgaze (entrapment of inferior rectus/soft tissue), enophthalmos, V2 numbness |
| NOE complex | Telecanthus, nasal depression—high specialty care |
Diplopia + restricted motion after trauma = urgent specialty evaluation (muscle entrapment).
Mandible Fracture Sites
The mandible is a U-shaped bone; force often causes multiple fractures (e.g., body + opposite condyle).
| Site | Why it matters |
|---|---|
| Condyle / subcondyle | Common; risk to occlusion, growth in children, TMJ function; may be closed or open treatment |
| Angle | Often involves third molar region; unfavorable muscle pull can displace |
| Body | Mental nerve/inferior alveolar canal; dental roots may be in line of fracture |
| Symphysis / parasymphysis | Can widen mandible; airway if bilateral with posterior displacement |
| Ramus / coronoid | Less common; coronoid related to temporalis; trismus |
| Alveolar process | Dentoalveolar segment mobility—stabilize teeth/bone segment |
Clinical diagnosis of mandible fracture
- Malocclusion (“teeth don’t fit”)
- Step deformity along border
- Floor-of-mouth ecchymosis (Coleman’s sign) suggests body/symphysis fracture with possible bleeding into floor—airway watch
- Anesthesia in IAN distribution
- Premature posterior contact / anterior open bite patterns with bilateral condylar fractures
Favorable vs unfavorable (angle fractures—concept)
Muscle vectors (masseter, medial pterygoid, temporalis, suprahyoids) determine whether fragments are pulled into reduction (favorable) or out of reduction (unfavorable). Unfavorable fractures more often need open reduction internal fixation (ORIF).
Immediate dental office actions
- Soft diet if stable and referred promptly
- Avoid forcing occlusion
- Analgesia, antibiotics when compound (fracture through tooth socket/periodontal ligament into mouth is open fracture—antibiotic consideration)
- Tetanus update if indicated
- Urgent OMFS referral for displaced, open, or airway-threatening injuries
Dentoalveolar Trauma Classification
Use standardized systems (WHO / Andreasen-type categories commonly taught):
Hard-tissue injuries
| Injury | Definition / key care point |
|---|---|
| Enamel infraction | Crack without loss—monitor |
| Enamel fracture | Chip—smooth or restore |
| Enamel–dentin fracture | Cover dentin; pulp protection if near pulp |
| Enamel–dentin–pulp fracture | Vital pulp therapy vs RCT by apex/maturity |
| Crown–root fracture | Often complex; fragment removal ± extrude/extract |
| Root fracture | Location matters (apical third better prognosis); reposition & splint per guidelines |
Periodontal (luxation) injuries
| Injury | Features | Urgency note |
|---|---|---|
| Concussion | Tender, no displacement | Monitor pulp |
| Subluxation | Mobility, bleeding from sulcus, no displacement | Flexible splint sometimes |
| Extrusive luxation | Partial displacement out of socket | Reposition & splint; pulp risk high |
| Lateral luxation | Displacement with bony lock | Reposition; often alveolar fracture |
| Intrusive luxation | Driven into bone | Severity by depth; immature vs mature apex pathways differ |
| Avulsion | Complete displacement out of socket | Time-critical for permanent teeth |
Avulsion of permanent teeth (high-yield overlap with endodontics)
- Handle crown, not root
- Replant ASAP if clean permanent tooth; if contaminated, gentle rinse with saline
- Storage media if cannot replant immediately: milk, Hank’s balanced salt solution, saline, saliva—not dry tissue
- Flexible splint typically ~2 weeks (guideline-dependent)
- Tetanus, antibiotics often considered
- Pulp management by open/closed apex and extraoral dry time
- Primary teeth: do not replant (risk to permanent successor)
Alveolar Process Fractures
Mobile segment of teeth + bone moving as a unit. Reposition under anesthesia and splint (typically longer than simple luxation—often ~4 weeks). Check occlusion and pulp status serially.
Imaging Choices in Trauma
| Situation | Modality concept |
|---|---|
| Dental trauma, isolated | Periapicals ± occlusal; panoramic adjunct |
| Suspected mandible fracture | Panoramic screening; CT if complex/OR planning |
| Midface / orbital | CT face with coronal/sagittal reconstructions |
| Soft-tissue tooth fragment | Soft-tissue radiograph of lip |
Pediatric Trauma Notes
- Mixed dentition occlusion can confuse “malocclusion” assessment—compare midline and wear facets
- Condylar fractures in children: growth disturbance risk; favor function-preserving approaches
- Intrusion of primary teeth: watch permanent bud; avoid aggressive replantation of primary avulsions
Rapid review list
- ABC + C-spine before occlusion perfection
- Le Fort I floating maxilla; II pyramidal; III craniofacial disjunction
- Mandible: condyle, angle, body, symphysis—often multiple sites
- Open mandible fracture through socket → infection risk pathway
- Dental trauma: hard tissue vs luxation vs avulsion
- Permanent avulsion: replant ASAP; store in milk/HBSS; primary teeth not replanted
- Orbital blowout: diplopia/restricted gaze → urgent specialty care
- CT for midface; don’t miss airway in bilateral mandible fractures
Section 18.4 integrates chronic orofacial pain/TMD with acute dental emergency triage that often presents alongside surgical problems.
A high-energy trauma patient has a mobile maxilla at a low horizontal level with the palate/teeth moving as a unit relative to the rest of the midface, without craniofacial disjunction. Which Le Fort pattern best fits?
Which clinical finding is most concerning for a mandible fracture requiring urgent attention rather than routine delayed dental follow-up alone?
An 8-year-old avulses a primary maxillary central incisor 20 minutes ago. The parent brings the tooth in milk. What is the correct management principle?
After blunt trauma to the orbit, a patient has diplopia and restricted upward gaze. Which injury pattern is most likely?