Facial Trauma

Original Editor - User: Wendy Walker

Top Contributors - Wendy Walker, Jess Bell, Tarina van der Stockt, Kim Jackson, Ewa Jaraczewska, Lucinda hampton, Wanda van Niekerk, Aminat Abolade, Nupur Smit Shah and Rishika Babburu  

Introduction

Trauma to the face and head can be caused by a number of events: explosions, gunshot, road traffic accidents (RTAs), falling masonry, flying glass, sports injuries, and blunt force trauma. Soft tissue injury comprises lacerations, abrasions and avulsions.

There can be:

• Bony damage - fractures can occur in any of the bones of the head and face, but are particularly common in the mandible and nose - and also soft tissue injury. CT scanning is essential for diagnosis as this shows fractures of facial bones more reliably than plain X-ray, and also shows soft tissue injury.
• Facial Nerve or the Trigeminal Nerve damage may occur with facial and head trauma.
• Direct damage to the eye.
• It is important to be aware that a number of patients who suffer trauma to the face also suffer from brain injury, and some have co-existing cervical spine injury.

Initial repair following serious facial trauma is performed by surgeons: fractured bones will be plated or wired; skin and soft tissue lacerations will be stitched; large areas of severe soft tissue damage may require grafting.

The physiotherapy rehabilitation of these patients is thus largely post-operative rehabilitation.

Epidemiology

The main causes of facial trauma are road traffic accidents, falls, assaults and sports injuries. Many studies from different countries show that world-wide the prevalence of facial trauma is considerably higher in men than women, It is clear that the causes of maxillofacial injuries vary from one country to another, and even within the same country as a result of environmental, socioeconomic and cultural factors.

Developing Countries

In developing countries which have a high usage of motorised vehicles, RTAs account for up to 93% of facial injuries, with a high proportion of these involving motorcycles. One study reports that as many as 50 to 70% of RTA survivors suffer from facial trauma. In countries where motorcycles are a major form of transport, such as Malaysia, RTAs involving motorcycles, are the biggest single cause of facial trauma.

Developed Countries

One large study in Austria found that the causes of maxillofacial injury were: in 38% of cases, an activity of daily life, in 31% sports, in 12% violence, 12% RTA, 5% work accidents, 2% other causes.

Initial Stages

The face has a very rich blood supply, so healing is usually rapid.

Soft Tissue Injury

In areas of thin skin (eg. the eyelids) sutures can normally be removed after just 3-4 days, and elsewhere on the face, they are often removed after 6 days. Sutures in cartilage, for example, the ear or the nose, are often left in situ for 10-14 days.

Lacerations are frequently treated with sutures, but if large areas of skin and muscle have been severely damaged, skin graft surgery will be required.

Bony Injury

For more information on the bones of the face, see the Facial Skeleton page.

Surgical repair is often required for a bony injury, which may involve wiring or plating, or more substantial surgical techniques to rebuild the damaged bone, such as bone grafting.

Illustration of bones of the face: maxilla, mandible, nasal and zygomatic.

Surgical Interventions

Maxillary Repair

The maxilla bone forms the upper jaw and houses the upper teeth. It forms the hard palate, as well as the floor of the eye socket. Fractures of the maxilla may require surgical intervention, plating or wiring.

Mandibular Repair

The mandible, AKA jaw bone, is frequently injured in facial trauma. It is the only moving bone in the face, and it houses the lower teeth.

In some cases, Mandibular Maxilla Fixation, MMF, may be required - this involves wiring the jaws closed while the bony healing occurs.

Later Stages

Once the surgical repair techniques have been completed, the body continues the healing, producing scar tissue.

• The proliferation phase (AKA fibroblastic phase) of scar tissue lasts for 2-3 weeks, and it is in this phase that the majority of the scar tissue, collagen, is laid down; after this time there is a slowing of proliferation for the next 4-6 months.
• This is followed by the remodelling (AKA maturation) phase, when the scar tissue continues to rebuild and remodel, becoming more organised and functional, and more similar to the tissue it is repairing. This process continues for up to a year.

Please see the Soft Tissue Healing page for more details on scar tissue formation.

Characteristics of Facial Muscles

The facial muscles have different characteristics compared to muscles in the trunk and limbs:

• They have a more complex pattern of innervation of extrafusal fibres
• They have a larger percentage of slow-type nerve fibres
• Many facial muscles insert not into bone or fascia, but into the skin
• Many facial muscles are very thin in structure and are poorly differentiated, merging with other facial muscles

Physiotherapy Following Facial Trauma

Rehabilitation should begin as soon as the surgeons permit it.

The aim of physiotherapy is to restore as much facial range of movement as possible, which will result in the restoration of facial function.

Clinical Presentation

Any of the following may occur, often several in combination:

• Reduced facial range of movement
• Inability or reduced ability to close the eye
• Inability or reduced ability to move the lips eg. into a smile, pucker
• Inability to bite or chew
• Asymmetry of the facial structures
• Difficulties keeping food in the mouth when eating
• Difficulties forming a lip seal on a vessel when drinking
• Dry eye
• Dry mouth
• Reduction in non-verbal communication through facial expression

Rehabilitation

Manual Techniques

Manual techniques to the soft tissues are frequently utilised, with the aim of restoring the flexibility of the soft tissues. The nature of scar tissue means that as it heals there is a tendency for loss of both elasticity and length, and this can result in a reduced range of movement.

Gentle passive stretching techniques can be used to lengthen the tissues.

Injury to the eye and the surrounding area can be problematic: if the eyelid is injured, as it heals and shortens, it may result in insufficient passive length resulting in incomplete eye closure. This in turn means that the eye itself is at risk of being damaged. The tissues of the eyelid are extremely thin, and with careful, gentle stretching techniques the length can be restored.

Active Exercises

Once tissue length is established, the patient should be encouraged to move the affected area of the face actively through the newly gained range.

Electrotherapy

While several electrotherapeutic techniques are known to improve soft tissue healing, the face is such a vascular area that in the majority of cases these are not required as the tissue spontaneously heals swiftly and well.

Temporomandibular Joint [TMJ] Rehabilitation

• Active and passive joint movements are considered to be an important part of post-operative exercise rehabilitation and long term follow up is recommended
• Active exercises to increase TMJ range of movement. These should include all TMJ movements:
  • depression of the mandible = mouth opening
  • elevation of the mandible = mouth closing
  • lateral movement of the mandible - these actions are used in chewing
  • protraction of the mandible
• There are 4 muscles of mastication which act on the TMJ:
• Masseter, Temporalis, Lateral Pterygoid and Medial Pterygoid
• Of the 4 muscles which act on the TMJ, the masseter is the strongest, its action is to close the mouth. If the temporomandibular joint and/or the masseter is injured, the patient will initially have marked weakness of the chewing action.
• There is only one muscle which produces opening of the mouth/mandible depression: Lateral Pterygoid. Injuries to this muscle produce difficulty and weakness in closing the mouth
• Learn more about TMJ Disorders, assessment, and management

Rehabilitation for Injured Facial Muscles

Injury to the muscles of the upper face can result in difficulties closing the eye; protection of the eye is of paramount importance. The sphincter muscle of which closes the eye is called orbicularis oculi, so if this muscle is damaged they eye may remain open and be unable to close.

Trauma to the lower facial muscles frequently causes difficulties in eating and drinking. The orbicularis oris muscle controls the movement of the lips, and if injured the person may struggle to drink out of a cup or glass without spilling the fluid, as well as having problems with keeping food in the mouth when eating.

Nerve Injury Rehabilitation - Trigeminal Nerve

Damage to the Trigeminal Nerve results in loss of sensation to the skin of the face. Of the three branches of the Trigeminal Nerve, the 3rd branch, V3 known as the Mandibular nerve, is the only one which carries motor fibres; the other two branches, V1 Ophthalmic Nerve and V2 Ophthalmic Nerve, carry only sensory fibres. Thus if the Mandibular nerve is damaged, the power of the chewing function is affected.

Active exercises, and in some cases even Trophic Electrical Stimulation, will be required to restore function and improve ease of eating.

Nerve Injury Rehabilitation - Facial Nerve

Trauma to the cheek region can easily result in damage to the facial nerve. Surgical exploration is required to evaluate the condition of the nerve: if it is completely transected, surgical repair or even nerve graft will be performed, and the recovery of active movement will be delayed as the axons grow through the repaired nerve at a rate of approximately 1mm per day.

There are a series of pages on this topic; the main one to consult is the Facial Palsy page.

Very often, if the facial nerve is damaged, the orbicularis oculi muscle is unable to contract, which results in the patient being unable to close the eye, and the eye will not produce tears as this function is also supplied by the facial nerve. The person will need to be taught appropriate eye care (see the Dry Eye page for more detail) including use of artificial lubrication products and how to tape the eye closed at night.

Psychological Effects of Facial Trauma Injury

The disfigurement caused by facial injuries can lead to psychological difficulties, ranging from depression, anxiety, a tendency to become socially isolated and in some cases increased hostility. A number of patients report they experience social stigma.

Post-traumatic stress disorder PTSD, can occur following facial trauma. One study found that 23% of patients continued to suffer from PTSD one year after the incident.