Facial Trauma

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (27/10/2020)

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  

One Page Owner - Wendy Walker as part of the One Page Project

Introduction

Trauma to the face and head can be caused by a number of events: explosions, gunshot, road traffic accidents, 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 and head trauma can also cause damage to the Facial Nerve or the Trigeminal Nerve.

In addition there may be direct damage to the eye.

It is important to be aware that a number of patients who suffer trauma to the upper regions of 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 is road traffic accidents (RTAs), followed by 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 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.

Bony Injury

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

Surgical repair is often required for 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.

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.

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 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 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 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 being 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 in closing the mouth.

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 approx 1mm per day.

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