Emergency Medicine

TRAUMATIC CONDITIONS OF THE FACE AND MOUTH

Maxillofacial and Dental Emergencies 431

MANAGEMENT

1 Try to gently reduce without sedation if recurrent in the absence of a fracture.
(i) Give midazolam 0.05–0.1 mg/kg i.v. or diazepam 0.1–0.2 mg/kg
i.v. with a second doctor and full resuscitation facilities available
if unsuccessful.

2 Reduction of the dislocation:
(i) Stand in front of the patient and place your gauze-wrapped
thumbs inside the mouth over the posterior molar area, with
your fingers under the chin.
(ii) Press firmly downwards to distract the condyle applying pressure
to the angle of the jaw, then push backwards and up to relocate
the condyle in the fossa.
(iii) Reduce one side at a time in bilateral dislocations.
(iv) Repeat the X-ray to confirm reduction, and refer to the next
maxillofacial surgery clinic. Advise the patient to avoid excessive
mouth opening.
(v) Apply a barrel bandage to discourage wide opening if the
dislocation is recurrent or required midazolam or diazepam i.v.

Fracture of the zygoma or zygomaticomaxillary (malar) complex

DIAGNOSIS

1 This injury is due to a direct blow to the cheek, which may fracture the
zygomatic arch in isolation, or cause a ‘tripod’ fracture to the zygo-
maticomaxillary (malar) complex that extends through three structures:
(i) Superiorly through the zygomaticofrontal suture.
(ii) Laterally through the zygomatic arch or zygomaticotemporal
suture.
(iii) Medially through the zygomaticomaxillary suture or the
infraorbital foramen region.

2 There is flattening of the cheekbone (malar process) best seen from above
which may become masked by oedema, epistaxis, subconjunctival haemor-
rhage extending posteriorly, and infraorbital nerve paraesthesia.
(i) Jaw movement may be limited if the coronoid process is
obstructed under the zygomatic arch.

3 Although these fractures are best diagnosed clinically by finding focal bony
tenderness, request facial X-rays including occipitomental views (OM 10°
and OM 30°).
(i) Look carefully for the fractures, comparing with the normal side, or
(ii) Look for secondary evidence of injury, e.g. opacity of the
maxillary antrum from bleeding into the maxillary sinus or
overlying soft-tissue swelling.