CHAPTER 25: MANAGEMENT OF FACIAL FRACTURES

ppt / book

evaluation of mandible

bimanual palpation by placing pressure over the mandible posterior and anterior to the fracture area

evaluated by extraorally palpating all areas of the inferior and lateral borders and the temporomandibular joint

evaluation of maxilla

to assess mobility:

• patient’s head should be stabilized by using pressure over the forehead with one hand.

• With the thumb and forefinger of the other hand, the maxilla is grasped; firm pressure should be used to elicit maxillary mobility

general signs and symptoms

bleeding from the mouth

limitation in mouth opening

bony discontinuity, lacerations

blood in external auditory canal

swelling, pain, crepitus, tenderness

ecchymosis, fractured, subluxed, luxated teeth

neurosensory deficits of the inferior alveolar nerve

changes in facial contour or mandibular arch form

periorbital ecchymosis

• bruising around the eye.

• especially when associated with subconjunctival hemorrhage.

• may indicate:

  • orbital rim fracture

  • zygomatic complex fracture

battle sign

bruising behind the ear.

suggests a basilar skull fracture

floor-of-mouth ecchymosis

usually suggests an anterior mandibular fracture

anisocoria

refers to unequal pupil sizes

• in a lethargic patient → may suggest:

  • intracranial bleeding

  • subdural hematoma

  • epidural hematoma

  • intraparenchymal bleeding

  • other intracranial injury

• irregular/asymmetric pupil

  • especially if not round

  • may suggest globe (eyeball) perforation.

• abnormal eye movements

  • may indicate:

    • central neurologic injury involving CN III, IV, or VI

    • mechanical restriction of eye muscles due to orbital fractures

radiographic examination

cephalometric

submentovertex

jug handle view

water’s view

reverse-Towne

cephalometric

lateral projection of the sagittal or median plane

obtained to evaluate the relationship of the oral and facial structures

submentovertex

shows base of the skull

jug handle view

shows zygomatic arches (a modification of the submentovertex view)

water’s view

shows maxillary sinus, frontal and ethmoidal sinuses

reverse-Towne

shows the posterior view of both condylar heads and necks (similar to postero-anterior view)

mandibular bone fractures

comprised 10–25% of all facial fractures

classified and named as to:

• anatomic region

• type of fracture or fracture pattern

• terms associated with TMJ fractures

• direction of muscle pull and angle of fracture

mandibular bone fractures as to anatomic region

condylar neck → most commonly fractured

angle of the MN → second most common

coronoid process → least common

condylar fracture

fracture extending from the sigmoid notch to the posterior border of the ramus

ideal anatomic reduction is not always necessary.

minimal to moderate displacement may still result in good function and occlusion if proper occlusion is maintained during healing

angle

more easily treated through an extraoral approach

fracture between distal aspect of second molar and the posterior attachment of the masseter muscle extending through the inferior border of the mandible

ramus

more easily treated through an extraoral approach.

fracture extending horizontally through the anterior-posterior borders of the ramus

or extending vertically from the sigmoid notch to the inferior border of the mandible distal to the second molar

coronoid process

fracture involving the coronoid process

symphysis

usually accessible through an intraoral approach

fracture involving the area between the lateral incisors extending vertically through the inferior border of the mandible subcon-axillary

parasymphysis

fracture between the mental foramen and the mesial aspect of the canine extending through the inferior border of the mandible

body

may use a combination approach: intraoral incision + small trocar/cannula through the skin.

fracture between the mental foramen and the distal aspect of the second molar extending through the inferior border of the mandible

alveolar

fracture confined to the tooth-bearing segment of bone

anteromedially

A fracture of the condylar neck (subcondylar fracture), will displace the head in what direction

deviation of the mandible on opening = towards the side of the fracture / ipsilateral

mandibular bone fractures as to type of fracture or fracture pattern

simple

compound

greenstick

comminuted

complex

simple fracture

a closed fracture

complete transection of the bone

minimal fragmentation at the fracture site

fracture does not communicate with the external environment

compound fracture

an open fracture

any jaw fracture in a tooth-bearing segment is considered this fracture

fracture communicates with external environment either thru skin or the PDL of a tooth

• communication may occur thru:

  • mucosal tears

  • sinus lining

  • overlying skin laceration

  • gingival sulcus/periodontal ligament

greenstick fracture

bone remains somewhat flexible.

usually has minimal mobility when palpated

common in children due to high organic content

a bone bends and cracks instead of breaking completely

comminuted fracture

ex: gunshot wounds, penetrating objects

bone is broken into multiple segments/fragments

multiple segments of bone as a result of greater force

complex

fracture involving damage to adjacent structures

mandibular bone fractures as to direction of muscle pull and angle of fracture

favorable fracture

unfavorable fracture

favorable fracture

does not separate the fragments

often managed by closed reduction

the fracture line and muscle pull resist displacement.

when muscle contracts, the fractured segments come closer

unfavorable fracture

open reduction may be needed

fracture line and muscle pull displaces the fracture

make a flap through either skin or mucosa to see the bone

separate the fragments and increase the gap of the fracture

line of fracture

determines whether muscles will displace fractured segments from their original position

mandibular bone fractures as to terms associated with TMJ fractures

displaced

dislocated

extracapsular

intracapsular

displaced TMJ fracture

movement of condylar (proximal) segment relative to remainder of the mandible

although the condyle is malpositioned, it is still within the confines of the glenoid fossa and has not ruptured the capsule of the TMJ

dislocated TMJ fracture

the condylar (proximal) segment is no longer within the confines of the glenoid fossa

extracapsular TMJ fracture

fracture not involving capsule of the TMJ

intracapsular TMJ fracture

fracture occurring within the TMJ capsule

Le Fort I midface fractures

aka: Guerin fracture, transmaxillary fracture

usually caused by a horizontal force to the maxilla.

• key features:

  • floating jaw

• fracture passes through:

  • alveolar ridge

  • lateral nose

  • inferior wall of the maxillary sinus

• separates the maxilla from:

  • pterygoid plates

  • nasal structures

Le Fort II midface fractures

pyramidal fracture, with the teeth at the pyramid base, and nasofrontal suture at its apex, force is applied more superiorly.

• key features:

  • CSF rhinorrhea

  • battle’s sign (ecchymosis in mastoid region)

• fracture arch passes through:

  • posterior alveolar ridge

  • lateral walls of maxillary sinuses

  • inferior orbital rim and nasal bones

• separates maxilla + attached nasal complex from:

  • orbital and zygomatic structures

Le Fort III midface fractures

aka: craniofacial disjunction fracture

horizontal force is applied at an even higher level

separation of midface from the cranial base → craniofacial disjunction

• key features:

  • dish face or pan face

  • raccoon eyes (bruising of the eyelids)

  • CSF rhinorrhea and otorrhoea → highest rate of CSF leak

• transverse fracture line passes through:

  • nasofrontal, maxillo-frontal, orbital walls

  • zygomatic arch or zygomaticofrontal sutures

• separates NOE complex + zygomas + maxilla from:

  • the cranial base

zygomatic complex fracture

the most common type of midfacial fracture

fracture of nasal bones, orbital rim or floor areas

usually caused by a blow to the lateral cheek

• key features:

  • bruising, swelling, blow-out fracture

• results when:

  • an object such as fist or baseball strikes the lateral aspect of the cheek

  • isolated fracture of nasal bones, orbital rim or orbital floor areas

• tripod fracture, fracture sites are:

  • zygomaticofrontal (ZF) suture

  • zygomaticomaxillary (ZM) buttress

  • zygomatic arch

• main treatment goals, restore:

  • ocular function

  • nasal function

  • masticatory function

  • facial esthetics

• usually treated with open reduction.

enophthalmos (sunken eye)

caused by blunt trauma to the eye leads to blow-out facture of the orbital floor

timing of treatment

• as soon as possible

• delayed treatment can cause:

  • increased risk of infection and malunion

  • more difficult or incomplete anatomic reduction

  • increased edema, especially during the first 2–3 days

• treatment may be delayed when:

  • the patient has more serious injuries requiring immediate treatment.

  • severe neurologic injury or other conditions increase surgical/anesthetic risk.

  • a short delay is needed for severe edema to decrease.

surgical principles for tx of facial fractures

• reduction of fracture → restoration of the bony segments to their proper anatomic location

  • open reduction (surgical)

  • closed reduction (non-surgical)

• fixation of fracture → immobilization of bony segments at the fracture site

  • internal fixation (inside skin)

  • external fixation (outside skin)

• restore the patient's preoperative occlusion.

• prevent or eliminate infection at the fracture site.

• bony repair should precede soft-tissue repair.

• order of fracture repair:

  • traditionally: mandible → midface

• layered closure:

  • close the wound from inside outward:

    • oral mucosa → muscle → subcutaneous tissue → skin

    
    

surgical principles for tx of mandibular fractures

reduce the fracture properly or place segments into proper relationship with each other

for fractures of tooth-bearing bones, teeth must be placed into the preinjury occlusal relationship

establishing a proper occlusal relationship by wiring teeth together:

• intermaxillary fixation (IMF)

• maxillomandibular fixation (MMF)

IMF or MMF techniques

ivy loops

continuous loop wiring

arch bar fixation → most common

arch bar fixation

most common

prefabricated arch bars are shaped and attached to teeth and secured by circumdental wiring teeth or acid-etch bonding

ivy loops

individual wire passed around specific teeth to create loops

continuous loop wiring

One wire loops around several teeth in a continuous chain

open reduction and internal fixation (ORIF)

best tx for mandibular fractures

surgical principles for tx of midface fractures

basis: bony structures within the face provide primary support or buttress in vertical and anteroposterior directions

these buttresses are reduced then fixated by means of:

• direct wiring

• bone plates

• suspension wiring techniques

buttresses responsible for anteroposterior support

frontal bar

zygomatic arch & zygoma

maxillary and mandibular segments

mnemonic: fucking zebra zit my mug

buttresses responsible for vertical support

zygomatic

nasomaxillary

pterygomaxillary

mnemonic: pinched nipple zummy

complications of fracture during healing

malunion

non-union

delayed union

malunion

fracture that has healed in nonanatomic alignment

non-union

failure of a fracture to heal within the expected time frame

delayed union

slower than expected fracture healing, but eventual union occurs

naso-orbito-ethmoid (NOE) injuries

• can cause:

  • spreading of nasal bones

  • displacement of medial canthal ligaments

  • increased intercanthal distance

• produces:

  • traumatic telecanthus (normal 30–35mm)

  • widening of the medial intercanthal distance

• treatment goals, restore:

  • normal nasolacrimal function

  • normal ocular function

  • properly reposition nasal bones

  • properly reposition medial canthal ligaments

  • achieve good facial esthetics

• usually requires open reduction.

• coronal flap is commonly used because it:

  • provides wide exposure of the upper face and nasoethmoidal complex.

closed reduction

treatment using MMF alone, without directly exposing the fracture surgically

if adequate reduction is achieved, MMF may provide sufficient stabilization during initial healing.

open reduction

direct surgical exposure and reduction of the fracture through an incision

• when is it needed?

  • unfavorable fractures

  • continued displacement of fractured segments.

  • may be preferred when rigid fixation can reduce or eliminate the need for prolonged MMF.

wire osteosynthesis

traditional method of bone fixation.

uses direct intraosseous wiring.

usually requires MMF for about 4–6 weeks until adequate healing occurs

rigid internal fixation

• uses:

  • bone plates

  • bone screws

• provides rigid stabilization during healing.

• usually allows little or no MMF

maxillomandibular fixation (MMF)

• duration:

  • adults: maximum 2–3 weeks

  • children: 10–14 days

• after MMF → aggressive functional rehabilitation.

• prolonged MMF can cause:

  • fibrosis, bony ankylosis

  • severe limitation of mouth opening

fractures that do not necessarily affect occlusion:

isolated zygoma

zygomatic arch

NOE (naso-orbito-ethmoid) complex

suspension wiring

stabilizes fractured bones by attaching them to a more stable bone superiorly.

• purpose:

  • prevent downward movement of the maxilla caused by the mandible during opening

• limitations:

  • wires provide less rigidity.

  • they may not maintain proper facial contours.

  • they may not resist muscular forces throughout healing.

  • rigid plating has largely eliminated the need for suspension wiring

  
  

miniature / micro bone plates

usually made of titanium alloy, used with screws.

thickness: approximately 0.6–1.5 mm.

• advantages:

  • more rigid stabilization

  • helps reconstruct facial pillars

  • useful for comminuted fractures

  • better restoration of normal bony contours

  • allows stabilization of multiple small bone fragments

titanium plates

biocompatible.

• usually do not need removal unless they become:

  • palpable, infected

  • interfere with later reconstructive surgery

resorbable plates

• made from polymers such as:

  • polyglycolic acid

  • polylactic acid

• may be useful in:

  • children, skull trauma

  • situations where growth or repeated CT imaging is a concern

• not routinely used because of:

  • mechanical limitations

  • need for tapping, cost

bone grafting

also improves stabilization

plates and screws also allow immediate bone grafting.

• useful for replacing:

  • missing bone

  • severely comminuted bone segments