Download Volume 11 Issue R8 Facial Fractures

Volume 11 • Issue R8
FACIAL FRACTURES
Shai Rozen, MD, FACS
Reconstructive
www.SRPS.org
Editor-in-Chief
Jeffrey M. Kenkel, MD
Editor Emeritus
F. E. Barton, Jr, MD
Contributing Editors
R. S. Ambay, MD
R. G. Anderson, MD
S. J. Beran, MD
S. M. Bidic, MD
G. Broughton II, MD, PhD
J. L. Burns, MD
J. J. Cheng, MD
C. P. Clark III, MD
D. L. Gonyon, Jr, MD
A. A. Gosman, MD
K. A. Gutowski, MD
J. R. Griffin, MD
R. Y. Ha, MD
F. Hackney, MD, DDS
L. H. Hollier, MD
R. E. Hoxworth, MD
J. E. Janis, MD
R. K. Khosla, MD
J. E. Leedy, MD
J. A. Lemmon, MD
A. H. Lipschitz, MD
R. A. Meade, MD
D. L. Mount, MD
J. C. O’Brien, MD
J. K. Potter, MD, DDS
R. J. Rohrich, MD
M. Saint-Cyr, MD
M. Schaverien, MRCS
M. C. Snyder, MD
M. Swelstad, MD
A. P. Trussler, MD
R. I. S. Zbar, MD
Senior Manuscript Editor
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30 Topics
Grafts and Flaps
Wound Healing, Scars, and Burns
Skin Tumors: Basal Cell Carcinoma, Squamous Cell
Carcinoma, and Melanoma
Implantation and Local Anesthetics
Head and Neck Tumors and Reconstruction
Microsurgery and Lower Extremity Reconstruction
Nasal and Eyelid Reconstruction
Lip, Cheek, and Scalp Reconstruction
Ear Reconstruction and Otoplasty
Facial Fractures
Blepharoplasty and Brow Lift
Rhinoplasty
Rhytidectomy
Injectables
Lasers
Facial Nerve Disorders
Cleft Lip and Palate and Velopharyngeal Insufficiency
Craniofacial I: Cephalometrics and Orthognathic Surgery
Craniofacial II: Syndromes and Surgery
Vascular Anomalies
Breast Augmentation
Breast Reduction and Mastopexy
Breast Reconstruction
Body Contouring and Liposuction
Trunk Reconstruction
Hand: Soft Tissues
Hand: Peripheral Nerves
Hand: Flexor Tendons
Hand: Extensor Tendons
Hand: Fractures and Dislocations, the Wrist, and
Congenital Anomalies
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SRPS • Volume 11 • Issue R8 • 2015
FACIAL FRACTURES
Shai Rozen, MD, FACS
University of Texas Souithwestern Medical Center at Dallas,
Dallas, Texas
INTRODUCTION
In the recent decade, we have seen tremendous
innovation in the area of facial reconstruction. A new
era of facial transplantation has commenced, and we are
making slow but steady progress in the science of tissue
engineering. Both fields will enable us to achieve optimal
reconstructive and aesthetic results that we have not
seen before with traditional reconstructive techniques.
However, formidable barriers lie ahead before we can
fully apply these in the daily clinical work for treating
patients with facial injuries. Regardless of what future
lies ahead, the basis for treatment of all compound facial
injuries involving both the bony frame and the softtissue envelope remain the same: perfect recreation of the
bony framework to its premorbid position avoiding late
irreversible sequelae of malpositioned concentric healing
of the soft tissue. The tenets of bony reconstruction of
the face are early intervention, wide exposure of the
facial skeleton, anatomic reduction, internal fixation,
and primary bone grafting. Non-adherence to these basic
rules will result in nearly irreversible facial deformity
caused by the insurmountable strength of the concentric
soft-tissue scarring, which occurs early after the injury.
Early intervention is key, and situations in which it is
contraindicated are rare.
The goal of this monograph is to provide not only
a list of references of the current literature on the subject
but also to afford the reader a readable and comprehensive
overlook on the subject that will hopefully intrigue the
reader to further in-depth reading.
PRINCIPLES OF OPEN REDUCTION AND
INTERNAL FIXATION
Fracture Environment
The facial skeleton provides protection of vital soft organs,
a rigid frame for masticatory and facial muscle function,
and support of the overlying soft tissue. Therefore,
restoration of bony anatomy should satisfy two major
goals: optimal function and normal appearance. To
provide optimal function, adequate anatomic shape and
stiffness (resistance to deformation under load) are basic
requirements. Fractures result from mechanical overload
that most commonly occurs in milliseconds when facial
fractures are concerned. The fracture not only directly
interrupts the structural integrity and stiffness of the bone
but also disrupts the internal blood supply of the bone.
External blood supply is further disrupted by implosion,
which is a unique phenomenon seen in facial trauma
that occurs immediately after the fracture. It involves
marked soft-tissue damage caused by cavitation. Therefore,
in addition to intracortical blood vessel disruption,
surrounding soft tissue vascular damage also occurs,
thereby further decreasing the blood supply to the bony
fragments. Yet experience in craniofacial surgery, namely
the midface and cranial region where the bony walls are
thin, shows that even bony fragments that are stripped
from their surrounding soft tissue regain circulation
rapidly. Thus, infections are minimal and healing is
generally good. The mandible, on the other hand, is to
some extent comparable to long bones because of its
cortical thickness. Therefore, delay in healing is expected
until intracortical circulation is restored.
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SRPS • Volume 11 • Issue R8 • 2015
Clinical healing is reached when the bony structures
can resume their full function. For optimal bone healing
to occur, both biological and mechanical conditions
have to be met. For optimal biological conditions to
occur, blood supply to the fragments is a prerequisite
and surgical and plating techniques therefore strive to
minimize devascularization of bone segments. Optimal
mechanical conditions around the fracture will also affect
bone-healing patterns. On the one extreme, when absolute
immobilization occurs, optimal conditions are created
for formation of bone. In this case, osteoclasts can drill
their canals across the immobilized contact zone and
newly formed osteons link the fragments together. This
process is called direct or primary bone union. On the
other end of the healing spectrum, high interfragmentary
motion occurs. Under this mechanical situation, the strain
in the fracture gap exceeds the level tolerated by bone
and ossification is not possible. In this scenario, a tissuedifferentiation cascade occurs and granulation tissue turns
into connective tissue, fibrocartilage, mineralized cartilage,
woven bone, and finally compact bone (Fig. 1).1 In most
fractures, various degrees of immobilization occur and
different patterns of bone healing might therefore be seen
in one fracture. Experience shows that remodeling of the
mandible to full load bearing and removal of the plate
requires 4 to 6 months versus 1.5 years in the tibia and 2
years in the fibula. However, in the midfacial and cranial
regions, bony fixation can occur after 1 month because of
the excellent blood supply in that region of the body. The
same rules apply to bone grafts, which similarly heal
very quickly.1
Potential complications of bone healing include
infection, refracture, delayed healing, nonunion, implant
loosening, and implant failure. Refracture is a rare
occurrence in the cranio-maxillofacial region because of
the rapid healing that occurs in that region. Therefore,
surgical refracturing (i.e., osteotomy) is needed in cases in
which reduction was not properly performed. Infections
are not common. They sometimes occur in cases of severe
soft-tissue injury when surrounding blood supply has been
severely compromised. Mere exposure of fixation devices
caused by skin or mucosal laceration does not mean that
deep infection will ensue.
Healing is considered delayed when union takes
longer than expected (longer than 4−6 weeks in the
midface and longer than 12 weeks in the mandible)
2
(Fig. 2).1 If nonunion is observed, resection is not
necessary. The problem is excessive mobility and strain
at the fracture sight, which prevents the mineralization
of the moving fracture gap. Use of a stiffer and stronger
implant, such as a reconstruction plate, will allow
further differentiation leading finally to compact bone.
Loose screws, insufficient number of screws, and undue
functional loading can all cause implant failure.
Indications for Operative Treatment of Fractures
Whether treating craniofacial trauma or performing
osteotomies for correction of craniofacial deformities,
the goals of surgery are expedient recovery of form and
function. Optimal, not maximal, stability is required.
Under these conditions, undisturbed healing occurs. It is
important that the surgeon performing internal fixation
understands the principals of conservative treatment first.
Closed, simple, non-displaced fractures can be treated by
conservative methods, namely inter-maxillary fixation for
several weeks in cases of maxillary or mandibular fractures.
Functionally stable internal fixation is indicated for the
following fractures:
•• Multiple or comminuted fractures of the
mandible or maxilla
•• Panfacial fractures
•• Defect fractures
•• Open fractures
•• Dislocated fractures
•• Fractures of the atrophic mandible in the
geriatric patients
•• Infected fractures of the mandible
Additional absolute indications for internal fixation are
inability and unwillingness of the patient to cooperate.
Early definitive care is also indicated for patients with
multiple traumatic injuries. All fractures should be treated
simultaneously, and swelling should not delay facial
fracture repair. Adequate stabilization is more important
than antibiotics for protection against infections and is key
in preventing concentric scarring and collapse of the softtissue envelope.
The general goals of surgery are early anatomic
SRPS • Volume 11 • Issue R8 • 2015
A
B
C
D
Figure 1. High interfragmentary motion is a mechanical situation in which the strain in the fracture gap exceeds the level
tolerated by bone. A tissue-differentiation cascade occurs, and granulation tissue turns into connective tissue, fibrocartilage,
mineralized cartilage, woven bone, and finally compact bone (Modified from Prein and Rahn.1)
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SRPS • Volume 11 • Issue R8 • 2015
Implant Materials
Stiffness of fracture
Normal
Delayed union
Nonunion
2
4
6
8
Healing time
10
weeks
Figure 2. Line graph depicts fracture healing and recovery
of mechanical function. Initially, a healing fracture presents
with low strength and low stiffness. Four to 6 weeks later,
a notable change in mechanical properties occurs. At that
time, in an undisturbed situation, mineralization across the
fracture plane takes place. If the loading of the mineralizing
fracture does not exceed certain limits, healing proceeds
normally. Undue loading of such a uniting fracture at a
critical moment can disturb the mineralization process and
lead to delayed union or nonunion. (Modified from Prein and
Rahn.1)
reduction of the fracture fragments, maintaining their
position after reduction, and achieving union in the
desired position. To achieve these goals, the plates used for
fixation must act directly at the fracture site and neutralize
the loads occurring under daily function at that specific
site. Considerations such as personality and compliance
of a patient, type and site of the fracture, and condition
of the overlying tissue can affect the selection of the
appropriate implant. The role of the implant is to share
the load of the fracture site until bone regeneration takes
over the load. Both compressive and tensile forces can
occur over fracture sites. Often, the bone can tolerate the
compressive forces across the fracture site thereby allowing
use of much smaller implants to share the tensile forces
occurring over the fracture. Still, underestimation of the
forces crossing the fracture site might lead to choosing
plates of insufficient size, culminating in early fracture of
the plate caused by fatigue failure.
4
The ideal implant material needs to be strong and ductile,
inert, biocompatible, and adaptable to fit bone. Until
1986, stainless steel was the metal of choice. Today,
however, commercially pure titanium is the material of
choice for craniofacial reconstruction. Titanium has a high
corrosion resistance because of the spontaneously forming
thin oxide layer on the surface, which assures that the
material will behave passively. Considering the inertness
of titanium and the involvement of multiple screws and
plates in most cranio-maxillofacial operations, removal of
the screws and plates is not indicated because of a small
but present risk of injury to structures during removal
and the additional risks inherent with any anesthesia.
Indications for implant removal include a general feeling
of disturbance caused by chronic infection or allergic
reaction. Aesthetic considerations, such as a shiny
appearance of the plate under thin skin, sensitivity caused
by changes in temperature, and problems with dentures,
can constitute additional indications for removal. It is
important to understand that infection in the presence
of an implant is not always an indication for implant
removal. If fixation is stable, the implant can be left until
complete stabilization occurs. Stabilization is the most
important way to treat infection. If the fixation is unstable,
plate removal and re-stabilization are mandatory. The use
of non-absorbable plates in the pediatric population is
controversial. Removal of the plates usually is indicated
not because of risk of growth retardation but rather
because of possible intracranial translation by
drift phenomena.
Plates and Screws
The use of specific types of plates and screws, such as
compression plates and screws, is noted in different
sections of the text. For a full description of the different
types of plates and screws, the reader is encouraged to read
the first chapter in the Manual of Internal Fixation in the
Cranio-Facial Skeleton.1
SRPS • Volume 11 • Issue R8 • 2015
GENERAL CONSIDERATIONS IN THE
TREATMENT OF FACIAL FRACTURES
Mechanism of Craniofacial Injuries and
Associated Injuries
The mechanisms of craniofacial trauma in the United
States include motor vehicle collisions, altercations,
assaults, home and industrial accidents, and athletic
injuries. A review of 7296 patients treated during an 11year period at The University of Maryland Shock Trauma
Center showed that motor vehicle collisions were the
most common mechanism of injury.2 The frequency of
severe facial trauma resulting from motor vehicle collisions
in the 1970s and 1980s has significantly decreased
because of increased use of seat belts, air bags, and strict
enforcement of laws against speeding and drunk driving.
Lee et al.3 presented a comprehensive review and analysis
of approximately 7300 patients admitted for craniofacial
trauma between the years 1983 and 1994. The average
patient age in that study was 33 years, and the ratio of
male predominance was 2:1. Motor vehicle collision was
the most common mechanism of injury. Overall mortality
was 5.9% but increased to 17% when the craniofacial
trauma was associated with brain injury. The midface was
the facial region most susceptible to fracture.3
Concomitant Injuries
Concomitant injuries are common in patients with facial
injury. Lim et al.4 showed in a population of 839 patients
with facial trauma that 11% sustained injuries outside the
facial skeleton, 8% had injuries of the extremities, 5% had
associated neurological injuries, 4% ocular injuries, and
1% spinal injuries. Injuries of the head, neck, and spine
occur in more than 50% of patients involved in motor
vehicle collisions. Because of the prevalence of associated
injuries, it is vital that a full and thorough multi-system
evaluation be conducted, including the airway, central
nervous system, and hemodynamic stability, before
treating the face. Patients with multiple traumatic injuries
should not be transferred to subspecialty services before
complete evaluation, yet treatment should be expeditious
once patient stability is obtained.5,6
Airway Management
Of cardinal importance in a patient with facial trauma is
the management of the airway. Many patients with facial
trauma do not require emergent intubation. The type of
elective intubation depends on the type of fracture and
surgical approach for repair. Patients who are most proned
for asphyxiation as a result of the trauma are those with
the following injuries:
1)Severely comminuted mandibular fracture
2)Combined mandibular fracture with
midfacial fractures
3)Pan-facial fractures
4)Associated brain injuries
Patients suffering from severe mandibular fractures
might lose anterior support of the tongue with resultant
movement of the tongue toward the posterior pharynx
and blockage of the airway. Simple maneuvers as anterior
retraction of the mandible, direct traction on the tongue,
and clearance of the oral cavity from any loose content
might suffice until elective airway control is obtained.
In the rare emergent situations, a cricothyroidotomy or
coniotomy is performed.7 This emergent procedure should
be converted to a tracheostomy as soon as possible to
avoid complications associated with long-term cricoid
intubation.8,9 Elective tracheostomy should be performed
in cases in which an oral tube would disrupt surgery
and in patients who would not be able to manage their
airways in a week’s time, as in some patients with panfacial trauma, head injuries, or chest injuries. A summary
of guidelines for emergent tracheal intubation and
tracheostomy is presented in an article by Dunham et al.10
The type of elective intubation should be decided based
on the type of trauma and whether maxillary mandibular
fixation (MMF) is necessary for fracture treatment.
Most fractures involving the frontal region, orbit,
zygoma, or nose do not require MMF, and oral intubation
is the preferred route of intubation. In cases in which
MMF is necessary, such as fracture of the mandible and
maxilla or any situation in which occlusion has been
disrupted, a nasal tube is the preferred route of intubation.
This should be performed with nasoendoscopy if a skull
base fracture is suspected to avoid inadvertent passage of
the tube into the cranium. Oral intubation can also be
performed in these cases if it is possible to place the tube
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SRPS • Volume 11 • Issue R8 • 2015
in teeth gaps or behind the molars. Another form of oral
intubation is the transoral approach in which the tube is
delivered via an incision through the floor of the mouth
exiting the submental area. The major disadvantage of this
route is the difficulty to re-intubate emergently if needed.
Blood Loss
Life-threatening hemorrhage occurs in 1.2% to 5% of
midface fractures.11,12 Seventy percent of them originate
from the internal maxillary artery or its branches. In
cases of superficial bleeding, direct pressure, packing,
or ligation generally suffices. Temporary reduction of
fractures manually or direct approximation of wounds by
suturing might help control bleeding until definitive care
is provided.
Anterior nasal bleeding can effectively be controlled
by nasal packing, which can be removed after a 2- to 3-day
period (Fig. 3).13 Bleeding from the nasopharyngeal region
is more difficult to control.14−16 The source of bleeding
usually is the posteriorly located internal maxillary artery.
Passing two Foley catheters, one through each nostril, into
the pharynx and inflating them 30 to 50 mL each can
help achieve rapid control of bleeding. The balloons are
then pulled into the posterior nasopharynx and provide
a posterior obturator against which several packs of
antibiotic impregnated petrolatum gauze are inserted into
each nasal cavity. The packing provides compression, and
the apparatus can be secured by tying the foley catheters
together over the columella. Necroses of the columella,
palate, and nose sometimes occur. Relieving the pressure
every couple of hours and a trial of balloon deflation
after an hour might decrease these complications. The
packing can be removed in 24 to 48 hours. Blindness is
a potential associated complication, and care should be
taken when severe comminuted fractures occur to avoid
intracranial insertion of the catheters. Manual reduction
and intermaxillary fixation (IMF) can substantially reduce
bleeding of midface fractures (Fig. 4).13
In cases in which persistent bleeding occurs,
selective arterial embolization is warranted.12,17,18 During
the whole period in which hemorrhage control is
attempted, coagulation function should be assessed and
corrected as needed. In cases in which all attempts have
failed, selective arterial ligation, including bilateral external
6
carotid arteries and temporal arteries, might decrease
blood flow in the midface and decrease bleeding.
Head Injury
All patients with head injuries should undergo thorough
clinical evaluation and classified by severity of injury based
on the Glasgow Coma Scale (GCS) (Table 1). Motor score
alone might be a good predictor of survival,19 and pupil
size and reactivity are good predictors.20 Patients with a
GCS score of 3 and fixed dilated pupils have nearly no
chance of survival.21−25 A computed tomographic (CT)
scan of the brain, skull, and face is essential for all facial
trauma patients. Any patient with head injury associated
with advanced age, decreased GCS score, hypotension,
abnormal posturing, prolonged intracranial hypertension,
or additional associated injuries such as spinal injury,
lung injury, or shock have a worse prognosis. Children, in
general, have a better prognosis.
Presence of coma alone should never delay
nor contraindicate the treatment of facial trauma.
Neurosurgical research has shown that nearly half the
patients who suffered from coma that lasted more than 1
week returned to useful work.26 Therefore patients who
survive severe head injury greatly benefit from timely
intervention of their facial trauma. Eighty percent of
patients who suffer from coma of less than 20 minutes
experience late symptoms, such as headaches, decreased
attention span, poor concentration, and behavioral
alterations.27 These patients might benefit from
intervention at a head injury rehabilitation center.26
Cervical Spine Injuries
Significant cervical spine injury is reported to occur in one
of 300 patients involved in accidents and in one of 14 of
patients who have been ejected from motor vehicles.28,29
Patients who are unable to move their extremities on
command or with sternal pressure, those with penetrating
injuries to the neck, and those who complain of cervical
pain or have decreased sensation or motor deficits should
be considered to have cervical spine injuries until proven
otherwise. Larger studies suggest that 10% of patients with
facial fractures have cervical spine injury and that 18%
of patients with cervical spine injury have maxillofacial
injury.30,31 Mandible fractures are associated with high
SRPS • Volume 11 • Issue R8 • 2015
Vertical strips
Catheter
Horizontal
strips
Post-nasal pack
Post-nasal pack
Figure 3. Illustration shows the technique of anterior-posterior nasal packing to stop severe nasopharyngeal bleeding. A, A
posterior pack is guided into the nasopharynx by a suture attached to a Foley catheter. Alternatively, a Foley catheter can have
its balloon inflated in the posterior pharynx and brought to the posterior choanal nasal opening. B, With either a posterior
nasal pack or a Foley catheter balloon in place, the nasal cavity is packed with strips of antibiotic ointment-impregnated
gauze. The entire cavity of the nose should be thoroughly packed and light pressure applied. If bleeding persists, the anterior
pack should be removed and the recesses of the nasal cavity carefully repacked. With severe fractures, care should be taken
not to enter the anterior cranial fossa or the orbit through areas of disrupted bone. (Modified from Mathes.13)
3
4
2
1
4
Figure 4. If nasal packing does not suffice to control bleeding, a Barton bandage can be used but is of limited usefulness.
Placement of the patient in intermaxillary fixation, however, is extraordinarily effective in cases of Le Fort fracture bleeding.
Selective angiography with embolization is the procedure of choice for persistent bleeding. If selective embolization by
angiography fails, application of external pressure and ligation of the superficial temporal and external carotid arteries are
performed. Selective arterial embolization requires angiographic clarification of the bleeding point. (Modified from Mathes.13)
7
SRPS • Volume 11 • Issue R8 • 2015
Table 1
Glasgow Coma Scale
Response
Eye opening
Verbal
Motor
Scale
Score
Spontaneous, open with blinking at baseline
4
Opens to verbal command, speech, or shout
3
Opens to pain not applied to face
2
None
1
Oriented
5
Confused conversation but able to answer questions
4
Inappropriate responses, words discernible
3
Incomprehensible speed
2
None
1
Obeys commands for movement
6
Purposeful movement to painful stimulus
5
Withdraws from pain
4
Abnormal (spastic) flexion, decorticate posture
3
Extensor (rigid) response, decerebrate posture
2
None
1
cervical spine injuries, and upper facial injuries are
associated with hyperextension injuries of the cervical
spine at all levels.
1)High clinical level of suspicion
The most commonly missed lesions are lower
and higher cord injuries: C1−C2 and C6−C7 cord
injuries.28,29,32−36 CT scans and magnetic resonance images
(MRI) are the imaging studies of choice if spinal injury is
suspected. Harris37 noted that cervical spine injuries are
missed in 10% of patients and that approximately 50% are
mismanaged. He recommended the following:
3)Full neurologic examination
8
2)Protection of the spine
4)Use of consultants
5)CT scans or MRI in addition to plain
film radiographs and when neurological
examination is abnormal
SRPS • Volume 11 • Issue R8 • 2015
Timing of Surgical Treatment
Mechanism
The timing of surgery in patients with facial injuries is
important for obtaining optimal results.25 In general,
treatment of facial injuries does not require emergent
surgical care. Reduction of fractures or closure of wounds
is not an emergency. Still the need for expedient care
cannot be overemphasized. Earlier intervention decreases
disfigurement and improves functional outcome.38,39 Bones
are more easily placed in their anatomic positions and less
extensive soft-tissue stripping is necessary.
Frontal sinus fractures usually are caused by direct impact.
The frontal sinus is involved in 2% to 12% of all cranial
fractures.41 Approximately one-third of frontal sinus
fractures involve the anterior table, 60% involve the
anterior and posterior tables and the nasofrontal ducts,
and the remaining involve the posterior table alone. Dural
laceration accompanies 60% of all frontal sinus fractures.
If the frontal sinus is well pneumatized, the majority of
the energy is absorbed and the posterior table usually
is uninvolved. If the frontal sinus is not well developed
or high-energy impact is involved, the posterior table
usually is involved and the risk of dural and intracranial
involvement is increased.42
Exceptions to immediate intervention include
the following:
1)Patients with ongoing bleeding and
hemodynamic instability
2)Patients with continuous intracranial
hypertension
3)Coagulation problems
4)Abnormal pulmonary ventilation pressures
These patients might not tolerate surgery, but open
wounds can be closed at the time of admission, MMF
can be applied, and gross reduction of fractures can be
performed. On the other hand, patients with head injuries
or multi-system trauma should not be delayed from
treatment simply based on those injuries.40
FACIAL FRACTURES BY ANATOMIC REGION
Frontal Sinus Fractures
Anatomy
The frontal sinuses are paired structures above the orbital
rims that have only ethmoidal anlages at birth. These
sinuses start pneumatization at the age of 3 years, but
substantial pneumatic expansion begins at the age of 7
years. The frontal sinus achieves full size at approximately
age 18 to 20 years. The sinus has two tables: an anterior
and a posterior table.41 In between, the sinuses are
lined with respiratory epithelium consisting of ciliated
membranes, which direct the mucin toward the nasofrontal duct, located in the inferior medial aspect of the
sinus. The exact function of the sinuses is not clear, but
when developed, they might absorb the energy created by
a trauma, thus protecting the intracranial content.
Diagnosis
The typical physical signs found in patients with frontal
sinus fractures include lacerations, bruises, and hematomas
of the periorbital and forehead regions. Anesthesia
in the supraorbital nerve distribution can occur, and
cerebrospinal fluid (CSF) rhinorrhea might be observed.
Subconjunctival or periorbital ecchymosis occasionally
occurs. In some patients, depression of the forehead is
seen. More often, swelling obscures the depression in
the acute setting. Existence of any of these signs must
raise suspicion of fractures. CT scanning is the imaging
modality of choice. Findings can include fractures,
orbital or intracranial air, and air fluid levels in the sinus
suggesting frontal duct occlusion, especially if persistent.
Small fractures can be difficult to detect, even on CT
scans, and a frontal sinus fracture occasionally presents as
a frontal sinus infection, mucocele, or abscess formation
secondary to nasofrontal duct occlusion.43−45
Treatment
The type of fracture dictates the type of treatment for
frontal sinus fractures, but uniformity in treatment
strategies does not exist. Classification systems attempt to
divide frontal sinus fractures into the following categories:
•• Anterior table, displaced or non-displaced
•• Posterior table, displaced or non-displaced
•• Anterior and posterior table, displaced or
non-displaced
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SRPS • Volume 11 • Issue R8 • 2015
•• Any of these fractures can include the
nasofrontal duct
It is generally agreed that an isolated non-displaced
anterior table fracture can be treated nonoperatively.
Displaced fractures of the anterior table generally are
treated with surgery. In cases in which the nasofrontal duct
is not thought to be involved, reduction of the fracture
with preservation of the sinus is warranted. The fracture
should be reduced with minimal manipulation of the
mucosa as long as nasofrontal duct injury is unlikely. After
reduction, fixation is performed with 1.0-mm microplates
or 1.3-mm plates, depending on the amount of stability
necessary. If the fracture is multifragmented, the bone can
be discarded and bone grafting is indicated. Radiological
evidence of air fluid level and direct visualization of
the duct during surgery help determine duct patency.
Injecting of the duct with saline or dye and applying dry
gauze in the middle meatus of the nasal cavity can help
with assessment. If the gauze stains, patency of the duct
is suggested. If staining is not observed, the nasofrontal
duct is probably occluded and obliteration of the sinus
is indicated. No one test clearly indicates duct injury,
but most surgeons agree that obliteration of the sinus is
indicated if duct injury is suspected.
Treatment of posterior table fractures is more
controversial. Rohrich and Hollier46 stated that if the
displacement of the posterior table is less than one table
thickness, nonoperative management can be considered.
Others think that any fracture of the posterior table,
regardless of the amount of displacement, should be
explored to rule out injury to the duct and the dura, which
are difficult to assess radiographically.47 The potential
severity of both acute and chronic complications is too
grave to leave untreated, in their opinion. If CSF leak
is noted, some surgeons consider this an immediate
indication for surgery whereas others consider initial
conservative treatment with elevation of the head and
observation for 5 to 7 days to assess persistence of CSF
leak. If the leak persists, cranialization and dural repair are
recommended (Fig. 5).44 Dura can be repaired directly, or a
periosteal or galeal flap or free fascia can be used. Rohrich
and Hollier suggested an algorithm for the management
of frontal sinus fractures (Fig. 6).46 Considering that the
frontal sinus is stronger than the midface bones but weaker
than the frontal bones, associated midface fractures are not
uncommon and should be suspected.
10
Complications
The main complications that occur in association with
frontal sinus injuries are infectious and obstructive
in nature. They can be divided into early and late
complications. Early complications, occurring during the
first 6 months after injury, include sinusitis, meningitis,
extradural or intradural abscesses, intracranial abscesses,
and osteomyelitis of the frontal bone. Sinusitis presents
with frontal headaches, and radiographs or CT scans
might show opacification or fluid levels, respectively.
Initial treatment can be conservative with decongestants
and antibiotics, and surgery is indicated in persistent cases.
Meningitis is fortunately rare but does occur, especially
when the posterior table is involved and a CSF leak is
present. Ioannides et al.48 reported two cases of meningitis
in 71 patients who underwent surgery for fractures of the
frontal sinus. The meningitis was successfully treated
with antibiotics.
Dura
Temporalis
muscle plug
Figure 5. Cranialization of a frontal sinus fracture with
comminution of the posterior wall. The posterior table is
excised, the nasofrontal duct is plugged with temporalis
muscle, and the anterior wall is reduced and stabilized with
rigid fixation, supplemented by bone grafting as necessary.
(Reprinted with permission from Luce.44)
SRPS • Volume 11 • Issue R8 • 2015
Anterior table fracture
Combined anterior and posterior table fracture
Displaced
Displaced posterior wall
No
No operative
intervention
Yes
No (<1 table width)
Nasofrontal duct involved
No
Reduction and stabilization
with sinus preservation
Yes
Yes (>1 table width)
CSF leak
No
CSF leak
Yes
No
Reduction and stabilization
and sinus obliteration
Yes
1. Reduction and
stabilization
of anterior wall
2. Cranialization
Nasofrontal
duct involved
No operative Allow 4 to 7 days
intervention for resolution.
If persistent, consider
cranialization
No
1. Reduction and
stabilization
of anterior wall
2. Sinus preservation
Yes
1. Reduction and stabilization
of anterior wall
2. Sinus obliteration
Figure 6. Algorithm for the management of frontal sinus fractures. (Modified from Rohrich and Hollier.46)
Late complications mainly include mucoceles and
mucopyoceles and usually occur several years after injury.
The anatomic bases for these complications are obstruction
of the nasofrontal duct, which occurs in one-third to
one-half of frontal sinus fracture cases, and inadequate
resection of sinus wall mucosa. The nasofrontal duct
passes through the anterior ethmoidal air cells exiting
adjacent to the ethmoidal infundibulum. Obstruction
of the duct prevents adequate drainage of the normal
mucosal secretions. This in turn disposes to development
of obstructive epithelium cysts: mucoceles or, if infected,
mucopyoceles. Mucoceles can also develop when islands
of mucosa are trapped by scar tissue within the fracture
lines and attempt to grow after injury, creating obstructed
mucous membrane-lined cystic structures.49−51
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SRPS • Volume 11 • Issue R8 • 2015
To avoid these complications, one must completely
obliterate the entire frontal sinus mucosa by burring the
bone and eliminating the duct mucosa rather than merely
stripping the mucosa. Regrowth of the entire sinus mucosa
has been demonstrated to occur from the remaining
ductal mucosa or from the foramina of Breschet, which
are invaginations of mucosa along the channels or veins
extending into the bones.47,52,53 Donald54 suggested this
concept of tenacity of the frontal sinus mucosa. Hardy and
Montogomery55 reported a series of 250 patients. Most
patients who suffered from chronic frontal sinusitis did
not respond to antibiotics and needed obliteration of the
sinus. Four percent required secondary revisions. Manson
et al.56 reviewed the postoperative results of 42 frontal
cranioplasties for which wire mesh methylmethacrylate
or autogenous bone was used. Despite previous reports
of high infection rates with acrylic cranioplasties, the
authors reported no difference in complications based
on the reconstructive material. Risk factors associated
with infections were timing of the procedures and
communication of the reconstruction with previously
infected ethmoid sinuses and the nose. History of previous
bone infections (62% in their series) and absence of the
frontal sinus were considered risk factors for infection.
Anatomy
The frontal process of the maxillae is the main structural
buttress of the NOE area (Fig. 7).1 It articulates superiorly
with the nasal process of the frontal bone (also termed
the internal angular process), medially with the nasal
bones, laterally with the zygoma, and posteriorly with
the laminae papyracea at the frontoethmoidal suture. The
medial canthus-bearing area is also referred to as the central
fragment (Fig. 8) and shows typical fracture patterns.64
The anterior and posterior ethmoidal foramina carrying
the respective vessels are located at the upper portion of
the lamina papyracea and mark the inferior border of the
cranial fossa (Figs. 9 and 10).65 Any procedure performed
above this area risks injury to the brain. Cranially, the
nasal process of the frontal bone lies anterior to the
frontonasal duct. Therefore, the nasofrontal duct usually
is not involved. In cases of highly comminuted NOE
fractures, patency of the nasofrontal duct can be lost and
obliteration of the frontal sinus might be necessary.66
The nasal bones often are fractured, but nasal support
mainly depends on the nasal pyramid proximally and the
cartilaginous septum distally. Depending on the degree of
comminution of these structures, the need for nasal bone
grafting is determined.
Nasoorbitoethmoid (NOE) Fractures
Definition
The simplest definition of an NOE fracture is a fracture
that causes displacement of the section of the medial
orbital rim, which carries the medial canthal ligament.
The simplest NOE fracture can theoretically involve
solely the medial orbital rim, although this is rare. Since
the midfacial skeleton is the area of the NOE area, most
NOE fractures involve the area of confluence of the nose,
orbits, and ethmoids.57 The anatomic structures involved
include the nose, medial and lower orbits, frontal sinus
and anterior skull base, and pyriform rim. Therefore,
NOE fractures have the potential to injure the skull base
with associated dural tears and CSF leaks58,59 or injure
the frontal sinus and nasofrontal duct. NOE fractures
always involve the orbital floor and medial orbital wall.60−63
Successful reconstruction of these structures in a Threedimensional pattern is one of the most difficult challenges
in facial trauma.
12
Figure 7. Frontal process of the maxilla is the main structural
buttress of the naso-orbital-ethmoid area containing the
insertion of the medial canthal ligament (inset). It is referred to
as the central fragment. (Modified from Prein and Rahn.1)
SRPS • Volume 11 • Issue R8 • 2015
A
B
Figure 8. A, Illustration of the central fragment of the nasoethmoid fracture. B, Butresses of the nasoethmoid area. (Reprinted
with permission from Markowitz et al.64)
Frontal bone
Supraorbital foramen
Ethmoid bone
Lacrimal bone
Zygomaticotemporal
foramen
Nasal bone
Zygomatic bone
Zygomaticofacial
foramen
Infraorbital foramen
Maxillary bone
Figure 9. Anatomic landmarks of the NOE region. The frontonasal suture can be followed posteriorly to the lacrimal fossa and
ethmoid bone. The medial canthal tendon attaches on either side of the lacrimal fossa. During medial canthopexy, the tendon
should be reattached just behind the apex of the lacrimal fossa. (Modified from Brady et al.65)
13
SRPS • Volume 11 • Issue R8 • 2015
Optic canal
Frontal bone
Posterior ethmoidal
foramen
Sphenoid bone,
lesser wing
Anterior ethmoidal
foramen
Ethmoid bone
Sphenoid bone,
greater wing
Optic strut
Superior orbital fissure
Foramen rotundum
Maxillary bone
Inferior orbital fissure
Figure 10. Anatomic landmarks of the NOE region. The ethmoidal vessels emerge through the anterior and posterior
ethmoidal foramina along the fronto-ethmoidal suture. Dissection should be kept below the level of the vessels and away
from the optic nerve (i.e., it should go no farther than the posterior foramen. (Modified from Brady et al.65)
Fractures of the NOE complex often occur because
of direct blow to the upper bridge of the nose, as often
occurs with motor vehicle collisions when the face hits
the dashboard or steering wheel. Because of the use of
air bags in most cars, the incidence of these fractures has
dramatically decreased. Markowitz et al.,67 reviewed the
University of California Los Angeles experience with NOE
fractures during a 4-year period in the mid-1980s. Of
342 patients treated for midface fractures, 105 had NOE
fractures. Of the 105 NOE fractures, 4.8% were classified
as high-energy injuries. This agrees with findings presented
by Swearingen68 on tolerance of the human face to crash
impact, that the force necessary to fracture the nasal bones
is 30 G (Fig. 11).69 However, the force needed to fracture
all surrounding structures is substantially less and the
surrounding structures of the nasoethmoid complex will
therefore “collapse and splinter like a pile of matchboxes
struck by a hammer.”59
14
Classification
Several classifications of NOE fractures exist. More
important is that the clinician must understand what is
occurring to the medial orbital rim segment, which bears
the medial canthal attachment, because this will classify
the fracture type and dictate the treatment. Perhaps the
most commonly used classification based on fracture
patterns was that described by Markowitz et al. (Fig.
12).64 It describes three main fracture patterns based
on the fracture pattern concerning the medial canthusbearing bone. With type I NOE fractures, the canthusbearing segment is large and single. It can be complete
or incomplete greenstick at the internal angular process
and can be unilateral or bilateral. With type II fractures,
the canthus-bearing segment is comminuted but the
canthus-bearing bony segment is still large enough that it
can be stabilized by plates. With type III fractures, severe
comminution is present and the medial canthus is attached
to a diminutive piece of bone that generally needs to be
detached to successfully perform direct canthopexy.
SRPS • Volume 11 • Issue R8 • 2015
Based on these patterns, treatment options can be
chosen. With type I fractures, reduction of the medial
canthus into position can be performed by fixation of the
bone with a combination of microplates and miniplates.
With type II fractures, treatment occasionally can be
performed solely by plating but transnasal wiring usually is
necessary. With type III fractures, the medial canthus must
be detached from the bony segment and independently
canthopexied with transnasal wiring.
Figure 11. Resistance of various parts of the facial skeleton
to fracture-producing forces. (Reprinted with permission from
Luce et al.69)
Diagnosis
Physical Examination—Any central midface injury
should raise suspicion for a NOE fracture. Severe nasal
injuries can be misdiagnosed as NOE fractures, but, more
commonly, NOE fractures are misdiagnosed as nasal
fractures. The clinical appearance is typical. The nose
is flattened with loss of dorsal nasal prominence, and
the angle between the lip and nasal columella is obtuse.
The medial canthal areas are swollen and distorted with
palpebral and subconjunctival hematomas. Ecchymosis
and subconjunctival hemorrhage are nearly always seen.
Telecanthus is a common finding, although substantial
swelling might mask it. To confirm medial canthal
involvement, the surgeon should grasp the medial canthus
with forceps and retract it laterally. If the canthus cannot
be pulled taut, the medial canthus is likely involved. If
diagnosis remains uncertain, a bimanual examination can
be performed in the operating room. The finger is placed
over the medial canthus and a clamp is placed intranasally
and pushed against the finger. Mobility of the canthusbearing segment confirms the diagnosis. Intranasal
examination reveals swollen, bulging mucosa and septal
fractures. Septal perforation is not uncommon. Septal
hematoma must be treated immediately by evacuation to
prevent septal perforation. Nasal lining might be torn and
devascularized, decreasing the survival of bony fragments.
Clear fluid from the nose is strongly suggestive of CSF
rhinorrhea70 by mechanism of extension of the fracture to
the cribriform plate through the perpendicular plate of the
ethmoid. CSF rhinorrhea nearly always presents as blood
Figure 12. Classification of NOE fractures. Left, Type I. Center, Type II. Right, Type III. (Reprinted with permission from Markowitz
et al.64)
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SRPS • Volume 11 • Issue R8 • 2015
but within a few days usually clears to clear fluid. Several
tests are available to confirm whether the fluid is CSF.
One should look for the double-ring sign, also known as
the halo sign. The test is performed by placing the fluid
on a towel. The blood remains in the center and the CSF
migrates laterally, thus creating a double ring. The fluid
can also be tested for glucose levels, with levels above 30
mg/dL confirming a leak. For the most reliable proof, the
fluid is tested for B-transferrin.
Radiographic Examination—CT scanning is the gold
standard imaging modality for examining NOE fractures.71
Four fractures must be revealed for the diagnosis of
NOE fracture:
1)Frontal process of the maxillae
2)Nose
3)Medial and inferior orbital rims
4)Medial orbital wall and orbital floor
Additional fractures might be noted. Fractures of the
anterior cranial fossa often are difficult to detect. Air in
the subdural or extradural space or, rarely, in the ventricle
is evidence of communication between the nasal cavity
or frontal sinus and the intracranial area. Frontal sinus
fractures might also be seen in conjunction with NOE
fractures. Le Fort level II or III fractures might also be
present.72−74 Markowitz et al.64 reported that 36% of his
series of NOE fractures were unilateral.
Treatment
All patients suffering from NOE fractures should be
considered to have brain injury until proven otherwise. If
the fracture involves the anterior cranial base or depressed
or open frontal skull, neurosurgical intervention is needed.
In the absence of frontal bone or sinus involvement,
fractures of the anterior skull base usually are short,
linear, non-displaced, and not in need of neurosurgical
intervention. As a general rule, even if brain injury is
suspected or has not been ruled out, surgery of the facial
fractures should proceed if appropriate intraoperative
intracranial pressure monitoring is available.
Thorough exposure of the fracture is necessary
for successful reduction and fixation. Three incisions
16
are needed: gingivobuccal, lower eyelid, and coronal
incisions.57,60,64,67,75−79 Rarely, if a large open wound is
found in the forehead, it can substitute for a coronal
incision. Incisions should not be extended because of poor
aesthetic results, nor should the “open sky” approach via a
transverse incision across the root of the nose, as described
by Converse and Hogan,80 be used. Excellent exposure
means complete subperiosteal elevation of the globe from
the floor of the orbit via the eyelid approach and complete
dissection of the orbital roof and medial orbital wall via
the coronal approach leaving the medial canthus intact.
The key for successful reduction of the NOE fracture is
transnasal reduction of the medial orbital rims by placing
transnasal wiring posterior and superior to the canthal
ligament insertion. The drill holes are placed superior
and posterior to the lacrimal fossa. To ease the drilling,
the canthus-bearing segments can temporarily be pulled
anteriorly. No. 26 wires are inserted through the segment
and transferred to the contralateral medial canthusbearing segment across the interorbital space. The wires
are tightened only after the medial canthus-bearing bones
are reduced into place (Fig. 13).64 When wire tightening
is used to reduce the fractures, the wire nearly always cuts
or microfractures the thin bone. Once the canthus-bearing
segments are reduced and fixated, the surrounding bone
segments should be reduced and fixated with microplates.
On rare occasions, the medial canthal tendon is avulsed
from the bone to create a type III fracture. In reality, this
occurs more often iatrogenically, during dissection of the
medial orbital wall, than from the original injury. The
medial canthal ligament has three main limbs: anterior,
posterior, and superior with an inferior free border.
Anderson81 and Zide and McCarthy82 emphasized the
importance of a vertical component of the medial canthal
tendon. The posterior and superior limbs are the key
elements of exerting the force that keep the eyelid tangent
to the globe. Anderson,81 Zide and Jelks,83 and Zide and
McCarthy82 proposed that the posterior and superior
branches of the canthus are responsible for the vertical
canthal position. Considering that the posterior limb is
weak, the suture is passed through the anterior limb but
fixation is directed toward the posterior limb attachment.
The preferred technique presented by Markowitz et al.64
(Fig. 13) is identifying the medial canthal tendon from an
external incision just medial to the medial commissure of
the eyelid and passing a 2-0 braided non-absorbable suture
through the tendon twice. After inserting two trans-nasal
SRPS • Volume 11 • Issue R8 • 2015
Complications
Complications of fractures in the orbital region
associated with orbital or NOE fractures include
diplopia, retrobulbar hematoma, implant or bone graft
complications, visual loss, lid complications, and ptosis of
the upper lid. Some of these are discussed in further detail
in the section on orbital fractures. Complications that are
uniquely associated with the NOE fractures are lacrimal
system injury and telecanthus.
Figure 13. A, Transnasal wire in front of the canthal ligament
allows splaying of the posterior aspects of the fracture. B,
Posterior transnasal wire prevents rotation of the medial
orbital rim. (Reprinted with permission from Markowitz et al.64)
Lacrimal System Injury—Most lacrimal system
obstructions occur from malpositioning of the bone rather
than direct damage to the lacrimal apparatus.64,84,85 Becelli
et al.86 reported a 47% incidence of lacrimal obstruction
after NOE fractures, one-third of which cleared
spontaneously. Many of the patients in that series received
late primary treatment. If obstruction persists, external
dacryocystorhinostomy is 94% successful in eliminating
the obstruction. If transection of the canalicular lacrimal
system has occurred, repair should be performed over fine
tubes with magnification.
wires in addition to those that may be used for reduction
of the medial segments, the suture is tied down after the
wires have been singed down.
It is important to emphasize the that anatomic
landmarks through which the transnasal wires are passed
are just posterior and superior to the lacrimal fossa, but
the wire should never be superior to the frontonasal suture
and frontoethmoid sutures and anterior and posterior
ethmoidal foramens, all indicating the lower limit of the
anterior cranial fossa. Any wire above that level could
result in direct brain injury. Also, the wire should not be
passed posterior to the posterior ethmoidal artery because
of the risk of injuring the optic nerve.
The cartilaginous nasal septum often is destroyed
and does not provide sufficient nasal support. Primary
bone grafting is necessary in such cases, and the graft
usually is attached to the proximal nasal bones (Fig. 14).13
Cartilage graft might also be needed to provide
columellar support.
Figure 14. With this technique, a plate is attached by short
screws to the underside of the proximal portion of the bone
graft to stabilize it to the frontal bone. A dorsal nasal bone
graft can be used to increase nasal height or produce a
smooth nasal dorsal contour. The illustration shows a case in
which a thin graft works well. Its marrow has been hollowed
out to produce a shell of the bone graft, which provides
only thin smooth covering over the reassembled fracture
fragments. (Modified from Mathes.13)
17
SRPS • Volume 11 • Issue R8 • 2015
Telecanthus—Residual telecanthus characterized by
increased intercanthal distance, flattening of the nasal
root, and, frequently, dysfunction of the lacrimal system, is
caused by late treatment or, more commonly, inadequate
reduction of the NOE fracture. The medial canthus is
rounded, with narrowing of the palpebral opening and
epiphora. Normative values for intercanthal distance have
been described as being 33 to 34 mm in Caucasian men
and 32 to 33 mm in Caucasian women, but the best way
to confirm abnormal distance is to compare the medial to
lateral canthal distance on the injured side with that of the
normal side.76 Secondary correction of telecanthus is much
less successful than accurate primary correction.
Orbital Fractures
Definition
Orbital fractures include simple fractures that involve the
internal orbital bones—also known as blowout fractures—
and fractures involving the orbital rims and internal
orbit.87−89 They commonly are associated with other facial
fractures, such as malar, Le Fort, or NOE fractures.
Anatomy
Appreciating the anatomy of the orbit is key to
understanding the mechanism, patterns, and treatment of
orbital fractures. The orbits are the bony cavities, which
encompass the globes and surrounding structures, and
are separated in the midline by the interorbital space,
which contains the ethmoid and frontal sinus.90−92 The
strong bone structure of the orbital rim protects the
orbital content. The inferior orbital rim consists of zygoma
laterally and maxilla medially. The medial orbital rim
consists of the nasal bones, the nasal spine of the frontal
bone, and the frontal process of the maxilla. The superior
orbital rim consists of the supraorbital rims, and the lateral
orbital rim consists of the zygomatic process of the frontal
bone and frontal process of the zygoma.
The orbital cavity is comprised of seven bones: the
frontal, maxilla, zygoma, ethmoid, lacrimal, greater and
lesser wings of the sphenoid, and the palatine bone. The
orbital floor consists of the orbital surface of the maxilla,
the maxillary process of the zygoma, and the orbital
process of the palatine bone. The floor is separated from
18
the lateral wall by the inferior orbital fissure, and the
infraorbital nerve in its canal originates in the anterior
third of the fissure, progressing nearly straight anteriorly
toward the infraorbital foramen. The orbital floor bulges
upward immediately behind the globe, contributing to the
forward globe support. The anterior portion of the floor
is concave and the remaining posterior portion is convex.
The inferior oblique muscle arises from the maxillary
portion of the orbital floor immediately posterior to
the rim and lateral to the lacrimal groove. The inferior
rectus muscle lies immediately above the infraorbital
canal. These muscles can be involved in fractures that
involve the medial aspect of the orbital floor and medial
orbital wall. Fractures involving the orbital floor lateral
to the infraorbital groove or canal less commonly cause
entrapment of these muscles.
The medial wall is comprised anteriorly of the
sturdier frontal process of the maxilla and posteriorly of
the lacrimal bone, lamina papyracea of the ethmoid bone,
and lesser wing of the sphenoid that incorporates the
optic canal. The lamina papyracea is the thinnest bone in
the body yet is slightly more resistant to fractures than is
the thicker orbital floor because of the honeycomb bony
structure of the ethmoid sinus with its bony septa that
provides additional strength. During dissection one must
remember that the optic canal is not at the orbital apex
but is rather more anterior and medial. Dissection should
not proceed posterior to the posterior ethmoidal artery.
Anteriorly lies the lacrimal fossa in which the lacrimal sac
lies and where the nasolacrimal duct originates and travels
toward the inferior nasal meatus.
The lateral orbital wall consists of the zygoma and
sphenoid bone. The superior orbital fissure runs between
the orbital roof and the lateral wall. The fissure separates
the lesser and greater sphenoid wing and allows passage
of the nerves innervating the ocular muscles (Cranial
Nerves III, IV, and VI) and the ophthalmic division of
the trigeminal nerve. Anteriorly and laterally, the fissure
is related to the temporal fossa, and posteriorly, a small
portion abuts the middle cranial fossa and the temporal
lobe. Between the lateral wall and orbital floor is the
inferior orbital fissure leading to the infratemporal fossa,
which includes the maxillary portion of the trigeminal
nerve and veins communicating to the temporal fossa.
SRPS • Volume 11 • Issue R8 • 2015
The orbital roof contributes to a portion of the floor
of the anterior cranial fossa and consists of the orbital plate
of the frontal bone and a small posterior contribution
from the lesser wing of the sphenoid. The roof is especially
thin medially. The medial superior orbital rim is where
the pulley (trochlea) of the superior oblique muscle and,
slightly laterally, the supraorbital and supratrochlear nerves
are located. Fractures in the medial superior orbital rim
region can therefore cause diplopia and anesthesia of the
forehead and scalp.
The bony orbit can be conceptualized in anterior,
middle, and posterior thirds. The anterior third is the thick
bony orbital rim. The middle section is thin and often
breaks before the rim absorbing fracture energy, and the
posterior third is thick and is generally protected from
fractures in most cases. Thus, the middle portion of the
globe often fractures first and the rim second, protecting
the posterior segments that include the most important
neurovascular structures and also the globe itself from
rupture. If the middle portion were thick, the globe would
most likely rupture in every orbital trauma. The orbital
dimensions are very important to remember (Fig. 15).91
The widest diameter of the orbit is 1 to 1.5 cm behind the
rim and not at the rim itself. Posterior to that area, the
orbit narrows dramatically. As previously noted, the optic
foramen lies on the superomedial aspect of the medial wall
in the orbital apex. In children, the orbital floor lies more
inferiorly in relationship to the inferior orbital rim because
the maxillary sinus is not well developed. Knowing the
structure and measurements of the orbit assists in the safe
dissection of the orbit when treating orbital fractures.
Surrounding the globe is an intricate system of
supportive ligaments (Fig. 16).93 This system provides
support to the globe and prevents significant vertical
height loss of the globe when orbital fractures occur.
Manson et al.,94 Iliff et al.,95 and Koornneef96 described
in detail this ligamentous support system. The system
includes several structures: the medial and lateral canthal
ligaments; an inferior sling comprised of Lockwood
ligament,93 condensations of the inferior rectus muscle,
and Tenon capsule;97 a fascial structure that subdivides
the orbital cavity into an anterior (or precapsular) and
posterior (or retrocapsular) segment; and a superior sling
composed of Whitnall ligament, condensations of the
levator and superior rectus fascia, and Tenon capsule.
35
45
36
40
17
Figure 15. Orbirtal dimensions (in millimeters) from the rim
to the internal landmarks of the internal orbit. (Modified from
Manson and Iliff.91)
Diagnosis
History—Orbital fractures are sometimes isolated but
often are associated with other facial fractures. A history
of the accident, visual disturbance, visual acuity, visual
problems before the trauma, and previous ocular surgery
should be documented. Patients seldom note previous
unilateral visual disturbances because of compensation
from the other side, but after surgery, the disturbances
might be notable and blamed on the surgeon.
Physical Examination—A thorough eye examination must
be performed in any patient with orbital fractures. The
incidence of ocular injury with facial fractures has been
reported to be 7% to 40%.98−102 Fifteen percent to 20% of
patients with major facial trauma suffer vision-threatening
injuries. Soparkar and Patrinely103 suggest a systematic
approach for eye examination in the setting of trauma. We
recommend this article to every plastic surgery resident.
It provides a simple guide for an ocular examination in
the setting of trauma in addition to an ophthalmology
specialist evaluation. Among other issues, this article
emphasizes the importance of the red color saturation in
assessing optic nerve function and the importance of visual
field examination. Additionally, examination should detect
edema, corneal abrasions, contusions, lacerations, and
retrobulbar and vitreous hemorrhage and should exclude
globe injury, extraocular muscle injury, levator muscle
19
SRPS • Volume 11 • Issue R8 • 2015
injury, levator tendon injury, and retinal detachment. A
subconjunctival and periorbital hematoma confined to the
orbital septum should be considered sine qua non with
an orbital fracture until proven otherwise. Another good
review of ocular examination was presented by Gossman
et al.104 It provides a guideline for ocular examination by
the non-ophthalmologist without specialized equipment
within 5 minutes. In any case of orbital trauma, a detailed
examination must be performed before reducing and
performing fixation of the fracture (Fig. 17).105
Traumatic Optic Neuropathy
Once globe rupture has been ruled out, the incidence of
blindness associated with optic neuropathy is reported to
be 2% to 2.4%.106−108 The mechanism is thought to be
either direct blunt trauma to the optic nerve109 or nerve
ischemia secondary to nerve compression secondary to
edema, hemorrhage, or, rarely, fracture of the narrow optic
canal.104 Operative treatment can cause further damage by
the same mechanism.110−113 High-resolution CT scanning
is important in cases of diminished visual acuity and can
identify the cause of blindness, most commonly found to
be swelling of the optic nerve, followed by fractures within
the optic canal.114−117
The ideal management of optic neuropathy is
somewhat controversial. Most physicians agree that
prognosis is significantly worse if a patient presents with
blindness compared with a patient who is progressively
losing their sight. Wang et al.118 evaluated 61 consecutive
patients presenting with visual loss after incurring facial
trauma. Outcomes of three groups of patients based
on treatment modality were retrospectively compared.
Treatment options were high-dose steroids, surgical
intervention, and observation. Twenty-seven percent
of patients who presented with no light perception
improved, compared with 100% of those who had light
perception or better at presentation. Patients suffering
from penetrating trauma also had a worse prognosis.
Additionally, improvement was observed in 38% of
patients with orbital fractures versus 83% of patients
without orbital fractures. Based on these findings, the
authors suggested an algorithm for management of optic
neuropathy based on degree of visual loss (Fig. 18). They
recommended use of megadose steroids for all patients
with optic neuropathy regardless of mechanism or degree
20
of visual loss at presentation. Other authors suggested a
steroid regimen consisting of a loading dose of 30 mg/kg
of methylprednisolone and then 15 mg/kg 2 hours later
and every 6 hours.119 Based on a review of 34 patients,
Mine et al.120 suggested that surgical decompression of
the optic canal results in improved vision in patients who
can initially perceive hand movements or better versus
no improvement in patients who present with only light
perception or worse.
Radiological Examination
CT scans, including axial and coronal planes with
bony and soft-tissue windows, are the most informative
radiographic modality. Additional sagittal views, which
are regularly obtained at many institutions, help reveal
the posterior extent of the fracture with its relationship to
the orbital apex and visualize the inclination of the orbital
floor; 1.5-mm sections are recommended unless threedimensional reconstructions are required, in which case
1-mm sections are preferred. In general, three-dimensional
views are not necessary. CT scans can suggest muscle
entrapment, but physical examination is more informative.
The scans can also suggest which patients might develop
enophthalmos based on volumetric measurements.121
No clear radiographic indication for surgery has been
delineated, but some authors have suggested surgery for
defects larger than 1 cm2.72,122 −125
Treatment
The goals of orbital fracture treatment are restoration of
function and form. They can be summarized as follows:
•• Release all soft-tissue structures of the orbit
and restore ocular range of motion.
•• Restore orbital content into the confines
of the orbit and restore orbital volume
and shape.
•• Restore the orbital wall into its original
shape, thus allowing the tissue to
presumably scar in a position closest to the
original anatomic position.
Indications for surgery are not standardized and are
somewhat controversial.
SRPS • Volume 11 • Issue R8 • 2015
Medial
canthal lig.
Palpebral limit
of orbital septum
Orbital septum
Lateral extension
of levator tendon
Lacrimal component
of orbicularis m.
Lateral
canthal lig.
Lacrimal sac
Lateral attachment
of Lockwood lig.
Medial attachment
of Lockwood lig.
Medial
check lig.
Lateral check lig.
overlying lateral
suspensory lig.
Fascial bulbi
(Tenon capsule)
Lateral
rectus m.
Medial
rectus m.
Inferior
rectus m.
Figure 16. Suspensory apparatus of the eye. lig., ligament; m., muscle. (Modified from Lockwood.93)
I. Cornea conjunctiva sclera
Lucency
Lacerations
Abrasions
Foreign bodies
III. Iris
Size
Shape
Iridodonesis
Reaction to light
Direct
Consensual (Marcus-Gunn)
V. Vitreous
Hemorrhage
Foreign bodies
II. Anterior chamber
Depth
Hyphema
Foreign bodies
IV. Lens
Lucency
Subluxation
Dislocation
VI. Retina
Edema (Berlin)
Hemorrhage
Disc
Edema
Arterial pulse
Figure 17. Checklist for evaluating the injured eye. (Modified from Barton and Berry.105)
21
SRPS • Volume 11 • Issue R8 • 2015
Figure 18. Algorithm for the management of traumatic
optic neuropathy. NLP, no light perception; LP, light
perception. (Reprinted with permission from Wang et al.118)
Globe malposition, whether enophthalmos,
exophthalmos, or vertical dystopia, and double vision
with CT evidence of incarcerated ocular muscle or forced
duction suggest entrapment. Manson and Iliff126 stated
that hypoesthesia in the infraorbital nerve distribution
associated with rim fractures that are medially displaced
and compressing the nerve is an indication for surgery.
Some authors127 contend that increasing numbness is
an indication for surgery. It is important to differentiate
muscle incarceration from other reasons that can
cause diplopia, such as hematoma, muscle edema, and
neurogenic origins that will not respond to surgery.
Timing
Emergent surgery for isolated orbital fractures is rarely
necessary unless muscle entrapment is suspected. In
cases in which substantial edema, globe injury, or
retinal detachment is present, delaying intervention is
recommended. Significant edema can render surgery
difficult by attempting to replace the tissue to its original
anatomic space. Symptoms often subside, rendering
surgery unnecessary.
When substantial orbital fractures occur, early
intervention is recommended for better functional and
aesthetic results. In a larger series of facial fractures
reported by Hakelius and Pontén,128 22% of patients with
midface fractures had diplopia. The patients were evaluated
22
in two groups. Sixteen percent of those who underwent
surgery within 2 weeks of the trauma had diplopia, and
this occurred only when fatigued. Twenty-four percent of
the group who underwent delayed treatment suffered from
late diplopia. In a series of 50 patients who had delayed
presentation of 4 weeks between accident and surgery,
43 patients experienced restricted ocular motion. Emery
et al.,122 in a series of 179 patients, reported diplopia in
60% of untreated patients who initially presented with
double vision. Double vision in a functional field of gaze
associated with evidence of muscle or fat entrapment
on CT scan is an indication for surgery.126 Correction
of enophthalmos is more difficult in the delayed setting
because the muscles or orbital ligaments or fat might have
scarred in an abnormal position. Surgical intervention can
worsen the diplopia by positioning the globe in the field of
action of a shortened muscle and can risk additional injury
to the muscles, which are closely located to the orbital
walls in the posterior aspect of the orbit.
Techniques
The three most common incisions are the
transconjunctival, subciliary, and subtarsal incisions.
The transconjunctival incision is performed through the
conjunctiva a few millimeters above the inferior fornix.
Its most medial aspect should not go beyond the inferior
punctum, which could risk injury to the canaliculi.
Laterally, it can be extended as a lateral canthotomy
through the inferior limb of the lateral canthus if exposure
of the lateral orbital wall is needed. Once the incision is
made, two approaches to the orbital floor are available:
pre- and post-septal. A pre-septal approach necessitates
incision through the lower lid retractors, dissection
along the preseptal plane toward the arcus marginalis,
and continued dissection in the subperiosteal plane. A
post-septal approach can be used with direct approach
to the orbital fat, avoiding contact with the lower eyelid.
If further exposure of the lateral orbital wall is needed, a
lateral canthotomy can be performed by incising the lower
limb of the lateral canthus. Accurate reattachment of the
inferior limb to its original location at Whitnall tubercle
is necessary to avoid malpositioning the lower eyelid. If
medial extension is needed to address the medial orbital
wall, a transcaruncular approach can be used.129 The
subciliary approach is performed 1 to 2 mm inferior to the
SRPS • Volume 11 • Issue R8 • 2015
lower eyelid lashes. Care should be taken not to injure the
lashes. With this approach, dissection usually is performed
between the orbicularis oculi muscle and orbital septum
pre-septally. Manson et al.130 modified the subciliary
approach with a lateral extension below the lateral canthus
to enable access to the lateral orbital wall and zygomaticofrontal suture.
The subtarsal approach allows access to the orbital
floor via an incision just inferior to the tarsus in a subtarsal
crease. The dissection proceeds in the pre-septal plane
down to the orbital floor. It is useful, especially in the
older population in which the subtarsal crease is deep and
the scar can be well hidden.
Restoration of Orbital Wall Continuity
The primary goal of orbital repair is restoration of the
volume and shape of the orbit. The secondary goal is
separation of the orbit from the maxillary sinus. If orbital
exploration is indicated, repair of the orbital floor is
required in almost all cases other than cases in which
entrapment occurred in a very small trapdoor deformity
and the orbital contents remain in the orbit after their
reduction. Alloplastic materials are currently most
commonly used, and few plastic surgeons continue to use
bone grafts.
Several studies compared the approaches in terms of
postoperative risk for ectropion and scleral show. Appling
et al.131 reviewed the cases of 163 patients who underwent
either a subciliary or a transconjunctival incision approach
for orbital floor repair. In the subciliary group, 28%
developed permanent scleral show and 12% developed
transient ectropion. With the transconjunctival approach,
3% developed transient ectropion and 0% had permanent
ectropion.132
Bone Grafts—The most common bone grafts used are
calvarial grafts.133 Less commonly used bone grafts are
split rib grafts. Antonyshyn et al.134 reported superior
results with bone grafts. The potential advantage is
revascularization of the bone, but perhaps more important
is the decreased adhesions of the orbital content to
the bone, as opposed to titanium or MEDPOR, if reexploration is required. Complete absorption of the bone
was also reported. Dingman and Grabb135 reported use
of irradiated or banked bone, but it is difficult to justify
because of readily available donor bone.
Dissection—Regardless of the incision chosen, it is key to
perform the orbital dissection in the subperiosteal plain.
Any other plain increases the risk for injury of the ocular
muscles and other intraorbital structures. When incising
the periosteum at the beginning of the exposure, it is
advisable to tag the periosteal edges with sutures because
they often are difficult to identify at the end of the case.
Not all surgeons close the conjunctiva, but periosteal
closure is paramount to avoid midface dropping and
possible traction on the eyelid. During the subperiosteal
dissection, it is important to identify the ledges of the
fracture, especially the posterior ledge, which can be
found even 40 mm posterior to the rim. The orbital
content descending to the maxillary sinus should be gently
retracted back to its intraorbital position rather than
aggressively pulled, which could potentially cause damage.
As noted previously, the surgeon should be familiar with
the orbital dimensions and cognizant of the extent of the
dissection, particularly with medial wall dissection. Once
the dissection is completed and continuity of the orbital
wall restored, a forced duction test should be conducted to
verify full range of motion of the globe.
Alloplastic Reconstruction—Several materials are available
for orbital reconstruction including silastic,136 titanium,
polymethylmethacrylate, Teflon,137,138 and high-density
porous polyethylene (Porex Corporation, Fairburn, GA).
MEDPOR (Stryker, Kalamazoo, MI) or titanium covered
with MEDPOR is commonly used, and these materials
have very low reported associated infection rates with
the advantage of not creating a donor site defect. In their
series, Choi et al.139 reported a series of 25 patients who
underwent reconstruction with MEDPOR. During a
follow-up period of 31 months, no infections or loss of
structural support occurred. It is important to use thick
enough implants (1.5 mm rather than 0.8 mm) to keep
the reconstruction from bending toward the maxillae with
subsequent enlargement of the orbit. It is also important
to place any material far enough posteriorly on a stable
ledge of bone and to fixate it with a screw to prevent
anterior displacement and to avoid risk of extrusion
through the eyelid. Use of the smooth portion of the
implant toward the orbit is recommended to theoretically
decrease the chance of adhesion of the ocular muscles to
the surface.
23
SRPS • Volume 11 • Issue R8 • 2015
Hollier et al.140 reported use of absorbable plates,
which are potentially most useful in the pediatric
population. With a mean follow-up of 6 months, the
authors reported enophthalmos in two of 12 patients
and stated that it occurred secondary to initial placement
of the implant rather than resorption. Bauman et al.141
reported different results. In their study, five of six patients
developed enophthalmos after the use of resorbable
implants for defects of 2.5 to 4.0 cm2.
Complications
Ectropion or retraction of the lower lid can occur from
trauma, especially if the lower lid was directly involved
in the initial trauma, or secondary to dissection. The
pathological condition can occur secondary to scarring
of the anterior, mid, or posterior lamellae of the eyelid.
It more commonly occurs with subciliary incision,131
although it has been reported to occur with all incisions.
Although not prospectively shown, it is the authors’
opinion that a transconjunctival post-septal approach
might be the safest approach considering that dissection
does not involve the lid structures. Aside from a careful
and accurate anatomic dissection, an additional measure
that can be taken is application of a frost stitch, a stitch
that is inserted in the lower eyelid lateral to the lateral
limbus and taped to the forehead or stitched behind the
hair-bearing scalp. This provides additional mechanical
support during the first 2 to 3 days after surgery and still
permits examination of vision after surgery. If ectropion
does develop, frequent massaging of the scar with
supportive taping of the lid in a superior vector usually
leads to resolution of the problem. If the ectropion persists
beyond 6 months, it should be addressed surgically based
on the lamellae involved. In the meantime, the cornea
needs to be lubricated and protected to avoid permanent
corneal damage.
Enophthalmos—Acute enophthalmos is a consequence
of increased orbital volume, but persistent enophthalmos
results from inadequate restoration of orbital volume with
subsequent scarring of the extraocular muscles causing
contraction of the globe in the anterior-posterior vector.
Early repair of all fractures involving the orbit usually
result in less chance of enophthalmos compared with late
24
repairs, as was shown in a study by Dulley and Fells,142
who reported a 72% incidence of enophthalmos in
patients who underwent repair more than 6 months after
the initial trauma versus 20% in those who underwent
repair within 14 days. In the late repair group, 40% of the
patients required subsequent surgery of the muscle or orbit
in an attempt to correct the problem. Per Manson et al.,143
insertion of implants into the orbit usually is not sufficient
to correct the problem in the anterior to posterior
direction, and complete orbital dissection to free the
content from the orbit followed by orbital augmentation
with calvarial bone grafts is necessary.
Diplopia—Persistent diplopia after surgery can be caused
by several different mechanisms: inadequate release of
entrapped orbital content, scarring of orbital content to
the orbital wall or repair, scarring and shortening of one or
more of the ocular muscles, increased intraocular pressures,
or neurogenic injury. A forced duction test must be used
at the end of each surgery to verify that entrapment is not
present. This test can be performed in an awake patient
with appropriate administration of local anesthetic to rule
out mechanical restriction. If motion is not limited by
entrapment or scarring, diplopia is unlikely to have been
caused by entrapment. In such cases, neurogenic diplopia
might be the cause, which can take 6 months or longer
to resolve.144 Biesman et al.145 reviewed the cases of 54
patients and found that 86% had preoperative diplopia
defined as double vision interfering with daily activities
and 37% percent had persistent diplopia over 6 months
postoperatively. Such patients need to be followed by
an ophthalmologist specializing in muscle surgery. If
symptoms persist beyond 6 months, ocular muscle surgery
should be considered.
Infection Associated with Orbital Implants—
Infection associated with orbital implants is rare and
more commonly occurs with implants that form a
pseudocapsule, such as silicone or Teflon, which prevents
vascular ingrowth. Infection might also occur with a
procedure that causes transient bacteremia.146−149 Highdensity porous polyethylene that allows some vascular
ingrowth has been associated with very low infection rates.
In cases of infection, implants should be removed.
SRPS • Volume 11 • Issue R8 • 2015
Extrusion of Implants—Extrusion of implants is also a rare
occurrence. Brown and Banks150 presented three patients
who experienced extrusion of implants 10 to 17 years after
initial surgery. When placing implants, they should be
fixed to the orbital rim to prevent anterior displacement.
Blindness—Blindness can occur after surgery for several
reasons. Inadvertent injury to the optic nerve and resulting
blindness can occur because of overzealous dissection,
particularly along the medial orbital wall. Impingement
of the optic nerve by an implant placed too posteriorly at
the time of reconstruction can also occur. Postoperative
retrobulbar hematoma is another potential cause. One of
the first early signs of optic nerve injury is loss of ability to
identify the color red during examination. Early diagnosis
and emergent surgery are indicated, and, in most cases,
emergent CT scanning of the orbit is recommended before
performing surgery.
Superior Orbital Fissure Syndrome (SOFS)—Rowe and
Killey151 credit Hirschfeld with the first description of
SOFS. SOFS is caused by extension of the fracture line
into the superior orbital fissure, causing injury to cranial
nerves III, IV, and VI and the ophthalmic division of
cranial nerve V. This produces ophthalmoplegia, upper lid
ptosis, proptosis, a fixed and dilated pupil, and sensory
disturbance over the ophthalmic distribution of the
trigeminal nerve, including the loss of the corneal reflex.
On examination, the pupil is unresponsive to both direct
and indirect light stimulation; however, the consensual
pupillary response is intact, indicating that the optic nerve
(the afferent arc) is uncompromised.152−155 Most patients
with SOFS should be treated conservatively unless there is
radiographic evidence of nerve compression.
Orbital Apex Syndrome (OAS)—OAS is similar to SOFS
except for the additional finding of blindness caused by
direct extension of the fracture into the optic canal or
severe optic neuropathy.156 Kjœr157 first described OAS in
1945. Treatment is similar to that described in the section
of optic neuropathy.
Trapdoor Fractures
Trapdoor fractures generally are orbital floor fractures in
which the fracture spontaneously reduces while entrapping
orbital content as ligaments or muscle causing mechanical
ocular motion limitation. These fractures usually are
greenstick fractures that occur in the pediatric population,
and some patients exhibit oculocardiac reflex (bradycardia,
nausea, and syncope) caused by incarcerated
orbital content.158
Blow-In Fractures
Orbital blow-in fractures are uncommon. Decreases
in orbital volume and increases in intraorbital pressure
occur with these fractures.159 Orbital blow-in fractures
sometimes include the rim; these are defined as “impure”
blow-in fractures. Some do not involve the rim and
are thus defined as “pure” blown-in fractures.160−166
Associated clinical findings include universal proptosis,
diplopia (32%), upward vertical dystopia (i.e., upward
displacement of the globe) (28%), globe rupture
(12%), SOFS (10%), and optic nerve injury.164,167 Early
intervention is key for successful treatment to prevent
intraorbital damage secondary to increase in orbital
pressures typical of these injuries. The treatment goal is
relief of intraorbital pressure and restoration of orbital
structure.
Medial Orbital Wall Fractures
Medial orbital wall fractures can involve the floor, be
part of a NOE fracture, or be isolated. Medial orbital
wall fractures might be tempered by the honeycomb
architecture of the ethmoid sinus and occur slightly less
frequently than do the thicker orbital floor fractures, but
displacement of the medial wall will cause significant
enlargement of the orbital volume. Entrapment of the
medial rectus muscle is rare, occurring in fewer than 1%
of cases,168 and the medial rectus muscle often is found
to be contused. The medial wall can be approached
from the floor via a transconjunctival incision with a
transcaruncular extension,129 a subciliary or subtarsal
approach, an upper blepharoplasty approach, or a coronal
approach. The best view is achieved via a coronal incision.
Whatever the approach chosen, if the medial wall fracture
is extensive and involves the floor, the initial repair
25
SRPS • Volume 11 • Issue R8 • 2015
should be of the floor, thus providing a medial strut for
stabilization of the additional bone graft or alloplastic
material used for reconstruction. Often, the posterior
extension of the fracture is to the posterior ethmoidal
artery and dissection beyond this point risks injury to the
optic nerve located approximately 5 mm posteriorly. Once
exposure is obtained, the grafts or alloplast can be stacked
on the inferior reconstruction until intraorbital volume is
restored (Fig. 19).13
fracture rather than the orbital aspect to prevent decreasing
the orbital volume and to avoid exophthalmos after repair
(Fig. 20).13
Zygomatic Arch and ZMC Fractures
Definition
Zygomatic fractures include fractures of the ZMC, also
known as malar fractures or isolated zygomatic arch fractures.
Lateral Wall Fractures
Isolated lateral orbital fractures are rare. The majority of
lateral wall fractures are part of a more extensive fracture
involving the floor and lateral orbital rim, such as occurs
with zygomaticmaxillary complex (ZMC) fractures, which
are discussed in detail in the following sections.
Orbital Roof Fractures
Orbital roof fractures are rare and usually occur as part
of more extensive fractures, such as frontal sinus fractures
and NOE fractures.165,169,170 The exception is isolated
orbital roof fractures that occur in children younger than
7 years. Children of this age do not have a developed
frontal sinus, and forces are thereby transmitted via the
rim to the orbital roof. The classic presentation of these
patients is exophthalmos, proptosis, upper eyelid ptosis,
and diplopia.163,171 The medial orbital roof is weaker
than the lateral roof and is therefore more involved in
fractures.172,173 Posterior displacement can cause pressure
on the superior orbital fissure, causing SOFS.154,174,175 If
the fracture involves the optic canal, it can cause blindness,
as occurs with OAS. If the superior rim of the orbit is
involved, the trochlea of the superior oblique muscle can
be displaced, causing diplopia in its field of action, which
usually resolves spontaneously.176 The orbital rim and roof
can be displaced superiorly or inferiorly and often are
associated with brain injury or dural tears. Left untreated,
cerebral content will herniate down into the orbit and
cause the classic pulsatile exophthalmos in adults and
inferior displacement of the orbit in the growing child.
Treatment usually involves the neurosurgical team and
repair of the brain, and dural injury should be performed
before orbital repair. Once exposure is obtained, a bone
graft should be secured on the cerebral aspect of the
26
Figure 19. Illustration shows bone grafting of a medial
orbital defect. (Modified from Mathes.13)
Figure 20. Illustration shows intracranial bone graft
reconstruction of the orbital roof. (Modified from Mathes.13)
SRPS • Volume 11 • Issue R8 • 2015
All ZMC fractures involve the orbital floor, lateral orbital
wall, and zygomatic arch.
Anatomy
The zygomatic bone creates the lateral buttress of
the midface. It forms the malar eminence, provides
prominence to the cheek, and forms the lateral and
inferolateral walls of the orbit. It has a quadrilateral shape
and articulates to four adjacent bones: the maxilla, frontal,
temporal, and sphenoid bones (Fig. 21).136 Therefore,
fractures of this malar complex should be termed tetrapod
fractures rather than the more commonly used misnomer,
tripod fracture. The zygoma is the origin of several facial
muscles, including the masseter, temporalis, zygomaticus
major and minor, and zygomatic head of the quadratus
labii superioris muscles. Malar fractures usually cause the
zygoma to displace downward, medially, and posteriorly
because of the forces of trauma but more so secondary
to the pull of the masseter muscle. Nerves that pass
through the zygoma include the zygomatic temporal and
zygomatic facial nerves. The inferior orbital nerve passes
on the medial aspect of the bone; therefore, fractures can
cause numbness in related areas. With isolated zygomatic
arch fractures, the arch might be significantly impacted
medially and cause severe pain and possible mechanical
impingement while attempting to open the mouth or
during mastication. In cases of high-energy trauma with
severe comminution of the arch, bony fragments might be
pushed into the glenoid fossa, preventing mouth closure
and creating an open bite. Because the lateral canthus is
attached to the lateral orbital rim at Whitnall tubercle,
inferior to the frontozygomatic suture compound, malar
fractures often create an antimongoloid slant of the
palpebral fissure. These fractures all include the orbital wall
and can thus create significant vertical dystopia (Fig. 22).13
Diagnosis
History—Understanding of the mechanism of the trauma
provides information about the energy and direction of the
force involved. In cases of penetrating trauma, the surgeon
should seek potential foreign material embedded in the
soft tissue. History can help diagnose a malar fracture or
isolated zygoma fracture, but a good examination usually
provides even more accurate assessment.
Physical Examination—Typical findings in patients
with zygomatic complex fractures, excluding fractures
of the arch, are periorbital ecchymosis, edema, and
subconjunctival hemorrhage. Because of the confinement
of the bleeding by the orbital septum, a spectacle
Figure 21. Zygoma and articulating bones. A, The zygoma
articulates with the frontal, sphenoid, and temporal bones
and the maxilla. Shaded areas show the portions of the
zygoma and maxilla occupied by the maxillary sinus. B,
Lateral view of the zygoma. (Modified from Kazanjian and
Converse.136)
A
B
Figure 22. A, Normal position of the lateral canthus in a
fracture without displacement. The palpebral fissure slants
slightly upward from the medial to the lateral canthus
by several millimeters. B, Downward displacement of the
globe and lateral canthus results from a frontozygomatic
separation wth inferior displacement of the zygoma. The
globe and periorbita are permitted to sink into an enlarged
orbital cavity, and the lateral canthus with the attachment
of the eyelids and orbicularis are dragged inferiorly as a
result of the displacement. (Modified from Mathes.13)
27
SRPS • Volume 11 • Issue R8 • 2015
hematoma usually is created. Periorbital hematoma and
subconjunctival hematoma are the most accurate physical
signs of orbital fracture, which might include the zygoma.
Ipsilateral numbness of the cheek, lip, nose, and teeth are
typical because of some degree of injury to the infraorbital
nerve. The lateral canthal ligament might be displaced
inferiorly and the lower lid might be pulled inferiorly.177
Intraoral swelling can be detected by physical examination.
Malocclusion or difficulty in moving the mandible can
be caused by medial displacement of the arch or posterior
displacement of the malar eminence. Enophthalmos
and vertical dystopia might also be present with malar
fractures.174,178,179 Some malar fractures are displaced
medially, decreasing the volume of the orbit and causing
exophthalmos. These blow-in fractures have been described
by Antonyshyn et al.164 and by Stanley and colleagues.180,181
Radiology—CT scans are the radiographic images of
choice for evaluating zygomatic fractures. Plain film
radiographs are redundant if CT scans are obtained.
Traditionally, the Waters view is the single best film to
fully assess a malar fracture,182−185 but, as noted, CT
scans yield the most information, especially if axial and
coronal views are included, including soft-tissue and
bony windows.186 Coronal views are especially helpful for
evaluation of the orbital floor and the amount of orbital
content descending into the maxillary sinus. Threedimensional CT reconstructions can be helpful when
comparing the normal with the abnormal rim and malar
eminences but is less accurate in evaluating thin bony
fractures of the orbital walls.187,188
Intraoperative CT scans are gaining in popularity
and have potential value in the management of zygomatic
and ZMC fractures.189 However, the main goal of the use
of CT scans is to enable accurate assessment of reduction.
Postoperative CT scans are essential in
evaluating reduction.
Classification
The main goal of classification systems151,190−196 was to
define which fractures could be treated by closed reduction
versus open reduction. Manson et al.195 and Afzelius and
Rosén197 created a classification system based on the energy
of the trauma. Higher energy traumas required more
frequent operative intervention and wider exposure.
28
Treatment and Techniques
Malar fracture treatment developed with facial trauma
treatment. Cranial fixation devices, percutaneous
fixations (such as Kirschner wires and direct fixation with
interosseous wires), and immediate bone grafting when
needed improved the results of treatment of facial fractures
between 1960 and 1980.198,199 With the advent of rigid
fixation devices (plates and screws) in the mid-1980s,
results further improved and the need for bone grafting
further decreased.
The most important elements of malar fractures
that determine the therapeutic approach are the amount
of displacement and the degree of comminution of
the fracture. Non-displaced fractures can be treated
conservatively without operative intervention, but patients
should be followed closely, two to three times during a
six-week period. The forces exerted on the zygoma by
the masseter muscle can displace the malar segment. If
such displacement occurs, early surgical intervention is
indicated. To decrease the chances of displacement during
the period of observation until stable healing is achieved,
the patient should be restricted to a soft diet, be instructed
to avoid physical activities that would risk trauma to the
area, and refrain from sleeping with pressure on the side
of the injury. If any displacement is noted, most authors
prefer surgical intervention. Some authors200 advocate
closed reduction to treat minimally displaced fractures,
but it is generally known that many surgeons advocate
different degrees of exposure and internal fixation based on
the degrees of displacement and comminution.
Isolated fractures of the zygoma should be
differentiated from fractures of the malar complex.
Trismus caused by impingement of the temporal muscle
by the zygomatic arch and contour deformity are the
two main indications for surgery for isolated zygomatic
arch fractures. The operative approach can be through
the mouth. More commonly, a Gillies approach is used
(Fig. 23).201 The technique involves a small incision in
the temporal region, behind the hairline if possible,
dissecting deep to the temporalis fascia and identifying
the muscle. The elevator is inserted along the muscle
inferiorly until it is deep to the arch. It is then leveraged
on the calvaria to elevate the fractured segment. An
audible click often is heard, and assessment is conducted
by inspection and palpation intraoperatively. This
procedure usually is successful because the periosteum
SRPS • Volume 11 • Issue R8 • 2015
of the arch usually is intact because of the greenstick
character of the fracture, allowing anatomic reduction
with relative ease. Most isolated arch fractures remain
stable after reduction,114,201,202 but some authors prefer
to externally partially stabilize the fracture until healing
is achieved.203,204 Stabilization can be accomplished by
inserting two sutures deep to the arch and securing a rigid
piece of fixation, such as an Aquaplast splint, over the
fracture area. To avoid skin necrosis under the splint, the
splint should not be excessively tightened.
More complex zygoma fractures should be evaluated
on an individual basis in terms of degree of exposure and
fixation necessary to obtain good results. Most malar
complex fractures can be treated via three incisions (Fig.
24).114 To expose the lateral zygomaticmaxillary buttress,
an upper gingivobuccal incision is made, allowing
exposure of the maxillae, zygoma, and inferior orbital rim.
During this dissection, the infraorbital nerve is identified
and protected. To expose the inferior orbital rim and, if
needed, the orbital floor and lateral orbital wall, an eyelid
incision (transconjunctival, subciliary, or subtarsal) can be
used based on the experience of the surgeon. Exposure of
the frontozygomatic suture is obtained via a lateral upper
blepharoplasty incision or direct incision over the frontal
zygomatic suture. A brow incision should be avoided
because the alopecia that can occur secondary to scar
is difficult to successfully treat. Manson et al.38 noted a
preference to initially expose all the fractures and perform
initial fixation of the frontal-zygomatic suture with 1.0- to
1.3-mm plates. The orbital rim is plated next, usually with
a 1.0 plate applied to the superior aspect of the inferior
orbital rim rather than externally to decrease chances of
palpability. This is followed by the zygomaticmaxillary
buttress reduction and fixation with the use of 1.5- to
2.0-mm plates, usually L plates. The tooth roots should be
avoided when drilling the lateral buttress plates. In reality,
screws that penetrate teeth have not had the frequency of
adverse sequelae initially predicted.205 Only after reduction
is verified are the plates secured. The anatomic area, which
is most informative to the surgeon about the accuracy
of reduction, is the congruity of the lateral orbital wall
that can be ascertained either from within the orbit or
externally via the temporal fossa.
In cases of severe ZMC comminution or severe
comminution of the arch, a coronal exposure might
be needed. This is also indicated when reduction of a
severely impacted malar fracture is not possible via more
limited approaches. In these scenarios, it is difficult to
orient and reduce the fractures via limited approaches
and the reduction and fixation of the zygomatic arch
provides pertinent information. Every surgeon who treats
facial fractures should be knowledgeable in performing a
coronal incision and exposing the zygomatic arch, while
understanding the temporal anatomy and avoiding injury
to the frontal branch of the facial nerve. Once the arch is
exposed, a nearly straight plate should be used for fixation.
Delayed Treatment of Zygoma Fractures
As with any facial fractures, early reduction facilitates
obtaining optimal results. Consolidation of the bones
begins in the malreduced position as early as 1 week
after injury and is organized in 3 weeks. Any delay in
fracture repair of more than 2 weeks after the injury might
require osteotome-assisted reduction because of fibrous
or bony ankylosis. After mobilization is performed, all
bony edges should be inspected and fibrous ankylosis or
bony proliferation removed. Otherwise, malalignment
will occur.206 In fractures that are treated late, a formal
osteotomy should be performed rather than mobilization
Skin
Temporal
parietal fascia
Temporalis
fascia
Temporalis
Zygomatic
arch
Mandible
Figure 23. Temporal incision for reduction of isolated
zygomatic arch fractures. A and B, Incision is continued
through temporoparietal and temporalis fascia. C, Dingman
elevator is placed deep to the temporalis fascia behind
depressed zygomatic arch. (Modified from Feinstein and
Krizek.201)
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SRPS • Volume 11 • Issue R8 • 2015
Upper lid incision
Subtarsal incision
Gingivobuccal incision
Figure 24. Common incisions for exposure of the zygoma. Upper and lower eyelid incisions are shown. (Modified from Rohrich
et al.114)
with blunt force. The latter could create additional fracture
lines, which could extend into the orbital canal and cause
blindness. In cases of delayed fracture repair, the masseter
muscle might shorten and mobilization of the malar
complex might be achieved only by cutting through its
insertion into the inferior aspect of the malar eminence.
Complications
Early Complications—
1)Bleeding is a rare occurrence and usually is
self-limiting. In cases of persistent bleeding
that do not respond to direct cauterization,
angiographic embolization might be
required.
2)Sequestration of devitalized bone fragments
can cause infections of the sinus (acute
sinusitis). Inappropriate drainage of the
30
sinus increases the chance for sinus infection
and can lead to the need for endoscopic
sinus surgery to clear the sinus ostia. Failure
to recognize inadequate sinus drainage can
result in a persistent oral antral fistula in the
sublabial region.207
3)Extraocular muscle injury can result from
contusion or, less frequently, interference by
bony segments or entrapment of muscle or
fat.
4)Blindness has been reported to occur after
malar fraction reduction.208,209
Late Complications—
1)Malunion most commonly occurs because
of inadequate reduction caused by errors
in judgement during surgery. This also
occurs in untreated fractures that heal
in malposition. Treatment consists of
SRPS • Volume 11 • Issue R8 • 2015
removal of any applied plates and screws,
osteotomies, and proper reduction and
fixation.210 A malaligned fracture often
results in bone loss and necessitates adding
bone grafts to regain buttress height or
malar projection.
often occurs when closed reduction is
attempted and can be caused by excessive
reduction forces. If the arch abuts the
coronoid process, fibroosseous ankylosis
can occur, limiting the mandibular motion.
If limited motions persists after reduction
of the arch or if reduction is not possible,
coronoidectomy via an oral approach is
considered. If motion is regained after this
procedure, vigorous postoperative exercise
for up to 6 months is essential to preserve
motion.
2)In general, ectropion and scleral show are
mild and usually resolve spontaneously.
An estimated 10% of patients undergoing
subciliary approaches to the orbital floor
develop temporary ectropion.
3)Diplopia and orbital dystopia can be
caused by gross downward movement of
the zygoma. An excess of 5 mm of inferior
orbital dystopia is required to produce
diplopia. Osteotomies, mobilization,
reduction, and fixation are necessary for
correction. If malar projection is deficient,
bone grafting might be necessary.210,211 If
enophthalmos is present because of loss
of orbital volume, volume augmentation
can be achieved by either bone grafting or
artificial material, such as MEDPOR.
4)Enophthalmos or exophthalmos is caused
by decreased or increased orbital volume,
respectively, after trauma. Enophthalmos
usually results in orbital floor involvement,
and treatment is described in the orbital
fracture segment. Exophthalmos results
from a compressed malar fracture, and
treatment consists of malar reduction with
or without treating the orbital floor based
on floor involvement.
5)Chronic infection usually results from
preexisting sinus infections and can be
caused by inadequate drainage of the sinus.
Clearing the sinus with endoscopic surgery
is recommended if osteotomies are planned
for correction of malalignment.
6)Mandibular motion limitation and trismus
can occur. Malposition of the zygomatic
arch or body or bony fragments can
interfere with motion of the coronoid
process and require osteotomy.90,91 This
7)Persistent anesthesia or hypesthesia
can occur, with hypesthesia resolving
spontaneously in most cases.212,213 If it
persists for longer than 6 months, it is most
likely because of transection or entrapment
of the nerve. If entrapment by scarring or
compression of medially displaced zygoma
is suspected, the surgeon can attempt to
decompress the nerve, which includes the
foramina, and along the course of the nerve
in the orbital floor.
Nasal Fractures
Definition
Nasal fractures include fractures of bony or cartilaginous
portions of the nose, including the nasal septum.
Anatomy
The upper nasal skin that lies on the bony portion of
the nose is mobile compared with the thicker, more
sebaceous skin of the lower third of the nose that is
more adherent to the cartilaginous portion of the nose.
The rich blood supply of the nose allows extensive and
safe submuscular dissection and results in early rapid
healing of the soft tissue and bones of the nose. The
supporting framework of the nose is comprised of a
complex, semirigid, cartilaginous portion that is attached
to a solid and inflexible bony structure of the nose. The
cartilaginous portion includes the upper and lower lateral
alar cartilages, the septal cartilages, and small sesamoid
cartilages. The bony structure consists of the nasal spine
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SRPS • Volume 11 • Issue R8 • 2015
of the frontal bone, the paired nasal bones and the bony
septum, which includes the vomer and the perpendicular
plate of the ethmoid. Proximally, the nasal bones are thick
and narrow; distally, they are thinner and wider. Because
of this configuration, proximal bony nasal fractures occur
infrequently compared with distal bony nasal fractures.
Classification
Stranc and Robertson214 classified nasal fractures into
lateral impact and frontal impact. Frequently both
components are seen in one nasal fracture.
Lateral and frontal nasal fractures can be divided
into three planes. Plane I involves mostly unilateral
displacement of the distal nasal bones into the nasal cavity.
Plane II involves bilateral nasal bone fractures, the frontal
process of the maxillae, and the septum. Plane III involves
the fracture pattern seen in plane II and the frontal bone
with extension into the medial orbital rim, creating a hemi
NOE fracture (Fig. 25).13
Treatment
In general, most nasal fractures can be reduced by closed
techniques. Frontal impact fractures in planes II and III
with loss of nasal height or length, should be treated with
open reduction and primary bone or cartilage grafting
to restore support and fill the soft-tissue envelope before
irreversible concentric scarring occurs.215,216 Verwoerd217
described the indications for open and closed reductions
in 1992. Summarized below are the modifications
recommended by Metzinger et al.218
Indications for closed reduction are as follows:
1)Unilateral depressed nasal pyramid fractures
with stable dorsum
2)Bilateral fractures without significant loss of
septal height
3)Disruption of upper lateral cartilage
from septum
Indications for open reduction are as follows:
Diagnosis
Clinical Examination—Clinical examination must include
external and internal nasal examinations. Mobility,
crepitus, and tenderness are noted with nasal palpation.
A hematoma over the nose extending into the periorbital
area is present but does not extend beyond the insertion
of the orbital septum, differentiating it from hematomas
that occur in association with orbital fractures that do
extend beyond the insertion of the orbital septum and are
described as spectacle hematomas. Intranasal examination
must be performed to rule out a septal hematoma. If
present, a septal hematoma must be evacuated by a linear
or L-shaped incision and closed with quilting sutures
to avoid reaccumulation of blood. An untreated septal
hematoma can result in septal infection and possible septal
necrosis. For a properly performed intranasal examination,
oxymetazoline should be applied to the nasal mucosa.
Radiology—Plain film radiographs can help delineate
nasal fractures, but the mainstay of radiographic diagnosis
is the CT scan. CT scans reveal the most detail, delineate
fracture pattern, which can be obscured by soft-tissue
swelling, and, more importantly, confirm the absence of
injury to adjacent bones, such as the maxilla and orbits.
32
1)Bilateral fractures with or without lateral
dislocation of nasal dorsum but with
significant septal injury and potential for
loss of septal height
2)Bilateral fractures with buttress dislocation
with or without major septal injury
3)Fractures or dislocations of
cartilaginous pyramid
Open Reduction Techniques—When extensive fractures
occur or open lacerations provide ample exposure, bone
or cartilage grafting often is necessary to restore nasal
height. An open rhinoplasty approach might be necessary
for reduction. With an open approach, the fragments
can be accurately reduced and fixed with No. 30 or 32
wires or, more commonly, with 1.0-mm plates and screw
fixation. If nasal height or length is lost, bone or cartilage
grafting should be used and can be fixed with Kirschner
wires or preferably with plates. If cartilaginous structures
are separated from the bone, they can be fixed with clear
nylon sutures. Open reduction usually yields better results
than does closed reduction.
SRPS • Volume 11 • Issue R8 • 2015
A
B
C
Figure 25. Stranc classification of displacement after nasal fractures. Frontal impact nasal fractures are classified by degrees
of displacement, as are lateral fractures. A, Plane I frontal impact nasal fractures: Only the distal ends of the nasal bones and
the septum are injured. B, Plane II frontal impact nasal fractures: Injury is more extensive, involving the entire distal portion of
the nasal bones and the frontal process of the maxilla at the piriform aperture. The septum is comminuted and begins to lose
height. C, Plane III frontal impact nasal fractures: One or both frontal processes of the maxilla are involved, and the fracture
extends to the frontal bone. These fractures are nasoethmoidal-orbital fractures because they involve the lower two-thirds
of the medial orbital rim (central fragment of the nasoethmoidal-orbital fracture) and the bones of the nose. (Modified from
Mathes.13)
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SRPS • Volume 11 • Issue R8 • 2015
Closed Reduction Techniques—In principal, the nasal
bone or septal fracture must first be completed and only
then replaced into its proper position. The nasal bones are
pushed superiorly and fractured laterally on both sides
and are then pushed into proper position with digital
compression. Similarly, the septal fracture is completed
and then repositioned in the midline. If the bones are
comminuted or loose and tend to sink posteriorly after
reduction, internal packing (commonly with Doyle nasal
splints; Xomed, Jacksonville, FL) will help prevent collapse
and external nasal splinting is added.
1)Bruising and ecchymosis with pigmentation
of skin and eyelids
In cases of plane II fractures, when collapse of
the nasal structures occur after attempted reductions,
a technique that is very useful is insertion of transnasal
wiring through the cartilaginous septum with the aid
of a spinal needle while retracting the nose anteriorly.
The wires traverse the nose at the level of the piriform
aperture and are pulled through an orthopaedic felt that
is covered with Xeroform gauze (Covidien, Washington,
DC). This semi-soft dressing is further compressed by a
Supramid plastic plate or MEDPOR plate, through which
the wires traverse. This technique controls the fracture in
the anterior–posterior plane and prevents widening of the
fractured nasal bones that would otherwise regress into
their morbid wide position.
4)Bleeding usually occurs within the first 2 to
3 days after injury; rebleeding sometimes
occurs 7 to 10 days after injury
Timing of Treatment—In reality, most nasal fracture
treatments are deferred until the edema has partially
resolved but should be treated in 5 to 7 days. After 2
weeks, partial healing in malalignment has occurred. In
fractures resulting in reduced volume, concentric scarring
renders reduction more difficult. Osteotomies might be
necessary at that stage.217 Acute open rhinoplasty usually
results in resection of telescoped septum and osteotomies.
Elective secondary rhinoplasty usually is preferable to
obtain better results. The exception to this is treatment
of NOE fractures for which early intervention is the rule.
All patients should be warned that because of the chance
of cartilage warping and scar contraction, the nose might
change shape with time and secondary surgery might be
necessary.
2)Septal hematoma, which develops between
the mucoperichondrium and cartilage and
results in septal perforation or fibrosis;
organization of the hematoma can lead to
thickening of the cartilage
3)Breathing obstruction can occur when
severe septal deviation or thickening is
present
5)Nasal growth retardation in children219,220
6)Soft-tissue infection can occur; some
surgeons prescribe antibiotics for any nasal
fracture
Late Complications—
1)Septal thickening and airway obstruction;
if untreated, septal hematoma can become
organized, resulting in subperichondrial
fibrosis and thickening; septum can become
as thick as 1 cm and require sculpturing or
resection; submucous resection of thickened
portions of nasal septum, outfracturing
turbinates, and partial resection of
turbinates can help with obstruction
2)Synechiae can occur in areas of soft-tissue
lacerations of septum and turbinates
when tissues are in contact;221 treatment
includes division and placement of splint
or nonadherent gauze for 5 to 7 days until
reepithelialization
Complications
3)Obstruction secondary to malunion of nasal
bones, telescoping, or lateral deviation of
nasal septum can occur; if loss of soft tissue
occurred during initial injury, scarring
prevents simple reduction; excision of scar
and grafting or insertion of flaps is necessary
to attempt to prevent soft-tissue contracture
Early Complications—
4)Residual osteitis or infection of bone
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SRPS • Volume 11 • Issue R8 • 2015
or cartilage; secondary grafting can be
performed after 6 months without evidence
of infection
5)Chronic pain is infrequent and usually
affects the external nasal branches222
6)Malunion of nasal fractures is common after
closed reductions; palpation after reduction
to confirm reduction is often inaccurate
and external splints often fail to prevent
deviation because of release of “interlocked
stresses” after cartilage fracture223,224
7)Misdiagnosis of NOE fractures as nasal
fractures is frequent and can result in
severe deformity that is difficult to treat;
telecanthus, loss of nasal height, and
upward tilting of the caudal nose with
subsequent contraction of the soft tissue
create severe deformity that necessitates
soft-tissue expansion by repeated grafting;
initial correct diagnosis is most effective way
to prevent this complication
Midface (Maxillary) Fractures
Definition
The midface is considered to be the area between the lower
orbital rim, alveolus, and maxillary dentition. The largest
bony portion of the midface is the maxilla. Maxillary
fractures are less common than mandibular, zygomatic,
and nasal fractures.225
sufficient trauma, absorbing and dissipating the energy,
thereby protecting the skull base and brain.232 The maxilla
contributes to the formation of the midportion of the face
and forms part of the orbit, nose, and palate. It has four
processes: frontal, zygomatic, palatine, and alveolar. The
frontal process provides anchorage to the nasal bones and
cartilage and the medial canthal ligaments. The zygoma is
stabilized by its articulation with the sphenoid, the frontal
bone, and the temporal bone. The maxilla stabilizes the
zygoma indirectly by stabilizing the surrounding facial
bones to which the zygoma articulates. The maxilla is
stabilized to the skull base via its anterior articulations,
medially in the glabellar region to the frontal bone and
nasal bones, laterally via its articulation to the zygoma,
and posteriorly via the third vertical buttress, which is
the pterygomaxillary buttress. The alveolar process of the
maxilla is strong and thick and provides support for the
teeth. It provides a strong horizontal buttress and protects
the upper portion of the maxilla. As teeth are lost, the
alveolar process thins, weaken, and resorbs.233
Most fractures of the maxilla result from direct
impact. Their pattern depends on the magnitude and
direction of the forces, whether frontal, lateral, or inferior
impact.234
Muscle contraction plays a less important role in the
displacement of bony fragments than its role with other
types of fractures, including zygomatic fractures, which are
Anatomy
The maxilla consists of vertical, horizontal, and sagittal
buttresses that are thick sections of bone capable of
resisting considerable forces (Fig. 26).226 The vertical
buttresses, considered the strongest, are the medial
nasofrontal buttress, the lateral zygomaticmaxillary
buttress, and the pterygomaxillary buttress
posteriorly.227,228 Overall, the maxilla is designed to
absorb forces of mastication and provide strong vertical
buttress for the occluding teeth of the mandible.229 Via
the buttress system, the load is distributed over the entire
craniofacial skeleton.230,231 The midface collapses with
Figure 26. Vertical buttresses of midfacial skeleton.
(Reprinted with permission from Manson et al.226)
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SRPS • Volume 11 • Issue R8 • 2015
under the immense pull of the masseter muscle.226 The
muscles of facial expression anteriorly and the pterygoid
muscles posteriorly are weaker but can influence the
direction of the maxillary fragments, as seen with sagittal
fracture of the maxilla,235 a fracture that splits the palate
in the anterior−posterior direction and pulls the segments
laterally.236
Classification
The buttresses of the maxilla are comprised of thick strong
bones. The remainder of the maxilla is made of thin
weaker bones through which fracture lines occur. Usually,
the fracture lines travel adjacent to the thicker portions of
the bones.
Le Fort clarified the areas of weakness in the maxilla
and designated them as the line of weakness.237 Between
the areas of weakness are areas of strength. Based on his
experimentations, Le Fort developed a classification of
midfacial fractures. The Le Fort level I, II, and III fracture
patterns are based on the highest level and components of
the fracture on each side.
In reality, most fractures are not pure bilateral
fractures but rather permutations and combinations of
these fractures. It is more common to observe different
levels of fractures on each side than exactly similar
fractures on both sides.238 Manson238 further classified Le
Fort fractures to include a fourth level Le Fort fracture that
includes the frontal bone. Manson added two elements
to the classification that can be associated with midface
fractures: first, the pattern of fragment that includes the
maxillary dentition; second, associated fractures of the
mandible, NOE, and frontal sinus.
For the student who is getting acquainted with
the Le Fort classification of midface fractures, there is no
substitute for reviewing a pictorial of the fracture patterns
in conjunction with a real or model skull inclusive of the
cranium (Fig. 27). It also is helpful to remember that
all Le Fort level fractures have one thing in common: all
involve fractures through the pterygoid plates.
Le Fort Level I Fracture or Transverse (Guerin) Fractures—
Le Fort level I fractures are transverse fractures that can
traverse across the maxilla at different levels ranging from
the base of the maxillary sinus to beneath the orbital rim.
They usually occur bilaterally and most commonly traverse
at the base of the maxillary sinus and the inferior margin
36
of the piriform aperture. They can be higher and cross
just beneath the zygoma and at times reach just under the
inferior orbital rims, thus creating a pattern very similar to
that seen in a low Le Fort level II fracture or a high Le Fort
level I osteotomy.
Le Fort Level II Fractures or Pyramidal Fractures—Le Fort
level II fractures occur with blows to the central maxilla,
especially involving a frontal blow. The fracture begins
above the level of the apices of the maxillary teeth laterally
and posteriorly in the zygomaticmaxillary buttress,
extending through the pterygoid plates. Medially, the
fracture line travels superiorly to cross through the medial
portion of the inferior orbital rim, extending across the
nose. The level of fracture through the nose varies greatly
and crosses at a high level across the junction of the nasal
bones and the frontal bones (high Le Fort level II fracture),
through the mid nose, or through the nasal cartilage
(low Le Fort level II fracture). Damage to the ethmoid
region is common via the fracture at the medial orbit,
and lacrimal system injury can occur if the fracture line
traverses the lacrimal fossa. With higher energy impact,
fractures include a combination of Le Fort level I and level
II fractures, with or without a split palate.235,239
Le Fort Level III Fractures or Craniofacial Disjunction—
When fractures extend laterally through the zygomatic
arch, zygomatic frontal suture, and orbital floor and
medially through the medial orbital rim and nose, the
midface is disconnected from the cranium. Occasionally,
the midface fracture is a large single fragment, which is
only slightly displaced or immobile.225 These fractures
might be only minimally displaced and present with
“black eyes” and with subtle malocclusion. In these
scenarios, the midface is incompletely detached from
the base of the skull and suspended by soft tissue and a
greenstick fracture.240
Le Fort Fracture Treatment
From the time Le Fort fractures were first described
in the 1900s by French orthopaedic surgeon Rene Le
Fort237 through the period in which these fractures were
treated with open reduction of the midface fractures and
internal fixation with wires suspended to the upper face, as
advocated by Adams in 1942198 and 1956,199 the treatment
of midface fractures changed significantly. Advances in the
last 25 years have been achieved, including the aesthetic
SRPS • Volume 11 • Issue R8 • 2015
I
II
III
Figure 27. Le Fort classification.
aspects of fracture treatment.38,241−246 The reasons for this
development can be summarized as follows:
1)The increased use of CT scans with fine
delineation of the bony and soft-tissue
injuries
2)The use of wide exposure of all fractures as
opposed to previously advocated limited
exposures
3)Open reduction and rigid internal fixation
techniques with improved implant materials
with use of plates and screws instead
of wires, allowing three-dimensional
stabilization
4)Immediate bone grafting to replace or
augment unusable bone fragments as
pioneered by Gruss et al.247
Goals of Le Fort Fracture Treatment
Several important goals should be achieved with the
treatment of midfacial fractures:
1)Reestablish midfacial height and width.238
2)Reestablish occlusion.
3)Restore the nose and orbit.
4)Restore the bony midface between the
buttresses to provide proper soft-tissue
support and contour.
The untreated midface tends to be elongated and
retruded. The most common complication of the treated
midface, as originally described by Ferraro and Berggren,248
is reduced midfacial height and projection. Therefore,
to restore midface height and projection, it is key to
restore the facial buttresses to their anatomic positions.
Anteriorly, the nasomaxillary and zygomatic maxillary
buttresses should be reduced and reconstructed with bone
grafts if needed. Fixation should then be applied. The
posterior pterygomaxillary buttress is not reconstructed
but rather reduced by means of IMF. If the mandibular
condyle and ramus, which constitute the posterior sagittal
buttress and provide facial height, are intact, IMF to
the anatomically stable mandible provides a guide to
correctly achieve posterior height of the midface. If the
mandibular ramus or condyle is fractured, ORIF must be
achieved before treating the midface. Otherwise, the risk
of midfacial height malposition is high. The same problem
can occur if a sagittally split palate is undiagnosed,
resulting in midfacial lower height, increased width, and
malocclusion.235,236
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SRPS • Volume 11 • Issue R8 • 2015
Vertical or Sagittal Fractures
Vertical or sagittal fractures are less common fractures that
traverse the maxilla vertically and separate the segments in
a sagittal anteroposterior plane.235 These fractures traverse
the alveolus and the palate with different patterns that
are mostly associated with Le Fort level I fractures but are
also seen with Le Fort level II fractures (Fig. 28).236 They
often occur at the junction of the maxilla and the vomer.249
Fifty percent of these fractures are associated with other
maxillary fractures.250 When these types of fractures
are present, treatment of the Le Fort fracture is more
complicated and can be complicated by facial and dental
arch width problems in addition to vertical and anterior or
posterior displacement.251
Diagnosis
History—The most common causes of Le Fort fractures
are frontal and lateral impacts. Most commonly, the
patient is thrown anteriorly onto a dashboard, steering
wheel, or other object. A maxillary fracture can occur
from upward trauma to the face exerting force to the
midface via the mandible.68,252 Displacement of the maxilla
usually is posterior and inferior because of the pull of
the pterygoid muscles. Midfacial elongation is seen. The
maxillary occlusal fragments tilt downward, creating an
anterior open bite, often more prominent on one side than
the other. Impacted maxillary fractures occur, although
less frequently. The maxilla can be so impacted into the
interorbital space or pharyngeal space that mobility is
not noticed during physical examination.240 Most Le Fort
fractures have evidence of bilateral maxillary sinus fluid
and malocclusion. Upper level Le Fort fractures have
bilateral periorbital ecchymosis.
Physical Examination—Malocclusion is the one most
sensitive physical finding that suggests midface fracture.
Yet the hallmark of midfacial fracture is mobility of
the maxillary dentition, if it occurs. Not all midfacial
fractures demonstrate mobility of the maxillary segment.
Incomplete fractures (greenstick fractures) or singlefragment Le Fort level I fractures without comminution
can be diagnosed only by bilateral periorbital ecchymosis
and minor malocclusion. Rowe and Killey225 thought
that these rare fractures occur in 5% of the cases.
38
Demonstration of bilateral bimaxillary sinus fluid is
the most reliable CT finding considering that fracture
lines often cannot be seen on the scans. Additional
findings of epistaxis, periorbital ecchymosis, facial
edema, and subcutaneous hematomas are suggestive of
maxillary bone fractures. Because the maxillary segment
usually is displaced posteriorly and inferiorly, class
three malocclusion and anterior open bite are observed.
Intraoral digital examination can reveal soft-tissue tears
of the labial vestibule or the palate, indicating alveolar or
palatal fracture. After several days, the face might look
elongated and retruded. If the zygoma laterally is lower
than the maxilla medially, zygoma fracture is suggested.
If the maxilla is lower, maxillary fracture is suggested.
If nasal mobility is felt, Le Fort level II or III fracture
is present because the nose is always involved in these
two fractures. During examination, maxillary motion is
assessed by holding the forehead with one hand and the
maxilla and palate with the other and moving the maxilla.
As noted previously, with high Le Fort level III fractures,
greenstick fractures might not be discernible. Therefore,
even malocclusion, to which patients are highly sensitive,
might not always be confirmed by the patient at the
time of injury. Occlusion has to be closely examined by
the physician, considering wear facets and occasionally
needing previous dental records to assess whether the
patient had pre-injury malocclusion. CSF might leak
from the middle or anterior cranial fossa in high Le Fort
fractures and is then apparent in the nose or ear canal.70,253
Radiographic Examination—CT scan of the maxillae
from the palate to the cranial fossa is the examination of
choice for midfacial fractures. Axial and true coronal views
are preferred, but axial views and coronal reconstruction
usually are adequate.227,254 Non-displaced or minimally
displaced fractures often are difficult to see, even on CT
scans, but bilateral fluid collections in the maxillary sinus
are always seen with maxillary fractures.
Treatment
Treatment of midfacial trauma should be approached as
any other trauma per the Advanced Trauma Life Support
Manual.255 After the airway is secured and hemorrhage
controlled, soft-tissue lacerations should be closed and
SRPS • Volume 11 • Issue R8 • 2015
Figure 28. Above left, Type 1 posterolateral alveolar fracture. Above center, Midline sagittal palatal fracture in a child. Above
right, Paramedian-sagittal palatal fracture. Below left, Para-alveolar sagittal fracture. Below center, Palatal fracture of complex
pattern. Below right, Transverse palatal fracture. (Reprinted with permission from Hendrickson et al.236)
IMF applied. The latter procedure is the single most
important treatment of maxillary fracture.226 IMF can be
accomplished at bedside under local analgesia if any delay
occurs in bringing the patient to the operating room.
Performing open reduction and internal fixation (ORIF)
is the gold standard of treatment of any facial fracture, but
soft-tissue closure and repositioning are equally important.
Two steps must be performed with soft-tissue
closure: 1) closure of skin, muscle, fascia, and periosteum
at the incisional areas; and 2) fixation of the fascia
or periosteum to the skeleton. By doing these simple
maneuvers, soft-tissue descent and irreversible retraction of
the soft tissue can be prevented.
Principles of bony repair are proper exposure,
reduction, and internal fixation. In any subunit of the face,
the most important dimension to restore is facial width.
Bony reduction and fixation must be accurate because they
allow correct draping of the soft tissue. If this is not done
immediately, the soft tissue develops internal scarring (or
“memory”), creating irreversible internal deformity
and thickness.
A unique property of the midface is the thinness
of its bone. The midface therefore can be considered a
“dependent” structure.256 Because of the thin bones of the
midface, plating cannot be considered rigid fixation but
rather a positioning technique. Additionally, with current
midface repair techniques, the only relatively strong
sagittal buttress that is not addressed is the pterygoid
buttress. Therefore, the midface must be guided in its
reduction by a clear anatomically correct structure,
usually the mandible. If the lower midface, considered
the area below the Le Fort level I fracture line, is guided
by the upper midface, which has weak sagittal support,
severe facial deformities, such as lack of projection,
enophthalmos, malocclusion, or increased facial width, can
occur ensued by soft-tissue deformities, such as descent,
diastasis, fat atrophy, thickening, and rigidity of skin. IMF
in proper occlusion is the single most important maneuver
in treating midfacial fractures, and its importance cannot
39
SRPS • Volume 11 • Issue R8 • 2015
be overemphasized.227,257 It is simple and can be performed
nearly in any situation, even at the patient’s bedside
if necessary. Because of the tendency of the mandible
musculature to be in a rest position, close to centric rest,
fixating the midface to the mandible repositions it in a
near anatomic position and corrects the midface retrusion
and elongation. Applying the IMF reduces fragment
distraction, often helps with control of bleeding, and
places the maxilla at rest.
Alveolar Fractures
Most alveolar fractures can be digitally repositioned
and held in reduction while arch bars are applied. For
additional stability, the arch bar can be acrylated. If the
alveolar segments cannot be adequately reduced manually
or if premature contact occurs between the teeth of the
maxilla and the mandible, ORIF usually is necessary. The
reason is usually an incomplete fracture or intervening
soft issue within the fracture line. In these cases, fixation is
performed with monocortical screws in addition to IMF.
Fixation should be maintained for at least 4 to 12 weeks
or until clinical immobility is achieved.235 The teeth in the
alveolar segment often are insensate because of damage
to neurovascular structures within the pulp and require
proper endodontic evaluation.
Palatal Fractures
Fractures of the midface are seldom symmetrical, and
segmental fractures of the alveolus and palate are common.
Several classification schemes of fractures of the edentulous
maxilla have been suggested for palatal fractures.236,251,256
Hendrickson et al.236 described six types of palatal
fracture (Fig. 28) as follows:
Type I, anterior and posterolateral alveolar
large individual segments and no comminution. After
rigid internal fixation is applied, increased stability often
is obtained such that the palatal splint can be eliminated.
If the fractures cannot be adequately reduced and rigidly
aligned, they are managed with palatal splints. The
authors stated, “…splints are necessary for all complex
fractures and for some large segment fractures to provide
further occlusal alignment.” They also reported that for
comminuted fractures, the use of a splint is not only
indicated but is the easiest method of providing vault
stabilization. Care must be taken not to devascularize the
buccal, gingival, or palatal mucosa during exposure of the
fracture (Fig. 29).236 Full open reduction must include
reduction and stabilization of the palatal vault, the dental
arch (alveolus or piriform aperture), and the four anterior
vertical buttresses of the maxilla (Fig. 30).236
Park and Ock251 also developed a classification
scheme for palatal fractures that is based on anatomic
location of the fracture line and related treatment plans
(Table 2). The authors found that closed reduction
and immobilization for 4 to 6 weeks often is adequate
treatment for alveolar fractures. All other fractures of the
palate are treated with open reduction and rigid internal
fixation followed by IMF for 2 to 6 weeks. The authors
used an acrylic palatal splint to check occlusion before and
after rigid fixation. Intraoral splints can be useful adjuncts
to midfacial fracture reduction and immobilization.
They range from the simple type that helps stabilize an
isolated alveolar ridge fracture, to sophisticated palatal
and Gunning splints used with complex or comminuted
fractures of the maxilla. Unfortunately, in the acute trauma
setting, it might be difficult to compensate for the fracture
lines on the dental model, with a resulting ill-fitting splint
(Fig. 31).235 The trend in palatal fracture management, as
voiced by both Manson et al.235 and Park and Ock,251 is
toward wide exposure with ORIF, using splints only when
needed to supplement the fixation.
Type II, sagittal
Type III, parasagittal
Type IV, para alveolar
Type V, complex
Type VI, transverse
The authors reported that fractures selected for internal
fixation are oriented anteriorly to posteriorly and have
40
Fractures of the Edentulous Maxilla
Fractures of the edentulous maxilla are less common and
usually are associated with additional extensive fractures
of the middle facial bones.233,258,259 The absence of teeth,
which usually transmit the forces to the maxilla, can
decrease the chance for bony disruption. The presence
of dentures can decrease the energy transmitted to the
maxillae by fracturing first.
SRPS • Volume 11 • Issue R8 • 2015
If the fracture does not cause facial deformity,
adjusting or remaking the dentures can correct any
slight discrepancy in the occlusion. In cases in which
a significant facial deformity or occlusal discrepancy
will occur if the fracture remains non-reduced, ORIF
should be performed with a plating system. In cases in
which comminution is so severe that accurate reduction
Figure 29. Above, Incisions for palatal fracture treatment
must be carefully designed. In some cases, the traditional
transvesre vestibular maxillary incision (dotted line)
should be reoriented vertically (dashed line) to prevent
devascularization of the inferior gingival mucosa. Below,
In the absence of a vault laceration, incisions in the palatal
vault should be longitudinal and should avoid the area of
the greater palatine artery, which travels anteroposteriorly
just above the palatal mucoperiosteum. The dotted area
represents the safe region. (Reprinted with permission from
Hendrickson et al.236)
is difficult, dentures or splints can be designed to enable
IMF to the stable and anatomically positioned mandible.
For quick fixation of the dentures, they can be screwed
into thicker alveolar bone, if present, to assist in IMF but
should be removed after reduction and fixation before
making new dentures.
Figure 30. Above, the plan for fixation of the maxillary
alveolus involves palatal vault and piriform aperture or
alveolar plating plus buttress reconstruction. Below, the
buttresses of the fractures maxilla and palate include a
transverse (circumferential) buttress across the palatal vault,
a circumferential buttress across the alveolar ridge, and
the six vertical buttresses of the maxilla. With traditional
maxillary fracture open reduction techniques, only the four
anterior buttresses—the naso-maxillary and zygomatoicomaxillary buttresses (solid vertical lines)—are stabilized. The
posteror buttress—the pterygo-maxillary buttress (dotted
vertical lines)— is not routinely stabilized. (Reprinted with
permission from Hendrickson et al.236)
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SRPS • Volume 11 • Issue R8 • 2015
Table 2
Classification and Suggested Treatment of Palatal Fractures251
Treatment
Immobilization
(weeks)
Exposure and Rigid Fixation
Corresponding Fracture
Type per Hendrickson
Classification236
Anterior Surface
Palatal Surface
Closed reduction
-
-
4-6
Alveolar
Anterior
+
-
2-3
Alveolar, para-alveolar,
transverse
Anterior and palatal
+
+
2-3
Sagittal, parasagittal
Combined
+
+/-
4-6
Para-alveolar, complex,
transverse
Early Complications
Hemorrhage—Extensive hemorrhage can occur in
association with fractures of the midface. Management
might involve the following techniques:
1)Identification of the bleeding vessel
and ligation
2)Tamponade by direct pressure, packing,
or, most often, by manual reduction of
fractures; reduction into IMF
3)Angiographic embolization
4)Ligation of external carotid or superficial
temporal artery
Airway Obstruction—With most large midface fractures,
posterior displacement of the maxillae is combined
with swelling of the soft tissues of the nasal, oral, and
pharyngeal cavities, leading to partial compromise of the
airway. Simple maneuvers, such as sitting the patient in
bed and manually reducing large segments, might prevent
the need for emergency airway protection but often
nasotracheal, endotracheal, or tracheal intubations are
necessary for airway protection.
42
Figure 31. Acrylic splint helps stabilize fractured palate after
reduction and fixation with intermaxillary elastics. A small
wire coapts the segments at the posterior margin of the
bone palate. (Reprinted with permission from Manson et al.235)
SRPS • Volume 11 • Issue R8 • 2015
Infection—Maxillary infections are less common than
mandibular infections.260 Despite the bony fragments that
often are pushed into the surrounding sinuses, infection
is not common. Infections more commonly occur if the
sinuses are diseased or persistent occlusion of the sinus
orifices occur as a result of displaced bone or blood clots.
If infection does occur, treatment includes removal of
devitalized tissue and bone, opening of occluded sinuses,
removal of foreign material, and antibiotic treatment based
on culture sensitivities and specificities.
Lacrimal Obstruction—Lacrimal duct obstruction can
lead to dacryocystitis and require external drainage.261
Infection can spread into orbital soft tissue, leading to
increased orbital pressure and subsequent blindness.260
CSF Rhinorrhea—CSF rhinorrhea occurs more commonly
in association with Le Fort level II or III fractures that
involve the cribriform plate. The role of antibiotics is
unclear, and antibiotics should be administered for 48
hours after reduction. Long-term prophylactic antibiotics
should be avoided to avoid selecting resistant strains. Also,
nasal packing and blowing the nose should be avoided to
avoid obstruction or backflow of infected nasal content
into the meninges.
Blindness—Blindness is a rare complication that occurs
more often in association with Le Fort level II or III
fractures. The common reason is compression of the optic
nerve or decrease in its capillary blood supply as it traverses
the narrow optic canal rather than optic nerve transection.
Late Complications
Because many complex maxillary fractures, especially Le
Fort level I and II fractures, involve the orbit or malar
complex, late complications in these areas are discussed
separately in their respective sections.
Nonunion—Nonunion of the maxilla is rare100,262 and
usually is a consequence of complete neglect or failure
to provide any basic type of IMF or open reduction.
If nonunion is diagnosed, the approach must include
complete exposure of the fracture, removal of all fibrous
tissue at the fracture site, reduction of the remaining bony
segments, removal of bony proliferation, replacement of
the bony gaps with bone grafts, and “rigid” fixation of the
fracture with plates and screws.133,263,264 The term rigid is
used guardedly considering complete stable fixation with
the thin bones of the maxilla is not possible. With this
approach, healing is nearly almost the rule. It is essential
to bone graft gaps that are larger than 3 to 5 mm in the
buttress system265,266 and over the anterior maxillary wall,
which strengthens the repair and prevents prolapse of soft
tissue into the sinus.
Malunion—The maxilla usually heals in within 6 to 8
weeks after the fracture or after fracture repair. Patients
suffering from comminuted fractures must be watched
for an additional 4 to 5 weeks on a weekly basis to ensure
the patient has not moved out of occlusion. If the patient
continues to demonstrate mobility of the maxillae, it will
usually heal within 4 additional weeks. Close observation
is necessary on a weekly basis after IMF is released to verify
that occlusion is maintained. If deviation of the occlusion
occurs, the first sign usually is an anterior open bite
with lack of cuspid contact. Once this is noticed, elastic
traction should be initiated. After 4 weeks of stable correct
occlusion, the arch bars can be removed. A soft-foods diet
should be initiated with progression to a regular diet.
Impacted fractures or fractures that are several
weeks old might be impossible to reduce despite complete
exposure of the fracture. Sometimes application of IMF
with elastic bands reduces the fractures.100 In most cases,
an osteotomy is required to obtain the necessary reduction
and has been shown to be a safe and efficient technique.260
Reduction with Rowe disimpaction forceps is less
desirable, especially at Le Fort levels II and III, because of
an increased risk of adding fracture lines including into the
orbital apex, resulting in blindness.267
If malocclusion occurs secondary to malunion
at Le Fort level I, gingivobuccal incisions are made and
osteotomies performed. Pterygomaxillary dysjunction
might be necessary to mobilize the segment. Increased
posterior maxillary height with normal or shortened
anterior maxillae is a problem that sometimes occurs. In
such cases, resection of the posterior maxillae and portions
of the pterygoid plates is necessary. Bone grafting where
bony gaps are present, especially at the buttresses, often
is essential.
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SRPS • Volume 11 • Issue R8 • 2015
In cases of malunion at Le Fort level II or III,
exposure is obtained via incisions in the gingivobuccal
area, appropriate lid incisions, and coronal incisions,
which are necessary. After proper exposure, osteotomies,
and mobilization, bone grafts often are necessary.
Plate Exposure—Plates and screws often are exposed
after repair of fractures, more often at Le Fort level I.268
Screws can migrate,205 and plates placed in the alveolus
of edentulous fractures might not permit comfortable
wearing of dentures and thus require removal.
Nasolacrimal Duct Injury—Transections or obstruction
of the nasolacrimal duct can occur in midfacial fractures
between Le Fort level I and Le Fort level III.86,269 When
the canalicular system is intact in the canalicular portion
but is obstructed by bony displacement or proliferation,
dacryocystorhinostomy is indicated.270 With Le Fort level
II and III fractures associated with NOE fractures, the
nasolacrimal sac or duct might be blocked by displaced
bone at the orbital rim level. Anatomic reduction of the
bone usually is the most effective maneuver to avoid
these problems, but if occlusion occurs, initial external
drainage and then secondary dacryocystorhinostomy are
necessary.271
of the three areas are termed panfacial fractures (Fig. 32).13
With panfacial fractures, various areas of the facial
skeleton are involved.241,242,246,272 Each area can be treated
by applying the techniques previously described to achieve
anatomic structural integrity of the facial skeleton. The
most common mechanism of injury for these fractures
is high-velocity motor vehicle collision, although the
fractures occur less commonly since the advent of air bags.
These facial injuries typically occur concomitantly with
multi-organ system traumatic injuries, and patients are
therefore often in critical condition.
Timing of Treatment
Regardless of the severity of the injuries, cutaneous
wounds can be irrigated, debrided, and closed and
IMF can be applied. This initial urgent treatment is
the minimum that should be administered in cases of
mandibular or maxillary injuries. In cases of mandibular
fractures, dental impressions can help with planning, old
dental records should be obtained, and pre-trauma photos
can assist with assessing the premorbid facial dimensions
of width, projection, and height. These elements also
provide clues regarding pre-injury occlusion.
Extraocular Muscle Injury—Extraocular muscle injury
can occur as a result of contusion during the initial
injury or from surgical dissection. These injuries are
more common in midface fractures involving the orbit,
NOE, and ZMC. Malpositioning of the globe can occur
after repair of such fractures, with malproper alignment
of the orbital rim or walls. Orbital enlargement with
subsequent enophthalmos is also seen after treatment of
NOE fractures, zygomaticmaxillary fractures, and orbital
fractures, as discussed in previous related sections.
Pan Facial Fractures
Definition
Panfacial fractures are fractures that involve the upper,
middle, and lower portions of the face: the frontal bone,
maxillae, and mandible. In reality, fractures involving two
44
Figure 32. Panfacial fractures. (Modified from Mathes.13)
SRPS • Volume 11 • Issue R8 • 2015
Perhaps the most important aspect in the treatment
of these fractures is understanding the role of the overlying
soft tissue in the pathomechanics of the injuries. The soft
tissue in facial trauma, especially in panfacial trauma,
is severely contused and suffused with blood. The soft
tissue tends to scar quickly and to assume the shape of
the underlying malreduced or malaligned bones. The soft
tissue develops internal thickening, rigidity, and memory
that render it nearly impossible to restructure it to its
original shape. Only early treatment of the underlying
bone can obtain correct draping of the soft tissue
envelope. Thus, contraindications for immediate definitive
management are few.
The contraindications include:
1)Uncontrolled intracranial pressure (>20
mmHg)
2)Acute hemorrhage with depleted clotting
factors, as observed with large pelvic
fractures or massive intraabdominal bleeds
3)Coagulopathy, as evidenced with severe
central nervous system injuries
4)Acute respiratory distress syndrome
Coma without associated intracranial hypertension,
mechanical ventilation, or other organ injuries is not
a contraindication for immediate treatment of facial
fractures. In comatose patients, CT scans of the head can
be obtained and intraoperative intracranial monitoring
can be conducted. Initial physiological resuscitation and
stabilization are essential first steps. Further diagnostic
workup includes CT scanning of the face. Based on the
types of injury, several specialists need to be involved in
the surgical planning, including neurosurgeons
and ophthalmologists.
Treatment
The optimal timing for intervention is within a few
hours after injury before edema and soft-tissue rigidity
begin. This is not always possible if other injuries that
take priority occur, such as life-threatening injuries and
neurosurgical and ophthalmological emergencies. Onestage skeletal reconstruction to anatomic position is the
current preferred method of treatment.242 The incisional
approaches are the same as those described in previous
sections based on the anatomic area of injury. The coronal
incision allows access to the frontal sinus, superior orbital
rims, orbital roof, lateral orbit, NOE complex, and upper
nose. Lid incisions allow access to the orbital floor and
inferior orbital rim, and the gingivobuccal incisions
allow approach to the maxilla. The lower gingival and
retromandibular incisions provide approach to most
mandibular fractures.
Because the fractures are in a three-dimensional
plane and the surgeon cannot see all the fractures at one
time, use of temporary wiring might help with initial
positioning until plates and screws are applied. Although
previously noted, it cannot be overemphasized: bone grafts
are essential for healing and stability in cases of substantial
bone gaps (>3−5 mm), especially when reconstructing the
structural buttresses of the face.265
If dental alveolar process is missing, a dental splint
with an occlusal stop often is necessary to provide stability
to the IMF, provide soft-tissue support, and provide
correct facial height. Many sequences for treatment of
panfacial fractures have been described: top to bottom,
bottom to top, outside in, and inside out. Forrest and
Antonyshyn273 presented an algorithm for repair of
complex fractures of the midface.
Gruss and colleagues57,75,274,275 stated that the
zygomatic arch is the key area in midfacial fractures that
should be reduced and stabilized first to reestablish the
pre-traumatic facial width and to prevent further lateral
spread. Glassman et al.276 preferred starting from the NOE
region proceeding laterally and emphasized that there is
no one correct approach. As long as anatomic reduction is
safely and correctly achieved, the approach and sequence
are less important.
Following is the order of reconstruction of panfacial
fractures per Glassman et al.276:
1)Place the mandible and maxillae in IMF
with arch bars.
2)If the palate is split or the mandible has
fractures in the horizontal plane, these
fractures should be reduced and plated
before proceeding to IMF. The arch bar
then acts as a tension band.
3)In alveolar, palatal, and mandibular
fractures, impression and model surgery
45
SRPS • Volume 11 • Issue R8 • 2015
assist in putting the mandible and maxillae
in the proper arch form.
4)For angle, body, parasymphyseal, and
symphyseal fractures of the mandible,
intraoral incisions usually suffice for access.
5)For severely comminuted mandibular
fractures of the body or angle or condylar
fractures, external open approaches
usually are preferred. Wires can be used
for temporary fixation until alignement is
achieved, and rigid fixation can then
be applied.
6)Before proceeding to mandibular reduction
and fixation in cases of combined midface
and mandibular fractures, the maxillary
arch should be anatomically reconstructed
and can serve as a guide to the mandible.
If the palate or alveolus is fractured, it
must be reduced and rigidly fixed. A splint
can act as an occlusal stop or provide
additional stability for patients with highly
comminuted fractures or missing bones.
Once the dental arch is stable, it serves
as a guide for mandibular width, dental
inclination, and occlusal position. The
mandible is approached as described in
items 4 and 5, based on the fracture pattern.
If larger bone gaps occur, the reduction
might need external fixation or a 2.4-mm
reconstruction plate can be used to bridge
the gap until final reconstruction with bone
and soft tissue, if needed, is performed.
The basal portion of the mandible usually
is reconstructed first, and then ORIF of
the ramus is performed via Risdon, preauricular, or retromandibular incisions
or a combination of incisions in cases of
severely comminuted ramal fractures when
better exposure is required. The reduction
should be performed when the mandible is
in IMF. Once reduction is completed, the
IMF should be released and the occlusion
checked while the condyles are carefully
seated in the fossa by finger pressure.
7)The coronal incision is used for exposure
46
of the frontal sinus, superior orbital rims,
zygomatic frontal process, medial and lateral
orbital walls, zygomatic arch, and the NOE
complex area. Glassman et al.276 preferred
reducing the nasoethmoid area first and
then aligns the zygoma to the medial
maxilla. Anatomic position of the zygoma
is best determined by inspecting alignment
of the lateral orbital wall at the suture of
the orbital process of the zygoma to the
greater wing of the sphenoid. One should
remember that the arch is straight rather
than “arched.”
8)The orbital floor should be reconstructed
anatomically. A small ledge of bone usually
is present in the posterior orbital floor, as
far back as 35 to 38 mm. This bony ledge
serves as a guide for the angle and slope
of the bone graft or reconstruction plate.
Preformed reconstruction plates are also
available from different companies. The
orbital rim is reconstructed with 1.0- to 1.3mm plates and should be flat, not curved
inferiorly.
9)The nasoethmoid region should be reduced
and fixed with transnasal wiring and
rigid fixation.
10)The medial and lateral orbital wall can be
approached via the coronal approach if a
coronal incision is made and either bone
grafted or plated with titanium plates or
MEDPOR.276,277
11)Before fixation at Le Fort level I, the
mandible must be reconstructed. It is
essential that the ramus height and anterior
projection be reconstructed anatomically.
If they are fractured, ORIF should be
performed. Before applying the IMF, it is
crucial to verify that the condylar heads
are sitting in the glenoid fossas. Only then
is IMF applied. Once IMF is achieved,
reduction and fixation of the nasoethmoidal
and zygomatic areas are completed. At this
stage, fixation of the upper and midface
is performed at the nasomaxillary and
SRPS • Volume 11 • Issue R8 • 2015
zygomaticomaxillary buttresses on both
sides. In severe cases in which the height
of the buttresses is difficult to assess and
reconstruct because of loss of bone, the
lip-tooth position can be used as a guide for
buttress height reconstruction.
12)Soft-tissue repositioning is key to successful
restoration of premorbid appearance.
Successful ORIF is not sufficient. If the
soft tissue is not fixed to its presurgical
position, soft-tissue ptosis will result.
Closure must include the periosteum over
the zygomatic frontal suture, attaching the
orbital periosteum to the temporalis fascia
and the malar periosteum to the inferior
orbital rim, and closure of the muscle layers
at the gingivobuccal incisions. Marking
the periosteal layers during the inferior
orbital rim incisions helps resuspend
them anatomically after bony reduction
is completed. If the mentalis muscle is
degloved, it should be repositioned at its
original position or else lower lip ectropion
can ensue. Correcting soft-tissue descent is
much more difficult secondarily and results
in worse outcomes versus performing it
correctly the first time.
Complications
Complications in treatment of panfacial fractures include
those of the bones and soft tissue.
1)Instability of fixation in micro-fractures:
Because of the small size and thin bone
of the microsegment, the inserted screws
can pull out, resulting in deviation and
malreduction.
2)Unstable reduction or malreduction of the
mandible can result in displacement of the
maxillae.
3)Misplaced or malreduced condylar
fractures can cause loss of height of the
midface. If the mandible is adapted to
impacted maxillae and the condyle is
pulled anterior to the glenoid fossa during
maxillomandibular fixation, the patient will
drop into an open bite upon release of
the MMF.
4)Soft-tissue ptosis can result from inadequate
repositioning and reattachment of the
fascial layers before closure of the skin.
Despite the classic teaching of maximum
exposure of fractures, the soft-tissue
stripping can be kept to a minimum in
certain cases in which exposure is sufficient.
Gunshot Wounds to the Face
Definition and Pathomechanism
Gunshot wounds to the face involve ballistic injuries of
different energy intensities and different levels of loss of
soft tissue and bone.278 The degree of injury depends on
the energy transferred to the tissue, which correlates to the
mass and speed of the projectile. Additional factors that
affect the degree of injury are area of contact, trajectory of
the missile, tumbling, soft-tissue drag, tissue density, and
soft-tissue penetration. For a more in-depth explanation
of the mechanisms of injury, one should read the review
of common misconceptions in wound ballistics presented
by Fackler.279 Hollier at al.280 presented a review of 121
patients with facial gunshot wounds. Multiple gunshot
wounds to the face occurred in one-third of the patients.
The overall mortality rate was 11%. Two-thirds had
skeletal injury, and three-fourths required surgery. Onefifth of the patients had intracranial injury, half of which
required surgery.
Classification
Ballistic injuries can be divided into low-, medium-, and
high-energy injuries.281,282 Low-energy ballistic injuries
usually result from civilian handgun gunshot wounds and
include both soft-tissue and bone injuries with little loss of
those components. Conversely, medium- and high-energy
ballistic injuries usually result from military or hunting
rifles or shotguns and include substantial soft-tissue and
bone injury with loss of those components. Each group
of ballistic injuries is divided into four types based on the
anatomic location of the injury and the degree of softtissue and bone injuries and loss (Fig. 33).283
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SRPS • Volume 11 • Issue R8 • 2015
Low-Velocity Injuries
Low-velocity ballistic injuries usually do not result in
a substantial amount of soft-tissue or bone loss. The
majority of the soft-tissue injury is within the path of the
projectile. Conceptually, the majority of these injuries
can be treated as facial fractures with overlying soft-tissue
lacerations and thus should be treated primarily with
reduction and internal fixation and, if necessary, primary
bone grafting, especially of the upper face, with repair of
the overlying soft tissue. Based on the study of ballistic
injuries conducted by Manson,238 four anatomic injury
types were recognized and are the basis for the
following classification.
Type I (Lower Face)
Injuries of this type usually involve the tongue, floor of the
mouth, and mandible.
Figure 33. Four patterns of gunshot wounds of the face.
Type I, lower facial wounds involving the mandibular area
and tongue. Type II, injuries involving the lower midface and
lower orbit. Type III, injuries characterized by involvement of
the bilateral orbit and zygomatic and temporomandibular
joint areas. Type IV, injuries involving the frontal bone
and the orbit. Dashed lines, bullet tracks. (Reprinted with
permission from Clark et al.283)
Treatment
Treatment of ballistic injuries to the face remains
controversial. Some authors advocate delayed treatment,
especially for patients in whom future rehabilitation
might be difficult, as in cases of suicide attempts.284-286
Conversely, immediate reconstructions of the soft and
bony tissues with second-look procedures have more
recently been advocated.283,287 Immediate reconstruction of
the bones and then immediate soft-tissue reconstruction
provides both improved functional anesthetic results with
shorter periods of disability and improved rehabilitation.
When formulating a plan for treatment of gunshot
wounds to the face, it is helpful to identify the entry and
exit wounds, to identify the presumed path of the bullet,
and to appreciate the mass and velocity of the projectile.
Doing so can help predict the amount of soft-tissue and
bone injury and the amount of soft-tissue and bone loss.
48
1)Approximately one-fourth of these
patients develop marked edema that
warrants consideration of either prolonged
intubation or tracheostomy.
2)Soft-tissue loss generally is minimal with
this type of injury. Débridement of the
bullet track, including the entry and exit
wounds, is recommended. Drainage of the
neck, floor of the mouth, and ballistic track
is necessary.
3)In the majority of these cases, the bony
fragments of the mandible can be internally
reduced and fixed. Ramus and condylar
injuries should generally be treated with
ORIF, with short periods of intra-maxillary
fixation and early mobilization.
4)When a maxillary defect is present, primary
bone grafting can be delayed for secondary
procedures if the oral mucosa is not intact.
Bone graft infections occur at a high
percentage if oral communication exists. It
is better to assure a surgically clean wound
with intact oral mucosa before performing
bone grafting. Vascularized bone flaps might
be preferred, especially if the bone defect
exceeds 4 cm.
SRPS • Volume 11 • Issue R8 • 2015
Type II (Midface)
Type IV (Craniofacial)
Type II injuries involve the lower midface, including the
maxillary alveolus, maxillary sinuses, and lower portion of
the nose and zygoma.
Type IV injuries are characterized by intracranial
involvement. The supraorbital bones, orbital roofs, frontal
bones, and frontal sinus are involved. Globe or optic nerve
injuries are present in 40%, with blindness in 25%.
1)Some patients require only drainage of the
maxillary sinuses. In others, ORIF of the
zygoma or maxillary fractures is necessary.
In cases of teeth or palatal injuries, palatal
fistulae can be closed with local
rotational flaps.
1)Exploration of the cranial base fractures
often is needed with the assistance of the
neurosurgical team.
2)In case of significant nasal oral swelling,
airway management might be indicated.
2)Neurosurgical débridement of dural or
cerebral lacerations with the repair of dural
fistulae and elimination of frontal sinus
function by mucosal stripping and burring
of the walls is necessary.
3)With this type of injury, Le Fort fractures
are not seen.
3)Immediate bone grafting of frontal bone
should be performed.
Type III (Orbital)
Intermediate- and High-Velocity Injuries
Type III injuries involve the orbital and nasoethmoidal
complex. The contralateral temporomandibular joint
(TMJ) often is involved.
Intermediate- and high-velocity injuries usually involve
both soft-tissue and bone loss. The primary goal of
treatment is to achieve anatomic reduction of the bone
and immediate soft-tissue coverage. Soft-tissue coverage
can be obtained by approximating skin-to-skin, mucosa
to mucosa, or mucosa to skin. This should be followed by
serial débridement of soft tissue until all necrotic tissue,
hematomas, and fluid collections are removed and drained.
In most cases, the loss of bone and soft tissue is less than
initially appreciated. With civilian casualties, most injuries
occur from shotgun or high-energy rifle gunshot wounds
and often are the result of suicide attempts. Close-range
shotgun wounds usually result in extensive soft-tissue and
bone loss. Hollier et al.280 described free tissue transfer as
an early stage of treatment.
1)All bony injuries are best treated with open
reduction and immediate bone grafting, if
necessary.
2)Considering that damage to the globe
occurs in almost 90% of cases, with bilateral
blindness in 50% and unilateral blindness
in 40%, careful ocular examination is
imperative.
3)Lacrimal injuries occur in one-third of the
patients, and disruption can be managed by
primary simple intubation or repair of the
lacrimal system, as described by Callahan.288
Secondary reconstruction might require
dacryocystorhinostomy.
4)The TMJ can be treated by expiration and
débridement, and if a small gap exists, it can
be left and early mobilization permitted. If
larger gaps exist, definitive reconstruction
with a costal chondral graft covered by a
vascularized temporal parietal flap with
postoperative mobilization and elastic
guidance is an option.
The four types of intermediate- and high-velocity
injuries are based on patterns of soft-tissue and bone
loss. The extent of soft-tissue and bone injury usually far
surpasses the area of soft-tissue and bone loss (Fig. 34).283
Type I (Central Lower Face)
Type I injuries are characterized by injury to the central
mandible, lower lip, upper lip, inferior nose, and midmaxilla, extending up to the orbit and at times involving
the cranial base and causing cranial injury. They can also
extend posteriorly to the posterior portion of
the mandible.
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SRPS • Volume 11 • Issue R8 • 2015
be addressed at a later procedure.
3)The maxillary and bony deficiencies should
be addressed when soft-tissue coverage is
obtained. In the interim, both the mandible
and maxilla should be placed in anatomic
positions and stabilized with a combination
of rigid internal fixation or IMF throughout
the period of soft-tissue and bone
reconstruction to avoid malocclusion and
the effects of concentric soft-tissue scarring.
4)Reconstruction of bony defects of the
mandible or maxilla usually is obtained by
applying free osteo-cutaneous flaps, such
as fibular flaps, free iliac flaps, or any other
osteo-cutaneous flaps.
Type II (Lower Lateral Face)
Figure 34. Four patterns of soft-tissue and bone loss
(shaded areas) in shotgun injuries. I, Central mandibular and
midface. II, Lateral mandibular. III, Maxillary and orbital. IV,
Orbital and cranial. (Reprinted with permission from Clark et
al.283)
Type II shotgun injuries are the most commonly seen
high-velocity ballistic injuries. They are characterized
by soft-tissue and bone injuries in the lateral
mandibular region.
Treatment—
Treatment—
1)Maxillary and mandibular bone loss
generally occurs anteriorly and should be
treated by external fixation or by plate and
screw fixation in the anatomic position,
reducing and stabilizing the bone defect.
Plating and screws can be used whether
coverage can be obtained acutely
or secondarily.
2)Soft-tissue coverage often can be obtained
primarily. This can be accomplished by
approximating skin-to-skin, mucosa-tomucosa, or, when necessary, skin to mucosa.
Serial débridement procedures usually
are necessary, but after each débridement
procedury, soft-tissue closure should be
the goal. If closure of soft tissue causes lip
shortening, nasal distortion, or distortion of
any other facial structure, the distortion an
50
1)Primary closure of intraoral, skin, and
soft-tissue defects should be attempted.
Intraoral defects should be closed with nonabsorbable sutures. Skin defects usually can
be closed by applying regional skin flaps,
such as neck or cheek flaps.
2)If intraoral soft-tissue defects are not
amenable to primary closure, for smaller
defects, local tongue flaps can be used and
for larger defects, free tissue transfer might
be the choice.
3)Bone defects of the mandible should be
addressed by anatomic reduction and either
external or internal fixation. In case of very
communited fractures, bone segments can
be absorbed over time. Bone grafting should
be performed only when mucosal continuity
is achieved. In general, bone grafts are less
reliable than free osteo-cutaneous flaps.
SRPS • Volume 11 • Issue R8 • 2015
Type III (Midface)
Type IV Injuries (Craniofacial)
Type III defects involve the maxilla, zygoma, orbit,
and maxillary sinus. The naso-ethmoid region is
always involved. The unique aspect of these injuries is
involvement of the maxillary sinus in the lack of sinus
lining after the injury.
High-velocity type IV ballistic injuries involve the upper
third of the face. This involves the zygoma, orbit, globe,
frontal bone, frontal sinus, and, occasionally, the NOE
complex. They can also involve intracranial injury.
Treatment—
1)In any situation in which primary closure
of mucosa and skin can be achieved,
bony reduction and fixation should be
performed, including necessary bone
grafting if indicated. This constitutes the
best treatment plan. The major problem
associated with these injuries is combined
loss of maxillary lining and maxillary
bone. If a substantial amount of maxillary
lining of the sinuses is absent, the chances
of successful bone grafting to an area of
bone loss is low. Most bone grafts in these
situations end up infected and necrotic and
need to be removed. It is therefore necessary
to either achieve continuity of the lining
or obliterate the maxillary sinuses. Sinus
obliteration can be performed by inserting
a soft-tissue free flap, whether muscle or
omentum, to obtain closure of the sinus
and vascularized lining on which bone
reconstruction can be performed.
2)In cases of substantial lining or bone loss
of the maxillary sinus, bone reconstruction
should in general be performed in a delayed
fashion after sinus lining continuity is
reestablished. In cases in which small sinus
lining defects occur, the defects can be
allowed to heal secondarily or attempted to
be close primarily with permanent sutures.
If skin and soft-tissue defects are closed
under tension where there is no sinus lining
continuity, the chances of skin breakdown
are notable.
3)All bone fractures in the zone of injury
where there is no bone loss should be
reduced and fixed in the anatomic position.
1)In cases in which sufficient soft-tissue
coverage or lining is present, primary
reduction and fixation of the bones with
possible bone grafting is indicated. Primary
bone grafting is safe even when one-third
of the orbital lining is compromised. Often
times, the amount of bone and soft tissue
loss is less than initially appreciated. In
cases with substantial loss of lining or softtissue coverage, local flaps should be used
for closure. Free flaps might be indicated.
In such cases, bone grafts can safely be
performed once the surgical site is clean
and lining is available. Success rates of bone
grafting in the middle and upper face are
much higher than in the mandible.
2)In any case, bony reduction fixation should
be performed even if serial débridement
procedures are necessary. Bone grafting can
proceed if soft-tissue coverage and lining
are achieved or can be performed at a later
stage after reconstruction of the soft-tissue
envelope and lining.
Mandibular Fractures
Fractures of the mandible are common, and correct
treatment to avoid long-term morbidity is paramount.
Before the advent of rigid internal fixation, treatment of
mandibular fractures was limited to closed techniques
or open techniques with wire osteosynthesis. The trend
toward open reduction and rigid internal fixation (plating)
avoids maxillomandibular fixation and is supported by
biomechanical and bone healing studies. Concepts in
fracture management, specific patient populations, and the
management of complications are herein reviewed.
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SRPS • Volume 11 • Issue R8 • 2015
Surgical Anatomy
The tooth-bearing portion consists of a thick, compact
anterior border supporting a superiorly located alveolar
process. The ascending ramus terminates in the coronoid
process and condyle. The angle, ramus, coronoid process,
and condyle are insertions for the muscles of mastication
(Fig. 35). The condyle articulates with the cranium to
form the TMJ, a compressed fibrous disc interposed
between the mandibular condyle and articular fossa.
Mandibular blood supply is two-fold: the
inferior alveolar artery and the muscular attachments.
The inferior alveolar artery arises from the mandibular
portion of the maxillary artery. It descends between the
sphenomandibular ligament and the mandibular ramus.
It enters the mandibular foramen just below the lingula
on the medial aspect of the ramus and courses inferiorly
and laterally, traversing the body to exit via the mental
foramen with the inferior alveolar nerve. Throughout
the mandibular canal, the inferior alveolar artery sends
numerous apical and periodontal branches. The major
muscle groups of the lower face supply blood to the
mandible through perforating periosteal arterioles. The
inferior alveolar nerve innervates the mandible and
mandibular teeth, paralleling the course of the inferior
alveolar artery within the bone.
The Angle classification of dental occlusion describes
the relationship of the mesial buccal cusp of the maxillary
first molar to the mesial buccal groove of the mandibular
first molar (Fig. 36). Abnormal occlusal relationships are
caused by skeletal deformities, malalignment of the teeth,
or a combination of the two.
border alternate compressive or tensile forces during the
masticatory cycle, thus yielding an overall torsion effect.
The TMJ functions by hinge and translational
movement. Rotation about the center of the condyle
occurs early during jaw opening, whereas sliding
translational motion occurs later during wider opening
as the condyle moves anteriorly and inferiorly along the
articular eminence of the temporal fossa.
Condyle
Coronoid
process
Ramus
Angle
Body
Symphysis
Figure 35. Anatomic regions of the mandible.
Figure 36. Angle classification of occlusal status. Class I,
normal; Class II, mesial; Class III distal.
Biomechanics
An adequate soft-tissue envelope and appropriate
functional loading are paramount for normal mandibular
development. Deformation results when functional
and dynamic forces, such as muscle contractions and
chewing, place an unbalanced load on the mandible.289
Generally, tensile forces predominate along the alveolus
and superior border and compressive forces act on the
inferior border. Proximal to the canines in the symphyseal
area, the prevailing force varies with type of occlusal
loading, producing a torsion effect at the alveolus and
inferior border (Fig. 37).290 The alveolus and inferior
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SRPS • Volume 11 • Issue R8 • 2015
Figure 37. Natural forces acting on the mandible
from the pull of the masseter, medial and lateral
pterygoids, and temporalis muscles (tension) and the
geniohyoid, genioglossus, mylohyoid, and digastric
muscles (compression). (Reprinted with permission from
Niederdellmann and Shetty.290)
The overall shape of the mandible is also affected by
the presence or absence of teeth. Without tooth eruption,
the alveolar bone will not develop. The alveolar bone
resorbs if teeth and their functional stimuli are lost. An
edentulous mandible will atrophy at the alveolar ridge,
with consequent decrease in vertical dimension of its
tooth-bearing portion.
Bone Healing
Mandible healing is similar to that of long bones,
depending largely on bone contact at the fracture site
and the degree of movement. Primary healing is direct
bone formation without multistage connective tissue and
cartilage differentiation.291 Fibroblasts form along the
long axis of the fractured bone, followed by osteoblasts,
which produce new osteons. Direct union of touching
fragments is accomplished via remodeling of haversian
canals. Absolute stability, such as that achieved after
placement of rigid bone plates and screws, is necessary for
this type of contact healing to occur. Gap healing occurs
in closely adapted and compressed fractures in which not
all bone surfaces are in contact. Lamellar bone is deposited
perpendicular to the long axis of the fractured bone and
is subsequently remodeled, thus achieving final healing in
two stages.
Secondary healing, which occurs when there is
relative instability of the reduced fracture and mobility of
bone ends, such as with MMF with wires, has well-defined
phases.292 Disruption of the Haversian systems results in
bone death and resorption of the fracture ends. A callus
consisting of clot, fibrous tissue, and osteogenic cells of
periosteal and endosteal origins is formed to stabilize the
fractured segments. Differentiation of osteogenic cells
forms new trabecula or chondroblasts, which in turn form
cartilage. Callus remodeling ultimately replaces cartilage
with bone (Fig. 38). Despite the intermediate stages of
tissue differentiation in secondary as compared with
primary healing, the time to stable bone is equivalent.
Classification
Fractures are classified as closed or open, displaced or
nondisplaced, complete or incomplete, and linear or
comminuted.159 Angulation of the fracture line is of little
clinical significance. A fracture is considered open if it
communicates with the external environment through
a tear in the mucosa or skin or with a tooth socket.
Nondisplaced fractures often occur in the condyle,
coronoid process, and ramus, partly because large muscle
masses in those areas serve to stabilize the fractures.
Displaced fractures can be the direct result of the trauma
sustained or can occur secondary to muscle contraction
and subsequent distraction of the fractured segments.
Common sites of displaced fractures are the body,
symphysis, and angle, probably because of the lack of
support by major muscle groups in the direction of muscle
pull in these regions.
Epidemiology
The thick, cortical, inferior border of the mandible renders
it an efficient stress-absorbing structure. Its prominent
position and its mobility predispose it to injury from
trauma directed at the lower facial third. More than half
of all mandibular fractures are caused by personal assault.
Motor vehicle collision is the second most common cause.
Fracture site is related to type of trauma. Personal
assault, usually involving a laterally directed impact, will
produce frequent body and angle fractures and fewer
condylar, symphyseal, and alveolar fractures. Motor
vehicle collisions, which involve posteriorly directed
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SRPS • Volume 11 • Issue R8 • 2015
Figure 38. Types of bone healing. A, Primary bone healing by direct contact of the fractured ends. B, Primary healing in which
lamellar bone bridges the gap between the segments. C, Secondary bone healing involving callus formation and remodeling.
forces along the anterior mandible, produce fractures in
the symphyseal, alveolar, and condylar regions.293 One
series cites a 24.5% incidence of multiple fractures of the
mandible. Otherwise, most fractures seem to occur in the
body of the mandible.294-298
translation of the ipsilateral condyle, indicating a possible
condylar fracture. The TMJ is assessed via palpation of the
external auditory canal and preauricular area. A positive
tongue blade test (patient able to grasp and hold tongue
blade against attempt to remove it) excludes mandibular
fracture.299
Physical Examination—Palpation elicits tenderness and
can define fracture edges or cause movement of segments.
Pain, malocclusion, trismus, swelling, anesthesia,
paresthesia, hemorrhage, and ecchymosis are associated
with fractures. If the injury is several days old, pain and
swelling might be secondary to an inflammatory process
and the ecchymosis might have migrated away from the
fracture along fascial planes.
Avulsed, loose, or fractured teeth found during
intraoral examination should be documented. Multiple
crowded, rotated, or missing teeth make fracture reduction
more difficult. Malocclusion should be recorded and
compared with the preinjury occlusion, recognizing that
malocclusion often is present in the general population
and is not necessarily the result of a fracture. Preinjury
occlusion is ascertained by matching the wear facets on
the cusps of the mandibular teeth with the opposing wear
facets on the maxillary teeth.
Ecchymosis in the floor of the mouth often
indicates a fracture. Function is assessed by measuring
incisional opening and lateral excursion. Mandibular
protrusion and deviation during opening denotes limited
Radiographic Evaluation—Three imaging techniques
evaluate suspected mandibular fractures: mandibular
series, Panorex, and CT scanning. A mandibular series
Diagnosis
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SRPS • Volume 11 • Issue R8 • 2015
consists of facial radiographs in the anterior, posterior,
right and left lateral, oblique, and Towne projections.
Condylar and subcondylar areas frequently are obscured
by superimposed structures in the Towne view, but careful
interpretation should disclose any fractures in the region.
A properly performed and interpreted mandibular series
yields 90% sensitivity.
A Panorex image is the best diagnostic tool in
cases of suspected mandibular fractures, allowing easy
identification of condylar and ramus fractures and showing
relation of the fracture line to the mandibular teeth.
Properly performed and interpreted Panorex imaging has
a sensitivity of 90% and is highly cost effective.300 Panorex
plus anteroposterior view radiograph is perhaps the best
combination of plain films. Although a CT scan cannot
provide the details of dental occlusal relationships that a
Panorex does, the sensitivity for all anatomic fractures is
close to 100%.301,302
Cervical spine injuries must be ruled out in all
patients with mandibular fractures. Based on an analysis
of mandibular fractures and related cervical spine injury,
Andrew et al.303 recommended using liberal guidelines for
obtaining cervical spine films of any patient with cervical
tenderness, neurological deficit, multisystem injury, or loss
of consciousness.
Management Goals
1)Achieve anatomic reduction and
stabilization
2)Reestablish pretraumatic functional dental
occlusion
3)Restore facial contour and symmetry
4)Balance facial height and projection
Conservative treatment includes a soft or liquidonly diet for at least 30 days after trauma, restricting
mouth opening, and maintaining oral hygiene.304 Patients
must be followed closely to ensure that pretraumatic
occlusion is preserved until the fracture is
completely healed.
Surgical Treatment
Restoration of pretraumatic occlusion is paramount,
regardless of the specific anatomic site of injury. The
location and condition of fracture dictate the type of
reduction and immobilization in each case. Closed
reduction is used for either nondisplaced or minimally
displaced fractures. Arch bars and wires are applied, and
then maxillomandibular wires or elastics are added for
2 to 6 weeks to ensure stable reduction.297,305 Displaced
fractures usually require open reduction with or without
internal plate fixation.
Timing of Reduction
Reduction should be performed as soon as possible to
minimize pain, prevent progression of soft-tissue injury,
and reduce risk of infection. If treatment must be delayed,
the fracture should be temporarily stabilized with bridle
wires around the teeth adjacent to the fracture. Edentulous
patients can be temporarily stabilized with external
dressings such as a Barton bandage or cervical spine collar.
Open fractures should be immobilized within 72 hours of
injury.306 If definitive treatment is delayed longer than 3
days, infection at the fracture site should be treated with
MMF and intravenously administered antibiotics before
performing ORIF. Oral hygiene should be maintained in
the interim until reduction.
Nonsurgical Treatment
Treatment by Fracture Site
The following characteristics indicate conservative
treatment:
Many mandibular body fractures can be managed by
closed techniques, particularly if the fracture is isolated
and reducible and the teeth are intact. If multiple teeth are
missing or if substantial displacement or comminution is
present, ORIF is indicated.
1)Radiographic evidence of minimal or no
displacement
2)Pretraumatic dental occlusion
3)Normal mandibular range of motion
The fracture usually is approached through an
intraoral incision. After reduction and IMF, a plate is
55
SRPS • Volume 11 • Issue R8 • 2015
applied along the inferior border. Although not usually
necessary, an extraoral approach via Risdon incision (Fig.
39) also provides access to the fracture.307 Either an arch
bar at the alveolar process or a second monocortical plate
at the superior border is indicated as a tension band.308
Masseter muscle
Skin
incision
Marginal mandibular
branch of VII
Periosteal incision
Figure 39. Risdon incision. VII, cranial nerve VII. (Modified
from Fonseca and Walker.307)
Traditional treatment of severely comminuted
mandibular fractures is by closed reduction to avert
periosteal stripping. Smith and Johnson309 were successful
using an extraoral approach with 2.0-mm miniplates for
16 comminuted fractures. All patients healed to bony
union without grafting and with satisfactory postoperative
form and function.
Angle fractures often are the result of personal
assault. A single lateral blow to the side of the face can
produce a mandibular angle fracture, commonly associated
with a fracture of the contralateral mandible.295 The angle
is prone to fracture for several reasons, including the
presence of third molars, which decrease osseous support; a
thinner cross-sectional area; and biomechanical lever effect
on the angle.
Patients with third molars sustain a higher
percentage of angle fractures.310 Management of third
molars at the site of a mandibular angle fracture is
controversial. Damaged or diseased teeth and those
preventing reduction should be extracted. Otherwise, the
molar should be maintained because it contributes to the
strength and stability of the angle region.
56
Angle fractures are associated with the highest
surgical complication rate, and their treatment has
evolved substantially during the past 15 years.310 Most
angle fractures are best managed with ORIF because
of their tendency toward displacement of the proximal
segment. The fracture can be exposed and plated via a
buccal vestibule incision, which leaves no external scar and
reduces the risk of marginal mandibular nerve injury.
Angle fracture fixation methods have evolved from
absolute rigid fixation using plates larger than 2.4 mm
along the inferior border to the use of smaller double
2.0-mm non-compression plates to the application of a
single, malleable, non-compression miniplate for bony
fixation.310-315
Ellis310 presented a landmark 10-year study of
mandibular angle fractures treated by closed reduction
or intraoral ORIF with a rigid AO/ASIF reconstruction
bone plate or by two 2.0-mm mini dynamic compression
plates, two 2.4-mm dynamic compression plates, two
non-compression miniplates, or a single non-compression
miniplate. The large series had a high complication rate
(17%) associated with closed reduction and nonrigid
fixation. The use of either extraoral ORIF with the AO/
ASIF reconstruction plate or intraoral ORIF with a single
miniplate was associated with the fewest complications.
Ellis contended that angle fracture complications are
inversely proportional to the rigidity of the fixation
applied. He noted the following:
1)Higher complication rates are associated
with two points of fixation versus singlepoint fixation.
2)Single miniplate fixation requires more
limited dissection than absolutely rigid,
two-plate fixation.
3)Absolute rigidity might not be required for
mandibular angle fracture healing.
4)Complications arising from single miniplate
fixation are more easily managed and often
do not require readmission or reoperation.
The use of a solitary lag screw has been described for
the treatment of mandibular angle fractures.316 Although
lag screws provide highly satisfactory fracture reduction
and a low complication rate, the results are sensitive to the
operative technique used. Comminuted angle fractures are
SRPS • Volume 11 • Issue R8 • 2015
rare, but when multiple fragments are present, an external
Risdon incision improves access to the fracture for better
control of fragment reduction and stabilization.
Stable symphyseal fractures in patients with
normal occlusion can be treated by closed means. True
midline fractures are rare; parasymphyseal fractures
are common. ORIF is appropriate for many of these
fractures via intraoral incision. Reduction forceps are
used to anatomically align the bone fragments, and the
jaws are placed in pretraumatic occlusion while plates or
lag screws are applied to immobilize the fracture.316 Lag
screws are elegant, minimally invasive, and well suited for
reduction of symphyseal and parasymphyseal fractures.
Biodegradable polylactide screws have also been used with
good success.317
Stabilization typically requires two 2.0-mm
miniplates, a single 2.4-mm or 2.7-mm plate, or an
inferior border miniplate and an arch bar. Care must be
taken to avoid stretching or avulsing the mental nerves
exiting the mental foramen.
Ramus fractures seldom are displaced, probably
because of the splinting effect of the masseter,
temporalis, and medial pterygoid muscles. Vertical and
horizontal fractures of the ramus usually are treated by
closed reduction and MMF. Similarly, fractures of the
coronoid process seldom require ORIF and are managed
conservatively.
Condyle fractures are grouped into head, neck, and
subcondylar regions. The neck is prone to fracture because
of its relatively small diameter. During blunt impact to the
mandible, kinetic energy is transferred along the length
of the jaw to the condylar neck, where the force of the
blow frequently exceeds the compressive strength of the
bone.318-320
In contrast, a condylar head fracture is an
intracapsular injury and has a proclivity for ankylosis. If
no malocclusion has been generated by the fracture, these
injuries can be treated without MMF and the patient can
be placed on a soft diet. If malocclusion is present, the
patient should be placed in MMF with either rigid fixation
or elastics for 2 weeks, at which time a regimen of intraoral
elastics is started. A postfixation physiotherapy program is
essential. Stretching exercises consisting of active incisor
opening and lateral excursions eventually progress to active
and digitally assisted jaw levering.
Open versus closed reduction of subcondylar and
condylar neck fractures remains a contentious point.
Previous work321,322 supports a conservative approach
(closed reduction) of these fractures. In 1947, a report
from the Chalmers J. Lyons Club presented data on 120
cases of condylar fractures that favored closed reduction.321
A more recent study from Austria322 compared 229
consecutive patients with subcondylar and condylar neck
fractures, 161 of which were treated with MMF. The
other 68 were treated with ORIF. The results showed no
significant differences in mobility, joint problems,
or occlusion.
Another landmark study293 examined 348 patients
with condylar fracture for distribution patterns and
fracture causes. The results of conservative treatment were
reported, revealing similar occlusal and functional results
in patients treated with ORIF, supporting conservative,
nonoperative treatment of condylar fractures.
Joos and Kleinheinz323 list the following indications
for nonsurgical treatment of condylar fractures:
1)Condylar neck fractures in children
2)High condylar neck fractures without
dislocation
3)Intracapsular condylar fractures
Proponents of ORIF are critical of the conservative
approach, believing that TMJ dysfunction has been
underreported and that a higher incidence of traumatic
arthritis, decreased range of motion, and malocclusion
might exist than previously suspected in closed reduction
series.323-325
Zide and Kent320 described four absolute indications
for open reduction of condylar neck fractures:
1)Displacement of the condyle into the
middle cranial fossa
2)Difficulty obtaining adequate occlusion by
closed reduction
3)Lateral extracapsular displacement of the
condyle
4)Foreign body within the condyle
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Treatment method is determined by the degree of
fracture displacement and condylar dislocation. Klotch
and Lundy326 provided a particularly useful algorithm
(Fig. 40). Ellis and colleagues170,327−332 reported a 10year, 200-patient experience with condylar fractures and
concluded
the following:
1)More consistent occlusal results can be
expected in fractures of the mandibular
condylar process treated by open reduction.
2)Greater postoperative condylar mobility
is expected in patients treated by open
reduction.
3)More consistent facial symmetry is achieved
with open reduction techniques.
Bilateral subcondylar fractures associated with
midfacial fractures traditionally are managed with ORIF
of the condylar neck, at least unilaterally, to reestablish the
vertical facial dimension. Newman333 presented an analysis
of long-term outcomes of bilateral condylar fractures that
supports ORIF. However, proceedings of the Netherlands
meeting in 1988 found little scientific evidence that a
period of rigid IMF has any benefit, that it might adversely
affect future joint function, and that closed treatment
normally consists of a delay while swelling and spasm
settle. Non-rigid MMF with elastics is then applied for 1
to 6 weeks.325
Proponents of endoscopic fixation of condylar
fractures334-337 asserted that the technique offers
the benefits of direct fracture reduction with better
visualization and precise anatomic alignment of the
bony segments without the facial scars and nerve
injuries associated with open techniques. Endoscopic
techniques have been expanded to the management of
late complications. Troulis et al.171 described a series of 10
consecutive patients treated by endoscopic condylectomy
and costochondral graft reconstruction followed for a
mean of 17 months. Indications included idiopathic
condylar resorption (seven cases), malunion of a fractured
condyle (two cases), and degenerative joint disease (one
case). No complications occurred, and good correction of
occlusion and mandibular position were reported.
Transient facial nerve weakness is the most common
complication of open treatment of condylar process
58
fractures.332 Hypertrophic scarring, which in the series
presented by Ellis338 averaged 7.5%, ranks second. The
clinical and surgical factors predisposing to malocclusion,
hypomobility, facial asymmetry, and dysfunction have
also been examined.338 Facial morphology after open
(n = 65) versus closed (n = 81) treatment for condylar
fractures revealed increased facial shortening with closed
techniques.338
Fixation Devices
External Appliances—External skeletal fixation (with the
Joseph Hall Morris biphasic appliance) was previously
widely practiced.305,339-345 Although largely replaced by
internal fixation techniques, external fixation is still
useful in stabilizing large, comminuted defects from
gunshot wounds or severe mandibular infections with
osteomyelitis.
Splints—The indication for splinting is lack of adequate
dentition on which to place arch bars for MMF, such as in
children who are at mixed dentition stage or in adults who
are missing teeth.
Maxillomandibular Fixation—Problems associated
with the use of MMF include feeding difficulties and
subsequent nutritional insufficiency, airway compromise,
social and communication difficulties, and poor oral
hygiene. In an otherwise healthy patient, these are not
serious consequences, but in the elderly and otherwise
compromised patients, MMF can be problematic.346 The
duration of fixation clearly is dependent on the specifics of
the fracture. Chuong et al.347 achieved clinical union by 4
weeks in 79% of fractures and by 5 weeks in 90%, based
on weekly palpation and manipulation of the fracture site.
In most cases, release of fixation is possible by the third or
fourth week.347
Rigid Internal Fixation—Since the early 1970s, rigid
internal fixation has undergone many modifications.348,349
Current trends are toward the use of rigid internal fixation
techniques and smaller hardware to achieve fixation, and
the period of MMF is minimized.
SRPS • Volume 11 • Issue R8 • 2015
Dentulous
Bilateral
Unilateral
Not dislocated
or telescoped
Dislocated
or telescoped
IMF
Generally
ORIF
Not dislocated
or telescoped
Dislocated
or telescoped
No
midface
Unstable
midface
No
midface
Unstable
midface
IMF
Possible
ORIF
ORIF
at least
one side
ORIF
both
sides
Figure 40. Algorithm for treatment of condylar neck fractures in the adult dentulous mandible. (Modified from Klotch and
Lundy.326)
An understanding of the biomechanical principles
of jaw function and the forces acting on the mandible is
paramount to the success of internal fixation techniques.
Masticatory movements of the jaw result in tension along
the alveolus in the body and angle and compression along
the inferior border in the same areas. Fixation plates must
be applied so as to counteract these deforming forces.
AO/ASIF versus Champy—AO/ASIF espouses rigid
fixation. Champy philosophy advocates less rigid but
functionally stable fixation. Champy proposes strategic
placement of plates along natural lines of force to
sufficiently stabilize fractures and achieve union and
avoids the inherent disadvantages in using larger plates
(i.e., difficulty in plate contouring, wide exposure,
malocclusion).350-352 Szabó et al.353 described the technique
of internal fixation of mandibular fractures using these
principles, the best example of which is the use of a single
miniplate along the oblique ridge of the mandible to
stabilize an angle fracture.354-356
Outcome studies comparing the two philosophies
showed similar results. Davies et al.356 treated 64
consecutive displaced fractures using Champy principles
without postoperative IMF and showed favorable
results with an overall complication rate of 3% and no
postoperative malocclusion. Chuong and Donoff,357
Dierks,358 Souyris et al.,359 and Nishioka and Van Sickels308
detailed transoral fracture plating schema.
Regardless of technique, the main advantage
of plates and screws to treat mandibular fractures
is the elimination of IMF. In the majority of plated
fractures, postoperative IMF is unnecessary unless
59
SRPS • Volume 11 • Issue R8 • 2015
concomitant fractures (subcondylar) dictate the need
for jaw immobilization. Compared with MMF, plating
dramatically shortens the time to normal jaw function and
helps maintain body weight.360-362
Lag Screws—Ellis and Ghali316,363 reviewed lag screw
fixation, confirming that a properly placed lag screw of the
right length and design creates sufficient bony compression
and stability to successfully repair oblique fractures of
the body, symphysis, and angle (Fig. 41).364 Shetty and
Caputo365 evaluated the biomechanics of a solitary lag
screw technique in the management of mandibular angle
fractures, finding that the solitary screw, as a tension band,
provides sufficient compression and stability to withstand
functional mandibular loading.
Niederdellmann and colleagues290,366 popularized the
use of a 20- to 40-mm lag screw in the angle, reducing the
fracture via an intraoral incision and single transbuccal lag
screw. Leonard367 reviewed the many uses of lag screws in
mandibular fractures.
Locking Reconstruction Plates—Originally developed for
postresection mandibular reconstruction, locking plates are
available in a wide range of sizes and provide rigid fixation
with low-profile, high-strength plates that do not require
absolutely precise plate contouring.368-373 Advantages
include the following:
1)Easier adaptation to bone contour
2)Less plate hole deformation
3)Less plate palpability
4)Stable fixation, even in poor-quality bone
5)Less risk of screw loosening or stripping
6)Less sensitive to operative technique
Herford and Ellis368 analyzed the results of
mandibular reconstruction with a locking bone plate
and screw system in 84 patients. The authors found
loss of fixation in one case and no cases of malocclusion
or technical difficulties. Stability without requiring
the plate to be compressed to the bone was cited as a
major advantage over conventional plating techniques.
Kirkpatrick et al.370 noted a 6.4% infection rate, although
no loss of fixation occurred in their series.
60
Figure 41. Lag screw is inserted through a drill hole of the
same diameter as the screw threads. In the inner cortex of
the bone, the drill bore should match the inside diameter of
the screw. (Modified from Spiessl.364)
Children
Mandibular fractures represent 5% to 50% of pediatric
facial fractures, with the most common cause being
motor vehicle collision.372 During early childhood, the
mandible is weakened by numerous unerupted and
developing permanent teeth, which limit the amount of
bone and create regions susceptible to fracture (Fig. 42).373
Nevertheless, fractures in children tend to be incomplete
and minimally displaced because of the relative lack of
thick cortical bone and tissue elasticity, which allows the
bones to bend rather than break.374
Two-thirds of mandibular fractures in children
younger than 10 years occur in the condylar region.375-379
The proportion drops to approximately 40% in children
who are 11 to 15 years of age.
The treatment of mandibular fractures in children
is different from that in adults because of the presence
of deciduous and unerupted teeth.380 Other factors
influencing management options are the capability
for rapid healing in children and the risk of treatment
interfering with future mandibular growth. Most fractures
are best managed by closed reduction. ORIF often is
difficult because the developing tooth buds leave little
room for placement of fixation devices.380-382
SRPS • Volume 11 • Issue R8 • 2015
establish preinjury occlusion. An acrylic splint is fashioned
to the lingual surface of mandibular dentition and is
secured with circummandibular wires.
Permanent
canine
Premolars
First permanent molar
Permanent
incisors
Second permanent molar
Second permanent molar
Premolars
First permanent molar
Permanent
incisors
Permanent
canine
Figure 42. Location of developing permanent tooth buds
in the pediatric maxillofacial skeleton must be kept in
mind when applying rigid plate fixation. (Modified from
Winzenburg and Imola.373)
Regarding closed reduction, stabilization is most
frequently achieved with either IMF or lingual splints.
The use of arch bars in children younger than 9 years
frequently is problematic. It is difficult to maintain wires
around the bases of the deciduous teeth because of the
absence of a distinct cingulum and because these teeth are
prone to extrusion when the wires are tightened. IMF is
best achieved using a circummandibular wire anteriorly
connected to a wire passed through a drill hole in the
piriform aperture.
Stabilization of parasymphyseal and body fractures
can also be achieved using lingual splints fashioned from
dental impressions. In the case of displaced fractures, the
models are cut at the fracture site and are repositioned to
Condylar head fractures in children are associated
with risk for growth disturbance.42,381-387 The condyle
in children is highly vascular and can fragment when
subjected to compressive trauma, with resultant
hemarthrosis and subsequent ankylosis. Early mobilization
to prevent ankylosis and close follow-up to detect growth
disturbances are imperative.
In condylar neck or subcondylar fractures,
preservation of ramus height and TMJ function are key.
Closed reduction usually is sufficient, with lingual splints
to bridge other associated fractures. Immobilization
is limited to 5 to 10 days, and active exercises then
begin.372-377
Multiple long-term outcome studies support
conservative management of pediatric condylar
fractures.42,361,388−392 Nørholt et al.42 found that the
functional and aesthetic results 10 years after condylar
fractures were satisfactory after conservative treatment in
55 patients whose ages were 5 to 20 years. For patients
older than 18 years, however, operative treatment
proved superior.
Posnick et al.393 noted that 34% of 318 pediatric
facial fractures involved the mandible. Based on that series,
the authors advocated conservative treatment of most
condylar process injuries and nondisplaced, simple body
and angle fractures. Comminuted or displaced fractures
are treated by ORIF.
Rémi et al.394 retrospectively reviewed 30 fractures
in 19 pediatric patients with a mean follow-up duration
of 28 months. The condyle was involved in 16% and
the subcondylar region in 28% of cases. Conservative
functional (closed) treatment was used in the majority
of cases. Body and condyle fracture combinations were
treated by ORIF and MMF. No infections or facial growth
disturbances were reported. One patient had TMJ
pain syndrome.
Conservative treatment of condylar fractures in
children, when followed by early restoration of function
and diligent physiotherapy, can be expected to produce
good healing, normal growth of the jaw, and little or no
interference with movement of the TMJ.
61
SRPS • Volume 11 • Issue R8 • 2015
Edentulous Patients
Fractures in edentulous patients are difficult to
treat because:
1)Teeth on which to anchor
maxillomandibular fixation are lacking.
2)The alveolar ridge often is atrophic and the
mandibular cross-section is small, so that
muscle pull easily displaces the fragments.
3)The fractured bone is primarily cortical,
with little capacity for repair.
Fixation with skeletal wires attached to dentures frequently
is inadequate and unstable without risking soft-tissue
necrosis. Closed management involves the use of existing
dentures or Gunning splints to stabilize the fracture or
the use of external fixators such as the Morris appliance.
Closed treatment avoids periosteal stripping of already
atrophic bone. However, a series presented by Bruce
and Ellis395 of 104 consecutive edentulous fractures
found higher rates of delayed or fibrous union in closed
treatment versus ORIF (25% versus 12.6%) and increased
morbidity, increased disability time, worse jaw function,
and worse aesthetics. Plates should be large (>2.4 mm),
and screws should be locking screws.
The authors correlated treatment results with degree
of atrophy and recommended supraperiosteal plating
along with primary bone graft when alveolar height is
significantly reduced.
Teeth in the Line of Fracture
With increasing understanding of jaw function
biomechanics, teeth are retained whenever possible and
removed only when nonrestorable or severely broken.399-402
Even then, they sometimes are retained for stabilization
and carefully extracted only after MMF release.
Shetty and Freymiller403 offered guidelines for the
management of teeth in the line of fracture:
1)Intact teeth in the fracture line should be
left in situ if they show no evidence of
severe loosening or inflammatory change.
2)Impacted molars, especially complete
bony impactions, should be left in place to
provide a larger repositioning surface and
for the application of tension bands. The
exceptions are partially-erupted molars with
pericoronitis or associated with a
follicular cyst.
1)Edentulous patients tend to be older and
have systemic disease.
3)Teeth that prevent reduction of fractures are
removed.
2)Associated anesthetic risks and postoperative
morbidity are high.
4)Teeth with exposed root apices or where the
fracture line follows the root surface from
apical region to gingival margin tend to
develop healing complications. Hemisection
should be considered as an alternative
to extraction.
Bone plate placement is controversial.
Bradley396,397 demonstrated that the main blood supply
to the edentulous mandible is via a subperiosteal plexus
dependent on overlying soft tissues and therefore
recommended supraperiosteal plating. However, treatment
failures are recognized as secondary to fragment instability
rather than inadequate blood supply.312 Luhr et al.398
presented a report of 84 edentulous fractures treated with
compression plates without postoperative MMF, proposing
a classification system for mandibular atrophy that is based
on midpoint body vertical bone height, as follows:
5)Teeth with crown fractures may be retained,
provided emergency endodontic therapy. All
teeth with fractured roots must be removed.
6)Teeth that appear nonvital should be
treated conservatively, recognizing
recovery potential.
7)Primary extraction is preferred when
extensive periodontal damage with broken
alveolar walls and a deep pocket.
•• Class I, 16−20 mm
•• Class II, 11−15 mm
•• Class III, <10 mm
62
A 117-patient study conducted by Baykul et al.404
SRPS • Volume 11 • Issue R8 • 2015
further supports the practice of retaining asymptomatic
impacted teeth in the uncomplicated fracture line. Open
fractures were treated with IMF, and no unerupted teeth
were extracted. No complications occurred, and fractures
healed without sequela.
Tooth fractures range in severity from cracks in the
enamel to complete breaks in the crown. A partial fracture
of the crown in a tooth that is otherwise intact with a
stable root is an indication for restorative dentistry.290,405-407
Postoperative Care
The airway is the primary concern in patients treated
with MMF. A nasogastric tube, positioned during
surgery, should be left in place until the patient is ready
for extubation. A patient with MMF applied should not
be extubated until fully awake. Prophylactic antibiotics
are recommended for all open facial wounds, such as
compound mandibular fractures. Zallen and Curry408
reported a 50% infection rate without antibiotics. No
correlation exists between infection and the removal or
retention of teeth. Feeding should progress from clear
liquids, to a high-protein full-liquid diet, to a blended
diet.409
Complications
Potential complications include infection, malocclusion,
malunion, nonunion, plate exposure, and nerve injury.
Nonunion frequently is the result of inadequate fracture
immobilization or alignment, interposition of tissue
or foreign body between fracture fragments, infection,
segmental bone loss, and plate misapplication.410 A series
of 308 patients presented by Moulton-Barret et al.411
revealed a 14% overall complication rate, with infection
accounting for half of the complications and malunion
and malocclusion the remainder.
The incidence of nonunion is 3.2%, with the
mandibular body comprising most of these. Haug
and Schwimmer412 identified risk factors predictive of
nonunion, finding that inadequate immobilization,
location (mandibular body), teeth in the line of fracture,
and late postsurgical infections correlated well with
the development of fibrous union. Alcohol and drug
abusers and noncompliant patients are also at high risk
for nonunion. Conversely, age, race, sex, mechanism of
injury, and failure to use antibiotics were not risk factors.
Treatment of nonunion includes removal of infected
teeth, débridement the fracture, and reapplication of rigid
internal fixation with or without bone grafting.412
Mathog et al.413 analyzed a 906-patient series (1432
fractures) to identify factors contributing to nonunion
and found that multiple fractures were associated with
nonunion, the mandibular body was often involved, and
osteomyelitis was a frequent finding. Failure to provide
antibiotics, treatment delay, teeth in the fracture line,
alcohol and drug abuse, surgeon inexperience, and patient
noncompliance also correlated with complications.
Pretreatment inferior alveolar nerve sensory
abnormalities are found in 56% of patients with fractures
between the mandibular and mental foramina and become
permanent in 19%.414-416
Malocclusion is entirely preventable. The most
common cause of malocclusion is maladaption of the
plate used for fixation, with resultant bony malreduction
and movement of dentition. This should be recognized at
the end of surgery when MMF is released and occlusion
assessed. Any occlusal discrepancy should prompt the
surgeon to remove fixation, reestablish MMF, and reapply
bone plates. Considering that postoperative malocclusion
secondary to internal fixation requires repeat operation in
the vast majority of cases, the surgeon should not rely on
elastics or MMF to correct the problem.
63
SRPS • Volume 11 • Issue R8 • 2015
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