What is the initial management of patients with Fractures of the face?

Treatment involves basic trauma management and then treatment of specific fractures of the face.

• Making sure that the patient can breathe, if there is difficult breathing, it will be the first step in management
• Material may be present in the mouth that may block the airway should be removed
• Oxygen, if required
• Tracheal or nasal intubation (inserting a tube into the airway to assist breathing)
• Dressing of wounds
• Antibiotics
• Tetanus immunization
• Suturing of the Open wounds to stop bleeding
• Nasal packing to control nosebleed.
• Ice fomentation and pain killers

Confirmation of the exact site of fracture of bones of face is done by doing a 3D CT scan of face along with a 3DCT Scan of the head to rule out any head injury

Fracture Upper Jaw (Maxilla)

The maxilla is the bone of the upper jaw that stays fixed, unlike the mobile lower jaw. It also contributes to the bony skeleton of the eyes, nose and cheeks. Fractures of this bone are known as mid-face fractures and are classified into three types as per Le Fort classification.

• Le Fort I : This is the fracture in the upper jaw above and along the upper lip, separating the teeth apart from the maxillary bone, including the lower portion of the nose.
• Le Fort II : It is a pyramid-shaped fracture that involves the teeth at the base and the nasal bridge at its highest point, along with the eye sockets and extending up to nasal bones.
• Le Fort III : This fracture occurs across the nasal bridge, through the eye sockets, and outward to the sides of the face. This is the most complicated kind of upper jaw fracture and is caused due to severe blow to the face.

In fractures of the upper jaw, the patient is unable to fully open the mouth, or the mouth opening is painful. Often alignment of teeth is disturbed and there may be tooth loss also. The face appears elongated or concave or dish shaped.

A 3D CT scan of the face usually confirms the diagnosis, helps in the classification of the fracture patterns and aids in planning the surgery.

• Non-surgical approach for treatment is considered for minimal, non-displaced fractures, or in medically ill patients. This would include regular analgesia, a soft diet and taking care to avoid any trauma. Rest all the cases need surgical intervention.
• Surgery for Lefort fractures is necessary to maintain facial features and contour. And, like lower jaw, upper jaw fractures also need reduction and immobilization to heal. It means approximating the broken bone edges as close together as possible. Reduction manipulation of the broken jaw is done by closed approach or open surgical approach.

1. This can be done by manipulating the broken upper jaw which is called "closed reduction" and immobilizing the jaws (intermaxillary fixation-IMF) with an arch bar and wires for 4-6 weeks.
2. "Open Reduction and Internal Fixation" technique or ORIF- An "open reduction" is the usually preferred technique as accurate reduction is possible with this method, where an incision is made, the fracture is found and is physically manipulated into place. This definitive reduction treatment is most of the time stabilized surgically by plates and screws fixation of the broken bones under vision so that fractured ends meet accurately.

There is no need to immobilize the jaws in IMF after the surgery with this technique. Various types of plates and screws are used depending on the type of fracture and patient factors.

The patient is usually discharged from the hospital on the third day after the surgery and is kept on a soft diet for 2 to 3 weeks.

3. Apart from a fixation with plates and screws after the open reduction, the upper jaw can be immobilized with stainless steel wire woven across the fractured bone segments to avoid re-displacement of bony edges. If this method of reduction is used, the immobility of bone is maintained by the arch bar and stainless-steel wire Inter maxillary fixation for a minimum of 4 weeks.

Usually, the broken bone gains 80% of its normal strength by 3 weeks and 90% by 4 weeks.

Fracture Nose

Fractures of the nose usually bleed profusely at the time of blow. So, the first step in management is to give external compression to control bleeding. It usually takes a few minutes to stop bleeding after which nasal packing is done.

Diagnosis is made clinically by feeling the crackling sound or the visible deviation of the nose bridge. X-ray usually confirms the diagnosis.

Treatment of the nasal bone fracture would depend on the time of presentation after the fracture.

• If the patient arrives early after the nose fracture, reduction of the bone and immobilization with a plaster slab over the nose is given.
• The reduction of the fracture is still possible conveniently till one week after the accident after which reduction becomes a little difficult as the fracture starts to unite in the wrong position after a week.
• This reduction becomes surgically difficult if three weeks have elapsed after the accident and bones would have united in the wrong position. So, in fractures of nasal bone which are more than 3 weeks old and the deformity is severe, refracture of nasal bones and correction of alignment is done.

Orbital fractures (eye socket)

Orbital fractures are the fractures of the bones of the eye socket around the eyeball. They are classified in two different ways:

• Orbital rim fracture- It includes fracture of the outer margin of the bony socket. The outer rim of the eyeball is a strong structure and is broken by a strong force or blow.
• Orbital floor fractures- In this case, the orbital rim is not damaged, instead, there is a break in the floor of the eye socket that leads to entanglement of eyeball structures into the fracture line or herniation of contents of the orbit into the maxillary sinus. It can cause symptoms like enophthalmos (sunken eye appearance), inability to move the eyeball upwards (due to muscle entrapment), double vision, severe pain and swelling etc.

A 3D CT scan of the face usually confirms the diagnosis of the orbit. Orbital fractures can be accompanied by fractures of the cheek bone, nose or upper jaw or can be a part of NOE complex fracture.

Treatment of eye socket fractures requires

• The conservative approach, if fracture is undisplaced or if not causing any symptoms.
• In cases of displaced orbital rim fracture or orbital floor fracture, urgent surgical intervention is needed.
• Orbital rim fractures are fixed by open reduction with lower blepharoplasty incision and fixation is done with low profile 1.5 mm plates and screws.
• Orbital floor fractures with double vision, sunken eye appearance and muscle entrapment, surgery is done. Surgical release of the soft structures of the eye is done with a lower blepharoplasty incision, close to the lower eyelashes so that the scar is imperceptible to the human eye after the surgery. After the release of the orbital septum and entrapped structures carefully, the orbital floor is supported with the metal mesh.

When orbital fractures are accompanied by nasal bone and ethmoid bone fractures, they are called NOE (Naso-orbito-ethmoid) fractures. NOE fractures lead to the depressed forehead-orbital-nose area and are very difficult and notorious to treat, and the best time is to treat them early than to be sorry for later.

When multiple bones of the face are fractured together, the condition is called PAN-FACIAL fracture. The management of PAN-facial fractures of the face is quite challenging and requires proper treatment policy, sequencing and plating algorithm for the various fractures of the face to maximise the functional and cosmetic outcome.

Best plastic surgeon, Dr. Amit Agarwal is an American Board Certified, extensively trained, and best Plastic & Aesthetic surgeon in Lucknow. He is the Chief Plastic Surgeon heading the Department of Plastic, Microvascular, and Craniofacial surgery at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, U.P, India. He maintains a busy practice at Avadh and Nishat Hospital and his own center - Kayakriti Plastic Surgery & Dental Center. He was formerly a Consultant in the Department of Plastic Surgery and Burns at the prestigious SGPGI, Lucknow.

MS, DNB (General Surgery) MCh, DNB (Plastic Surgery),
MNAMS, FACS, FICS, FRCS (Edinburgh, UK)

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