Facial Fractures

Introduction

Fractures involving the facial bones can result in functional impairment and a distorted appearance, affecting essential activities like eating, speaking, and swallowing. Managing facial fractures due to trauma depends on factors such as the location, number of bones involved, accompanying soft tissue injuries, and the patient’s age. Soft tissue injuries in the facial region also require tailored management.

Lower Jaw (Mandible)

Fracture mandible is a fracture in the lower jawbone. Few particular sites in the lower jawbone are more prone to fracture.

After a fracture, 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.

These fractures are most common in young males and the main reason is road accidents and trauma during fights.

OPG and Plain X-rays are used for diagnosis, but 3D CT scans are more commonly done these days to find the exact location of the fracture, and the amount of displacement of a broken bone and to rule out associated multiple fractures.

How is the fracture of the lower jaw treated?

Surgical management is the key to the treatment of fractures of the lower jaw. The reduction of fractured bone fragments is the first step in managing the fracture of the lower jaw. It means approximating the broken bone edges as close together as possible.

The “Open Reduction and Internal Fixation” technique or ORIF is the usually preferred technique in today’s time 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.

Recovery after surgery –

• There is no need for the IMF to immobilize the jaws after the surgery with this technique.
• The patient is usually discharged from the hospital on the second day after the surgery and is kept on a soft diet for 2 to 3 weeks.
• Usually, the broken bone gains 80% of its normal strength by 3 weeks and 90% by 4 weeks.

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 midface 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 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 by 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 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.

How are Lefort fractures treated?

A. 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.

B. 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.

The “Open Reduction and Internal Fixation” technique or ORIF- 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.

Recovery after surgery –

• There is no need to immobilize the jaws in IMF after the surgery with this technique.
• 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.

Cheek Bone (Zygoma)

Zygoma is also known as the malar/cheekbone. Fractures of the Zygoma bone lead to cosmetic deformities mostly.

Patients with cheekbone fractures can also have difficulty opening their mouths. These fractures are usually accompanied by fractures in the upper jaw (maxilla) and eye socket bone .

A 3D CT scan of the face usually confirms the diagnosis.

How are fractures of Zygoma bone treated?

A. Non-surgical approach for the treatment of cheekbone fractures 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.

B. Reduction manipulation of the zygoma bone is done by an open surgical approach only. Incisions are made in such areas that scars are not visible to the human eye (within the hairline, inside the mouth, or below the eyelashes). Fractures are found and physically manipulated into the correct place. The definitive treatment is most of the time done surgically by plates and screws fixation of the broken bones under vision so that fractured ends meet accurately. This is referred to as the “open reduction and internal fixation” technique or ORIF.

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.

Nasal Fractures

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.

How is a nasal fracture treated?

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 have united in the wrong position. So, in fractures of nasal bone that are more than 3 weeks old and the deformity is severe, refracture of nasal bones and correction of alignment is done.

Forehead (Frontal Bone)

The frontal bone is the main bone in the forehead area. A high-impact injury to the head can cause a fracture of the frontal bone and floor of the sinuses.

The fracture is most likely to occur in the middle of the forehead. That’s where the bone is the thinnest and weakest.

An injury may cause the bone to be indented (pushed inward). Substantial force is required to fracture the frontal bone, so often other injuries to the face and skull or neurological trauma may be present.

Associated problems may include leakage of the cerebrospinal fluid, eye injuries, and damage to the sinus ducts. A 3D CT scan of the face and head usually confirms the diagnosis.

Treatment of frontal bone fracture –

• Simple undisplaced fractures are best left alone and no surgery is required.
• Displaced fractures with depressed forehead need surgery in the form of open reduction and plate fixation.

Orbit (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 the entanglement of eyeball structures into the fracture line or herniation of contents of the orbit into the maxillary sinus. It can cause symptoms like

• a) enophthalmos (sunken eye appearance),
• b) inability to move the eyeball upwards (due to muscle entrapment),
• c) double vision,
• d) 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 cheekbone, nose, or upper jaw or can be a part of NOE complex fractures.

How are eye socket fractures treated?

• The conservative approach is if a fracture is nondisplaced 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.

Panfacial Fractures and NOE Fractures

• Pan-Facial Fractures: These occur when multiple facial bones fracture simultaneously, posing complex challenges. Effective management requires a well-defined treatment plan to optimize both function and aesthetics.
• NOE (Naso-Orbito-Ethmoid) Fractures: NOE fractures involve the nasal, orbital, and ethmoid bones, typically centered around the nasal root. Early treatment is crucial to prevent complications in these complex fractures.

Causes of Facial Fractures

Facial fractures can result from various causes, including:

• Road Accidents: High-impact collisions on the road often lead to facial trauma.
• Sports Injuries: Contact sports, accidents, or falls can cause facial fractures.
• Violence: Physical altercations or assaults may result in facial injuries.

Facial fractures have significant implications for both function and appearance. Early diagnosis, accurate classification, and appropriate treatment are essential for optimal outcomes. Healthcare providers like Dr. Amit with a comprehensive understanding of facial fractures can better serve patients and ensure the best possible recovery.