Section Editor

Fred G. Fedok

Contributors

Daniel G. Becker

Ara A. Chalian

Donn R. Chatham

John L. Frodel, Jr.

Richard D. Gentile

David Goldenberg

Bradley J. Goldstein

Robert M. Kellman

Ayesha N. Khalid

Christopher K. Kolstad

J. David Kriet

Samuel M. Lam

Phillip R. Langsdon

E. Gaylon McCollough

Marcus W. Moody

Michael P. Ondik

Stephen S. Park

Daniel E. Rousso

Francis P. Ruggiero

Barry M. Schaitkin

John M. Schweinfurth

Dhave Setabutr

Scott J. Stephan

Jonathan M. Sykes

Travis T. Tollefson

Key Features

Nasal fracture clinical presentation may include epistaxis, change in external nasal appearance, nasal airway obstruction, and infraorbital ecchymosis.

Epidemiology

Nasal fractures are cited as the most common type of facial fracture, accounting for approximately half of all facial fractures. These injuries occur largely in the younger, physically active segments of the population and predominantly in males. The most common mechanism is blunt trauma; these fractures also occur via penetrating and high-energy injuries. Finally, nasal fractures occur not only in isolation but also frequently in conjunction with more extensive facial fractures.

Evaluation

Physical examination is facilitated if the nose is decongested. Visual inspection, manual palpation, and anterior rhinoscopy are essential. If possible, nasal endoscopy can be performed to increase the acquisition of meaningful clinical data.

The tip and lower two thirds of the nose should be examined. Is there an injury to the cartilaginous framework? Determining the status of the septum is frequently underemphasized; however, appropriate appreciation and management of septal injuries is essential to the restoration of optimal nasal function and appearance. And finally, the examiner should look for and document the presence or absence of a septal hematoma. If present, it should be expeditiously and appropriately managed.

Photographs should be done similar to the views obtained for rhinoplasty evaluation. Planar radiographs and computed tomography (CT) rarely add more valuable data than that obtained through the physical examination and medical history.

Treatment Options

Observation

When it has been determined that there is minimal displacement of the nasal bones, minimal soft tissue injury, and minimal compromise of the nasal airway, recommend observation and undertake no active surgical or manipulative intervention.

Closed Manipulation

Under local or general anesthesia, the patient’s fractured nasal bones and septum are mobilized and reduced digitally. This may be aided with the use of blunt instruments such as the Boise elevator or Ashe forceps. Traditional closed manipulation is best applied in patients who have actual subluxation or displacement of the nasal bones without significant fracture of the nasal bones themselves.

Modified Open Reduction with Osteotomies

The modified open technique is a limited version of an open technique in which intranasal incisions are made for the introduction of osteotomes. Such patients frequently benefit from manipulation of the nasal bones into position after undergoing bilateral microosteotomies. As with closed manipulation, the position of the septum may impede the success of this technique. A secondary procedure may then be necessary or other treatment offered.

Open Nasal/Septal Repair

The open nasal/septal repair refers to an aggressive approach to the acute management of complicated injuries using existing lacerations or external and intranasal incisions. With this approach the surgeon can reduce, graft, and fixate fractured anatomic components under direct visualization.

Formal septorhinoplasty after nasal fracture is employed in two general clinical situations: when there has been minimal displacement and treatment is delayed until swelling has resolved, and as a secondary procedure after initial acute management.

Outcome and Follow-Up

Externally stabilizing dressings should be applied similarly to rhinoplasty care. When there have been significant septal injuries, internal soft silastic splints may provide stabilization and aid in the prevention of synechia. Packing is only occasionally necessary.

ICD-9 Codes

Further Reading

Fedok FG, Ondik MP, Preston TW, Goldenberg D. Management of trauma to the nasal bones and septum. In: Stucker FJ, De Souza C, Kenyon GS, Lian TS, eds. Rhinology and Facial Plastic Surgery. Heidelberg/New York/Berlin: Springer-Verlag; 2009

Oeltjen JC, Hollier LH. Nasal and naso-orbital-ethmoid fractures. In: Stewart MG, ed. Head, Face, and Neck Trauma: Comprehensive Management. Stuttgart/New York: Thieme; 2005:39–51

Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg 2000;106(2):266–273

Key Features

Epidemiology

Injury results from severe trauma to the frontal and midface region. The most common mechanism is a motor vehicle accident with an unrestrained driver. Seatbelt and airbag use has reduced its incidence in recent years.

Clinical

Signs and Symptoms

Often, patients with NOE fractures have life-threatening injuries and require initial trauma evaluation and stabilization. Eye and brain injuries are common. Concurrent ocular injury, such as globe rupture, lens dislocation, retinal detachment, or vitreous hemorrhage, occurs in ~30% of patients. Patients may have cerebrospinal fluid (CSF) leakage, due to disruption of the anterior skull base. Typical associated signs and symptoms include severe epistaxis, CSF rhinorrhea, diplopia, epiphora, and severe facial pain. The typical facial deformity resulting from disruption of the ethmoids and medial canthal tendon attachments includes flattening of the nasal dorsum, upward tip rotation and loss of projection, and increased interpupillary distance (traumatic telecanthus).

Differential Diagnosis

Imaging

Thin-cut axial and coronal CT is the most useful imaging study. Fractures of the facial and nasal bones are readily visualized, with excellent detail of the medial orbital walls and lacrimal region. The integrity of the skull base may be assessed, as well as the presence of pneumocephalus or other intracranial injury. NOE fractures can be categorized according to the degree of comminution at the medial canthal tendon insertion:

• Type I: Large central fragment

• Type II: Comminution of central fragment but not involving the tendon

• Type III: Comminution involving lacrimal fossa and tendon attachment site with tendon laceration

Labs

Routine trauma and preoperative lab studies are necessary as indicated, including complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), electrolytes, and possibly a toxicology screen.

Treatment Options

Treatment of an NOE fracture requires open reduction with internal fixation. For relatively limited fractures, external ethmoidectomy incision may afford adequate exposure. Often, the surgeon may take advantage of large lacerations for bony exposure. However, a coronal (often termed bicoronal) incision is generally used. Stabilization of the central fracture fragment, to which the medial canthal tendon is attached, is achieved with plating to stable bone, especially in types I and II injuries. Occasionally, intercanthal wiring is necessary to achieve an adequate result, especially in type III injuries, in which severe comminution is present. Many surgeons advocate slight initial overcorrection. Bone grafting may be necessary.

Outcome and Follow-Up

Admission and perioperative antibiotics are required. Frequent vision examinations are performed following repair of orbital fractures. Infection, hematoma, or vision change requires prompt attention to correct underlying issues.

Further Reading

Oeltjen JC, Hollier LH. Nasal and naso-orbital ethmoid fractures. In: Stewart MG, ed. Head, Face, and Neck Trauma: Comprehensive Management. Stuttgart/New York: Thieme, 2005;39–51

Strong EB. Frontal sinus and naso-orbital-ethmoid complex fractures. In: Papel ID, ed. Facial Plastic and Reconstructive Surgery. 3rd ed. Stuttgart/New York: Thieme; 2009:977–990

Key Features

A ZMC fracture may be called a tripod fracture because there are three sites of fracture—the frontozygomatic suture, the maxillary face, and the zygomatic arch. Isolated fractures of the orbital rim, floor, maxilla, or zygomatic arch can also occur. Surgical repair is indicated in most displaced ZMC fractures, with fixation of one or more fracture sites.

Epidemiology

ZMC fractures are the most common malar bone fractures and the second most common facial bone fracture after the nasal bones. Zygomatic arch fractures are most common in men (in the third decade) and are caused by sports injuries, motor vehicle accidents, or assault.

Signs and Symptoms

Patients suffering ZMC or orbital fractures may present with epistaxis, periorbital edema, lacerations, pain, vision change, diplopia, or step-off deformities at the site of fractures. Numbness of the ipsilateral upper lip, gum, nostril, and cheek is common due to fractures through the infraorbital foramen (V₂). Orbital signs include chemosis, subconjunctival hemorrhage, immediate proptosis, and enophthalmos. Entrapment of the inferior rectus muscle in the orbital floor fracture can result in diplopia due to impaired extraocular muscle function. Malocclusion may result from either a mobile midface (LeFort) fracture or a concomitant mandible fracture. A depressed zygoma fracture may cause trismus by compressing the coronoid.

Differential Diagnosis

As with any trauma patient, standard ABCs and cervical spine clearance (including C-spine films) should be the first priority. The widespread availability of maxillofacial CT scans with axial and coronal cuts makes plain film obsolete. Both axial and coronal cuts should be ordered to assess the orbital floor and diagnose the exact fracture sites. The pterygoid plates and zygomatic arches are best seen on axial films; the orbital rims, floor, and cribriform plate require coronal cuts. Subcutaneous air is often seen with medial orbital and orbital floor fractures. Foreign bodies or bone fragments near the optic nerve should be identified on CT to prevent damage during fracture reduction. The teardrop sign is seen in a coronal CT scan when orbital fat protrudes through a trap door orbital floor fracture. Indications for orbital floor fracture repair include a defect >1 cm³, muscle entrapment, and enophthalmos.

Treatment Options

Mildly displaced fractures can be managed with closed reduction. Moderate to severe ZMC fractures should be repaired with open reduction through a combination of approaches that may include transoral (to address the maxillary buttress), eyelid (orbital rim and floor), and upper blepharoplasty (frontozygomatic), or, less frequently, a bicoronal approach (associated supraorbital, frontal, or comminuted zygoma fractures). Fracture fixation usually includes plating at least one or two fracture sites for stability with 1.7-mm titanium plates (often L or J shaped) on the zygomaticomaxillary buttress and a 1.2-mm plate on the orbital rim and/or frontozygomatic suture. Orbital floor fractures are repaired by reduction of the herniated orbital contents through a transconjunctival approach. An implant such as titanium mesh or porous polyethylene is often used to maintain the reduction of orbital contents. Isolated zygomatic arch fractures can be reduced via a transoral, a temporal (Gilles), percutaneous, or, rarely, a coronal approach (comminuted fractures).

Complications

Increased intraocular pressure from an orbital hemorrhage can cause vision loss from the injury itself or as a complication of repair. Prompt treatment includes immediate lateral canthotomy and cantholysis, intravenous (IV) steroids (methylprednisolone), ophthalmology consult, and an urgent CT scan. Orbital decompression may be necessary. The most common complication of repair is inadequate fracture reduction with subsequent enophthalmos.

Outcome and Follow-Up

Standard perioperative antibiotics and steroids are used at the surgeon’s discretion. Strict precautions for no nose blowing should be enforced to prevent subcutaneous air.

Further Reading

Costello BJ, Papadopoulos G, Ruiz R. Pediatric craniomaxillofacial trauma. Clin Pediatr Emerg Med 2005;6:32–40

Folkestad L, Westin T. Long-term sequelae after surgery for orbital floor fractures. Otolaryngol Head Neck Surg 1999;120(6):914–921

Kellman R. Maxillofacial trauma. In: Cummings CW, Haughey BH, Thomas JR, et al, eds. Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia, PA: Elsevier Mosby; 2005:602–639

Stanley RB Jr. Use of intraoperative computed tomography during repair of orbitozygomatic fractures. Arch Facial Plast Surg 1999;1(1):19–24

Stewart MG. Zygomatic complex fractures. In: Stewart MG. Head, Face, and Neck Trauma: Comprehensive Management. Stuttgart/New York: Thieme: 2005:68–76

Key Features

Epidemiology

Most frontal fractures occur in young males at a higher proportion when compared with women (8:1). Although they can occur at any age, the highest incidence occurs during the third decade of life.

Clinical

Signs and Symptoms

Patients with frontal sinus fractures frequently have other associated facial fractures. Depending on the degree of force, patients may or may not have been conscious during the event and may have suffered significant head trauma. Those who are conscious during the inciting event and remain so will likely complain of frontal pain. Forehead swelling, lacerations, and paresthesia may also be present. Obvious forehead deformity may be present, including significant depression, step-offs, and palpable crepitus, but typically the diagnosis is best characterized via a CT scan. CSF discharge may also be evident from the nose or wound.

Differential Diagnosis

Frontal sinus fractures should be distinguished from simple lacerations and contusions of the forehead. Frontal bone fractures can occur without involvement of the sinus, and CSF rhinorrhea is also seen in other isolated facial fractures. Adjacent facial structures must be evaluated for traumatic involvement (zygomaticomaxillary, orbital, NOE, and skull base fractures).

Evaluation

Physical Exam

The trauma ABCs must be assessed first. Swelling of the oral cavity and pooling of blood in the pharynx can complicate facial trauma by causing airway obstruction. An airway should always be established immediately. Neurologic and visual status evaluation should be done as soon as potentially life-threatening injuries are addressed. Vision loss may be prevented if recognized early via elevated intraorbital pressure or evidence of optic nerve injury. If a patient is either uncooperative or combative, gross evaluation of the facial nerve is recommended when a complete exam is unobtainable. Mobility of the midface, nose, and mandible should be assessed adequately. Lacerations need to be thoroughly irrigated and probed for evidence of any foreign body. CSF rhinorrhea or otorrhea should be considered if any clear discharge is present.

All patients with suspected frontal sinus fractures should undergo a fine-cut (1.5–3 mm) CT scan in axial and coronal planes. Axial images will allow good visualization of the anterior and posterior tables of the frontal sinus as well as of evidence of pneumocephalus. Coronal views allow for visualization of the frontonasal tract, the cribriform plate, and the floor of the frontal sinus. In general, a displacement of the posterior table of more than one thickness of adjacent bone is considered significant.

The role of x-rays is limited, although Caldwell’s view can evaluate resolution of fluid accumulation that may be found in the frontal sinus postinjury.

Labs

No specific laboratory tests are required for these patients; however, appropriate screening tests (CBC, chemistry, coagulation studies, drug screening) are often obtained during the initial trauma evaluation and may identify conditions warranting treatment.

Other Tests

When CSF rhinorrhea is suspected, β-2 transferrin testing may be performed on the nasal fluid to confirm the diagnosis. Frontonasal outflow tract obstruction is associated with development of frontal mucoceles, and, although typically best evaluated intraoperatively. Fluorescein, benzylpenicillin solution (white), or methylene blue dye is sometimes used to evaluate the integrity of the nasofrontal duct. Patency is evident when dye is seen intranasally after being introduced in the sinus.

Treatment Options

Antibiotic prophylaxis is recommended for frontal sinus fractures, although some argue that closed fractures and those isolated to a nondisplaced anterior table fracture are not in need of antibiotics. The evaluation of the patients should be directed at an assessment of whether the dura needs to be repaired, whether the outflow tracts have remained sufficiently functional, and whether there is a significant deformity. The concepts of importance in frontal sinus fracture repair are prevention of intracranial infection, prevention of frontal sinus disease such as sinusitis and mucoceles, and a cosmetically acceptable outcome.

Nondisplaced fractures of the anterior table without evidence of nasofrontal duct obstruction and no forehead deformity should be treated nonoperatively. Apart from this fracture, there is no apparent consensus regarding treatment.

Surgical access for frontal sinus fracture is best made with a bicoronal flap approach, supraorbital brow incision, or via an existing laceration. Minimally fragmented and nonfragmented fractures can be sufficiently reduced with miniplates. Technological advancement now allows for the use of endoscopic assistance to avoid external scars and frontal sinus fat obliteration by endoscopically opening the nasofrontal outflow tract widely and permanently.

Complications

Complications may include injury to sensory or motor nerves. It is essential to document nerve function prior to surgery. Most patients with sensory change will see improvement over 3 to 12 months. Prolonged retraction can cause temporary paresis of this branch of the facial nerve, but precise surgical technique can help to avoid permanent injury.

Outcome and Follow-Up

The patient is admitted after surgery and monitored for neurologic change, infection, CSF leak, visual change, hemorrhage, and pain control. The patient should be followed closely for the first several months with particular attention paid to follow-up CT to evaluate for mucocele development. The time frame for mucocele development can range from 2 months to 42 years; thus long-term follow up, though difficult, is paramount.

ICD-9 Code

Further Reading

Bell RB, Dierks EJ, Brar P, Potter JK, Potter BE. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg 2007;65(5):825–839

Cole P, Kaufman Y, Momoh A, et al. Techniques in frontal sinus fracture repair. Plast Reconstr Surg 2009;123(5):1578–1579

Cummings CW, Haughey BH, Thomas JR, et al, eds. Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia, PA: Elsevier Mosby; 2005

Gossman DG, Archer SM, Arosarena O. Management of frontal sinus fractures: a review of 96 cases. Laryngoscope 2006;116(8):1357–1362

Lalwani AK. Current Diagnosis and Treatment: Otolaryngology Head and Neck Surgery. 2nd ed. New York: McGraw-Hill; 2007

Strong EB. Frontal sinus and naso-orbital-ethmoid complex fractures. In: Papel ID, ed. Facial Plastic and Reconstructive Surgery. 3rd ed. Stuttgart/New York: Thieme; 2009:977–990

Key Features

Differential Diagnosis

Malocclusion is also seen in isolated dentoalveolar fractures. Adjacent facial structures must also be evaluated for traumatic involvement (mandible, zygomatico-orbital, nasoethmoid, frontal sinus, and skull base fractures).

Evaluation

Physical Exam

As with all trauma patients, the initial evaluation should include a detailed systemic examination using the advanced trauma life support protocol, and then a complete head and neck examination is performed. Airway compromise secondary to mucosal trauma and edema or profuse hemorrhage is possible, and the airway must be secured. The patient’s facial region should be thoroughly inspected and palpated for any bony step-offs. Midface mobility is assessed by applying traction to the maxillary central incisors and alveolus with one hand while stabilizing the forehead with the other. All teeth should be accounted for, and if any are fractured or missing, a chest radiograph should be performed to make sure the missing teeth did not enter the airway. A complete cranial nerve examination is critical. In the midface, injury to the maxillary division of the trigeminal nerve is common and facial nerve injury is also possible. Any deficits are documented prior to surgery. Visual acuity and extraocular motion are evaluated and ophthalmologic consultation obtained if these are abnormal or if ocular injury is suspected. Intranasal examination should assess for septal hematoma, septal perforation, and CSF rhinorrhea.

Imaging

All patients with suspected midfacial fractures should undergo a fine-cut (1.5–2 mm) CT scan in axial and coronal planes. High-quality reformatted coronal images are acceptable when cervical immobilization prevents direct coronal imaging. Traditional radiographs such as a Waters view are of historic interest only and should not be used for diagnosis and treatment planning. Many surgeons now routinely obtain CT images immediately postoperatively to confirm anatomic reduction and plating of the fractures. This is extremely useful in panfacial or comminuted fractures.

Labs

Other Tests

When CSF rhinorrhea is suspected, B-2 transferrin testing should be performed on the nasal fluid to confirm the diagnosis.

Treatment Options

The goal of treatment is restoration of preinjury function and facial aesthetics. Treatment within the first 7–14 days of injury allows tissue edema to subside and lessens the likelihood of aesthetic and functional deficits that are challenging to correct after delay.

Medical

Midface fractures that are nondisplaced, stable, and accompanied by normal occlusion can be observed, but the mainstay of treatment for all other midface fractures is surgical.

Surgical

Historically, midfacial fractures were managed with a prolonged course of maxillomandibular fixation (MMF) and/or suspension wires. Continued mobility of the fracture lines with this type of treatment led to a high incidence of residual bony and soft tissue deformity. As such, the standard treatment for displaced, mobile, or comminuted midface fractures is now open reduction and internal fixation.

Operative treatment begins with exposure of all fracture lines using surgical approaches that may include gingivolabial (maxillary face and buttresses), transconjunctival, or subciliary (orbital rim and floor), upper blepharoplasty (zygomaticofrontal and zygomaticosphenoid sutures), and coronal (zygomatic arches, frontal bone, and nasoethmoid area) incisions. The maxilla is next disimpacted and proper occlusion reestablished with MMF. Inquiry should be made as to preinjury malocclusion or orthodontic/orthognathic treatment. Internal fixation with titanium miniplates is performed along the medial and lateral buttresses and along the inferior orbital rims, zygomaticofrontal sutures, zygomatic arches, and glabellar region as indicated. Consideration should be given to primary bone grafting when interfragmentary gaps >5 mm are present. Miniplates (typically 1.5–2.0 mm) are used for medial and lateral buttresses. Microplates (1.0–1.3 mm) are used on the inferior orbital rim, and the zygomaticofrontal suture is treated with 1.3- to 1.5-mm plates. Although rigid or semirigid plating has greatly improved our ability to treat these injuries, the surgeon must be meticulous in achieving correct anatomic reduction and use exacting technique when adapting the plate to the bone to avoid “fixing” the patient in the wrong position. Most patients are released from MMF at the conclusion of surgery, although arch bars may be left in place for guiding elastics (occasionally useful with severe edema).

Complications may include injury to sensory or motor nerves. It is essential to document nerve function prior to surgery. Most patients with sensory change will see improvement over the next 3–6 months. Temporary paresis of the temporal branch of the facial nerve may be seen if prolonged retraction during a coronal approach is required, but with careful exposure and surgical technique, permanent injury is rare.

Malocclusion should be noted postoperatively and surgical technique reviewed. CT may be helpful in determining the cause of the malocclusion, and if fractures malalignment is noted, reexploration should be considered with repeat reduction and plating prior to fracture union. Guiding elastics may assist in very minor dental malocclusions but cannot correct grossly malaligned fractures.

Lower eyelid malposition is largely avoided with gentle tissue handling and meticulous surgical technique. Ectropion is more common after trans-cutaneous than transconjunctival approaches, though entropion may be observed after transconjunctival approaches (rare). Massage is useful in the postoperative period if lower eyelid retraction is noted. More severe malpositions may require surgical intervention.

Other incisional problems include dehiscence, local infection, hypertrophy, and alopecia and are treated as indicated.

Outcome and Follow-Up

The patient is admitted after surgery and monitored for airway status, visual change, hemorrhage, and pain control. Intermittent ice application is useful in decreasing edema, as is elevation of the head of the bed. The patient is instructed in oral hygiene consisting of frequent mouth rinses and gentle brushing, especially after meals. Diet should consist of soft foods for approximately 6 weeks and then a normal diet may be resumed. Cutaneous sutures are removed 5–7 days after surgery. Intraoral incisions are closed with resorbable sutures and do not require removal.

The patient should be followed closely for the first several weeks, with particular attention given to occlusal status and eyelid position. Long-term follow-up should also be scheduled, but this is sometimes challenging in this patient population.

ICD-9 Codes

Doerr TD, Mathog RH. Le Fort fractures (maxillary fractures). In: Papel ID, ed. Facial Plastic and Reconstructive Surgery. 3rd ed. Stuttgart/New York: Thieme; 2009:991–1000

Frodel JL, Marentette LJ. The coronal approach: anatomic and technical considerations and morbidity. Arch Otolaryngol Head Neck Surg 1993;119:201–207

Gruss JS, Mackinnoh SE. Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts. Plast Reconstr Surg 1986;78:9–22

Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing LeFort fracture treatment (organization of treatment for a panfacial fracture). J Craniofac Surg 1990;1:168–178

Klotch DW, Gilliland R. Internal fixation vs. conventional therapy in midface fractures. J Trauma 1987;27:1136

Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an approach to the management of Le Fort fractures. Plast Reconstr Surg 1980;66:54–61

Marchena JM, Johnson JV. Le Fort and palatal fractures. In: Stewart MG, ed. Head Face and Neck Trauma. New York: Thieme; 2005:77–85

Key Features

Clinical

Signs

Note the presence of malocclusion, with or without trismus. Edema and ecchymosis may be seen both intraorally and extraorally. Loose or fractured teeth should be identified, and attempts should be made to account for missing teeth (intruded teeth may occasionally be mistaken for avulsions). Intraoral lacerations are common at fracture sites. Paresthesia over the chin indicates injury to one or both inferior alveolar nerves.

Symptoms

Most patients with mandible fractures present because of pain or malocclusion, both of which tend to interfere with eating. Some notice oral bleeding and facial swelling. They may also complain of loose teeth.

Differential Diagnosis

If the patient is (or was) unconscious, the nature of the trauma may be difficult to determine. Swelling and muscle injury may masquerade as a fracture. A patient with a serious dental infection, with or without a history of trauma, may have clinical findings of pain, trismus, and malocclusion, which may make it difficult to determine whether a fracture is present.

Evaluation

Physical Exam

Examine for swelling, tenderness, and ecchymosis. Warmth and fever would be signs of infection, usually seen when presentation is delayed. Examination of the mandible itself might reveal mobility of fragments (to bimanual palpation), trismus, and malocclusion. Also look for loose, cracked, avulsed, and/or impacted teeth.

Imaging

Best results will be obtained if plain films, orthopantomogram (Panorex), and CT scans are obtained.

Labs

Pathology

Pathology studies are generally not applicable, unless there is a concern about a pathologic fracture in a patient with another underlying disease, or in a case of delayed management or complications of prior management, where there may be concern for posttraumatic mandibular osteitis or osteomyelitis.

Treatment Options

Medical

Nondisplaced, nonmobile fractures without malocclusion can be managed nonsurgically. The patient is maintained on a mechanical soft diet. The patient should be seen after 1–2 weeks to ensure patient compliance and that the fracture is healing uneventfully. Any change in occlusion status will require additional treatment. The occlusion class is based on the relationship of the retrobuccal cusp of the upper first molar to the buccal groove of the lower first molar:

• Class I occlusion (normal): The mesiobuccal cusp of the maxillary first molar occludes exactly with the mandibular first molar buccal groove.

• Class II occlusion: The mesiobuccal cusp is mesial or anterior to the mandibular first molar buccal groove.

• Class III occlusion: The mesiobuccal cusp is distal to the buccal groove.

Subcondylar fractures with minimal displacement and without malocclusion may be managed with physiotherapy and exercises.

For both of the above situations, mouth-opening exercises are important to prevent limitations in mouth opening.

Relevant Pharmacology

Antibiotic prophylaxis is recommended from the time of presentation until oral wounds have sealed after the repair. (Precise duration of antibiotic treatment after fracture repair is controversial.) An antibiotic that covers common oral flora is recommended.

Surgical

There are three basic surgical approaches to mandible fractures: (1) placement of oral appliances and application of rigid MMF (also called closed reduction, rigid fixation); (2) placement of oral appliances and the use of training elastics (nonrigid MMF; also called nonrigid closed reduction); and (3) open reduction of the fractures, generally used with rigid fixation of the fragments (also called open reduction and internal fixation or ORIF).

ORIF may be performed via either intraoral or extraoral approach. “Load-sharing” repairs are generally used when the bone being repaired is solid enough to provide a buttress, so that fixation can be placed in a biomechanically advantaged fashion that takes advantage of the naturally occurring forces of muscle function and mastication. This can be accomplished using the “Champy” technique, with miniplates placed along the “ideal line of osteosynthesis,” using monocortical screws to avoid injury to tooth roots and the inferior alveolar nerve. Two plates or two lag screws are generally used in the symphyseal and parasymphyseal regions, a single plate is commonly used along the mandibular body, and one or two plates (the choice is controversial) are used for angle fractures. Compression plates can be used as well along the symphysis and body (not at the angle), but this requires bicortical screws placed along the inferior border, so tension band plates or arch bars must be applied to avoid distraction of the alveolar portion of the fracture.

“Load-bearing” repairs are used when there is inadequate bone to form a buttress and share in the load. This requires the placement of longer, stronger reconstruction plates fixed with bicortical screws along the inferior border of the mandible. At least three and preferably four screws should be placed on either side of the fracture. Load-bearing reconstruction plate repairs are indicated to span areas of mandibular deficiency, such as defects, areas of comminution, atrophic mandibles (edentulous patients), and areas involved with infection (or previous nonunion). The reconstruction plate is also a fallback technique for any mandible fracture, particularly in the angle region after loss of an impacted third molar. Fractures of the condylar neck should be opened if there is significant foreshortening of the ramus of the mandible or persistent malocclusion. The endoscopic approach allows a mostly transoral repair of selected subcondylar fractures. Open reduction of condylar head fractures remains quite controversial.

Complications

A rigidly fixed malreduction should be reoperated, unless there are extenuating circumstances because MMF cannot repair this. Wound infections should be drained and managed expectantly. Loose hardware must be removed. Failure of fixation requires reoperation, and if infection has developed, a stronger, load-bearing repair will be necessary. Nerve injuries (motor and sensory) should be documented.

Outcome and Follow-Up

Patients should be followed closely for the first 6 weeks. At this point, most fractures are stable enough to allow removal of the arch bars. After this, patients should be followed until normal function is ensured.

ICD-9 Codes

Further Reading

Costello BJ, Papadopoulos G, Ruiz R. Pediatric craniomaxillofacial trauma. Clin Pediatr Emerg Med 2005;6:32–40

Davidson J, Nickerson, Nickerson B. Zygomatic fracture: complications of methods of internal fixation. Plast Reconstr Surg 1990;86:25–32

Johnson JV. Mandibular structures: symphysis, body, and angle. In: Stewart MD. Head, Face, and Neck Trauma: Comprehensive Management. Stuttgart/New York: Thieme; 2005:207–116

Kellman R. Maxillofacial trauma. In: Cummings CM. Otolaryngology Head and Neck Surgery. 4th ed. Philadelphia: Mosby; 2005:602–639

Stanley RB Jr. Use of intraoperative computed tomography during repair of orbitozygomatic fractures. Arch Facial Plast Surg. 1999;1:19–24

Key Features

For patients with facial nerve injuries, realistic expectations must be established at the initial encounter and candidly discussed between the physician and the patient and his or her family. Several points should be emphasized to the patient before the onset of treatment. First, no reanimation technique will restore the face exactly to its preparalyzed condition. The patient should understand that despite the most meticulous surgery some degree of synkinesis and residual weakness may persist. It is also important to stress that the results of these reanimation techniques may be augmented by physical therapy and rehabilitation.

Location of Facial Nerve Injury

Intracranial

Intracranial nerve injuries most commonly occur during resection of acoustic neuroma or other cerebellopontine angle (CPA) tumors. The incidence of facial nerve injury following CPA tumor surgery is reported to be 2.3%. In the event of facial nerve injury during CPA tumor surgery, immediate repair by either direct anastomosis or graft is advisable. If added length is needed, careful rerouting of the tympanic and mastoid segments of the nerve may add enough length for an end-to-end anastomosis.

Intratemporal facial nerve injury is usually encountered in patients following external head trauma with skull base fractures, or iatrogenic injury during or following otologic surgery. Most temporal bone fractures result from motor vehicle accidents and violent encounters. Seven to 10% of these fractures result in facial nerve dysfunction. In temporal bone trauma, facial nerve injury most often occurs in the perigeniculate and labyrinthine sections, with axonal degeneration extending a variable distance in both directions. Management of facial nerve injury following temporal bone trauma is controversial. Most patients who present with complete paralysis at the time of injury have a poorer prognosis than those with incomplete or delayed paralysis.

Extratemporal

Extratemporal injury to the facial nerve may occur during parotid surgery, temporomandibular joint procedures, or facelift procedures, or following traumatic lacerations of the face. The incidence of facial nerve paralysis after uncomplicated parotid procedures is reported at 20% for temporary palsy and 10% for permanent paresis of either the temporal or mandibular branches. Patients at higher risk for facial nerve injury during parotid surgery include children and those undergoing a total parotidectomy. Inadvertent transection of the nerve that is recognized during parotid surgery should be repaired as soon as possible.

Reanimation Options

The order of preference for restoration of function following total unilateral facial paralysis is as follows:

1. Spontaneous facial nerve regeneration (observation)

2. Facial nerve neurorrhaphy (facial nerve anastomosis)

3. Interpositional graft

4. Nerve crossovers (anastomosis to other motor nerves)

5. Muscle transfer

6. Eyelid procedures and prosthetics

Facial Nerve Neurorrhaphy

The surgical suturing technique for nerve repair requires magnification, either with loupes or a surgical microscope. The nerve endings should be freshened with a new scalpel blade. At this point, axoplasm may be seen oozing from the proximal stump. Number 8-0 to 10-0 nylon sutures with a 75- or 100-micron needle should be used.

This technique uses the contralateral normal facial nerve to innervate certain facial muscles on the paralyzed side. This technique should be considered an alternative to hypoglossal or accessory nerve grafting. It should not be performed as long as spontaneous regeneration is still possible or in cases in which direct or cable grafting of the facial nerve is possible.

Muscle Transfer Techniques

Muscle transfer techniques are used when neural techniques are unsuitable. Patients with long-standing facial paralysis (>3 years) are unlikely to benefit from any of the previously discussed reanimation procedures. Severe fibrosis occurs in the distal neuromuscular unit along with atrophy of the facial musculature making reinnervation unlikely.

Regional Muscle Transfer

Muscle transfer techniques entail transplanting a new neuromuscular unit into a region of the paralyzed face. This may be done in conjunction with a nerve graft or a crossover implanted in the transferred muscle. The two basic techniques to accomplish this are regional muscle transposition and a free-muscle transfer.

Regional muscle transfer is usually used to reanimate the lower third of the paralyzed face. The new neuromuscular unit is composed of the transposed muscle with its original nerve supply. Muscles available for these procedures include the masseter, temporalis, and digastric. It should be remembered that in all muscle transfer procedures, overcorrection is desired.

Free-Muscle Transfer