Facial Fractures –Mandible and Frontal Bones

Dale Reynolds, MD

UT Houston

Plastic & Reconstructive Surgery

Facial FracturesPhases

Emergency Treatment Airway

Edema Teeth Blood FB Mandible fracture tongue to pharynx Stridor, hoarseness, retraction, drooling ETT Tracheostomy

Long term IMF Cricothyroidotomy

Facial Fractures Hemorrhage

Anterior cranial fossa Midface Lacerations Nasal

Nasal, zygomatic, orbital, frontal, NOE, maxillary Reduction (IMF) Anterior/ posterior packing x 24-48 hrs Compression dressing Embolization Bilateral external carotid/ superficial temporal

ligation Blood factor replacement

Facial Fractures Aspiration

Low threshold for ETT Other

Eye Brain Spine

Facial Fractures Early injury care

History PE

Nerves, vision, intraoral, nasopharyngeal, dentition Radiographs Lacerations IMF Impressions

Facial Fractures Classification

Anatomy Closed v. open Le Fort

Radiography CT v. x-rays

Occlusion/ dentition

Facial FracturesMandible

Anatomy

Facial FracturesMandible

Anatomy

Facial FracturesMandible

Anatomy

Facial FracturesMandible

Anatomy

Facial Fractures Mandible

Most common facial fracture after nasal 10-25% of all facial fractures Body> angle> condyle> parasymphysis> other M: F = 2: 1 58% multiple (93% ,

3 fx) Preinjury relationships Stable bony union Facial proportions Avoid complications

Facial FracturesMandible

History Previous trauma Previous baseline Pre-injury photo

Facial FracturesMandible

PE Crepitance Symmetry Tenderness Oral/ dental – missing

teeth Step offs

Facial FracturesMandible

Radiography Panorex CT Plain films

PA, Towne’s, R and L lateral oblique views (mandibular series)

MandibleTreatment

Restore form and function

Occlusion, TMJ function, cosmesis

ORIF Exact anatomic reduction Allows early resumption of mandibular function

Mandible

MandibleTreatment

Closed Dependent on

splinting to maxilla to restore centric occlusion (maximal intercusspation)

If inadequate number of teeth,Gunning splint may be needed for IMF

Mandible Treatment

Open Accurate reduction

Within 2 weeks If maxilla cannot be used then mandible first or splints

Avoid prolonged IMF Traumitizes gingiva Impairs oral hygiene periodontal disease Uncomfortable Forces can alter tooth position and periodontal

attachments Great aspiration risk Contraindication in COPD, seizure d/o, impaired MS Articular surfaces under compression cause pressure

necrosis

MandibleORIF

Lag screw – Anterior

MandibleORIF

Reconstruction plate – Comminuted body

MandibleORIF

Two plate/ tension band – Angle

MandibleORIF

Dynamic compression plate - Condyle

MandibleTreatment

Contraindications to open Not required Not candidate

Rarely needed in children Simple Heal quickly Occlusion less established

Facial Fractures

MandibleTreatment by type

Simple CR + IMF x 8 weeks if reliable (unreliable avoid

IMF and open)

MandibleTreatment by type

Complex Multiple or segmental

Often interosseous wires/ reduction clamps/ temporary mini-plates help

Inferior “butterfly” segment

Difficult to reduce

Mandible Treatment by type

Complex Bilateral fracture each hemi-mandible

Simultaneous reduction may be required to avoid magnification of discrepancy

Arch bars and IMF may worsen Anterior fracture with one or both condyles

Consider reducing one or both condyles first if difficult to control flaring the inferior border

Unilateral segmental fracture in one hemi-mandible Close fractures – two plates Separated fractures – long spanning plate

MandibleTreatment by type

Complex Comminuted

High energy – GSW, SGW, MVC Easy to devitalize small fragments Difficult to accurately reduce Large reconstruction plate may be required Temporary external fixator may be used if condition

of patient or soft tissue requires Bone graft for extensive loss Pre-treatment infection: Debride small fragments Post-treatment infection: FB (bone or screw)

MandibleTreatment by type

Complex Edentulous

Atrophied and osteopenic poorer healing Early atherosclerosis (15 years) of inferior alveolar

artery 20% non-union Simple and undisplaced pureed diet and obs Use dentures or splints

Fracture with bony defect Rigid fixation with spanning reconstruction plate Bone graft/ flap within 5 years Soft tissue repair and IMF or ex fix until ready

MandibleTreatment

Infection More common if delayed care Abx, debridement Fracture line may resorb and form gaps –

larger plates Extreme cases may require external fixator with

secondary ORIF +/- graft

MandibleTreatment

Children Most need CR + immobilization (single arch bar

or lingual splint) x 2 weeks Conical shape makes arch bars less useful Indications for ORIF

Unstable fractures Not amenable to CR Bilateral fractures with gross instability

Use unicortical plates Remove 6-8 weeks later

Mandible Treatment

Children Condyle is growth center of mandible Trauma can cause hemarthrosis ankylosis Intracapsular fractures that do not alter the centric occlusion

should not be immobilized to avoid ankylosis which can occur >12 months later and requires aggressive treatment

Unilateral condylar fractures with altered centric occlusion are treated with arch bars or lingual splints and elastics

Displaced bilateral condylar fractures with posterior vertical collapse and anterior open bite deformity require CR + IMF x 4 weeks

Mandible Treatment

By Location Alveolar Process (1%)

Remove if devitalized o/w IMF or splint Symphysis (5.8%)

Often associated with condylar fractures Significant forces cause lateral flaring of posterior

segments (often worse with IMF) Parasymphysis (11.6%)

Often associated with contralateral fractures Mental nerve Burr/ osteotome may help lessen anterior curvature

MandibleTreatment

By Location Body (31.9%)

May require external approach Bi-cortical plates placed beneath mental canal

Angle (27.5%) May require external approach Often associated with contralateral Highest complication rate due to third molar teeth

and displacing forces

MandibleTreatment

By Location Ramus (2.5%)

Usually require extraoral approach Often stable due to splinting effect of masseter-

medial pterygoid muscle sling unless displacement causes vertical shortening (telescoping)

Coronoid process (1.8%) Soft diet usually enough Severe pain may require brief IMF

MandibleTreatment

By Location Condyle (23.8%)

Proximal segment can undergo AVN Intra-articular fractures: Very difficult ORIF, OA is

common outcome, usually brief IMF for malocclusion o/w early mobilization +/- elastics

Condylar neck: Anteromedial displacement of proximal segment by lateral pterygoid, usually treated with IMF x 6 weeks, ORIF if joint capsule is thought to be involved

MandibleTreatment

By Location Condyle

ORIF Displaced in to middle cranial fossa FB within joint Lateral extra-capsular displacement of condyle Displacement blocking opening or closing Posterior vertical shortening of mandible with

open bite after 2 week IMF trial Relative

Bilateral associated with unstable midface fractures

Bilateral edentulous without splint

Mandible Postoperative care

+/- Abx, airway control with IMF (wire cutters), HOB (secretions) + ice pack for edema

Diet CLD blenderized, 48o IVF, 15 lb wt loss

Splints/ IMF Oral hygiene (peridex, H2O2, brush), remove wax

Oral washouts Release IMF q 3-5 days if needed

Mandible Centric occlusion

Remove IMF to assess ORIF

Therapeutic rehabilitation Regain strength and mobility, PT if severe

(prolonged IMF or condyle fracture) Dental treatment (missing teeth)

Complications Malocclusion, malunion, non-union, hardware

exposure, infection, non-compliance

Mandible Teeth in

fracture line

Facial FracturesFrontal bone anatomy – 7 bones

Facial FracturesFrontal bone anatomy

Facial FracturesFrontal sinus anatomy

Middle meatus

Facial FracturesFrontal Sinus

MVC - ¾ Assaults – ¼ 2-3 x force to fracture

lower frontal sinus Other injuries associated

(1/4 die in 14d) Rare in children

Facial FracturesFrontal Sinus Fracture

Signs Rhinorrhea Step-off Supraorbital anesthesia Subconjunctival hematoma Subcutaneous crepitance

Facial FracturesFrontal Sinus Fracture

Diagnosis Plain films CT

Facial FracturesFrontal sinus fractures

Anterior Table (Thick) Displaced ORIF Blockage of nasofrontal

duct (methylene blue) Remove mucosa Bone graft nasofrontal

ducts, fill space Elevate and fixate bone

Posterior Table (Thin) Comminuted Cranialize Displaced greater than one wall thickness

ORIF

Facial Fractures Frontal Sinus Fracture

Complications (Posterior > anterior) Acute

Epistaxis CSF leak Meningitis Intracranial injury Hematoma

Subacute Mucocele Sinusitis

Chronic Osteomyelitis Abscesses

END