Mid-facial fractures and their management

DDS5

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Layout• Introduction• Causes• Midfacial bones• Facial Buttresses• Nerve supply of Midfacial region• Important blood vessels• History and examination• Types of Midfacial fractures• LeFort I,II,III and management• Zygomatic fractures and management• Orbital blow out and management• Nasal fractures and management

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Abbreviations

• CSF – Cerebrospinal fluid• NOE – Nasoorbital Ethmoid• CT - Computerized tomography

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Introduction

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Introduction• Middle third of the facial skeleton is an area bounded– Superiorly by a line drawn across the skull from the

zygomaticofrontal suture of one side, across the frontonasal and frontomaxillary sutures to the zygomaticofrontal suture on the opposite side

– Inferiorly by the occlusal plane of the upper teeth, or, if the patient is edentulous, by the upper alveolar ridge.

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• Posteriorly, the region is demarcated by the sphenoethmoidal junction, but includes the free margin of the pterygoid laminae of the sphenoid bone inferiorly.

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Causes of facial fractures

• Motor vehicle accidents• Assault/Domestic violence• Falls• Sports- related incidents• Pathological• Work- related incidents• Warfare

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Midfacial bones

Sphenoid (1)

Ethmoid (1)

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• The frontal bone, the sphenoid body and greater and lesser wings are not usually fractured.

• In fact, they are protected to a considerable extent by the cushioning effect achieved as the fracturing force will crush the relatively weaker bones comprising the middle third of the facial skeleton.

WHICH LEADS US TO TALK OF BUTTRESSES

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Facial buttresses

• The central midface has many fragile bones that could easily be crushed when subjected to strong forces.

• They are surrounded by thicker bones of facial buttress system lending it some strength and stability.

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Midface buttresses are composed of:

• Frontal bone• Maxillary bones• Zygomatic bones• Sphenoid bone

AND THEIR ATTACHMENTS TO ONE ANOTHER

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• 2 Components of Buttress system:–Vertical buttresses–Horizontal buttresses

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• Vertical buttresses: 1. Nasomaxillary2. Zygomaticomaxillary3. Pterygomaxillary4. Vertical mandible

• Resist occlusal load.

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• Horizontal buttresses:1. Frontal bar2. Infraorbital rim & nasal bones3. Hard palate & maxillary alveolus

• Interconnect and provide support for the vertical buttresses.

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Nerve Supply• The middle third of the face supplied by 2nd division

of the Trigeminal nerve.

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Maxillary nerve branchesMaxillary nerve

Infraorbital

Posterior superior alveolar

Palatine

Nasopalatine

Zygomatic nerve

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• The infraorbital nerve passes through the infraorbital canal below the floor of the orbit to innervate the soft tissues of the lower lid, the cheek and the lateral aspect of the nose and the upper lip.

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• The palatine branches innervate the mucosa of the palate.

• The nasopalatine nerve passes anteriorly in the mucosa of the nasal septum bilaterally and through the incisive foramen to innervate the mucosa of the anterior palatine area.

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Blood supply

• The facial region is supplied by branches of external carotid artery.

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Branches of external carotid artery

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Important blood vessels

• The third part of the maxillary artery and its terminal branches are closely associated with the fractures of the middle third of the face.

• Occasionally the artery or its greater palatine branch is torn in the region of the pterygomaxillary fissure or pterygopalatine canal resulting in severe life threatening hemorrhage into the nasopharynx.

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History taking

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Take AMPLE history

• A - Allergies• M - Medications (Anticoagulants, insulin and

cardiovascular medications especially)• P – Previous medical/surgical history• L – Last meal (time)• E – Events/Environment surrounding the

injury (Exactly what happened)

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History taking

• How did the accident occur?• When did the accident occur? Time since

injury.• What are the specifics of the injury, including

the type of object contacted, the direction from which contact was made?

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• Did loss of consciousness, vomiting, bleeding occur?

• What symptoms are now being experienced by the patient, including pain, altered sensation, visual changes, and change in bite?

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Physical examination

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Primary Survey: ABCDE

• Airway maintenance with cervical spine control

• Breathing and adequate ventilation• Circulation with control of haemorrhage• Degree of consciousness• Exposure of the patient via complete

undressing to avoid overlooking injuries camouflaged by clothing

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Physical examination

• Evaluate soft tissues for wounds.• Palpate bony landmarks beginning with the:– Supraorbital and lateral orbital rims– Infraorbital rims–Malar eminences– Zygomatic arches–Nasal bones.

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Physical examination

• Any steps or irregularities along the bony margin are suggestive of a fracture.

• Numbness over the area of distribution of the trigeminal nerve is usually noted with fractures of the facial skeleton.

• Inspect oral cavity for lost teeth, lacerations, occlusal alterations, step deformities.

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Types of Midfacial fractures

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Types of Midfacial fractures• LeFort I, II, III• Zygomatic complex fractures• Zygomatic arch fractures• Orbital blow out• Nasal fractures• NOE (Naso Orbital Ethmoid) fractures

MAY BE ISOLATED OR OCCUR IN COMBINATION

Rene LeFort 1901

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Classifications

• Helps for communication purpose and to plan treatment.

• Rene LeFort:– LeFort I, LeFort II and LeFort III.

• However there were other classifications also..

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• Erich’s (1942)- direction of the fracture line.

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• Another classification based on relationship of the fracture line to the zygomatic bone - –Below the zygomatic bone - Subzygomatic

fractures–Above or including the zygomatic bone -

Suprazygomatic fracture

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• Another classification depending on the level of a fracture line– Low level fracture–Mid level fracture–High level fracture

• The most universally used classification is LeFort’s classification.

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LeFort I fracture• Results from a horizontal force delivered above the

level of the teeth (to the maxilla).• The fracture courses from the lateral border of the

pyriform aperture above the canine eminence lateral antral wall behind the maxillary tuberosity across the lower third of the pterygoid plate.

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• Almost always involves the pterygoid process of the sphenoid bone.

• The fracture separates the maxilla from the pterygoid plates and nasal and zygomatic structures.

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• This type of trauma may separate the maxilla in one piece from other structures, split the palate, or fragment the maxilla.

• May involve the maxillary sinuses.• The resultant “floating” component is the

lower part of the maxilla and its teeth.

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• The nasal septum may be fractured also.• Le Fort I fracture may be unilateral or bilateral.• It may occur on its own or in combination with

other midfacial fractures.

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Clinical findings of LeFort I:

– Extra-orally• Swelling of the upper lip.• Soft tissue laceration.• Open mouth to accommodate the

displaced dentoalveolar portion.• Epistaxis.

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Intra-orally•Malocclusion.•Mobility of tooth bearing portion.• Dull sound on percussion.• Ecchymosis of the maxillary buccal sulcus.

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LeFort II fracture

• Results from a force delivered at a level of the nasal bones in superior direction.

• The fracture line occurs along the nasofrontal suture lacrimal bone across the infra- orbital rim in the region of the zygomatico-maxillary suture above the canine eminence inferiorly and distally along the lateral antral wall, but at a higher level than Le Fort type I across the pterygoid plate at its middle.

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• Separation of the maxilla and the attached nasal complex from the orbital and zygomatic structures.

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Clinical Findings of LeFort II

– Extraorally• Ballooning of the face• Lengthenening of the face• Circumorbital ecchymosis• Subconjunctival Haemorrhage• Epistaxis• Diplopia

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• Enophthalmos• CSF rhinorrhoea• Step deformity in the lower border of the

orbit• Intact zygomatic bone and arch

– Intraorally•Malocclusion• Gagging of the posterior teeth and anterior

open bite•Mobility of the maxilla• Ecchymosis of the sulcus

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LeFort III• Results when horizontal forces are applied at

a level superior enough (at orbital level) to separate the NOE) complex, the zygomas, and the maxilla from the cranial base (Craniofacial separation/dysjunction).

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• The fracture line courses through the zygomaticotemporal and zygomaticofrontal sutures lateral orbital wall inferior orbital fissure medially to the naso-frontal suture fractures the pterygoid plate at its base.

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• Most severe of the LeFort fractures.• Often associated with extensive soft tissue

injury.• Large force needed to cause this type of

fracture.• The resultant “floating” component is almost

the entire face.

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Clinical Findings of LeFort III

– Extraorally• Severe edema of the face “ballooning”• Lengthening of the face• Flattening of the cheek• Circumorbital ecchymosis• Subconjunctival Haemorrhage• Epistaxis• Enophthalmos• CSF rhinorrhoea

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– Intraorally• Gagging of the posterior teeth and

anterior open bite• Ecchymosis and Haemorrhage of the

buccal sulcus•Mobility of the maxilla•Mandibular interference

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• Obstructed airway – soft palate rest on posterior dorsum of tongue

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• Bilateral circumorbital ecchymoses – panda facies, or racoon eyes

• Bilateral subconjunctival ecchymosis

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• Diplopia due to:– Edema and hematoma–Restrictive motility disorder (mechanical)–Cranial nerve injury (neurogenic)

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Radiographs needed

• Occipito-mental view (Water’s View)• CT scan–Axial scan–Coronal scan– Sagittal–3 dimensional

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Treatment for LeFort fractures

• First aid and Preliminary treatment• Definitive treatment–Reduction– Immobilization

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• The principles of definitive treatment of LeFort fractures consist of reduction and fixation of the fractured bones to one another and to the skull– achieved by either conservative or

operative methods.

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• The sooner the treatment is carried out, the better the prognosis.

• Restoration of the occlusion is a must.

• The bony framework and buttresses of the midface must also be repositioned or restored and fixed.

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Methods of reduction for LeFort fractures

• Manual reduction– Simple manipulation by hand– Dental compound on impression tray– Gauze or rubber catheters– Special instruments

• Reduction by traction– Conservative treatment– Supervised spontaneous healing– Open reduction

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Manual reduction

–Carried out in all fresh fractures where the fragments are not impacted. –As a rule, arch bars are first applied to the

teeth. – The lower jaw serves as a template, so that

the occlusion can be checked.

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• Simple manipulation by hand is possible in fresh fractures, maxilla is held between the index finger and thumb and brought into normal occlusion.

• Another method is to fix two double wires encircling the first and second maxillary molars and twisting them individually on either sides.

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• Both the twisted wire ends are held by means of wire holders or hemostats and simultaneously downward movement of the maxilla will help to achieve the normal occlusion.

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• Dental compound loaded into impression tray was suggested by Dingman and Harding in 1951, for mobilizing the fractured fragment of maxilla.

• This can be used, where some amount of fibrosis has set in because of delayed treatment.

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• When the impression compound sets, then the firm grip can be taken on the maxillary arch and the handle of the tray is used for rocking the maxilla.

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• Propescu and Burlibasa in 1966, have described reduction by rubber dam sheets or by means of long ribbon/strip gauze or rubber catheters.

• Whenever the maxilla is impacted and simple manual mobilization is not possible, then this method can be tried, if sophisticated instruments are not available.

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• The rubber catheter’s end is passed from the nostril into the oropharynx and it is grasped with the help of hemostat and brought out of the oral cavity.

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• So, you have one end coming out from nostril and other end through the oral cavity, same procedure is repeated on the other side through the nostril.

• After grasping all four ends of the catheter and stabilizing the head, maxilla can be rocked into the normal occlusion.

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• Reduction by using special instruments—Specially constructed disimpaction forceps can be used to take firm grasp of the maxilla and reduce it into the position.

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• Rowe’s maxillary disimpaction forceps:–Available as right and left forceps. –Always used in pairs. – These are two pronged (divided) forceps,

where one prong fits into the nasal floor and another one on the hard palate.

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• Rowe’s Disimpaction Forceps

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• Anterior traction in the case of a split palate, may be facilitated by the use of the special forceps devised by Hayton Williams.

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• Applied to the buccal aspect of the alveolar process and medial compression exerted until the two halves of the upper jaw are approximated.

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• A screw top is adjusted to prevent crushing of the bone.

• Can be combined with Rowe’s maxillary disimpaction forceps.

• The stabilized maxillary block may then be disimpacted and drawn forward.

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Reduction by traction

–Repositioning the fractures that are already in a state of partial fusion OR when attempted manual reduction is met with failure, then reduction by elastic traction is tried to interdigitate the fractured fragments.

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• Mainly used in delayed cases, where the fracture is 10 to 14 days old and no longer sufficiently mobile.– Intraoral elastic traction.– Extraoral elastic traction with appropriate

extension bars and side bars.

• Intraoral intermaxillary elastic traction may be used in an appropriate direction to restore normal occlusion then replaced by IMF.

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• Conservative Treatment–Reduction and fixation of the fractured

midface is indicated in cases, where surgery is not possible due to poor general condition of the patient or where there is extensive comminution with tissue loss, making internal skeletal fixation impossible. –Also used as a supplementary measure with

the surgical treatment of midfacial fracture.

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• Supervised Spontaneous Healing–Where mobility at the fractured maxilla is

only slight, and occlusion is not disturbed. –Progress of healing is merely supervised. – The patient should avoid chewing during

the first 2 to 3 weeks and should take a liquid/semisolid diet.

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Monomaxillary fixation: – This method used when tooth bearing

section of the maxilla is not fractured and therefore can serve as fixation point. – The arch bar or palatal acrylic plates can be

used. – This can be used for unilateral fractures of

maxilla or higher fractures without occlusal discrepancies. –Maintained for 6 weeks.

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Intermaxillary fixation (IMF): Maintained for 3 to 4 weeks and at the end

of this period IMF wires and the lower arch bars are removed.

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Internal skeletal wire suspension: Many times in addition to IMF, additional

support is required for immobilization of the jaws.

Craniomaxillary or craniomandibular suspension can be carried out using the stable point above the fracture line.

The selection of the site for suspension wire will be dependent on the level of fracture line.

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The procedure for internal skeletal wire suspension is done through a minor surgery.• Application of arch bars• Reduction of fracture by closed method -

occlusion is checked• Fixation of the midface to the base of the

skull by means of suspension wires.

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• Fixation of the midface by tightening the suspensory wires and intermaxillary fixation.• For edentulous patients, available

prosthesis or Gunning splint is used.

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• LeFort I fracture: Intermaxillary fixation by zygomatic arch suspension, if necessary additional suspension at the piriform aperture.

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• LeFort II: Zygomatic arch suspension or frontal bone suspension. Intraosseous wiring may be done at infraorbital margins.

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• LeFort III: Intraosseous wiring at zygomaticofrontal sutures and bilateral frontomalar suspension is used after the application of arch bars. Intraosseous wiring may be done at the infraorbital margin, if step deformity exists

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Maxillary suspension

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• Open Reduction – Carried out under endotracheal anesthesia with

nasal intubation. – Intraoral vestibular incision is taken from first

molar to first molar region on either side. – Mucoperiosteal flap is reflected to expose the

fracture line. – After identifying the fracture line, in old fractures,

an osteotome is inserted to mobilize the fragment.

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– Disimpaction forceps can be used and the fragment is brought into normal occlusion by manipulation.

– Temporary IMF is carried out and fracture fragments are fixed under direct vision by intraosseous wiring or minibone plates with screws.

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• For extensive high level fractures of the midface bicoronal incision can be taken.

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Various skeletal incisions for exposure of midface skeleton are follows:

1. Supraorbital eyebrow incison2. Subciliary incision3. Median lower eyelid incision4. Infraorbital incision5. Transconjunctival incision6. Zygomatic arch incision7. Transverse nasal incision8. Vertical nasal incision9. Medial orbital incision.

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Circumzygomatic suspension Obwegeser technique

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Zygomatic fractures

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Anatomy of Zygomatic bone

• 4 processes which articulate with:– Maxillary bone– Frontal bone– Temporal bone– Sphenoid bone

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Foramina of the Zygoma

– Foramen allows for passage of zygomaticofacial and zygomaticotemporal nerves of Maxillary branch of Trigeminal nerve that supply sensation to cheek and anterior temple.

– Infraorbital nerve courses the floor of the orbit and exits the infraorbital foramen.

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Zygomatic fracture

• It is unusual for the zygomatic bone itself to be fractured, but in extreme violence, the bone may be comminuted or split across.

• The isolated zygomatic arch fracture may occur without displacement of the zygomatic bone.

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Types of zygomatic fracture

• Zygomatic complex fracture – separate of zygoma from its 4 articulations

• Zygomatic arch fracture – fracture of zygomatic arch in isolation

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Classification of zygomatic fractures (Henderson, 1973)

• Type 1 – Undisplaced fracture• Type 2 – Arch fracture only• Type 3 – Tripod malar fracture (Fronto-Zygomatic

suture intact)• Type 4 – Tripod malar fracture (Fronto-Zygomatic

suture distracted)• Type 5 – Pure blowout fracture• Type 6 – Orbital rim fracture• Type 7 – Comminuted and other fractures

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• In 1985, Rowe changed his 1968 classification and gave more clinical significance by dividing fractures into stable and unstable varieties.

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• Group A: Stable fracture—showing minimal or no displacement and requires no intervention.

• Group B: Unstable fracture—with great displacement and disruption at the frontozygomatic suture and comminuted fractures. Requires reduction as well as fixation.

• Group C: Stable fracture—other types of zygomatic fractures, which require reduction, but no fixation.

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Early clinical features of Zygomatic fracture

– Swelling and bruising over cheek– Depressed cheek prominence– Trismus and restricted lateral mandibular

movements– Ecchymosis at maxillary buttress region– Step deformity along infraorbital margins and

possibly along lateral orbital margin and zygomatic buttress

– Diplopia– Enophthalmos– Epistaxis on side of fracture

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Late clinical features of Zygomatic fracture

– Flat cheek– Enophthalmos– Altered pupillary level– Infraorbital paraesthesia– Diplopia

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• Anaesthesia or paraesthesia of infraorbital and anterior superior alveolar nerve, may take 5-9 months for full recovery.

• Proximal part of nerve recovers first ie. Cheek before upper lip. After 1 year 10% still complain of paraesthesia.

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Radiographs needed

• Water's view:• Submentovertex - "jug handle" • Caldwell view• CT Scan

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Treatment

• In majority of cases, early operation is advisable, provided that there are no ophthalmic or cranial complications.

• Whenever there is a gross periorbital edema and ecchymosis, postponement of the operation for 3 to 5 days can be done, but it should not be prolonged more than two weeks.

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• Stable fractures: Simple elevation will be sufficient, because of high degree of stability due to integrity of temporal fascia and the interdigitation of the fracture lines. No additional fixation is required after reduction.

• Type 1 : No treatment• Type 2 : Unless vertically displaced• Type 3 : and• Type 4 (a): Open reduction may be required and• transosseous wiring is advisable.

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• Unstable fractures: Require open reduction and transosseous wiring or bone plating.

• Type 4 (b)• Types 5, 6, and 7, 8

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• Operative technique: The approach of Gillies, Kilner and Stone (1927) is popular for reduction of fractures of zygoma

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Methods of reduction:

• Closed reduction (Gillies temporal approach) using:

- Bristow’s elevator - Rowe’s zygomatic elevator • Open reduction ( surgical )

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Gillies Temporal Approach

• The temporal fascia is attached to the zygomatic arch and the temporal muscle passes downward medial to the fascia to be attached to the coronoid process.

• Between these two structures a natural anatomical space exists into which an instrument can be inserted and it can be utilized to elevate the displaced zygoma or its arch into position.

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• Technique: The hair is shaved from the temporal region of the scalp.

• The external auditory meatus is plugged with cotton to prevent any fluid or blood getting inside.

• An incision about 2 to 2.5 cm in length is made, inclined forward at an angle of 45 degrees to the zygomatic arch, well in the temporal region.

• Care is taken to avoid injury to the superficial temporal vessels.

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• The temporal fascia is exposed which can be identified as white glistening structure.

• The incision is taken into the fascia and the fibers of temporalis muscles will be seen.

• Long Bristow’s periosteal elevator is passed below the fascia and above the muscle.

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• Once this correct plane is identified and instrument is inserted through it, downward and forward, the tip of the instrument is adjusted medially to the displaced fragment.

• A thick gauze pad is kept on the lateral aspect of the skull to protect it from the pressure of elevator while reduction is going on.

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• The operator has to grasp the handle of the elevator with both hands and assistant has to stabilize the head of the patient.

• (During elevation procedure care should be taken that pressure is not exerted on the lateral surface of the skull to end up with depressed fracture of the skull).

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• The tip of the elevator is manipulated upward, forward and outward.

• The snap sound will be heard as soon as reduction procedure is complete.

• Wound is closed in layers after withdrawing the elevator.

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• Care is taken that after surgery at least for 5 to 7 days, no pressure is exerted on the area till the bone consolidates.

• Patient is instructed to sleep in supine position or not to sleep on the operated side.

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Intraoral procedure

• Keen’s approach (1909): Introral buccal vestibular incision is taken in first and second molar region behind the zygomatic buttress.

• A pointed curved elevator (Monks’ pattern) is passed supraperiosteally up beneath the zygomatic bone.

• The depressed bone is then elevated with an upward, forward and outward movement.

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In (A)Intraoral reduction of zygomatic bone fracture by Keen’s Approach

(B)Stabilization of reduced fracture by using balloon catheter

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• Alternate methods like intranasal elevation via intra nasal antrostomy or oroantral elevations were suggested.

• Direct extraoral elevation can be done by inserting a sharp curved hook directly through the skin below and above the prominence of the zygomatic bone.

• Manipulation of the hook reduces the fracture

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• Gross separation of the zygomaticofrontal suture (Type 4(a), 4(b), 5(a),(b) and (c): Extraoral incision is taken in the wrinkles, one centimeter above the outer canthus or in the line of the outer aspect of the eyebrow.

• Holes are drilled approximately 0.5 cm away from the fracture ends of the frontal and zygomatic bones.

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• A periosteal elevator is placed on the medial aspect to protect the eye.

• The 26 gauge double wire is passed and twisted after passing through both the holes and approximation of the fragments.

• Instead of wire, 2 hole miniplates can also be used for direct fixation.

• Wound is closed in layers

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• Comminution of the orbital floor (Type 6(a)):–Use of antral pack or balloon catheter can

be done which is previously described.• Comminution and displacement of the orbital

rim (Type 7): –Direct figure of eight intraosseous wiring

can be done through extraoral infraorbital incision or semilunar orbital bone plate can be fixed

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• Associated coronoid fractures:–No separate treatment is indicated. –But if coronoid process is completely

detached and causing limitation of the oral opening after reduction then it should be excised through intraoral incision.

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Other indirect approaches

• Towel Clip : applied directly

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Open reduction techniques:• Lateral brow incision • Subcilliary (blepheroplasty) incision • Infraorbital crease incision • Bicoronal / Hemicoronal flap

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• Trans osseous wiring:– Wiring - 24 - 30 gauge stainless steel wire

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• Mini bone plates

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Malunion of the Zygomaticomaxillary Complex

It will show following signs and symptoms:1. Cosmetic2. Neurological3. Antral4. Masticatory5. Ophthalmic

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• Cosmetic: – Loss of contour or prominence of cheek will

be seen. –Correction may be done either by surgical

refracturing or camouflaging the deformity by means of onlay bone grafting or alloplastic material like hydroxylapatite blocks.

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• Neurological: – The paresthesia, dysesthesia or anesthesia

may be present. –Observation for recovery of infra orbital

nerve should be done for 6 to 12 months, otherwise surgical exploration of the nerve can be done.

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• Antral: –Persistent sinusitis may be due to the

presence of loose necrotic bone pieces or a foreign body, which should be removed via Caldwell Luc operation.

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• Masticatory: – Depressed zygomatic arch fracture impinges on

the coronoid process bringing about limitation of the mandibular movements and opening.

– In extensive fracture, via coronal incision the arch should be exposed, refractured and stabilized by direct fixation method.

– Osteotomy and bone grafting can be done if required.

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• Ophthalmic: –Change of the ocular level, diplopia,

enophthalmos, occulorotatory restriction are the residual deformities which are difficult to correct secondarily.– Exploration and surgical correction can be

attempted.

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Fracture of the Floor of the Orbit

(Blow-out Fracture)

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Fracture of the Floor of the Orbit(Blow-out Fracture)

• True blowout fracture occurs as a result of direct trauma to the orbit with an object larger than the globe size (cricket ball injury).

• Here primarily there is an increase in hydraulic pressure within the orbit resulting from compression of the orbital contents.

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• In addition, forces acting on the bone play a part.

• The fractured orbital floor gives way into the maxillary sinus.

• At the same time, orbital fatty tissue and sometimes muscles, (inferior rectus and inferior oblique) prolapse into the sinus like a hernia.

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Clinical symptoms:

• Circumorbital edema• Circumorbital ecchymosis• Ophthalmoplagia• Diplopia (upper & lateral gaze)• Enophthalmos

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Diagnosis can be confirmed by:

– Forced duction test–Hanging drop appearance in PA view,

Water’s position radiograph or by CT scan

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Figure

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• Forced duction test: Here a small tissue holding forceps is used to grasp the tendon of the inferior rectus muscle through the conjunctiva of the inferior fornix and the patient is asked for the entire range of motion.

• An inability to rotate the globe superiorly signifies entrapment of the muscles in the orbital floor

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Treatment

– Surgical exploration of orbital floor and reconstruction of the orbital floor by silastic sheet or bone graft, whenever necessary. –Otherwise balloon support or ribbon gauze

packing can be used in the maxillary sinus.

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Antral support

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Orbital floor reconstruction

• Autograft --rib, iliac crest, calvaria, as well as ear or nose cartilage

• Allograft --lyophilized dura, rib, iliac crest, cartilage

• Alloplast --Teflon, Silastic, Ti-Mesh, and Gelfilm have been described

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Nasal bone fracture

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Fractures of Nasal bone

• High Incidence because of prominence of nose.

• Usually due to direct injury; can occur as an isolated fracture or it may be combined with other facial fractures.

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• Leads to cosmetic deformity and functional disturbance.

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• Nasal fractures in children should be generally treated conservatively with closed reduction, because of the growth potential.

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• Often overlooked in multiple facial injuries. • Nasal symmetry, proper appearance and

adequate airway through the nose is important.

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• Anterior injuries: Direct, violent, and/or anterior force may result in smash fractures of the nasal bones, the frontal process of the maxilla, the lacrimal bones and the septum.

• Comminuted fragments may be driven laterally into the orbit or upward into the ethmoid region.

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• Splayed nasal fractures may be associated with damage to the nasolacrimal ducts, the perpendicular plate of the ethmoid, the ethmoid sinuses, the cribriform plate and the orbital parts of the frontal bone.

• Widening of the intercanthal distance is known as traumatic telecanthus.

• Buckling of the nasal septum may be seen.

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• Lateral injuries: Force applied from the side, may involve only one nasal bone with medial displacement, but most commonly in adults, a violent blow from the side results in fractures of both nasal bones and fracture of nasal septum with lateral shifting of the entire bony framework.

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• This is known as ‘open book’ fracture - Nasal septum collapsed and nasal bones splayed out.

• In most severe injuries, the septum may be fractured or displaced from the maxillary crest, from the vomerine groove or from its attachment at the anterior nasal spine of the maxilla, with displacement into the adjacent airway.

• Fractures of the septum occur in the vertical plane. • There may be telescoping or overlapping seen.

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Diagnosis

• History• Careful clinical examination• Radiographs

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History:

• History of previous nasal deformity, trauma, surgery or breathing difficulty should be asked for.

• Nature and direction of the trauma also should be asked.

• Patient’s chief complaints are usually nasal bleeding, pain, swelling and difficulty in breathing through the nose.

• Sense of smell also may be lost or diminished.

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Clinical features:

–Depressed bridge of the nose– Flattening or deviation of the nasal bone–Hematoma– Subconjunctival haemorrhage–Nasal obstruction may be caused by:

edema, blood clots, swelling of nasal mucosa, dislocated bone, cartilage

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– Subcutaneous emphysema may be present because of patient’s repeated attempts to blow nose–Circumorbital ecchymosis –Cerebrospinal fluid (CSF) rhinorrhoea–Crepitation and tenderness –Active bleeding or epistaxis should be taken

care immediately.

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Radiographs

• Occipitomental• Lateral views of the nasal bones• A lateral view taken with a small dental film

against the side of the nose also provides an excellent detailed study.

• Computed Tomography (CT) scan is helpful for higher level fractures of the nose.

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Management

• Closed reduction is the treatment of choice for most nasal bone and/or septal fractures.

• These fractures should be repaired within 7 to 10 days.

• Closed reduction can be done under LA with or with out sedation or general anesthesia.

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• It should never be conducted under intravenous sedation alone.

• As reduction procedure will provoke bleeding, the trickling of the blood near glottis may provoke a dangerous laryngeal spasm.

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• If the local anesthesia and sedation are used, it is important to protect the airway by packing ribbon or strip gauze soaked with local anesthetic agent plus vasoconstrictor for hemostasis.

• The pack is placed in the posterior aspect of the nose with suture attached to it for retrieval.

• Local anesthetic agent is then injected with vasoconstrictor intranasally.

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• The two specially designed instruments that are used for repositioning the nasal bones are Asche’s and Walsham’s forceps.

• In general, bony fractures should be reduced first, followed by reduction of septal fractures or its dislocation from the maxillary groove.

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• The reduction can be done by using a long, flat, narrow instrument such as Howarth’s periosteal elevator.

• Inferiorly or medially displaced nasal bones are lifted upward and laterally, by using Howarth’s elevator intonormal position.

• The laterally displaced nasal bones are brought into normal position by using Walsham’s forceps or digital pressure.

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• Walsham‘s forceps are used with unpadded blade inside the nasal cavity deep to the nasal bones and the other padded blade externally on the skin over the fractured nasal bones.

• The bones are manipulated between the blades until adequate mobility is achieved.

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• Anterior traction and medial rotation followed by lateral rotation to reposition the fragments is done.

• Operator will constantly check the external nasal contour with his palpating fingers.

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• Asche’s septal forceps are then introduced on either side of the septum along the floor of the nose and used to realign the septal cartilage in the groove in the vomer and having ironed out any deflection in the perpendicular plate of ethmoid or the vomer are slowly brought upward and forward to elevate the nasal bridge anteriorly.

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• At the end of the reduction, previous nasal pack with the suture is removed.

• Following complete reduction, internal stabilization is done with nasal packing using half inch ribbon gauze saturated with antibiotic ointment.

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• The pack is placed under direct vision in the superior nasal vault first and then packed inferiorly.

• Both the nostrils should be packed to support the nasal septum.

• The pack is removed after 3 to 4 days.

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• The external dressing consists of padding the area with cotton wool or gauze pieces and stabilizing it with adhesive tape in a ‘butterfly’ manner secured to the forehead and crossing over the nasal bridge on either side.

• External splints that may be used include dental impression compound mould, plaster of Paris, metal splints, lead plates or acrylic or prefabricated splints such as Denver splint.

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• The external splints are usually left in place for 5 to 7 days after reduction.

• The splint provides support for the nasal bones as well prevents hematoma and edema of the nasal structures.

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• Nasal fractures associated with maxillofacial injuries should be treated after stabilizing other fractures with miniplate system, so that IMF is not required and airway can be maintained through the oral route as the nostrils will be packed for 3 to 4 days postoperatively.

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• In extensive unstable fractures open reduction can be opted for.

• Open sky or bicoronal approach can be used and bone grafting, direct fixation of the fragments can be planned.

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References• Contemporary Oral and Maxillofacial Surgery 6th

Edition – Hupp, James (Chapter 25 Management of facial fractures)

• Maxillofacial injuries – A synopsis of Basic Principles, Diagnosis and Management - George Dimitroulis, Brian Avery (Chapter 6 ).

• https://sites.google.com/site/drtbalusotolaryngology/rhinology/buttress-system-of-midface ‘Buttress system of midface’. Accessed on 14.2.2016.

• Textbook of Oral and Maxillofacial Surgery 3rd Edition – Neelima Anil Malik (Chapter 29 + 30).

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Thank you for

listening