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  1. 1. Facial Fractures – Mandible and Frontal Bones Dale Reynolds, MD UT Houston Plastic & Reconstructive Surgery
  2. 2. Facial Fractures <ul><li>Phases </li></ul><ul><ul><li>Emergency Treatment </li></ul></ul><ul><ul><ul><li>Airway </li></ul></ul></ul><ul><ul><ul><ul><li>Edema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Teeth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood </li></ul></ul></ul></ul><ul><ul><ul><ul><li>FB </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mandible fracture  tongue to pharynx </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Stridor, hoarseness, retraction, drooling </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ETT </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tracheostomy </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Long term IMF </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Cricothyroidotomy </li></ul></ul></ul></ul>
  3. 3. Facial Fractures <ul><li>Hemorrhage </li></ul><ul><ul><li>Anterior cranial fossa </li></ul></ul><ul><ul><li>Midface </li></ul></ul><ul><ul><li>Lacerations </li></ul></ul><ul><ul><li>Nasal </li></ul></ul><ul><ul><ul><li>Nasal, zygomatic, orbital, frontal, NOE, maxillary </li></ul></ul></ul><ul><ul><li>Reduction (IMF) </li></ul></ul><ul><ul><li>Anterior/ posterior packing x 24-48 hrs </li></ul></ul><ul><ul><li>Compression dressing </li></ul></ul><ul><ul><li>Embolization </li></ul></ul><ul><ul><li>Bilateral external carotid/ superficial temporal ligation </li></ul></ul><ul><ul><li>Blood factor replacement </li></ul></ul>
  4. 4. Facial Fractures <ul><ul><ul><li>Aspiration </li></ul></ul></ul><ul><ul><ul><ul><li>Low threshold for ETT </li></ul></ul></ul></ul><ul><ul><ul><li>Other </li></ul></ul></ul><ul><ul><ul><ul><li>Eye </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Brain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Spine </li></ul></ul></ul></ul>
  5. 5. Facial Fractures <ul><ul><li>Early injury care </li></ul></ul><ul><ul><ul><li>History </li></ul></ul></ul><ul><ul><ul><li>PE </li></ul></ul></ul><ul><ul><ul><ul><li>Nerves, vision, intraoral, nasopharyngeal, dentition </li></ul></ul></ul></ul><ul><ul><ul><li>Radiographs </li></ul></ul></ul><ul><ul><ul><li>Lacerations </li></ul></ul></ul><ul><ul><ul><li>IMF </li></ul></ul></ul><ul><ul><ul><li>Impressions </li></ul></ul></ul>
  6. 6. Facial Fractures <ul><ul><li>Classification </li></ul></ul><ul><ul><ul><li>Anatomy </li></ul></ul></ul><ul><ul><ul><li>Closed v. open </li></ul></ul></ul><ul><ul><ul><li>Le Fort </li></ul></ul></ul><ul><ul><li>Radiography </li></ul></ul><ul><ul><ul><li>CT v. x-rays </li></ul></ul></ul><ul><ul><li>Occlusion/ dentition </li></ul></ul>
  7. 7. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>Anatomy </li></ul></ul>
  8. 8. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>Anatomy </li></ul></ul>
  9. 9. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>Anatomy </li></ul></ul>
  10. 10. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>Anatomy </li></ul></ul>
  11. 11. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>Most common facial fracture after nasal </li></ul></ul><ul><ul><li>10-25% of all facial fractures </li></ul></ul><ul><ul><li>Body> angle> condyle> parasymphysis> other </li></ul></ul><ul><ul><li>M: F = 2: 1 </li></ul></ul><ul><ul><li>58% multiple (93% , 3 fx) </li></ul></ul><ul><ul><li>Preinjury relationships </li></ul></ul><ul><ul><li>Stable bony union </li></ul></ul><ul><ul><li>Facial proportions </li></ul></ul><ul><ul><li>Avoid complications </li></ul></ul>
  12. 12. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><ul><li>Previous trauma </li></ul></ul></ul><ul><ul><ul><li>Previous baseline </li></ul></ul></ul><ul><ul><ul><li>Pre-injury photo </li></ul></ul></ul>
  13. 13. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>Crepitance </li></ul></ul></ul><ul><ul><ul><li>Symmetry </li></ul></ul></ul><ul><ul><ul><li>Tenderness </li></ul></ul></ul><ul><ul><ul><li>Oral/ dental – missing teeth </li></ul></ul></ul><ul><ul><ul><li>Step offs </li></ul></ul></ul>
  14. 14. Facial Fractures <ul><li>Mandible </li></ul><ul><ul><li>Radiography </li></ul></ul><ul><ul><ul><li>Panorex </li></ul></ul></ul><ul><ul><ul><li>CT </li></ul></ul></ul><ul><ul><ul><li>Plain films </li></ul></ul></ul><ul><ul><ul><ul><li>PA, Towne’s, R and L lateral oblique views (mandibular series) </li></ul></ul></ul></ul>
  15. 15. Mandible <ul><li>Treatment </li></ul><ul><ul><li>Restore form and function </li></ul></ul><ul><ul><ul><li>Occlusion, TMJ function, cosmesis </li></ul></ul></ul><ul><ul><li>ORIF </li></ul></ul><ul><ul><ul><li>Exact anatomic reduction </li></ul></ul></ul><ul><ul><ul><li>Allows early resumption of mandibular function </li></ul></ul></ul>
  16. 16. Mandible
  17. 17. Mandible <ul><li>Treatment </li></ul><ul><ul><li>Closed </li></ul></ul><ul><ul><li>Dependent on splinting to maxilla to restore centric occlusion (maximal intercusspation) </li></ul></ul><ul><ul><li>If inadequate number of teeth,Gunning splint may be needed for IMF </li></ul></ul>
  18. 18. Mandible <ul><li>Treatment </li></ul><ul><ul><li>Open </li></ul></ul><ul><ul><ul><li>Accurate reduction </li></ul></ul></ul><ul><ul><ul><ul><li>Within 2 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If maxilla cannot be used then mandible first or splints </li></ul></ul></ul></ul><ul><ul><ul><li>Avoid prolonged IMF </li></ul></ul></ul><ul><ul><ul><ul><li>Traumitizes gingiva </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Impairs oral hygiene  periodontal disease </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Uncomfortable </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Forces can alter tooth position and periodontal attachments </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Great aspiration risk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Contraindication in COPD, seizure d/o, impaired MS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Articular surfaces under compression cause pressure necrosis </li></ul></ul></ul></ul>
  19. 19. Mandible <ul><li>ORIF </li></ul><ul><ul><li>Lag screw – Anterior </li></ul></ul>
  20. 20. Mandible <ul><li>ORIF </li></ul><ul><ul><li>Reconstruction plate – Comminuted body </li></ul></ul>
  21. 21. Mandible <ul><li>ORIF </li></ul><ul><ul><li>Two plate/ tension band – Angle </li></ul></ul>
  22. 22. Mandible <ul><li>ORIF </li></ul><ul><ul><li>Dynamic compression plate - Condyle </li></ul></ul>
  23. 23. Mandible <ul><li>Treatment </li></ul><ul><ul><li>Contraindications to open </li></ul></ul><ul><ul><ul><li>Not required </li></ul></ul></ul><ul><ul><ul><li>Not candidate </li></ul></ul></ul><ul><ul><li>Rarely needed in children </li></ul></ul><ul><ul><ul><li>Simple </li></ul></ul></ul><ul><ul><ul><li>Heal quickly </li></ul></ul></ul><ul><ul><ul><li>Occlusion less established </li></ul></ul></ul>
  24. 24. Facial Fractures
  25. 25. Mandible <ul><li>Treatment by type </li></ul><ul><ul><li>Simple </li></ul></ul><ul><ul><ul><li>CR + IMF x 8 weeks if reliable (unreliable avoid IMF and open) </li></ul></ul></ul>
  26. 26. Mandible <ul><li>Treatment by type </li></ul><ul><ul><li>Complex </li></ul></ul><ul><ul><ul><li>Multiple or segmental </li></ul></ul></ul><ul><ul><ul><ul><li>Often interosseous wires/ reduction clamps/ temporary mini-plates help </li></ul></ul></ul></ul><ul><ul><ul><li>Inferior “butterfly” segment </li></ul></ul></ul><ul><ul><ul><ul><li>Difficult to reduce </li></ul></ul></ul></ul>
  27. 27. Mandible <ul><li>Treatment by type </li></ul><ul><ul><li>Complex </li></ul></ul><ul><ul><ul><li>Bilateral fracture each hemi-mandible </li></ul></ul></ul><ul><ul><ul><ul><li>Simultaneous reduction may be required to avoid magnification of discrepancy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Arch bars and IMF may worsen </li></ul></ul></ul></ul><ul><ul><ul><li>Anterior fracture with one or both condyles </li></ul></ul></ul><ul><ul><ul><ul><li>Consider reducing one or both condyles first if difficult to control flaring the inferior border </li></ul></ul></ul></ul><ul><ul><ul><li>Unilateral segmental fracture in one hemi-mandible </li></ul></ul></ul><ul><ul><ul><ul><li>Close fractures – two plates </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Separated fractures – long spanning plate </li></ul></ul></ul></ul>
  28. 28. Mandible <ul><li>Treatment by type </li></ul><ul><ul><li>Complex </li></ul></ul><ul><ul><ul><li>Comminuted </li></ul></ul></ul><ul><ul><ul><ul><li>High energy – GSW, SGW, MVC </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Easy to devitalize small fragments </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Difficult to accurately reduce </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Large reconstruction plate may be required </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Temporary external fixator may be used if condition of patient or soft tissue requires </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bone graft for extensive loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pre-treatment infection: Debride small fragments </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Post-treatment infection: FB (bone or screw) </li></ul></ul></ul></ul>
  29. 29. Mandible <ul><li>Treatment by type </li></ul><ul><ul><li>Complex </li></ul></ul><ul><ul><ul><li>Edentulous </li></ul></ul></ul><ul><ul><ul><ul><li>Atrophied and osteopenic  poorer healing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Early atherosclerosis (15 years) of inferior alveolar artery  20% non-union </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Simple and undisplaced  pureed diet and obs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use dentures or splints </li></ul></ul></ul></ul><ul><ul><ul><li>Fracture with bony defect </li></ul></ul></ul><ul><ul><ul><ul><li>Rigid fixation with spanning reconstruction plate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bone graft/ flap within 5 years </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Soft tissue repair and IMF or ex fix until ready </li></ul></ul></ul></ul>
  30. 30. Mandible <ul><li>Treatment </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><ul><li>More common if delayed care </li></ul></ul></ul><ul><ul><ul><li>Abx, debridement </li></ul></ul></ul><ul><ul><ul><li>Fracture line may resorb and form gaps – larger plates </li></ul></ul></ul><ul><ul><ul><li>Extreme cases may require external fixator with secondary ORIF +/- graft </li></ul></ul></ul>
  31. 31. Mandible <ul><li>Treatment </li></ul><ul><ul><li>Children </li></ul></ul><ul><ul><ul><li>Most need CR + immobilization (single arch bar or lingual splint) x 2 weeks </li></ul></ul></ul><ul><ul><ul><li>Conical shape makes arch bars less useful </li></ul></ul></ul><ul><ul><ul><li>Indications for ORIF </li></ul></ul></ul><ul><ul><ul><ul><li>Unstable fractures </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Not amenable to CR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bilateral fractures with gross instability </li></ul></ul></ul></ul><ul><ul><ul><li>Use unicortical plates </li></ul></ul></ul><ul><ul><ul><li>Remove 6-8 weeks later </li></ul></ul></ul>
  32. 32. Mandible <ul><li>Treatment </li></ul><ul><ul><li>Children </li></ul></ul><ul><ul><ul><li>Condyle is growth center of mandible </li></ul></ul></ul><ul><ul><ul><li>Trauma can cause hemarthrosis  ankylosis </li></ul></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>Unilateral condylar fractures with altered centric occlusion are treated with arch bars or lingual splints and elastics </li></ul></ul></ul><ul><ul><ul><li>Displaced bilateral condylar fractures with posterior vertical collapse and anterior open bite deformity require CR + IMF x 4 weeks </li></ul></ul></ul>
  33. 33. Mandible <ul><li>Treatment </li></ul><ul><ul><li>By Location </li></ul></ul><ul><ul><ul><li>Alveolar Process (1%) </li></ul></ul></ul><ul><ul><ul><ul><li>Remove if devitalized o/w IMF or splint </li></ul></ul></ul></ul><ul><ul><ul><li>Symphysis (5.8%) </li></ul></ul></ul><ul><ul><ul><ul><li>Often associated with condylar fractures </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Significant forces cause lateral flaring of posterior segments (often worse with IMF) </li></ul></ul></ul></ul><ul><ul><ul><li>Parasymphysis (11.6%) </li></ul></ul></ul><ul><ul><ul><ul><li>Often associated with contralateral fractures </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mental nerve </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Burr/ osteotome may help lessen anterior curvature </li></ul></ul></ul></ul>
  34. 34. Mandible <ul><li>Treatment </li></ul><ul><ul><li>By Location </li></ul></ul><ul><ul><ul><li>Body (31.9%) </li></ul></ul></ul><ul><ul><ul><ul><li>May require external approach </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bi-cortical plates placed beneath mental canal </li></ul></ul></ul></ul><ul><ul><ul><li>Angle (27.5%) </li></ul></ul></ul><ul><ul><ul><ul><li>May require external approach </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Often associated with contralateral </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Highest complication rate due to third molar teeth and displacing forces </li></ul></ul></ul></ul>
  35. 35. Mandible <ul><li>Treatment </li></ul><ul><ul><li>By Location </li></ul></ul><ul><ul><ul><li>Ramus (2.5%) </li></ul></ul></ul><ul><ul><ul><ul><li>Usually require extraoral approach </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Often stable due to splinting effect of masseter-medial pterygoid muscle sling unless displacement causes vertical shortening (telescoping) </li></ul></ul></ul></ul><ul><ul><ul><li>Coronoid process (1.8%) </li></ul></ul></ul><ul><ul><ul><ul><li>Soft diet usually enough </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Severe pain may require brief IMF </li></ul></ul></ul></ul>
  36. 36. Mandible <ul><li>Treatment </li></ul><ul><ul><li>By Location </li></ul></ul><ul><ul><ul><li>Condyle (23.8%) </li></ul></ul></ul><ul><ul><ul><ul><li>Proximal segment can undergo AVN </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intra-articular fractures: Very difficult ORIF, OA is common outcome, usually brief IMF for malocclusion o/w early mobilization +/- elastics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>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 </li></ul></ul></ul></ul>
  37. 37. Mandible <ul><li>Treatment </li></ul><ul><ul><li>By Location </li></ul></ul><ul><ul><ul><li>Condyle </li></ul></ul></ul><ul><ul><ul><ul><li>ORIF </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Displaced in to middle cranial fossa </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>FB within joint </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Lateral extra-capsular displacement of condyle </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Displacement blocking opening or closing </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Posterior vertical shortening of mandible with open bite after 2 week IMF trial </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Relative </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bilateral associated with unstable midface fractures </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bilateral edentulous without splint </li></ul></ul></ul></ul></ul>
  38. 38. Mandible <ul><li>Postoperative care </li></ul><ul><ul><li>+/- Abx, airway control with IMF (wire cutters), HOB (secretions) + ice pack for edema </li></ul></ul><ul><li>Diet </li></ul><ul><ul><li>CLD  blenderized, 48 o IVF, 15 lb wt loss </li></ul></ul><ul><li>Splints/ IMF </li></ul><ul><ul><li>Oral hygiene (peridex, H2O2, brush), remove wax </li></ul></ul><ul><li>Oral washouts </li></ul><ul><ul><li>Release IMF q 3-5 days if needed </li></ul></ul>
  39. 39. Mandible <ul><li>Centric occlusion </li></ul><ul><ul><li>Remove IMF to assess ORIF </li></ul></ul><ul><li>Therapeutic rehabilitation </li></ul><ul><ul><li>Regain strength and mobility, PT if severe (prolonged IMF or condyle fracture) </li></ul></ul><ul><ul><li>Dental treatment (missing teeth) </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Malocclusion, malunion, non-union, hardware exposure, infection, non-compliance </li></ul></ul>
  40. 40. Mandible <ul><li>Teeth in fracture line </li></ul>
  41. 41. Facial Fractures <ul><li>Frontal bone anatomy – 7 bones </li></ul>
  42. 42. Facial Fractures <ul><li>Frontal bone anatomy </li></ul>
  43. 43. Facial Fractures <ul><li>Frontal sinus anatomy </li></ul><ul><ul><li>Middle meatus </li></ul></ul>
  44. 44. Facial Fractures <ul><li>Frontal Sinus </li></ul><ul><ul><li>MVC - ¾ </li></ul></ul><ul><ul><li>Assaults – ¼ </li></ul></ul><ul><ul><li>2-3 x force to fracture lower frontal sinus </li></ul></ul><ul><ul><li>Other injuries associated (1/4 die in 14d) </li></ul></ul><ul><ul><li>Rare in children </li></ul></ul>
  45. 45. Facial Fractures <ul><li>Frontal Sinus Fracture </li></ul><ul><ul><li>Signs </li></ul></ul><ul><ul><ul><li>Rhinorrhea </li></ul></ul></ul><ul><ul><ul><li>Step-off </li></ul></ul></ul><ul><ul><ul><li>Supraorbital anesthesia </li></ul></ul></ul><ul><ul><ul><li>Subconjunctival hematoma </li></ul></ul></ul><ul><ul><ul><li>Subcutaneous crepitance </li></ul></ul></ul>
  46. 46. Facial Fractures <ul><li>Frontal Sinus Fracture </li></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><ul><li>Plain films </li></ul></ul></ul><ul><ul><ul><li>CT </li></ul></ul></ul>
  47. 47. Facial Fractures <ul><li>Frontal sinus fractures </li></ul><ul><ul><li>Anterior Table (Thick) </li></ul></ul><ul><ul><ul><li>Displaced  ORIF </li></ul></ul></ul><ul><ul><ul><li>Blockage of nasofrontal duct (methylene blue) </li></ul></ul></ul><ul><ul><ul><ul><li>Remove mucosa </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bone graft nasofrontal ducts, fill space </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Elevate and fixate bone </li></ul></ul></ul></ul><ul><ul><li>Posterior Table (Thin) </li></ul></ul><ul><ul><ul><li>Comminuted  Cranialize </li></ul></ul></ul><ul><ul><ul><li>Displaced greater than one wall thickness  ORIF </li></ul></ul></ul>
  48. 48. Facial Fractures <ul><li>Frontal Sinus Fracture </li></ul><ul><ul><li>Complications (Posterior > anterior) </li></ul></ul><ul><ul><ul><li>Acute </li></ul></ul></ul><ul><ul><ul><ul><li>Epistaxis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CSF leak </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Meningitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intracranial injury </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hematoma </li></ul></ul></ul></ul><ul><ul><ul><li>Subacute </li></ul></ul></ul><ul><ul><ul><ul><li>Mucocele </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sinusitis </li></ul></ul></ul></ul><ul><ul><ul><li>Chronic </li></ul></ul></ul><ul><ul><ul><ul><li>Osteomyelitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Abscesses </li></ul></ul></ul></ul>
  49. 49. END

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