• 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 management3/12/2016 2
• 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
• Posteriorly, the region is demarcated by the
sphenoethmoidal junction, but includes the
free margin of the pterygoid laminae of the
sphenoid bone inferiorly.
Causes of facial fractures
• Motor vehicle accidents
• Assault/Domestic violence
• Sports- related incidents
• Work- related incidents
• 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
• The central midface has many fragile bones that
could easily be crushed when subjected to strong
• They are surrounded by thicker bones of facial
buttress system lending it some strength and
Midface buttresses are composed of:
• Frontal bone
• Maxillary bones
• Zygomatic bones
• Sphenoid bone
AND THEIR ATTACHMENTS TO ONE ANOTHER
• 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.
• 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.
• The facial region is supplied by branches of
external carotid artery.
Branches of external carotid artery
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.
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)
• How did the accident occur?
• When did the accident occur? Time since
• What are the specifics of the injury, including
the type of object contacted, the direction
from which contact was made?
• Did loss of consciousness, vomiting, bleeding
• What symptoms are now being experienced
by the patient, including pain, altered
sensation, visual changes, and change in
Primary Survey: ABCDE
• Airway maintenance with cervical spine
• 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
• Evaluate soft tissues for wounds.
• Palpate bony landmarks beginning with the:
–Supraorbital and lateral orbital rims
• 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.
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
• Helps for communication purpose and to plan
• Rene LeFort:
–LeFort I, LeFort II and LeFort III.
• However there were other classifications also..
• Erich’s (1942)- direction of the fracture line.
• Another classification based on relationship of
the fracture line to the zygomatic bone -
–Below the zygomatic bone - Subzygomatic
–Above or including the zygomatic bone -
• 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 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
• Almost always involves the pterygoid process of
the sphenoid bone.
• The fracture separates the maxilla from the
pterygoid plates and nasal and zygomatic
• 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.
• 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.
Clinical findings of LeFort I:
• Swelling of the upper lip.
• Soft tissue laceration.
• Open mouth to accommodate the
displaced dentoalveolar portion.
• Mobility of tooth bearing portion.
• Dull sound on percussion.
• Ecchymosis of the maxillary buccal sulcus.
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.
• Separation of the maxilla and the attached
nasal complex from the orbital and zygomatic
Clinical Findings of LeFort II
• Ballooning of the face
• Lengthenening of the face
• Circumorbital ecchymosis
• Subconjunctival Haemorrhage
• CSF rhinorrhoea
• Step deformity in the lower border of the
• Intact zygomatic bone and arch
• Gagging of the posterior teeth and anterior
• Mobility of the maxilla
• Ecchymosis of the sulcus
• 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
• 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.
• Most severe of the LeFort fractures.
• Often associated with extensive soft tissue
• Large force needed to cause this type of
• The resultant “floating” component is almost
the entire face.
Clinical Findings of LeFort III
• Severe edema of the face “ballooning”
• Lengthening of the face
• Flattening of the cheek
• Circumorbital ecchymosis
• Subconjunctival Haemorrhage
• CSF rhinorrhoea
• Gagging of the posterior teeth and
anterior open bite
• Ecchymosis and Haemorrhage of the
• Mobility of the maxilla
• Mandibular interference
• Obstructed airway – soft palate rest on
posterior dorsum of tongue
• Bilateral circumorbital ecchymoses – panda
facies, or racoon eyes
• Bilateral subconjunctival ecchymosis
• Diplopia due to:
–Edema and hematoma
–Restrictive motility disorder (mechanical)
–Cranial nerve injury (neurogenic)
Treatment for LeFort fractures
• First aid and Preliminary treatment
• Definitive treatment
• 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
• 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
Methods of reduction for LeFort
• 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
–Carried out in all fresh fractures where the
fragments are not impacted.
–As a rule, arch bars are first applied to the
–The lower jaw serves as a template, so that
the occlusion can be checked.
• Simple manipulation by hand is possible in
fresh fractures, maxilla is held between the
index finger and thumb and brought into
• Another method is to fix two double wires
encircling the first and second maxillary
molars and twisting them individually on
• 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
• Dental compound loaded into impression tray
was suggested by Dingman and Harding in
1951, for mobilizing the fractured fragment of
• This can be used, where some amount of
fibrosis has set in because of delayed
• 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.
• Propescu and Burlibasa in 1966, have
described reduction by rubber dam sheets or
by means of long ribbon/strip gauze or rubber
• Whenever the maxilla is impacted and simple
manual mobilization is not possible, then this
method can be tried, if sophisticated
instruments are not available.
• 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.
• 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.
• 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.
• 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.
• Anterior traction in the case of a split palate, may be
facilitated by the use of the special forceps devised by
• Applied to the buccal aspect of the alveolar
process and medial compression exerted until
the two halves of the upper jaw are
• A screw top is adjusted to prevent crushing of the
• Can be combined with Rowe’s maxillary disimpaction
• The stabilized maxillary block may then be
disimpacted and drawn forward.
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
• Mainly used in delayed cases, where the
fracture is 10 to 14 days old and no longer
–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.
• 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.
• 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
–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
–This can be used for unilateral fractures of
maxilla or higher fractures without occlusal
–Maintained for 6 weeks.3/12/2016 80
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.
Internal skeletal wire suspension:
Many times in addition to IMF, additional
support is required for immobilization of
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
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.
• Fixation of the midface by tightening the
suspensory wires and intermaxillary
• For edentulous patients, available
prosthesis or Gunning splint is used.
• LeFort I fracture: Intermaxillary fixation by
zygomatic arch suspension, if necessary
additional suspension at the piriform aperture.
• LeFort II: Zygomatic arch suspension or frontal
bone suspension. Intraosseous wiring may be
done at infraorbital margins.
• 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
• Open Reduction
– Carried out under endotracheal anesthesia with
– Intraoral vestibular incision is taken from first
molar to first molar region on either side.
– Mucoperiosteal flap is reflected to expose the
– After identifying the fracture line, in old fractures,
an osteotome is inserted to mobilize the
– Disimpaction forceps can be used and the
fragment is brought into normal occlusion by
– Temporary IMF is carried out and fracture
fragments are fixed under direct vision by
intraosseous wiring or minibone plates with
• For extensive high level fractures of the midface
bicoronal incision can be taken.
Various skeletal incisions for exposure
of midface skeleton are follows:
1. Supraorbital eyebrow incison
2. Subciliary incision
3. Median lower eyelid incision
4. Infraorbital incision
5. Transconjunctival incision
6. Zygomatic arch incision
7. Transverse nasal incision
8. Vertical nasal incision
9. Medial orbital incision.
Anatomy of Zygomatic bone
• 4 processes which articulate with:
– Maxillary bone
– Frontal bone
– Temporal bone
– Sphenoid bone
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
–Infraorbital nerve courses the floor of the
orbit and exits the infraorbital foramen.
• 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
Types of zygomatic fracture
• Zygomatic complex fracture – separate of
zygoma from its 4 articulations
• Zygomatic arch fracture – fracture of
zygomatic arch in isolation
Classification of zygomatic fractures
• Type 1 – Undisplaced fracture
• Type 2 – Arch fracture only
• Type 3 – Tripod malar fracture (Fronto-Zygomatic
• Type 4 – Tripod malar fracture (Fronto-Zygomatic
• Type 5 – Pure blowout fracture
• Type 6 – Orbital rim fracture
• Type 7 – Comminuted and other fractures
• In 1985, Rowe changed his 1968
classification and gave more clinical
significance by dividing fractures into
stable and unstable varieties.
• 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
• Group C: Stable fracture—other types of
zygomatic fractures, which require reduction,
but no fixation.
Early clinical features of Zygomatic
– Swelling and bruising over cheek
– Depressed cheek prominence
– Trismus and restricted lateral mandibular
– Ecchymosis at maxillary buttress region
– Step deformity along infraorbital margins and
possibly along lateral orbital margin and zygomatic
– Epistaxis on side of fracture3/12/2016 103
• 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.
• 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
• 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.
• Unstable fractures: Require open reduction
and transosseous wiring or bone plating.
• Type 4 (b)
• Types 5, 6, and 7, 8
• Operative technique: The approach of Gillies,
Kilner and Stone (1927) is popular for
reduction of fractures of zygoma
Methods of reduction:
• Closed reduction (Gillies temporal approach)
- Bristow’s elevator
- Rowe’s zygomatic elevator
• Open reduction ( surgical )
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.
• 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
• 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
• 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.
• 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.
• 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).
• 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
• 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.
• 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
• The depressed bone is then elevated with an
upward, forward and outward movement.
• Alternate methods like intranasal elevation via
intra nasal antrostomy or oroantral elevations
• 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
• 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
• 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
• 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
• 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.
Malunion of the Zygomaticomaxillary
It will show following signs and symptoms:
–Loss of contour or prominence of cheek will
–Correction may be done either by surgical
refracturing or camouflaging the deformity
by means of onlay bone grafting or
alloplastic material like hydroxylapatite
–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.
–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.
– Depressed zygomatic arch fracture impinges
on the coronoid process bringing about
limitation of the mandibular movements and
– 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
–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
Fracture of the Floor of
Fracture of the Floor of the Orbit
• 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.
• In addition, forces acting on the bone play a
• The fractured orbital floor gives way into the
• At the same time, orbital fatty tissue and
sometimes muscles, (inferior rectus and
inferior oblique) prolapse into the sinus like a
• 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
–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.
Orbital floor reconstruction
• Autograft --rib, iliac crest, calvaria, as well as
ear or nose cartilage
• Allograft --lyophilized dura, rib, iliac crest,
• Alloplast --Teflon, Silastic, Ti-Mesh, and
Gelfilm have been described
Fractures of Nasal bone
• High Incidence because of prominence of
• Usually due to direct injury; can occur as an
isolated fracture or it may be combined with
other facial fractures.
• Leads to cosmetic deformity and functional
• Nasal fractures in children should be generally
treated conservatively with closed reduction,
because of the growth potential.
• Often overlooked in multiple facial injuries.
• Nasal symmetry, proper appearance and
adequate airway through the nose is
• 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
• 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.
• 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
• 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
• There may be telescoping or overlapping seen.
• History of previous nasal deformity, trauma,
surgery or breathing difficulty should be asked
• 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.
–Depressed bridge of the nose
–Flattening or deviation of the nasal bone
–Nasal obstruction may be caused by:
edema, blood clots, swelling of nasal
mucosa, dislocated bone, cartilage
–Subcutaneous emphysema may be present
because of patient’s repeated attempts to
–Cerebrospinal fluid (CSF) rhinorrhoea
–Crepitation and tenderness
–Active bleeding or epistaxis should be taken
• 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.
• Closed reduction is the treatment of choice for
most nasal bone and/or septal fractures.
• These fractures should be repaired within 7 to
• Closed reduction can be done under LA with
or with out sedation or general anesthesia.
• 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.
• 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
• 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.
• The reduction can be done by using a long,
flat, narrow instrument such as Howarth’s
• 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.
• 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.
• Anterior traction and medial rotation followed
by lateral rotation to reposition the fragments
• Operator will constantly check the external
nasal contour with his palpating fingers.
• 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.
• 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
• The pack is placed under direct vision in the
superior nasal vault first and then packed
• Both the nostrils should be packed to support
the nasal septum.
• The pack is removed after 3 to 4 days.
• 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.
• 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.
• 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
• 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.
• Contemporary Oral and Maxillofacial Surgery 6th
Edition – Hupp, James (Chapter 25 Management of
• Maxillofacial injuries – A synopsis of Basic Principles,
Diagnosis and Management - George Dimitroulis,
Brian Avery (Chapter 6 ).
system of midface’. Accessed on 14.2.2016.
• Textbook of Oral and Maxillofacial Surgery 3rd Edition
– Neelima Anil Malik (Chapter 29 + 30).