Facial Trauma Update

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Cover Artwork Design by Ziad Marei
Facial Trauma
Update
Ahmed M. Adawy, BDS, HDD, MDS.
Professor Emeritus, Dept. Oral & Maxillofacial
Surg.
Former Dean, Faculty of Dental
Medicine, Al-Azhar University.

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About the author
Ahmed Adawy
Professor Emeritus, Dept. Oral and
Maxillofacial Surgery, Faculty of
Dental Medicine, Al-Azhar University.
Former Consultant Maxillofacial
Surgeon, Al-Azhar University Hospitals.
Former Consultant Maxillofacial Surgeon, King Abdul-Aziz
Hospital, Makkah, KSA.
Former Chairman, Dept. Oral and Maxillofacial Surgery, Faculty of
Dental Medicine, Al-Azhar University.
Former Dean, Faculty of Dental Medicine, Al-Azhar
University. Former Editor in-chief, Al-Azhar Dental Journal.
Former Director, Permanent Scientific Committee for Professor and
Assistant Professor Promotion in Dental Science, Al-Azhar University.

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Preface
Facial trauma is without doubt a most challenging area within the specialty of
oral and maxillofacial surgery. Trauma with all its aspects has great importance,
being the main cause of morbidity and mortality with rising frequency worldwide,
especially in recent decades. Traumatic facial injuries are often associated with
high mortality and varying degrees of physical, functional, psychological damage,
cosmetic disfigurement, and concomitant injuries to other organs that may be
added complicating factors. Road traffic accidents represent the main cause of
facial trauma. According to WHO, Egypt leads the Middle East when it comes to
road accidents, with an average of 12,000 people killed annually. Interpersonal
violence is the second most prevalent etiologic factor. Our society is progressively
becoming more and more violent and impatient, perhaps due to overcrowding, so
the frequency of patients reporting in emergency with facial bones fracture is
increasing.
During the last three decades, significant advances have occurred in the methods
of fixation used for facial bone fractures, resulting in improved functional and
aesthetic outcomes. Surgical techniques have been moving away from delayed
closed reduction with internal wires suspension to early open reduction and
internal plate fixation. The transition from wire osteosynthesis to rigid internal
fixation in facial bone fractures using different micro or mini-plates and screw
systems is regarded as one of the greatest advances in the field of maxillofacial
surgery. I hope this book reflects the latest trends, concepts and innovations in the
care of patients with facial trauma.
For convenience, the text is divided into 3 sections. Section 1 deals with primary
care of the patients. Section 2 is concerned with midface fractures. In section 3
management of trauma to the lower face is discussed. Upper face injuries are not
included and the reader could find the subject elsewhere under the topic of
craniofacial traumatology. From the basic to the most complex, readers will find
that each chapter is sequentially organized to provide a concise, and practical
description of the operative details. The goal was to provide the reader with a fully
comprehensive, yet highly illustrated text on the subject of facial trauma.

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Many thanks are owed to all the staff members of the Oral and Maxillofacial
Surgery Department with whom I have enjoyed a prolific scientific cooperation
for almost 50 years. Thanks are extended to all young colleagues for their intense
cooperation. I hope that the information presented in this book will provide a
basis for education and training for surgeons in the future, with the ultimate goal
of improving the quality of patient care.
Ahmed Adawy

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Dedication
In the memory of my beloved wife Ahlam

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Table of contents
Section I: Primary care...............................................7
Chapter 1 Emergency management of patients with facial
trauma........................................................................................8
Chapter 2 Management of soft tissue injuries........................28
Section II: Midface fractures......................................42
Chapter 3 Facial bone fractures: An overview........................43
Chapter 4 Nasal and nasoethmoidal fractures..........................60
Chapter 5 Zygomatic complex fractures..................................78
Chapter 6 Orbital floor blow-out fractures...............................93
Section III: Trauma to the lower face........................109
Chapter 7 Mandibular fractures..............................................110
Chapter 8 Condylar fractures..................................................133

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Section I: Primary care
Chapter 1: Emergency management
of patients with facial trauma.
Chapter 2: Management of soft tissue
injuries.

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Chapter 1: Emergency management of
patients with facial trauma.

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Maxillofacial trauma is without doubt a most challenging area within the specialty of
oral and maxillofacial surgery. As with all traumas, basic Advanced Trauma Life Support
principles (ATLS) should be applied to the initial assessment of the casualty (1-3).
Currently, ATLS has become universally accepted as the gold standard in the initial
management of the multiply injured patients. The system divides the initial assessment
into a primary and secondary survey. The primary survey aims to identify immediate life-
threatening injuries. The secondary survey aims to identify all other injuries that will
require treatment but are not immediately life-threatening.
Assessment
As part of the primary survey, a brief but detailed history may be obtained, including
the timing and mechanism of the injury, and any previous treatment. The full extent of
some injuries may not be obvious during the initial assessment; serial examinations may
be necessary as hemorrhage, swelling, or other bodily injuries are identified. A
moredetailed examination may be performed in a delayed setting. The examination
should begin in a systematic fashion; an overall inspection of the face will reveal any
asymmetry, contusions, swelling, or hemorrhage. Frequently, asymmetry may be hidden
due to facial edema. Exposure is critical, so debris must be cleared first. Palpation of the
entire face will delineate any step-offs or instability from the underlying skeleton. A top-
down approach will make the examination more efficient and focused. The practitioner
should not be distracted by the obvious injuries as this could mask less obvious but more
significant problems. Soft tissue injuries should be noted, and any vital structures within
range tested; for example, a deep cheek laceration should prompt a test for Stenson’s
duct.
Similarly, cranial nerves should be examined for any deficits. Next, a complete ocular
examination should be given. Visual acuity, anterior chamber inspection, visual field
testing, pupillary reflexes, light perception, and extraocular movements can be tested
quickly and efficiently. If there is any concern for ocular injury, an ophthalmologic
consultation is recommended. The nose and septum should be palpated and inspected for

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irregularity and signs of fracture. The oral cavity should be inspected for malocclusion, as
well as any lacerations, foreign bodies, or dentoalveolar damage. The mandible should be
examined and palpated for any step-offs or injury. Proper photo documentation of current
damage is key, as post-injury states may be difficult to discern from postoperative
complications. Photographic consent should be obtained on a routine basis (4).
Sensory and motor innervation to the face should be evaluated. Paraesthesia after facial
trauma is highly suggestive of fracture due to injury or impingement of trigeminal nerve
branches. Mandible fractures can present with loss of lip sensation due to injury to the
inferior alveolar nerve. Midface injuries may present with cheek numbness due to injury
to the infraorbital nerve. Injury to the supraorbital and supratrochlear branches in the
forehead region may also occur. Facial nerve branches palsy may result from penetrating
injuries or superficial lacerations as the nerve exits beneath the external auditory meatus
and divides within the substance of the parotid gland (5).
The mnemonic for the primary survey is given by the letters ABCDE.
• Airway maintenance with cervical spine protection.
• Breathing and ventilation.
• Circulation with hemorrhage control.
• Disability: neurological status.
• Exposure/environmental control - undress the patient but prevent hypothermia.
Airway breathing and ventilation
The main cause of death in severe facial injury is airway obstruction. According to
Hutchison et al. (6), there are six specific situations associated with maxillofacial trauma,
which can adversely affect the airway:
(1) Posteroinferior displacement of a fractured maxilla parallel to the inclined plane of
the base of the skull may block the nasopharyngeal airway.

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(2) A bilateral fracture of the anterior mandible may cause the fractured symphysis and
the tongue to slide posteriorly and block the oropharynx in the supine patient.
(3) Fractured or exfoliated teeth, bone fragments, vomitus, blood, and secretions as well
as foreign bodies, such as dentures, debris, and shrapnel, may block the airway anywhere
along the oropharynx and larynx.
(4) Hemorrhage from distinct vessels in open wounds or severe nasal bleeding from
complex blood supply of the nose may also contribute to airway obstruction.
(5) Soft tissue swelling and edema which result from trauma of the head and neck may
cause delayed airway compromise.
(6) Trauma of the larynx and trachea may cause swelling and displacement of structures,
such as the epiglottis, arytenoid cartilages, and vocal cords, thereby increasing the risk of
cervical airway obstruction.
Airway management is commonly divided into two categories: basic and advanced.
Basic techniques are generally non-invasive and do not require specialized medical
equipment or advanced training and can be performed in pre-hospital setting. Advanced
techniques require specialized medical training and equipment and are further categorized
anatomically into supraglottic devices such as oropharyngeal and nasopharyngeal
airways, infraglottic techniques such as tracheal intubation, and surgical methods such as
cricothyroidotomy, and tracheotomy.
The first action in the process of early airway management is pre-oxygenation, which
may prolong the time interval up to hypoxemic state. However, mask ventilation (fig.1),
is problematical in the patient with maxillofacial trauma because the oral cavity and/or
oropharynx’s anatomy could be disarranged by the trauma and/or blocked by bleeding
(7). In such condition, debris (broken teeth, dentures) is removed from the mouth with a
finger sweep. A Magill's forceps may also be used for larger objects. Adequate lighting
and good suction are essential. The chin should be pulled forward either through chin lift,
(fig.2), or jaw thrust procedures, (fig.3). The jaw thrust and chin lift relieves soft tissue
obstruction by pulling the tongue, anterior neck tissues, and epiglottis forward (8). In a
bilateral fractured mandible, pulling the anterior part of the mandible forward may clear
the airway. The recovery position, (fig.4) is an important preventive technique for an
unconscious

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person. This position entails having the person lie in a stable position on their side with
the head in a dependent position, so fluids do not drain down the airway, reducing the
risk of aspiration (9).
Fig. (1): Bag valve mask ventilation.
Fig. (2): The head-tilt/ chin-lift is the most reliable method of opening the airway
but should be used with extreme caution in patients with suspected neck injuries.

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Fig. (4): The recovery position.
Fig. (3): Jaw thrust maneuver can open the airway with minimal spine
manipulation.

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Most airway maneuvers are associated with some movement of the cervical spine.
When there is a possibility of cervical injury, collars are used to help hold the head in-
line. Maintenance of patent airway is usually carried out by supraglottic devices. These
devices ensure patency of the upper respiratory tract without entry into the trachea by
bridging the oral and pharyngeal spaces (10). An oropharyngeal airway (fig.5) is
acceptable, however nasopharyngeal airways should be avoided in trauma, particularly if
a basilar skull fracture is suspected (11). Most commonly, patent airway could be
maintained with a combination of an oropharyngeal airway, suction, and jaw thrust.
Fig. (5): Oropharyngeal airways in a range of size.
If the foreign body cannot be removed quickly, it should be left, and a surgical airway
performed. A cricothyroidotomy (fig.6) is the preferred way to establish a surgical airway
in the emergency setting. A 5 or 6 mm cuffed tracheostomy tube (fig.7) should be
inserted through the incision. Surgery is seldom necessary but should be performed
without delay when indicated. With trained personnel, the procedure could be conducted
safely with minimal complications. The inability to secure or protect the airway may lead
to considerable morbidity and mortality. In a study of 2594 trauma mortality patients,
Gruen et al. (12) found that failure to ventilate, secure or protect the airway was the most
common factor related to patient mortality, responsible for 16% of inpatient deaths.

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Fig. (6): In cricothyroidotomy, the incision or puncture is made through the cricothyroid
membrane in-between the thyroid cartilage and the cricoid cartilage.

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Fig. (7): Cuffed tracheostomy tube.
In hospital setting, decision is then made about the need for a definitive airway
intubation. Based on the conscious level, severity of maxillofacial injury, risk of
aspiration (blood, vomitus etc.) and risk of obstruction secondary to gross neck edema,
gross facial soft tissue swelling, or concomitant laryngeal or tracheal injury, the need for
intubation is defined. The choice between oral and nasal routes of intubation depends
upon the surgical requirements, the presence of associated nasal and base of skull
injuries. Nasotracheal tubes, however, should be avoided in suspected or proven
comminuted skull base fractures due to the risk of displacement into the middle cranial
fossa (13). A cuffed endotracheal tube used in tracheal intubation is seen in Fig. (8).
Fiberoptic guided intubation (fig.9) remains the most reliable tool in accessing the
difficult airway (14).

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Fig. (8): A cuffed endotracheal tube used in tracheal
intubation.
Fig. (9): Video-laryngoscope to intubate the trachea.

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Circulation with hemorrhage control
Hemorrhage is defined as an acute blood loss. Hemorrhagic shock is associated with
blood loss totaling 30% or more of total circulating blood volume. Fortunately, life-
threatening hemorrhage occurs in only 1% to 11% of patients with facial fractures (15).
Delays in management of hemorrhage may be because of time delay in reaching the
appropriate medical facility, unrecognized bleeding, inadequate resuscitation, inability to
control hemorrhage by surgical means, and/or the presence of inadequate clotting factors.
The initial evaluation of the trauma patient should be focused on arresting thehemorrhage
and establishing wide-bore intravenous access.
In most cases, bleeding from the soft tissues of the head and neck can be controlled by
suturing or temporary packing of the fracture site. Scalp lacerations may bleed profusely
but are unlikely to cause hypovolemic shock with a reduction in blood pressure in an
adult. However, large scalp lacerations may be life threatening in children. Any arterial
source of bleeding in the scalp can be safely clipped off and further hemostasis may be
achieved with packing, Raney clips, suturing or stapling (16). Intra oral bleeding may be
controlled by getting the patient to bite on a swab. A conscious patient with maxillofacial
injuries is usually more comfortable sitting upright as this allows blood and secretions to
drain out of the mouth.
Bleeding from a tongue laceration can be torrential and direct pressure may be not
enough to control the bleeding; in such cases deep sutures across the laceration are
advised to achieve hemostasis. Bleeding from fractured mandible ends may be arrested
by manually reducing the fracture. In cases with a mobile maxilla the use of rubber
mouth gags is advisable. The mouth gags, which act as a splint compressing the maxilla
between the skull base and the mandible, are placed between upper and lower posterior
teeth bilaterally. Following induction of anaesthesia and intubation, manual reduction of
facial fractures can be carried out more readily and effectively if not already
accomplished. There are various ways to temporarily stabilize facial fractures, using
wires, splints, or rapid intermaxillary fixation.

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Extensive bleeding from the region of the nasopharynx following trauma to the middle
third of the facial skeleton can be difficult to control. Epistaxis from the nasal area can be
either anterior or posterior. Profuse anterior bleeding following trauma usually results
from laceration of the anterior ethmoidal artery and definitive control usually requires
nasal fracture reduction and firm anterior packing. Posterior bleeding is usually
associated with laceration of the posterior ethmoidal artery and may require anterior or
posterior nasal packing. Double lumen balloon catheters (epistat, fig. 10) with anterior
and posterior balloons can be very useful in these situations (17).
.
Fig. (10): Epistaxis balloon catheter
Occasionally, if bleeding continues despite reduction of facial fractures and packing,
ligation of the external carotid, internal maxillary, and ethmoidal arteries is traditionally
described. Due to the extent of most fractures and extensive collateral supply, ligation
may be necessary on both sides (18). However, this is a complicated technique and time-
consuming procedure, with variable success rates. In the presence of persistent

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hemorrhage, despite appropriate interventions, it is important to consider coagulation

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abnormalities, e.g. hemophilia, chronic liver disease, and warfarin therapy. At all times the
cervical spine must be carefully immobilized.
Transcatheter arterial embolization (TAE) offers a safe alternative to surgical ligation
in life-threatening facial hemorrhage. Catheter guided angiography is used to first
identify and then occlude the bleeding point or points. Embolization involves the use of
balloons, stents, coils or chemicals (19). In experienced hands, the technique is relatively
quick. Further, multiple bleeding points can be precisely identified, and embolization of
the bleeding branches can arrest the hemorrhage (20). The technique could be considered
early in the course of management to decrease mortality rate. Wu et al. (21) reported 7
cases where angioembolization was successfully performed in hemostasis of life-
threatening maxillofacial trauma hemorrhage. Fig. (11) Shows angiographic embolization
of the left maxillary artery.
Fig. (11): A, Angiography shows left maxillary artery (large arrow) and active contrast blush
(small arrow). B, No more contrast blush after coil embolization (small arrow).
By the meantime, not only must bleeding be identified and controlled as soon as
possible, but concurrent resuscitation must also be appropriate to each case. Prolonged
severe hypotension and associated tissue hypoperfusion may result in secondary organ
failure and death at a later stage. The longer patients remain ischemic from hypotension,
the greater the likelihood of them developing multi-organ failure. The statement ‘‘any
cold and tachycardic patient should be in hypovolemic shock until proven otherwise’’ (2)
is helpful.

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Arterial blood gases are also particularly useful in the early detection of hemorrhagic
shock.
The main goals of management are to rapidly prevent further blood loss and restore
tissue perfusion as soon as possible. The administration of intravenous isotonic fluids in
hypotensive trauma patients is currently one of the most controversial issues in trauma.
Sudden increases in the blood pressure by massive doses of fluid transfusion may
precipitate re-bleeding. Another common dilemma is which type of fluid should be given
during resuscitation? For many years the choice has been between crystalloids and
colloids, but more recently there has been interest in the use of hypertonic saline.
However, its use remains controversial, and a recent review of the evidence suggests that
there are insufficient data at present to justify routine use in patients with severe head
injury (22).
Within the last few years there has been a shift away from aggressive fluid
administration to accepting a lower blood pressure, with greater emphasis on the
immediate control of bleeding. This approach came mainly as a result of the Mattox trial
in 1994, which showed significantly better outcomes when fluids were withheld until
bleeding was controlled, rather than rapidly administered to patients preoperatively (23).
Although the optimal mean arterial pressure has not yet been established, it is now
suggested that the mean systolic blood pressure be kept at only 80 mmHg, in order to
maintain adequate brain perfusion. In an excellent review article Perry et al, (23)
discussed in-depth the topic of hypovolemia and facial injuries in the multiply injured
patient. Currently, the concept of ‘damage control’ has been well accepted. Damage
control has four phases. 1. Anticipation of ‘at- risk’ patients, based on the mechanism of
injury, and initial vital signs. 2. Damage-control procedures and surgery. These focus
only on controlling bleeding and preventing infection.
3. A period on ICU where the patient is fully resuscitated, minimizing the biologic
second hit. 4. A planned second procedure, where definitive repair of all injuries is
carried out.

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Cervical spine and neurological assessment
Patients with traumatic injuries to the head are at high risk of cervical spine injury. A
patient with a supraclavicular injury is considered to have a C-spine injury. Successful
diagnosis of cervical spine injury associated with maxillofacial trauma requires a high
index of suspicion in all cases besides a thorough clinical and radiological examination.
Until the C-spine is cleared radiologically and clinically, precautions must be made
during the perioperative period. The patient must be fitted with a neck collar (fig. 12) for
cervical spine immobilization. This is especially important during transport and
positioning for surgery.
Fig. (12): Neck collar for cervical spine immobilization.

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Injuries to the midface are most associated with C5-7 disruption (the most mobile part
of the cervical spine), while injuries to the lower face tend to be associated with C1-4
disruption. The incidence of cervical spine injury associated with maxillofacial trauma
varies in the literature from 0.3% to19.3% (24). Facial injuries associated with motor
vehicle accidents are more frequently associated with cervical spine injuries than those
caused by falls or assaults. The current recommendation is for radiological examination
of the cervical spine in every unconscious patient suffering from maxillofacial trauma. In
Fig. (13), MRI of fractured and dislocated neck vertebra compressing the spinal cord is
presented.
Fig. (13): Fractured neck vertebra.
Any patient with maxillofacial injury irrespective of whether it is associated with
fractures or not is always at risk of traumatic brain injury. Hence, all the patients with
maxillofacial injuries should be under neurosurgical observation and regular follow up.
Further, patients with maxillofacial fractures due to trauma have a higher risk of
intracranial hemorrhage when compared to those without maxillofacial fractures. Haug et
al (25), reported that 17.5% patients with facial fractures had some form of closed head

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injury whereas almost 10% sustained a severe intracranial injury. Early diagnosis of
traumatic brain injury leads to prompt treatment which is essential to improve the
outcome of these patients. In head injury patients, CT is the imaging modality of choice.
The predictors of intracranial hemorrhage include vomiting/ nausea, skull fractures,
seizures and C-spine injury. Among these C-spine injuries is the best predictor of intra
cranial hemorrhage. Vomiting is linked with a 25% higher risk of intracranial hemorrhage
and seizures are linked with a 15% higher risk of intracranial hemorrhage (26). If a
cerebrospinal fluid (CSF) leak is suspected, neurosurgical advice sought, and antibiotic
prophylaxis considered. CSF leak, (fig. 14) can happen because of trauma to ethmoid and
its cribriform plate, frontal sinus, anterior skull base and orbital roof. Most of the times
the patient presents with features like rhinorrhea, otorrhoea, headache, decreased hearing
sensation and a salty taste.
Fig. (14): Rhinorrhea & Otorrhoea.
Usually conscious patients with a Glasgow Coma Scale (GCS) score of 15 with no
clinical neurological abnormalities are not expected to have an intracranial pathology.
However, high velocity impact can result in intracranial hemorrhage. 2.8% of
neurologically “normal” patients suffer from intracranial hematomas (26). Hence
intracranial hemorrhage cannot be excluded in these patients. The use of the Glasgow
Coma Scale (27) became widespread in the 1980s when the first edition of the Advanced
Trauma and Life Support

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recommended its use in all trauma patients. The scale (fig. 15) is used to objectively
describe the extent of impaired consciousness level according to three aspects of
responsiveness: eye-opening, motor, and verbal responses. Reporting each of these
separately provides a clear, communicable picture of a patient’s state. Head injury is
considered severe if a Glasgow coma scores is less than or equal 8. The head injury is
considered as moderate, if a Glasgow coma score is 9 to 12, and in Glasgow coma scores
of 13 to 15, the head injury is considered as minor. However, the GCS requires
observation of eye-opening, motor and verbal score which is often unavailable in
intubated patients, brain steam injuries, and ocular trauma. Also, it must be interpreted in
cases of concurrent sedation. Further is the interpersonal variability in assessment of the
scores.
Fig. (15): Glasgow Coma Scale.

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References
1. Carmont MR. The Advanced Trauma Life Support part1 course: a history of its development and review
of related literature. Postgrad Med J; 81: 87, 2005.
2. American College of Surgeons, Committee on Trauma. Advanced trauma life support manual. 7th ed.
Chicago (Ill)7 American College of Surgeons; 2004.
3. Perry M. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 1:
dilemmas in the management of the multiply injured patient with coexisting facial injuries. Int J Oral
Maxillofac Surg; 37: 209, 2008.
4. Hollier LH, Kelley PK. Soft tissue and skeletal injuries of the face. Thorne CH. Grabb and Smith’s
Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; P: 315–332, 2007.
5. Ellis E III, Scott K. Assessment of patients with facial fractures. Emerg Med Clin. North Am; 16: 411,
2000.
6. Hutchison I, Lawlor M, Skinner D. ABC of major trauma. Major maxillofacial injuries. Brit Med J; 301:
595, 1990.
7. Krausz AA, El-Naaj IA, Barak M. Maxillofacial trauma patient: Coping with the difficult airway. World
J Emerg Surg; 4: 21, 2009.
8. Cranshaw J, Nolan J. Airway management after major trauma. Cont Edu Anaes, Crit Care & Pain; 6:
124, 2006.
9. Kostera RW, Baubinb MA, Bossaertc LL, et al. European Resuscitation Council Guidelines for
Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators.
Resuscitation; 81: 1277, 2010. 10. Finucane BT, Tsui BCH, Santora AH. Principles of airway management.
Springer, 2011.
11. Dupanovic M, Fox H, Kovac A. Management of the airway in multitrauma. Cur Opin Anaes; 23: 276,
2010.
12. Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality:
Lessons learned from 2,594 deaths. Ann Surg; 244: 371, 2006.
13. Seebacher J, Nozik D, Mathieu A. Inadvertent intracranial introduction of
a nasogastric tube, a complication of severe maxillofacial trauma. Anesthesiology; 42: 100, 1975.
14. Asai T. Videolaryngoscopes: Do they truly have roles in difficult
airways? Anesthesiology; 116: 515, 2012.
15. Wu SC, Chen RJ, Lee KW, et al. Angioembolization as an effective alternative for hemostasis in
intractable life-threatening maxillofacial trauma hemorrhage: case study. Am J Emerg Med; 25: 988,
2007.
16. Pallavan P, Sunil DP, Mannar MP,et al. A simple method to control scalp flap bleeding by plastic clips
made from disposable syringe barrel as an alternative method to Raney clips in cranial surgery. Ann Clin
Lab Res; 7: 278, 2019.
17. Ceallaigh P O´, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial
injuries in the emergency department. Part 1: advanced trauma life support. Emerg Med J; 23: 796, 2006.
18. Zachariades N, Rallis G, Papademetriou G, et al. Embolization for the treatment of pseudoaneurysm
and the transection of facial vessels. Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 92: 491, 2001.
19. Pritikin JB, Caldarelli DD, Panje WR. Endoscopic ligation of the internal maxillary artery for treatment
of intractable posterior epistaxis. Ann Otol Rhinol Laryngol; 107: 85, 1998.
20. Bynoe RP, Kerwin AJ, Parker 3rd HH, et al. Maxillofacial injuries and
life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma; 55: 74, 2003.
21. Wu S-C, Chen R-J, Lee K-W, et al. Angioembolization as an effective alternative

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for hemostasis in intractable life-threatening maxillofacial trauma hemorrhage: case study. Am J Emerg
Med; 25: 988, 2007.
22. Jackson R, Butler J. Hypertonic or isotonic saline in hypotensive patients with severe head injury.
Emerg Med J; 21: 80, 2004.
23. Perry M, O’Hare J, Porter G. Advanced Trauma Life Support (ATLS) and facial trauma: can one size
fit all? Part 3: hypovolaemia and facial injuries in the multiply injured patient. Int J Oral Maxillofac Surg;
37: 405, 2008.
24. Lalani Z, Bonanthaya KM. Cervical spine injury in maxillofacial trauma. Br J Oral Maxillofac Surg;
35: 243, 1997.
25. Haug RH, Savage JD, Likavec MJ, et al. A review of 100 closed head injuries associated with facial
fractures. J Oral Maxillofac Surg; 50: 218, 1992.
26. Kloss F, Laimer K, Hohlrieder M, et al. Traumatic intracranial haemorrhage in conscious patients with
facial fractures--a review of 1959 cases. J Cranio Maxillo fac Surg; 36: 372, 2008.
27. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet; 2:
81, 1974.

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Chapter 2: Management of soft tissue injuries

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Soft-tissue injuries with or without facial bone involvement are the most common presentation
following maxillofacial trauma. The damage can be limited to superficial tissues or involve
deeper structures. Males are more likely to sustain injury compared to females. Although rarely
life- threatening, the treatment of these injuries can be complex and may have significant impact
on the patients' facial aesthetics and function. The common causes of soft tissue facial trauma are
falls, activities of daily living, sports, violence, motor vehicle accidents, animal attacks, and self-
inflicted injuries (1,2).
Once the initial assessment has been performed and the patient stabilized, the soft-tissue facial
trauma can be carefully evaluated. Obtaining past medical and social history can help identify
factors that may affect wound healing. Compromised status such as diabetes, alcohol or tobacco
abuse, or past radiation therapy may negatively affect wound healing. The time and mechanism
of the injury should be recognized. An immunization history will help determine the need for
rabies or tetanus prophylaxis (3,4). Visual inspection and palpation should be used to
systematically examine the face for symmetry. Examination should start superiorly, with the
scalp and frontal bones, and proceed inferiorly and laterally. Thorough physical examination
should be performed. Clinical evaluation should be carried out under adequate light source. The
quality of the wound is examined, along with an assessment of the lacrimal apparatus, the
external auditory meatus, the facial nerve, parotid duct, and the underlying bone. The location,
size, shape, and depth of any wound should be noted, and exploration of the wounds should be
done for foreign bodies. In particular, the presence of nonviable tissue and/or the presence of
gross contamination are important to discern. The face is extremely vascular, and even minor
injuries may result in profuse bleeding. Copious irrigation should be used to clean and accurately
assess the injury. The wound is irrigated with normal saline and any debris and small foreign
bodies are removed to prevent infection or traumatic tattooing. Digital agitation can help
facilitate irrigation, or normal saline can be placed in a large syringe with an 18-gauge needle to
increase the pressure of irrigation. Devitalized tissue is then removed conservatively with sharp
debridement while preserving as much soft tissue as possible. Bleeding is controlled initially to
arrest gross hemorrhage; then hemostasis is achieved again during and after irrigation and
debridement. Direct pressure is the primary method to stop bleeding, along with the
identification and tying of visible vessels.

Fig. (1): Contusions.
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Facial soft tissue injuries vary in severity based on the impact force and type of injury into
minor superficial wounds to massive avulsions. In general, injuries can initially be classified as
open or closed wounds. A closed wound is one that damages underlying tissue and/or structures
without breaking the skin. Examples of closed wounds include hematomas, contusions, and crush
injuries. In contrast, open wounds involve a break in the skin, which exposes the underlying
structures to the external environment. Open wounds include simple and complex lacerations,
avulsions, punctures, abrasions, accidental tattooing, and retained foreign body.
Wounds can be classified according to their general condition, size, location, the way the skinor
tissue is broken, and the agent that caused the wound (5):
1. Contusion:
Contusion (fig.1) typically caused by blunt trauma. There is extravasation of blood
within the tissue that may or may not be accompanied by a hematoma. Most frequently,
contusions are treated with conservative therapy even if a hematoma is present. In some
instances, a hematoma may require evacuation and if neglected may lead to the
accumulation of scar tissue.

32
2. Abrasion:
Abrasions (fig.2) are partial-thickness disruptions of the epidermis without disruption of the
deeper dermal layer as a result of sudden, forcible friction. These wounds require cleansing with
mild non irritating soap and left uncovered. Only when contaminated, topical application of
antibiotic ointment, is indicated. Ointment keeps the wound moist and prevents scab formation,
which aids in the re-epithelialization process. Antibiotic ointment is recommended in the first 2
to 7 days, followed by ointment without antibiotics, such as petroleum jelly (6). Systemic
antibiotics are generally not recommended in clean, simple wounds of the face and neck that are
adequately irrigated and debrided.
Fig. (2): Abrasions.

33
3. Laceration:
A laceration (fig.3) is a disruption of both the epidermis and dermis. The resultant wound may
have clean edges that can be repaired with little manipulation or nonviable tissue that requires
extensive debridement before closure. Simple lacerations are the most common type. Skin repair
should be undertaken when underlying tissues are put in order. Muscles involved in a deep
lacerated wound should be accurately approximated with fine sutures. The wound is then closed
in layers from the inside out. Ragged wound edges should be considerably excised to provide
perpendicular edges that will heal primarily with a minimum of scar. Lacerations of the parotid
duct and/or facial nerve may require microsurgical techniques for re-anastomosed.
Fig. (3): Lacerations.
4. Avulsion:
An avulsion (fig.4) is the forcible tearing away or separation and subsequent loss of a bodily
structure or part, either as the result of injury or as an intentional surgical procedure. Avulsion

34
injuries are the most challenging to repair and should not be allowed to heal spontaneously by
the scar tissue. Completely detached tissue pieces and some small avulsions can be sutured back
into position as grafts. If the wounds cannot be closed because of avulsion and loss of soft tissue,
dressing of the area with a split-thickness skin graft provides immediate closure and avoids
infection. Larger defects may require local or regional flaps. In extensive avulsion injuries, free
tissue transfer may be required.
Fig. (4): Avulsions.
The face can be divided into specific areas, designated as “aesthetic units”, within which the
skin has similar characteristics, such as color, thickness, amount of subcutaneous fat, texture and
presence of hair. These “units” are separated from each other by relatively well- defined ridges
and creases, designated as “aesthetic borders”. The borders include easily discernable landmarks
such as the hairline, eyebrows, nasolabial fold, philtrum, vermillion border and labiomental fold

35
(7).The original 14 aesthetic units as classified by Gonzales-Ulloa (8) included: forehead, right
and left cheeks, nose, right and left upper lids, right and left lower lids, right and left ears, upper
lip, lower lip, mental region, and the neck. Burget and Menick (9), revitalized interest in the field
of aesthetic facial units by introducing the concept of the “subunit theory.” They observed facial
surfaces and described ridges and valleys, which formed convex and concave regions allowing
different light reflection. They further surmised that if a graft or a suture line is matched to the
shape of a subunit, the natural appearance of lights and shadows is restored, thereby allowing the
reconstruction to remain imperceptible because the scars are perceived as normal facial
topography. Application of this principle led to the establishment of nasal subunits by nasal
reconstructive surgeons. Additional minor modifications of the aesthetic subunits have been
proposed.
Fig. (5): Modified facial aesthetic units/subunits.

36
Principles of repair
Regardless of whether the injury is an abrasion, avulsion, or laceration, the initial management
is the same. Keeping the wound moist with sterile saline-soaked gauze is recommended. All dirt,
debris, and foreign material must be carefully and thoroughly removed to avoid the risk of
infection or traumatic tattoos. If irrigation techniques are not sufficient, then a scrub brush may
be used to remove all material, paying careful attention as to not further damage the delicate
tissues or devitalize any partially avulsed flaps. Tissue manipulation can be performed under
local infiltration of anesthetic for most wounds, although regional nerve blocks may also be
appropriate in some settings. In severe, multiple injuries general anesthesia is required.
The timing of repair has been a topic of debate over the course of the past 20 years. Currently,
however, the paradigm has shifted to immediate definitive repair after irrigation and initial
debridement of devitalized tissue. Hochberg et al. (10), argue that the best period for primary
repair is within 8 hours of the injury. Tissues are less vulnerable to infection, and wound healing
is at its optimum during that time. Further, early closure seals off the pathways of infection and
promotes rapid healing which keeps scar contracture a minimum. Delayed closure is reserved for
grossly contaminated wounds, selected animal bites, infected wounds, and wounds greater than
24 hours old. This is thought to reduce the chances of becoming infected. Primary closure of
contaminated wounds may lead to an increased chance of infection.
Antibiotics:
Classifying traumatic wounds as either clean or dirty helps to determine need for prophylactic
antibiotics and tetanus treatment. Clean traumatic wounds or lacerations without evidence of
contamination or signs of infection and do not require prophylactic antibiotic treatment.
Prophylactic antibiotics should be used in contaminated wounds, with devitalized tissue, patients
with prosthetic devices, and patients with compromised host defenses. Other factors that must be
considered include the mechanism of injury and the time of presentation. Wounds associated
with compound fractures deserve prophylactic antibiotic treatment as well. In general 5 to 7 days
is sufficient. Grossly infected wounds are given therapeutic treatment with 48 hours of
intravenous antibiotics, followed by a total 10 to 14 days of the oral equivalent.

37
Wound closure
Techniques for wound closure depend on the location, depth, and characteristics of the injury.
Suturing is the commonest method of wound closure, especially with full- thickness or deep
lacerations. These are usually closed “in layers.” The underlying tissues are precisely aligned to
eliminate any “dead space” beneath the surface. Closing the skin only and leaving a potential
space or cavity can predispose to abscess formation and compromise wound healing. When
closing the skin, the aim is to produce a neatly opposed and everted wound edge. A small amount
of eversion is reported to compensate for depression of the scar during wound contraction.
Inversion of the wound edges produces an inferior result and should be avoided.
There are many well-known suturing techniques; however, regardless of the type of repair
performed, 3 important principles should be met: precise approximation and eversion of the skin
edges, avoidance of excessive tension, and a layered closure to prevent dead space and fluid
accumulation (11). A small amount of eversion is reported to compensate for depression of the
scar during wound contraction. Inversion of the wound edges produces an inferior result and
should be avoided. Any tension on the skin layer increases risk of a widened scar or wound
dehiscence. Employment of a multi-layered closure most ably creates a tension-free wound (12).
Additional key elements include covering any exposed cartilage or bone with soft tissue.
When applicable, closure along the relaxed skin tension lines, also referred to as “RSTL”, and
abiding by the facial aesthetic units, can aid in making a scar more inconspicuous. Relaxed skin
tension lines (fig.6), described by Borges and Alexander (13), result from the orientation of the
collagen fibers in the skin. These tend to heal well and mature into acceptable scars that mimic or
are disguised by natural wrinkles. Unfortunately, this luxury is not always available when
managing traumatic wounds, whereas some lacerations may be sited unfavorably and typically
presented perpendicular to the RSTL. These are more likely to heal poorly and stretch.

38
Fig. (6): Relaxed skin tension lines.
There are two fundamental suture types: absorbable and permanent (14). Suture selection is
based on several factors including the depth of the injury, the extent of skin loss, and the
anatomic structures involved. In general, muscle edges are realigned with a 4-0 absorbable
suture. For deep dermal sutures, a 4-0 or 5-0 resorbable monofilament is appropriate. For
superficial skin layers, a 5-0 to 7-0 fast- absorbing or non resorbable monofilament, such as
propylene or nylon, is used. Meticulous realignment of skin edges is important, especially along
the borders of esthetic subunits. The amount of undermining necessary prior to closure varies
with the degree of tension anticipated with the closure. Special attention should be paid to realign
the vermilion-cutaneous border, eyelid margin, nasal rim, brow or any hair-bearing borders.
Commonly used suture techniques are presented in Fig. (7).

39
Fig. (7): Commonly used suture techniques for laceration repair.

40
The use of drains in acute facial trauma is not routine but may be advisable in wounds with
extensive dead space or following closure after evacuation of a hematoma. A simple latex (e.g.,
Penrose) drain may be used to facilitate drainage and inhibit re-accumulation. In areas with a
large dead space closed suction drains may be more appropriate. Sutures placed in the face are
usually removed around 5 days after surgery, or even earlier in delicate tissues such as the
eyelids. With neck lacerations, sutures are often retained for longer (7-10 days). Scalp sutures are
similarly left for 7-10 days. It should be mentioned that the most common reasons for suture scar
or suture mark are closing the wounds under tension and delayed sutures removal.
Alternatives to sutures include metal clips, adhesive paper tapes and skin adhesives (e.g.,
cyanoacrylate glue). Staples can be used in hair-bearing areas, and tape with or without adhesive
can be used alone in sub-centimeter wounds or in conjunction with sutures. These can be applied
quickly, but accurate alignment of skin edges can be difficult. Metal clips tend to be reserved for
lacerations involving the scalp. Adhesive paper tapes and skin glues are especially useful in
children and those who will not cooperate. The final cosmetic results are less predictable with
these techniques compared to carefully placed sutures.
Delayed primary closure may be necessary when doubt exists about the viability of a wound,
or if it becomes infected. This is most likely to be the case following blast or high-impact
injuries. Crushed tissues are especially difficult to manage. These may initially appear viable but
may later become necrotic. Multiple surgical procedures may be required. Split-thickness skin
grafts may be used as a temporary measure if there is tissue loss, with revision surgery delayed
until the patient has recovered or there are minimal risks of infection. Frequently, extensive
injuries with massive tissues loss or avulsions may be encountered. In these situations, proper
planning, staging of the surgical procedures, and use of local or regional flaps may provide the
patient with acceptable aesthetic and functional outcome.
There are many methods available to import tissue to the head and neck region; the management
plan is individualized to the case at hand. Local tissue flaps have limited amounts of tissue and a
modest vascular supply, and thus are often saved for the final stages of reconstruction for minor
contouring. Pedicled myocutaneous flaps offer large amounts of tissue with reliable vascularity
for soft tissue coverage but are often bulky and are limited by the length of the vascular pedicle.

41
Free tissue transfer allows the early reconstruction of damaged bones and provides soft tissue
coverage soon after injury (15). Additional reconstructive techniques and tools include implants,
tissue expanders, and epidermal skin grafting, although these are not frequently used in the acute
setting (16).

42
References
1. Kraft A, Abermann E, Stigler R, et al. Craniomaxillofacial trauma: synopsis of 14,654 cases with 35,129
injuries in 15 years. Craniomaxillofac Trauma Reconstr; 5: 41, 2012.
2. Gassner R, Tuli T, Hächl O, et al. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067
injuries. J Craniomaxillofac Surg; 31: 51, 2003.
3. Bailey AM, HolderMC, Baker SN, et al. Rabies prophylaxis in the emergency department. Adv Emerg Nurs J;
35: 110, 2013.
4. Miyagi K, Shah AK. Tetanus prophylaxis in the management of patients with acute wounds. J Plast
Reconstr Aesthet Surg; 64: e267, 2011.
5. Marks M, Polecritti D, Bergman R, et al. Emergent soft tissue repair in facial trauma. Facial Plast Surg Clin N
Am; 25: 593, 2017.
6. Crecelius C. Soft tissue trauma. Atlas Oral Maxillofac Surg Clin North Am; 21: 49, 2013.
7. Ilankovan V, Elhunandan M, Seah TE. Facial units and subunits. Local flaps in facial reconstruction. 23-43, 2014.
8. Gonzales-Ulloa M: Restoration of the face covering by means of selected skin in regional aesthetic units. Br J
Plast Surg; 9: 212, 1956.
9. Burget GC, Menick FJ: The subunit principle in nasal reconstruction. Plast Reconstr Surg; 76: 239, 1985.
10. Hochberg J, Ardenghy M, Toledo S, et al. Soft tissue injuries to face and neck: early assessment and repair,
World J Surg; 25: 1023, 2001.
11. Thorne CH. Grabb and Smith’s plastic surgery. 7 th edition. Philadelphia: Lippincott Williams & Wilkins; p.
2, 2014.
12. Key SJ, Thomas DW, Shepherd JP. The management of soft tissue facial wounds. Br J Oral Maxillofac
Surg 33:76, 1995.
13. Borges, AF, Alexander, JE. Relaxed skin tension lines, z-plasties on scars, and fusiformexcision of lesions. Br J
Plast Surg; 15: 242, 1962.
14. Ratner D: Basic suture materials and suturing techniques. Semin Dermatol; 13: 20, 1994.
15. Futran ND, Farwell DG, Smith RB, et al. Definitive management of severe facial trauma utilizing free
tissue transfer. Otolaryngol Head Neck Surg; 132: 75, 2005.
16. Jaiswal R, Pu LL. Reconstruction after complex facial trauma: achieving optimal outcome through
multiple contemporary surgeries. Ann Plast Surg; 70: 406, 2013.

43
Section II: Midface fractures
Chapter 3: Facial bone fractures: An overview
Chapter 4: Nasal and nasoethmoidal fractures
Chapter 5: Zygomatic complex fractures
Chapter 6: Orbital floor blow-out fractures

44
Chapter3: Facial bone fractures: An overview

45
Craniofacial skeleton
The skull (fig.1) is composed of three principle bony structures: cranial vault, cranial base, and
facial skeleton. Eight bones form the cranial vault: two parietal bones, two temporal bones,
frontal bone, occipital bone, sphenoidal and ethmoidal bones. The rigid cranial vault protects the
brain from external injury. The brain rests on cranial base. This constitutes ‘‘neurocranium’’ (1).
The facial skeleton (fig. 2) can be divided for convenience into three parts.
the upper third of facial skeleton being a part of cranial vault and comprising of frontal bone,
the middle third comprising of central midfacial bone: the maxilla, the nasoethmoid, and lateral
midfacial bone: zygoma,
and the lower third comprising of rigid bone: mandible, with its condylar articulation to base of
skull (1). The facial skeleton constitutes with the oral cavity and other associated soft tissues,
‘‘viscerocranium’’. Fifteen irregular bones form the facial skeleton: three singular bones lying in
the midline; mandible, ethmoid, and vomer and six paired bones occurring bilaterally; maxilla,
inferior nasal concha (turbinate), zygomatic, palatine, nasal, and lacrimal bones. The facial
skeleton is made up of a series of irregular flattened bones that (with exception of the mandible)
is joined by static articulations called sutures. In adults, sutures are believed to function primarily
as shock absorbers to dissipate stresses transmitted through the skull (2). Anatomically, thebones
of the cranial vault and the mandible have a basic structure like many other bones of the skeleton
with a strong outer cortex and a cancellous center. In contrast, most of the bones of the midfacial
region are comprised only of a thin layer of cortical bone (fig.3) and exhibit significant variations
in their thickness and composition (3).

46
Fig. (1): Craniofacial skeleton.
Fig. (2): Facial skeleton.

47
Facial bone fractures
The bone and soft tissues of the midfacial region can absorb the energy from impact forces.
Force to the bone in the elastic range causing the deformation and after force removal, bone
returns to its previous state, but if the force be greater than the elasticity of bone, a permanent
displacement occurs and be irreversible. Furthermore, when these forces exceed the strength of
these tissues, a variety of fractures can occur at this region. Fig. (4), shows the load deformation
curve.
Fig. (4): Load-deformation curve.
The characteristics of fractures resulting from trauma are determined by a dynamic factor
(given by the force and energy of the impact) and by a static factor (given by the anatomic
characteristics of the bone involved). A small impact area results in a localized fracture, whereas
a large impact
Fig. (3): Thin, fragile mid-facial bones.

48
area leads to more extensive indirect fractures, because the force is being transmitted over a
larger area of bone (4). According to geometry of face, protruding areas are most likely to
sustain injury. Thus, the nasal bones are most injured, followed by malar bones, orbital rims, and
symphysis of the mandible. The area of the frontal bone is most resistant to injury. As fracture
occurs energy absorption takes place, thus protecting the brain from violent deceleration. The
nasal bones were the most fragile of the facial bones, with tolerance levels for minimal fracture
in the 25-75 Nm range. The maxilla displayed low tolerance level in the range of 150-300 Nm.
The relatively fragile zygomatic arch displayed tolerance levels between 200 and 400 Nm,
whereas the body of the zygoma displayed a higher tolerance level with a grouping in the 200-
650 Nm range. The massive frontal bone displayed the highest tolerance levels with grouping
between 800 and 1600 Nm. The minimum load required to fracture different bones of the facial
skeleton is given in fig. (5). Interesting to note that the bite forces in healthy middle-aged
humans averages 520 Nm for males and 340 Nm for females. However, maximal forces have
produced up to the high 700s.
Fig. (5): Load required to cause fracture of facial bones.

49
The buttress theory:
The buttress theory proposes that the midfacial region is like a framework that is stabilized by
horizontal and vertical buttresses. These buttresses believed to absorb considerable amount of
traumatic energy approaching the midface region from below. However, the midface has very
low tolerance to impact forces applied from other directions, with nasal bones exhibiting the
least resistance (5). Bio-mechanical load distribution along facial buttresses is illustrated in fig.
(6). The buttresses represent areas of relative increased bone thickness that support both the
functional units and the form of the face in an optimal relation, and forces directed toward the
face are distributed along these buttresses. Facial buttresses can be classified into vertical and
horizontal buttresses (5). The vertical buttresses are: the nasomaxillary buttress (connections
between the maxilla and nasal bones), the zygomaticomaxillary buttress (from the maxilla to the
zygomatic region), the pterygomaxillary buttress (from the maxilla to the pterygoid process) and
the posterior or mandibular buttress (ascending ramus of the mandible). The horizontal
buttresses include: (1) frontal bar, (2) transverse zygomatic buttress, (3) transverse maxillary
buttress, (4) upper transverse mandibular buttress, (5) lower transverse mandibular buttress.
Fig. (6): Biomechanical load distribution along facial

50
Etiology
The most common causes of maxillofacial trauma are traffic accidents, injuries from fights,
sport accidents or falls. The combination of traffic accidents and injuries from fights account for
80% of maxillofacial fractures (6). The force of impact can be derived from the equation F =
m×a (7), where: Force = mass (weight) × acceleration (speed).
Classifications
Around the turn of the 19th into the 20th centuries, René Le Fort, a French surgeon, conducted
a series of experiments using human cadavers to study facial bone fractures resulting from blunt
trauma. The impacts included hitting the midface of a whole or decapitated cadaver with a
baseball bat and hitting the midface region onto a granite tabletop. He then cut the body
segments open and studied the fractures they had sustained (8). He concluded that midface
fractures occurred through ‘lines’ of inherent weakness in the facial skeletal structure, producing
defined injury patterns. The fracture patterns were predictable and reproducible, depending on
the site of impact on the midface. He then formulated a classification system still extensively
used today: Le Fort classification. Common to these fractures is involvement of the pterygoid
plates. The Le Fort I fracture extends horizontally across the maxilla above the level of the roots
of the teeth, traversing the lower lateral walls of the pyriform aperture and the lower nasal
septum. It extends posteriorly across the lateral, medial and posterior walls of the maxillary
sinus and involves the pterygoid plates. Unique to Le Fort I fracture is the involvement of the
lateral walls of the pyriform aperture. The Le Fort II fracture is pyramidal, with the apex at the
naos-frontal suture. From the apex, the fracture line extends inferolaterally through the medial
wall of the orbit, orbital floor, inferior orbital rim and through the zygomatico-maxillary suture.
It also extends posteriorly to the pterygoid plates. Unique to Le Fort II fractures is involvement
of the inferior orbital rim. The Le Fort III fracture, also known as cranio-facial disjunction, is
like the Le Fort II, and comprises dissociation of the naso-frontal suture. However, this is
horizontally oriented, traversing the medial and lateral walls of the orbits, the zygomatico-
frontal suture and the zygomatic arch. Involvement of the latter is unique to type III fractures
(9). Fig. (7) Shows the anatomical locations of Le Fort I fracture classifications.

51
Fig. (7): Le Fort fractures. Three-dimensional CT images of an adult skull in frontal
and lateral orientations with color overlays show the osseous facial structures that are
typically affected by type I (red), type II (blue), and type III (yellow).
Although useful in describing a midface fracture, Le Fort’s classification is based on low-
velocity trauma and does not completely reflect the breadth of high-velocity fractures
encountered in modern practice. In addition, it underestimates the complexity of facial fracture
patterns, which often include combination of front-orbital, zygomatic, and nasoethmoidal
fractures with maxillary injury. Moreover, it does not define the facial skeletal supports or the
more severely comminuted fractures.
Currently, facial fractures are classified into central midface fractures, lateral midface fractures
and mandibular fractures. Central midface fractures include nasal, nasoethmoidal, orbital wall,
maxillary sinus, Le Fort I, and Le Fort II fractures. Lateral midface fractures include fractures of
the zygomatic-malar complex, zygomatic arch, and orbital floor fractures. While Le Fort III
fractures are combined central and lateral midface fractures. In another way, facial bone
fractures are classified as isolated or complex fractures. In a series of multi-trauma patients with
over 7,000 facial bone fractures, 24.3% affected the mandible and 71.5% affected the central
and lateral midface. Almost one third of fractures simultaneously affected more than one area of
the face (10). In another study comprising 2,094 cases with facial bone fractures (11), the most
common isolated fracture site was the nasal bone (37.7%), followed by the mandible (30%),

53
(7.6%), zygoma (5.7%), maxilla (1.3%) and the frontal bone (0.3%). The largest group with
complex fractures included the inferior orbital wall and zygomaticomaxillary (14%).
Nasal fractures
Nasal fractures (fig. 8), are the most common facial fractures, accounting for 50% of isolated
fractures of the face (12). Any fracture that involves the nasal bones, septum, or the nasal
process of the maxillary process is considered a nasal fracture. Symptoms may include bleeding,
swelling, bruising, and an inability to breathe through the nose. They may be complicated in
complex pattern by other facial fractures.
Fig. (8): Nasal fracture.
Nasoethmoidal fractures
Nasoethmoidal fractures (fig. 9), occurred at a frequency of 7%. These fractures most often
result from a frontal blow over the bridge of the nose, and the nasal pyramid is displaced
posteriorly, fracturing the nasal bones, frontal processes of the maxillae, lacrimal bones,
ethmoid sinuses, cribriform plate, and nasal septum. In patients with comminution, the bony
segments may spread medially into the nasal cavity, superiorly to the anterior cranial fossa, and
laterally into the orbit. CSF leaks should be suspected.

54
Fig. (9): Axial CT, nasoethmoidal fractures.
Zygomatic bone fracture
Zygomatic bone fracture (fig.10) is the second most common midfacial injury, following nasal
fracture. A zygomatic complex fracture is characterized by separation of the zygoma from its
four articulations (frontal, sphenoidal, temporal, and maxillary). An independent fracture of the
zygomatic arch (fig.11) is termed an isolated zygomatic arch fracture.
Fig. (10): Axil CT, zygomatic complex fracture.

55
Fig. (11): Axial CT, isolated zygomatic arch fracture.
Orbital fractures
Because of the complex anatomy of the region, orbital fractures are often associated with
maxillary, zygomatic and/or nasal fractures. Isolated orbital fractures can be classified as ‘blow-
out’ or ‘blow-in’. Most blow-out fractures affect the anteroinferomedial aspect of the orbital
cavity and displace the orbital globe posteromedially and inferiorly. A significant increase in the
volume of the orbital cavity results in herniation of the orbital floor and globe to the maxillary
sinus (fig.12). Less often, fracture segments can herniate upward into the orbit, which is called
blow-in fracture (13).

56
Fig. (12): Coronal CT, orbital floor fracture.
Panfacial fractures
Panfacial fractures (fig. 13) result from high-energy mechanisms such as motor vehicle
collisions and gunshot wounds. There are higher chances of cervical spine and cerebral injuries
with these fractures compared to the other facial fractures. The upper, middle, and lower faces
need to be involved to be labeled as panfacial fracture (14). Clinical examination and computed
tomography imaging are the gold standards in the diagnosis, planning, and management of
facial fractures (15).

57
Fig. (13): 3D CT, Panfacial fractures.
Treatment
Significant advances have occurred during the last two decades in the methods of fixation used
for facial bone fractures, resulting in improved functional and aesthetic outcomes. Surgical
techniques have been moving away from delayed closed reduction with internal wires
suspension to early open reduction and internal plate fixation. The transition from wire
osteosynthesis to rigid internal fixation in craniofacial reconstruction using different micro or
mini-plates and screw systems is regarded as one of the greatest advances in the field of
maxillofacial surgery. The high degree of ductility in these microplate screw fixation systems
permits an optimal adaptation to the thin facial bone and provides three-dimensional stability
(16). Interesting to note that plating of fractures began in 1895 when Lane first introduced a
metal plate for use in internal fixation (17). Lane’s plate (fig. 16) was eventually abandoned
owing to problems with corrosion. Today, the use of miniplates provides the principal modality
of treatment for reduction and fixation of displaced facial fractures. Titanium plates and screws
are, currently considered the “gold standard” to immobilize displaced fracture segments.

58
Fig. (16): Lane’s plate. Please note the design and morphology of the
plate. The plate shows four holes and is retained by mono cortical
screws (18).
The main limitation with plate fixation is the larger surgical exposure required and greater
profile (thickness) of the plate beneath the soft tissue. The conventional fixation of
osteosynthesis plates requires areas of enough cortical bone mass to insert screws. This may be
difficult to achieve at sites where the boney structures are very thin and can cause further
fractures due to the force applied to the fragments (19). The face has relatively little soft tissue
to provide coverage to hardware from the outer surface. It is therefore not surprising that
palpable/ prominent plates and screws are one of the common complications in craniofacial
procedures. The sliding of the overlying soft tissue of the face over the hardware can result in
erosion, infection and subsequent exposure of the fixation devices. Large size hardware has a
larger tendency toward eroding the overlaying tissue (20). The use of biodegradable implants,
glues and adhesive for fracture fixation has potential to overcome many of the problems
associated with microplate screw fixation systems. However, to date, substances with adhesive
properties for bone gluing purposes are limited due to bad biocompatibility, high infection rates
and lack of enough adhesive stability (21). The principle aim of these devices and techniques is
to reconstruct the pre-traumatic facial appearance, including the facial width, projection, and
height (22). The restoration of the normal function of the facial structures is another aim in
facial fracture management. Modern therapy also mandates the rigid stabilization of the vertical
and horizontal facial buttress to withstand the forces of mastication. Different treatment
approaches exist to restore the facial skeleton using the different facial buttresses as landmarks.
The frontal bar defines the contour of the upper third of the face. The inferior orbital rim and
malar prominence define the width and projection of the midface. The maxillary alveolus and
piriform aperture provide the platform for nasal reconstruction. Re-establishment of these
buttresses is essential for the maintenance of midface

59
height, width, and projection. Reconstruction can be done in a “bottom up & inside out” or “top
down & outside in” (23). The occlusion gives a reference for the width and the vertical and
horizontal planes. Starting from a stable area to an unstable one is advocated.
Despite the advancement in the different types of technologies and methods of bone fixation,
clinicians continue to experience complications and challenging reconstruction conditions.
Several authors reported an overall complication rate among craniofacial procedures between
14% and 22% (24,25). Infection is one of the most encountered problem and is one of the main
causes for removal of maxillofacial internal fixation hardware. Nonunion or malunion usually
results from failure to either adequately reduce disparate fracture fragments or not establishing
adequate bone-to-bone contact. This can result in excessive motion between the bone segments
and cause tissue rupture in the forming callus and / or hardware failure. Mobility of the bone
fragments can cause numerous problems such as malocclusion and diplopia (26,27). As such,
but even so, we are still far from ideal.

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Wolters Kluwer business. P. 486, 2015.
2. Rafferty KL, Herring SW, Marshall CD. Biomechanics of the rostrum and the role of facial sutures. J
Morphol; 257: 33, 2003.
3. Richard A. Pollock RA. Craniomaxillofacial Buttresses: Anatomy and Operative Repair. Thieme New York •
Stuttgart. P. 48, 2012.
4. Schuknecht B, Graetz K. Radiologic assessment of maxillofacial, mandibular, and skull base trauma. Eur
Radiol; 15: 560, 2005.
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Winegar B, Murillo H, Tantiwongkosi B. Spectrum of critical imaging findings in complex facial skeletal trauma.
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11. Hwang K, Sun Hye You SH. Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J
Plast Surg; 43: 42, 2010.
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Surg; 60: 398, 2008.
13. Som PM, Brandwein MS. Facial fractures and postoperative findings. In: Som PM, Curtin HD (eds). Head
and neck imaging. Mosby, St. Louis: P. 374-438, 2002.
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Am; 25: 649, 2013.
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facial fractures. Oral Maxillofacial Surg Clin North Am; 25: 545, 2013.
16. Terry BC, Härle F, Härle F, et al. Atlas of Craniomaxillofacial Osteosynthesis: Microplates, Miniplates, and
Screws. 2nd ed. Stuttgart; New York: Thieme, 2009. 17.
Lane WA. Some remarks on the treatment of fractures. Brit Med J; 1: 861, 1895. doi: 10.1136/bmj.1.1790.861.
18. Bechtol CO, Fergusson A B, Laing PE. Metals and engineering in bone and joint surgery. Baltimore:
Williams Wilkins. P. 20, 1959.
19. Smeets R, Marx R, Kolk A, et al. In vitro study of adhesivepolymethylmethacrylate bone cement bonding
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2459, 2007.
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27. Murthy AS, Lehman JA,Jr. Symptomatic plate removal in maxillofacial trauma: A review of 76 cases.
Ann Plast Surg; 55: 603, 2005.

62
Chapter 4: Nasal and nasoethmoidal fractures

63
Nasal bone fractures
The nasal pyramid is positioned on the center of the face and is significantly anteriorly
protruded compared to the other facial structures. The structural framework of the nose includes
the nasal bones, the nasal septum, the nasal process of the frontal bone, the frontal process of the
maxilla, the ethmoid bone, the vomer, and cartilaginous structures. The nasal bones superiorly
articulate through a serrated joint with the nasal part of the frontal bone. Laterally, they
articulate with the frontal process of the maxilla. The two nasal bones articulate with each other
around the midline of the nose. Superiorly, above the intercanthal line, the nasal bones are thick,
they gradually thin to the notched inferior borders that are continuous with the lateral nasal
cartilages. The transition between the thicker and thinner nasal bone is a common fracture site
(1). The quadrangular, or septal, cartilage comprises most of the septum with bony contributions
from the vomer inferiorly and perpendicular plate of the ethmoid posteriorly and superiorly. The
septal cartilage provides supports the nasal bones from below. The upper lateral cartilages
contribute to the midline support of the cartilaginous septum. The paired lower lateral cartilages
provide little septal support but are essential in the aesthetics and contour of the nasal tip. The
lateral nasal walls contain 3 pairs each of small, thin, shell-like bones: the superior, middle, and
inferior conchae, which form the bony framework of the turbinates. Lateral to these curved
structures lies the medial wall of the maxillary sinus. Anatomy of the nose is given in figs.
(1,2,3). Because of its central location and prominent position, nasal bone fractures are the most
common bony fractures of the face. According to several retrospective studies, nasal bone
fractures comprise up to 50% of all facial fractures (2). Fractures of the nose can not only result
in cosmetic changes, but also lead to functional concerns. In fact, it is quite common to have
permanent obstruction of the nasal passages after sustaining nasal trauma. Nasal fractures most
commonly result from blunt facial trauma in events, such as motor vehicle accidents, sports-
related injuries, assaults, and falls (3). It has been reported that fracture of nasal bone was
common in males than females and the common age group was between 20 and 39 years (4).

64
Fig. (1): Bones of the nasal cavity.
Fig. (2): Nasal septum.

65
Fig. (3): Cartilaginous structures of the nose.
Classification
No universally accepted classification of nasal fracture pattern exists although many clinical,
anatomic, and radiographic classifications have been proposed (1,5,6,7). Nasal fractures can be
classified in two broad categories based on impact force: lateral-type versus frontal-type injuries
(6). Lateral-type injuries tend to be more common, have fewer residual anatomic and functional
defects compared with frontal injuries, and are more amenable to closed reduction. Frontal
injuries classically produce a posteriorly displaced fracture where the nasal septum is always
involved. They have a higher risk of residual post-surgical deformity, and as the impact force
increases, nasal, orbital, and ethmoidal fractures occur in combination.
Assessment
A detailed record of the events surrounding the nasal trauma should be elicited to determine the
type and severity of injuries that may be present. Patients who have sustained an assault should
be questioned about the nature of the striking object and the direction of the sustaining blow.
Functional inquiry evaluates breathing and smell. Persistent watery discharge with salty taste
raises suspicion for a cerebrospinal fluid leak. A review of the patient’s medical history should
include any prior nasal injury, nasal deformity, nasal or facial surgery, allergies, or sinus disease.
The

66
presence of nasal swelling, nasal deformity, nasal obstruction, and epistaxis are all signs of nasal
trauma and warrant a complete examination. Physical examination of the nose should be
approached in a stepwise, routine fashion. Examination includes a visual assessment of the nasal
deviation, location of any lacerations, and assessment of the degree of swelling and bruising. The
patients most commonly, are presented with lacerated wound, nasal swelling, nasal deformity,
and epistaxis figs. (4&5). An intranasal examination to determine the status of the septum should
be carried out under adequate lighting and using a nasal speculum. A full endoscopic
examination is advised for a complete assessment of the nasal septum. This may reveal septal
hematoma and/ or deviated nasal septum, fig. (6&7). Usually, lateral force results in
displacement or a fracture of the septal cartilage from the maxillary crest, producing a partial or
complete obstruction on one side of the nasal cavity. In contrast, frontal force, may fracture the
septum in a more medial direction. Most septal fractures result in some deviation or telescoping
of the cartilages.
Fig. (4): Common presentation of nasal
fracture; lacerated wound, nasal swelling,
and epistaxis.
Fig. (5): Lateral impact results in fractures of
the nasal bone and septal cartilage.

Fig. (6): Septal hematoma. Fig. (7): Deviated nasal septum.
Palpation may reveal specific areas of tenderness, crepitus, or a bony step. Telecanthus, or
widening of the intercanthal distance, should be noted as well. The intercanthal distance may be
increased in severe injuries, indicating a more complex nasoethmoidal injury. Radiographic
examination, although routinely performed, is often of questionable value (8). Plain films
(fig.8), are of little benefit in the diagnosis or management of nasal fractures. A CT scan
provides better information, particularly of the position of the septum and patency of the airway
(fig.9). However, Lee et al (9) reported that sonography (fig.10) is superior to CT in terms of
accuracy and reliability in evaluating nasal fractures. Further, Chou et al (10), recommended its
use in preliminary assessment of a patient with suspected nasal bone fractures.
Fig. (8): Plain radiographs often are misleading about the existence of a nasal
fracture, and do not provide an assessment of the cartilaginous septum.

Fig. (10): Axial sonography showing depressed
fracture of the nasal bone.
Management
Not all nasal fractures require surgical manipulation. The extent of the bony or cartilaginous
deformity determines the appropriate treatment. The septal component requires accurate
reduction and alignment if secondary deformities are to be avoided. The extent of the septal
injury determines the appropriate technique for septal correction (11). There are different
modalities for reduction of fracture nasal bones starting from simple manipulation to open
reduction and rhinoplasty. Closed reduction of fractured nasal bone can be performed by
elevation of depressed bones or depression of elevated bones to restore the symmetry of the
nasal aperture. Septal injuries that cannot be realigned with a closed reduction should be
addressed with open techniques.
Fig. (9): Axial CT offers a much better view of nasal
anatomy.

Closed reduction
General anesthesia greatly facilitates a successful closed reduction. Although local anesthesia
alone is often used. The nasal bones usually can be manually manipulated back into a midline
position. If required, depressed nasal fragments can be elevated using the Boies straight elevator
internally and digital manipulation externally (fig.11). Minor dislocations of the septum along
the vomerine groove can be reduced with the same instrument. Walsham forceps may be
required for severe impactions as a method of grasping the septum and lifting (fig.12). Support
for the nasal bones and septum is usually provided by gel foam packing, which also aids
hemostasis. After reduction, the nose is taped (fig.13) and splinted for one week. Because of the
well-documented reports of recurrent deviation after closed reduction, patients are followed
closely for 1 year.
Fig. (11): The use of Boies straight elevator with digital manipulation to reduce
nasal fracture.

Fig. (12): Closed reduction of nasal bone using Walsham forceps.
Fig. (13): External nasal splinting to support and protect the
nasal reduction.
Open reduction
Open reduction is reserved for patients who have an unstable intraoperative result after closed
reduction or have presented more than 4 weeks from the time of injury. The key to successful
open reduction is management of the septum (12). The nose can be approached via the standard
rhinoplasty and bilateral marginal incisions. If lacerations exist from the patient’s injury, they
can be incorporated into the approach and often provide good access. The cartilage segments are
repositioned. Resection of an inferior strip of the cartilage may be necessary to permit reduction.
Appropriate reduction of the bones usually corrects any nasal deformities. Stabilization can be
achieved via titanium microplates.

Nasoethmoidal fractures
Nasoethmoidal fractures represent a spectrum of injuries, from simple nasal fractures with
undetectable ethmoid involvement to grossly comminuted nasoethmoidal fractures involving the
base of the skull and significant displacement. The complex anatomy and direction of the force,
together with the degree of development of the paranasal sinuses and related structures, often
mean that the fracture patterns may extend posteriorly into the orbit, the skull base, and the
frontal sinus. Thus, nasoethmoid injuries should also be considered as fractures of the orbit, with
all their associated problems. The key anatomical region is the central bone fragment of the
medial orbital rim, into which the medial canthal tendon inserts.
Assessment
The clinical findings are related to the time of examination of the patient after injury. Initial
presentation often reveals gross facial oedema with significant distortion of soft tissue
landmarks. Patients often report epiphora (overflow of tears onto the face) from nasolacrimal
duct obstruction, diplopia (double vision) from orbit or medal canthal tendon disruption,
anosmia (the inability to smell) from damage to the cribiform plate and nasal congestion
secondary to septal hematoma or bony/cartilaginous deformity (13). Clinically, the nasoethmoid
fractures may present with traumatic telecanthus and impaction of the bridge of the nose,
producing a characteristic appearance. The nasal tip is elevated, the bridge depressed, and the
nostrils projecting almost horizontally, to give the “pig snout” appearance (fig.14) when the
swelling has subsided (14).

Fig. (14): Telescoping of the nasal dorsum into the ethmoidal region and relative
elevation of the nasal tip causes this characteristic pig snout appearance.
The midline of the patient’s face and asymmetry of the canthi is important indicators. The
intercanthal and interpupillary distances should be measured. Although a gross increase in the
intercanthal distance (range in whites, 24-39 mm) is diagnostic, borderline cases can be difficult.
A better guide in clinical practice is to relate the intercanthal distance to the interpupillary
distance, provided there is no globe displacement due to gross orbital disruption (fig.15). The
interpupillary distance typically is twice the intercanthal distance (14). Careful exploration
should be directed at pulling the canthus to ensure that it is still attached to stable bone. If the
bone attachment has itself been fractured, lateral displacement of the canthus should be
evaluated.

Fig. (15): Traumatic telecanthus.
Bone fragments can be pushed posteriorly and disrupt the lacrimal sac. Most frequently
however, damage to the lacrimal apparatus is the result of direct laceration. Careful exploration
of lacerations in this area can reveal the extent of the damage to the canthal attachment or
lacrimal system, or both. More severe forces may extend the fractures into the base of skull
through the cribriform plate of the ethmoid; this frequently is associated with a cerebrospinal
fluid leak. Tears in the dura may occur if a fragment of misplaced bone punctures the membrane.
Shearing forces may tear the dura, particularly if the crista galli is fractured, as often occurs with
severely displaced nasoethmoid fractures. Physical examination findings often fail to elucidate
the all details of injuries. Good-quality CT scans (fig.16) are extremely valuable and can provide
more details for the diagnosis and management of NOE fractures (15).

Fig. (16): Axil CT scan revealed fracture involving the
ethmoid complex, nose, medial orbit, and maxillary sinus.
Classification
The bony attachment of the medial canthal tendon has been termed the ‘central fragment’ and
forms the basis of the most widely used classification system described by Markowitz et al. in
1991 (16). The classification system distinguishes three fracture types (fig.17):
Type I: in which the medial canthal tendon is intact and connected to a single large fracture
fragment.
Type II: the fracture is comminuted, and the medial canthal tendon is attached to a single bone
fragment.
Type III: comminution extends to the medial canthal tendon insertion site on the anterior
medial orbital wall at the level of the lacrimal fossa, with resultant avulsion of the tendon.

Fig. (17): Markowitz, et al classification of nasoethmoid fractures.
More recently, Ayliffe (17), described a useful practical classification (fig.18) that seems to offer
the most useful data collection, identifying the “difficult” cases, and provides much useful
correlation with outcome.
Type 0: minimally displaced fracture of the entire nasoethmoid complex.
Type I: displaced fracture, usually associated with a large pneumatized sinus and minimal
fragmentation, comminuted but “platable”.
Type II: comminuted fracture but canthal ligaments firmly attached with bone fragments that are
big enough to plate, requiring bone graft.
Type III: comminuted fracture with canthal disruption requiring cantoplexy.
Type IV: gross comminution needing bone grafting and lacrimal repair.

Type 0. Nondisplaced
Type I. Comminuted but “platable”
Type II. Requiring bone graft

Type IV. Lacrimal reconstruction
Fig. (18): Ayliffe classification of nasoethmoid fractures.
Treatment
Treatment should begin only when the surgeon has a clear understanding of the injuries and
has a precise plan and objective based on findings from the clinical and radiological
examinations. The plan must integrate surgery for the nasoethmoid fracture with treatment of
any other facial injuries. Because these fractures are often part of panfacial fractures, the more
peripheral facial injuries are treated first. The introduction of miniplates and microplates
revolutionized the treatment of these injuries. The principal benefit is the ability of the bone
plate to provide three- dimensional stability to the fractures and maintain the projection of the
nose. The aims of treatment (figs.19&20) should be to restore normal anatomy and
physiological function, particularly with respect to a patent functioning lacrimal system.
Symmetrical fixation of the
Type III. Canthal disruption, requiring canthoplexy

bones, restoration of orbital volume, globe position, frontonasal angle, and nasal projection are
essential for a satisfactory cosmetic outcome.
Fig. (19): Bone graft was needed because of gross comminution.
Access was gained through an existing laceration.
Fig. (20): Microplates placed through a coronal incision provide
good reduction and stability.

References
1. Murray JA, Maran AG, Busuttil A, et al. A pathological classification of nasal fractures. Injury; 17: 338, 1986.
2. Atighechi S, Karimi G. Serial nasal bone reduction: a new approach to the management of nasal bone fracture.
J Craniofac Surg; 20: 49, 2009.
3. VandeGriend ZP, Hashemi A, Shkoukani M. Changing trends in adult facial trauma epidemiology. J
Craniofac Surg; 26: 108, 2015.
4. Fornazieri MA, Yamaguti HY, Moreira JH, et al. Fracture of nasal bones: An epidemiologic analysis. Int.
Arch. Otorhinolaryngology; 12: 498, 2008.
5. Hwang K, You SH, Kim SG, et al. Analysis of nasal bone fractures; a six-year study of 503 patients. J
Craniofac Surg; 17: 261, 2006.
6. Stranc MF, Robertson GA. A classification of injuries of the nasal skeleton. Ann Plast Surg; 2: 468, 1979.
7. Park CH, Min BY, Chu HR, et al. New classification of nasal bone fractures using computed tomography and
its clinical application. J Clin Otolaryngol; 16: 270, 2005.
8. Logan M, O’Driscoll K, Masterson J. The utility of nasal bone radiographs in
nasal trauma. Clin Radiol; 49: 192, 1994.
9. Lee MH, Cha JG, Hong HS, et al. Comparison of high-resolution ultrasonography and computed tomography in
the diagnosis of nasal fractures. J Ultrasound Med; 28: 717e, 2009.
10. Chou C, Chen C-W, Wu Y-C, et al. Refinement treatment of nasal bone fracture: A 6-year study of 329
patients. Asian J Surg; 38: 191e, 2015.
11. Rohrich RJ, Adams Jr WP. Nasal fracture management: minimizing secondary nasal deformities. Plast
Reconstr Surg; 106: 266, 2000.
12. Gunter JP, Rohrich RJ. Management of the deviated nose: the importance of septal reconstruction. Clin Plast
Surg; 15: 43, 1988.
13. Rosenberger E, Kriet JD, Humphrey C. Management of nasoethmoid fractures. Curr Opin Otolaryngol Head
Neck Surg; 21: 410, 2013.
14. Ayliffe P, Booth PW. Nasoethmoid Fractures. In Maxillofacial Trauma and Esthetic Facial Reconstruction.
Booth PW, Eppley BL, Schmelzeisen R. (Editors). Saunders, Elsevier Inc. Chapter 12. P 209-221, 2012.
15. Nguyen M, Koshy JC, Hollier Jr LH. Pearls of nasoorbitoethmoid trauma management. Semin Plast Surg; 24:
383e, 2010.
16. Markowitz BL, Manson PN, Sargent L CA, et al. Management of the medial canthal tendon in nasoethmoid-
orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg; 87:
843, 1991.
17. Booth PW. 20 Naso-ethmoid Fractures. In Atlas of Craniomaxillofacial
Osteosynthesis Microplates, Miniplates, and Screws. Haerle F, Champy M, Terry BC. (Editors) 2
Stuttgart New York. Chapter 20 p 99-103, 2009.
nd
. Ed. Thieme

Chapter 5: Zygomatic complex fractures

Zygomatic complex fractures
The term “zygomatic complex” refers to zygomatic bone and parts of maxilla, frontal,
temporal and sphenoid bone (fig.1). It plays a key role not only in the structure and function but
also in the aesthetic appearance of the facial skeleton. It occupies a key position in the
anterolateral aspect of the face, contributing to set the width of the midface, and to define the
shape and contour of the inferior and lateral orbital borders as well as the cheek prominence.
Moreover, it separates the orbital contents from the infra temporal fossa and the maxillary
antrum (1). Further, it represents the major buttress for the face (2) and transmits the occlusal
stress to the base of skull along its vertical and horizontal struts.
Fig. (1): The zygomatic complex consists of zygomatic bone and
parts of maxilla, frontal, temporal and sphenoid bone.
Zygomatic complex fracture is the second most common fracture of facial region just behind
isolated nasal fractures. Forty-five percent of trauma to the midface constitutes fractures of the
zygomatic complex (3). The prominent convex shape of the zygoma makes it prone to trauma.
The most common etiologic factors involved in these injuries are interpersonal violence, road
traffic accidents, falls, and sports injuries (4). The incidence of zygomatic complex in males is
four times that in females. Most cases occur in young people in their second and third decades
of life. Fracture of the zygomatic complex, also known as a quadripod fracture, and formerly

to as a tripod fracture, varies in severity from a simple crack to major disruption. The severity of
the injury is directly proportional to force of the impact. Among the four articulating surfaces of
the zygoma, the zygomatico-maxillary suture line is relatively stronger than the zygomatico-
frontal, the zygomatico-temporal or zygomatico-sphenoidal suture line. So, the zygomatico-
maxillary suture line frequently remains intact even after multiple fractures of the complex (5).
Preoperative assessment
In majority of the cases of zygomatic complex fractures, the fractured part displaces inward.
This results in the flattening of the cheek. But this may be masked under the swelling of the
overlying soft tissues soon after injury. Flattening becomes obvious when swelling dissipates
(6). Periorbital edema and ecchymosis (fig.2) develop within few hours of injury. Ecchymosis in
the maxillary buccal sulcus is also an important sign. Subconjunctival hemorrhage is another
common feature. Acute loss of sensory function of the infraorbital nerve is often seen.
Numbness of the infraorbital nerve involves the upper lip and side of the nose along with the
anterior teeth. Traumatic injury to the infraorbital nerve may be due to compression, edema,
ischemia or laceration. Motion of the mandible may be inhibited because of impingement of
fractured zygomatic arch on the coronoid process. Ipsilateral epistaxis may occur because of
hemorrhage within maxillary sinus (7). If there is a significant component of an orbital fracture,
impairment of the extraocular muscles may be noted, or the position of the globe altered.
Enophthalmos can occur secondary to loss of orbital floor support. Evaluation for entrapment of
the globe is critical along with diplopia if the patient is alert and able to respond (1). Step
deformities of the orbital rim may also be palpable.

Fig. (2): Subconjunctival and periorbital ecchymosis.
Radiographic examination provides important evidence to confirm the findings of the physical
examination (8). This occurs through plain radiographs and includes a Water’s view, Townes
view, posteroanterior (Caldwell) view, lateral skull film, and Panorex examination. Although
these plain films are important, computed tomographic examination with or without three-
dimensional reconstruction has replaced most of these early radiographs (figs.3&4). Advances
in ultrasonography and computed tomography allows better visualization of orbital fractures,
often associated with zygomatic fractures, for better preoperative evaluation, planning, and
intraoperative repair (9). The creation of models based on these computed tomographic
examinations may assist with preoperative planning.
Fig.(3):AxialCT,displaced zygomatic
fracture.

Fig. (4): Coronal CT, fracture of the orbital
floor.
Classifications
Several classification systems have been proposed to describe zygomatic fractures to assist
with their management. Knight and North in 1961 developed a classification system (10) that is
based on 6 distinct groups of zygomatic fractures. Fractures without significant displacement of
the zygomatic bone are considered as group I fractures. Those with isolated displacement are
classified as group II, whereas fractures that are un-rotated (i.e. have displaced bodies) are group
III fractures. Group IV and V fractures are those that are medially and laterally rotated,
respectively. If there is an additional fractured line within the main fragment, then these are
categorized as group VI fractures.
Based on CT scans assessment, Manson et al. (1990) classified zygomatic fractures into three
general categories: low, middle and high-energy zygomatic fractures (11). Low-energy fractures
are those that do not result in displacement of the bone. Middle-energy fractures are those that
can moderate displacement and, in some cases, comminution. High-energy fractures are those
with severe displacement and comminution. Low-energy fractures are found to result in minimal
or no displacement and has intact zygomatic-frontal suture (ZF). Medium or high-energy
injuries resulted in fractures of all buttresses, including the ZF.

For proper diagnosis and treatment, Zingg et al (12) developed a classification system based on
the anatomical and clinical features of 1025 cases of zygomatic fractures. They separated these
injuries into types A, B, and C. Type A injuries are isolated to one component of the tetrapod
structure, including the zygomatic arch (type A1), the lateral orbital wall (type A2), and the
inferior orbital rim (type A3). Type B involves a fracture where all 4 processes of zygoma are
fractured (classic tetrapod fracture). Type C injuries are complex fractures with comminution of
the zygomatic bone itself.
Other classification systems (13) include the Henderson, Ellis, Schjelderup, Yanagisawa,
Spiessl and Schroll, Larson and Thompson, Fujii and Yamashiro, and Rowe and Killey
classifications. Most of these classification systems, however, are based on description of the
anatomic position of the displaced bone, whether inferior, medical or posterior as well as its
degree of comminution or to classify fracture using position and criteria for post- reduction
stability. None of the systems are accepted universally and no standard classification scheme
currently exists to assist in the assessment of zygomatic complex fractures severity and need for
surgical treatment.
Management
The management of zygomatic complex fracture depends on the degree of displacement and
the resultant esthetical and functional deficit. Management may therefore range from simple
observation of resolving edema, diplopia and paresthesia to a more aggressive open reduction
and internal fixation. Although it has been suggested that all displaced fractures require surgical
intervention, conservative management is frequently employed in cases of minimal
displacement, asymptomatic injury, patient noncompliance, or medical contraindication to
surgery (14). As a rule, nondisplaced or minimal displaced fracture can usually be treated
conservatively and regular follow up should be done to assess for any late displacement. The
decision to intervene surgically should be primarily based on displacement and rotation of the
malar complex. Fractures with functional or esthetic impairments in the form of diplopia,
extraocular muscle entrapment, malocclusion, restricted mouth opening and/or depression of the
malar prominence often necessitate surgical intervention. The first and most critical step in
management of zygomatic complex fractures is achieving adequate reduction (15). Questions
remain about the best approach

for reducing zygomatic complex fractures. When fractures are not significantly comminuted, the
entire zygoma may be reduced as a single unit. In such cases, fractures may be managed using
limited intraoral and extraoral incisions. Surgical reduction of zygomatic fractures by an
intraoral surgical approach was first described in 1909 by Keen (16). The intraoral approach
(fig.5) offers several advantages compared to the extraoral approach including no visible skin
scar, visualization of the fracture line at the zygomaticomaxillary buttress and the infraorbital
nerve, placement of fixation plates at the zygomaticomaxillary buttress through the same
intraoral incision, and diminished morbidity. However, further exposure of the
zygomaticofrontal junction or of the inferior orbital rim is necessary for severely displaced
zygomatic complex fractures, which require additional rigid fixation or reconstruction of the
orbital floor.
Fig. (5): Keen’s intraoral approach; the zygomatic
fracture stabilized with a bone plate across the
zygomaticomaxillary buttress.
In 1927, Gillies was the first to create an incision made behind the hairline and over the
temporal muscle to reach the malar bone (17). He described the use of a periosteal elevator that
is slid under the depressed bone below the temporalis fascia and to use the leverage of the
elevator for reducing the fracture (fig.6). The technique has been a commonly used for the
reduction of zygomatic complex fractures. However, this surgical approach is associated with a
facial scar in thehairline and risk of facial nerve palsy. Moreover, further exposure of the
zygomatico-frontal junction or of the inferior orbital rim is required for placement of mini-plates

fixation in case of an unstable zygomatic complex fracture.

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