Facial Fractures Mandible and Frontal Bones

VIVEK SHRIHARI

Facial Fractures
Phases
Emergency Treatment
Airway
       

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

Facial Fractures
Hemorrhage
Anterior cranial fossa Midface Lacerations Nasal
Nasal, zygomatic, orbital, frontal, NOE, maxillary

Reduction (IMF) Anterior/ posterior packing x 24-48 hrs Compression dressing Embolization Bilateral external carotid/ superficial temporal ligation Blood factor replacement

Facial Fractures
Aspiration


Low threshold for ETT Eye Brain Spine

Other
  

Facial Fractures
Early injury care
History PE


Nerves, vision, intraoral, nasopharyngeal, dentition

Radiographs Lacerations IMF Impressions

Facial Fractures
Classification
Anatomy Closed v. open Le Fort

Radiography
CT v. x-rays

Occlusion/ dentition

Facial Fractures
Mandible
Anatomy

Facial Fractures
Mandible
Anatomy

Facial Fractures
Mandible
Anatomy

Facial Fractures
Mandible
Anatomy

Facial Fractures
Mandible
Most common facial fracture after nasal 10-25% of all facial fractures Body> angle> condyle> parasymphysis> other M: F = 2: 1 58% multiple (93% , 3 fx) Preinjury relationships Stable bony union Facial proportions Avoid complications

Facial Fractures
Mandible
History
Previous trauma Previous baseline Pre-injury photo

Facial Fractures
Mandible
PE
Crepitance Symmetry Tenderness Oral/ dental missing teeth Step offs

Facial Fractures
Mandible
Radiography
Panorex CT Plain films


PA, Townes, R and L lateral oblique views (mandibular series)

Mandible
Treatment
Restore form and function
Occlusion, TMJ function, cosmesis

ORIF
Exact anatomic reduction Allows early resumption of mandibular function

Mandible

Mandible
Treatment
Closed Dependent on splinting to maxilla to restore centric occlusion (maximal intercusspation) If inadequate number of teeth,Gunning splint may be needed for IMF

Mandible
Treatment
Open
Accurate reduction
 

Within 2 weeks If maxilla cannot be used then mandible first or splints Traumitizes gingiva Impairs oral hygiene periodontal disease Uncomfortable Forces can alter tooth position and periodontal attachments Great aspiration risk Contraindication in COPD, seizure d/o, impaired MS Articular surfaces under compression cause pressure necrosis

Avoid prolonged IMF

   

  

Mandible
ORIF
Lag screw Anterior

Mandible
ORIF
Reconstruction plate Comminuted body

Mandible
ORIF
Two plate/ tension band Angle

Mandible
ORIF
Dynamic compression plate - Condyle

Mandible
Treatment
Contraindications to open
Not required Not candidate

Rarely needed in children

Simple Heal quickly Occlusion less established

Facial Fractures

Mandible
Treatment by type
Simple
CR + IMF x 8 weeks if reliable (unreliable avoid IMF and open)

Mandible
Treatment by type
Complex
Multiple or segmental


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

Inferior butterfly segment



Difficult to reduce

Mandible
Treatment by type
Complex
Bilateral fracture each hemi-mandible


Simultaneous reduction may be required to avoid magnification of discrepancy Arch bars and IMF may worsen Consider reducing one or both condyles first if difficult to control flaring the inferior border Close fractures two plates Separated fractures long spanning plate

Anterior fracture with one or both condyles



Unilateral segmental fracture in one hemi-mandible

 

Mandible
Treatment by type
Complex
Comminuted
    

  

High energy GSW, SGW, MVC Easy to devitalize small fragments Difficult to accurately reduce Large reconstruction plate may be required Temporary external fixator may be used if condition of patient or soft tissue requires Bone graft for extensive loss Pre-treatment infection: Debride small fragments Post-treatment infection: FB (bone or screw)

Mandible
Treatment by type
Complex
Edentulous
 

 

Atrophied and osteopenic poorer healing Early atherosclerosis (15 years) of inferior alveolar artery 20% non-union Simple and undisplaced pureed diet and obs Use dentures or splints Rigid fixation with spanning reconstruction plate Bone graft/ flap within 5 years Soft tissue repair and IMF or ex fix until ready

Fracture with bony defect

  

Mandible
Treatment
Infection
More common if delayed care Abx, debridement Fracture line may resorb and form gaps larger plates Extreme cases may require external fixator with secondary ORIF +/- graft

Mandible
Treatment
Children
Most need CR + immobilization (single arch bar or lingual splint) x 2 weeks Conical shape makes arch bars less useful Indications for ORIF
  

Unstable fractures Not amenable to CR Bilateral fractures with gross instability

Use unicortical plates Remove 6-8 weeks later

Mandible
Treatment
Children
Condyle is growth center of mandible Trauma can cause hemarthrosis ankylosis Intracapsular fractures that do not alter the centric occlusion should not be immobilized to avoid ankylosis which can occur >12 months later and requires aggressive treatment Unilateral condylar fractures with altered centric occlusion are treated with arch bars or lingual splints and elastics Displaced bilateral condylar fractures with posterior vertical collapse and anterior open bite deformity require CR + IMF x 4 weeks

Mandible
Treatment
By Location
Alveolar Process (1%)


Remove if devitalized o/w IMF or splint Often associated with condylar fractures Significant forces cause lateral flaring of posterior segments (often worse with IMF) Often associated with contralateral fractures Mental nerve Burr/ osteotome may help lessen anterior curvature

Symphysis (5.8%)
 

Parasymphysis (11.6%)
  

Mandible
Treatment
By Location
Body (31.9%)
 

May require external approach Bi-cortical plates placed beneath mental canal May require external approach Often associated with contralateral Highest complication rate due to third molar teeth and displacing forces

Angle (27.5%)
  

Mandible
Treatment
By Location
Ramus (2.5%)
 

Usually require extraoral approach Often stable due to splinting effect of massetermedial pterygoid muscle sling unless displacement causes vertical shortening (telescoping) Soft diet usually enough Severe pain may require brief IMF

Coronoid process (1.8%)

 

Mandible
Treatment
By Location
Condyle (23.8%)
 

Proximal segment can undergo AVN Intra-articular fractures: Very difficult ORIF, OA is common outcome, usually brief IMF for malocclusion o/w early mobilization +/- elastics Condylar neck: Anteromedial displacement of proximal segment by lateral pterygoid, usually treated with IMF x 6 weeks, ORIF if joint capsule is thought to be involved

Mandible
Treatment
By Location
Condyle


ORIF  Displaced in to middle cranial fossa  FB within joint  Lateral extra-capsular displacement of condyle  Displacement blocking opening or closing  Posterior vertical shortening of mandible with open bite after 2 week IMF trial Relative  Bilateral associated with unstable midface fractures  Bilateral edentulous without splint

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

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

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

Oral washouts
Release IMF q 3-5 days if needed

Mandible
Centric occlusion
Remove IMF to assess ORIF

Therapeutic rehabilitation
Regain strength and mobility, PT if severe (prolonged IMF or condyle fracture) Dental treatment (missing teeth)

Complications
Malocclusion, malunion, non-union, hardware exposure, infection, non-compliance

Mandible
Teeth in fracture line

Facial Fractures
Frontal bone anatomy 7 bones

Facial Fractures
Frontal bone anatomy

Facial Fractures
Frontal sinus anatomy
Middle meatus

Facial Fractures
Frontal Sinus
MVC - Assaults 2-3 x force to fracture lower frontal sinus Other injuries associated (1/4 die in 14d) Rare in children

Facial Fractures
Frontal Sinus Fracture
Signs
Rhinorrhea Step-off Supraorbital anesthesia Subconjunctival hematoma Subcutaneous crepitance

Facial Fractures
Frontal Sinus Fracture
Diagnosis
Plain films CT

Facial Fractures
Frontal sinus fractures
Anterior Table (Thick)
Displaced ORIF Blockage of nasofrontal duct (methylene blue)
 

Remove mucosa Bone graft nasofrontal ducts, fill space Elevate and fixate bone

Posterior Table (Thin)

Comminuted Cranialize Displaced greater than one wall thickness ORIF

Facial Fractures
Frontal Sinus Fracture
Complications (Posterior > anterior)
Acute
    

Epistaxis CSF leak Meningitis Intracranial injury Hematoma Mucocele Sinusitis Osteomyelitis Abscesses

Subacute
 

Chronic
 

END