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Information

Editors

KarinBlomgren
HannaThorén

Facial Fractures

Essentials

  • Facial fractures may cause changes in the facial appearance and may hamper breathing, speaking, eating, smelling and seeing.
    • Swelling of the upper airways and posterior displacement of the soft tissues associated with maxillary and mandibular fractures may cause acute respiratory failure.
  • Assaults as well as injuries associated with traffic and sporting accidents are the most common causes.
  • Remember the possibility of a brain or cervical spine injury in association with high-energy trauma.
  • Diagnosis is based on clinical examination and imaging.
    • Avoid unnecessary imaging. Plain facial radiographs are difficult to interpret and only seldom affect the treatment decisions.
  • Change in the facial skin sensation strongly suggests fracture of a bone.
  • Ask about and record the exact mechanism of the injury.
  • In case of an assault, encourage the patient to report the offence. Prevent the continuation of domestic violence; provide contact information to social services, shelter homes and telephone support services.
  • Facial fractures are treated in specialized care. Late and secondary repairs are troublesome.

Zygomatic fractures

Tripod fracture (zygomaticomaxillary complex fracture)

Mechanism of injury

  • A blowon the cheek from the side or from the front
  • Falling

Clinical examination

  • Palpation of the orbital margins
  • Inspection and palpation of the malar eminences and zygomatic arches
    • The symmetry of the malar eminences is best evaluated from above, standing behind the patient.
  • Opening and closing of the mouth
  • Testing of skin sensation
  • Because a tripod fracture always involves the orbit as well, don't forget to also examine
    • the position of the eyeball
    • eye movements.

Findings

  • Tenderness or step-off at the lateral margin of the orbit (frontozygomatic suture)
  • Tenderness or step-off at the inferior margin of the orbit
  • Tenderness or step-off intraorally at the anterior wall of the maxilla (on palpation under the upper lip)
  • Restricted opening of the mouth
  • Depression of the malar eminence
  • Subconjunctival haemorrhage
  • Decreased skin sensation on the cheek, side of the nose, upper lip, upper gingiva or incisor teeth

Imaging

  • FacialCT scan or cone beam CT (CBCT)

Treatment

  • If the fracture has caused a disturbing change in the function or appearance of the face, reduction and fixation of the fracture using titanium plates and screws is performed within a week from the injury.

Zygomatic arch fractures

  • A blow on the zygomatic arch from the side
  • Opening of the mouth may become restricted and the fracture may be visible as a depression at the zygomatic arch.
  • Treated by elevating the bone back to its original position with an elevator that is inserted from the hairline down under the zygomatic bone.

Isolated orbital fracture (blow-out fracture)

Mechanism of injury

  • A hard blow on the orbital margin by e.g. a fist, elbow, golf ball
  • The firm orbital margins remain intact but the thin floor and/or the medial wall will fracture.
  • The soft tissues surrounding the eye prolapse into the maxillary sinus and/or the ethmoidal cells.

Symptoms and findings

  • May be symptomless. Suspect a blow-out fracture if the mechanism of injury is suggestive of such.
  • Periorbital haematoma ("raccoon eyes"); eyelid bruises
  • Subconjunctival haemorrhage
  • Decreased skin sensation on the cheek, side of the nose, upper lip, upper gingiva or incisor teeth
  • Diplopia, usually when looking up or down
  • Pain or restricted movement, usually when looking up
  • Posterior displacement of the eyeball
  • Drop of the papillary level

Imaging

  • Orbital CT scan or cone beam CT (CBCT)
  • Note: In children, the imaging findings may seem normal even if there were a clinically significant greenstick fracture.

Treatment

  • If the fracture is aesthetically or functionally disturbing it is treated when the oedema has subsided.
  • The prolapsed soft tissues are reduced and the fracture site is covered with bone or with a titanium mesh or resorbable plate.
  • Note: If there is entrapment and restricted movement of ocular muscles, the fracture must be corrected as soon as possible. Symptomatic blow-out fractures are typical in children.

Maxillary fractures

Classification

  • Maxillary fractures are classified into so-called Le Fort types according to the fracture level (picture 1).
    • Le Fort I: Low horizontal fracture of the maxilla. The dentulous area of the maxilla is detached from the midface at the level of the maxillary sinuses and the base of the nose. The maxilla may be unstable.
    • Le Fort II: Pyramidal fracture of the maxilla. The fracture line passes through the anterior walls of the maxillary sinuses and the orbits to the root of the nose. The midface may be unstable.
    • Le Fort III: The fracture line traverses the upper face high through the orbits and the root of the nose. The midface is detached from the base of the skull. The midface may be unstable.

Symptoms and findings

  • Decreased skin sensation on the upper lip, side of the nose, upper gingiva or upper teeth
  • Change in the dental occlusion, the type of which depends on the fracture type
  • Swelling/bruise in the midface and/or in the oral mucosa
  • The upper jaw or the whole midface complex may be unstable when the upper jaw is moved back and forth.
  • Because Le Fort fracture types II and III always also involve the orbit, a change in the eyeball position, restriction of the eye movements as well as diplopia may be present.

Imaging

  • Facial CT scan or cone beam CT (CBCT)

Treatment

  • If the fracture is aesthetically or functionally disturbing it should be reduced and fixed within a few days using titanium plates and screws.

Mandibular fractures

Mechanism of injury

  • A blow at the lower jaw
  • Falling

Symptoms and findings

  • Sensory disturbance on the lower lip, tip of the jaw, lower teeth or lower gingiva
  • Change in the dental occlusion, the type of which depends on the fracture type
  • Lower jaw movements are painful and the opening of the mouth is restricted.
  • Swelling/bruise in the skin and/or in the oral mucosa, tenderness to palpation
  • Loosening of the teeth adjacent to the fracture line, gingival bleeding
  • Step-off in the dental line
  • Instability of the fracture line
  • Particularly in association with a fracture in the articular region of the mandible: bleeding from the ear canal, bruise in the anterior wall of the ear canal

Imaging

  • Pantomography, also in another projection if needed (usually in semi-axial projection of the mandible) or CBCT

Treatment

  • The treatment is almost exclusively surgical, and the operation should almost always be performed within a couple of days due to the high infection risk.