Facial Fractures – Mandible and Frontal Bones Dale Reynolds, MD UT Houston Plastic & Reconstructive Surgery

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 Other Low threshold for ETT Eye Brain Spine

Facial Fractures Early injury care History PE Radiographs Lacerations Nerves, vision, intraoral, nasopharyngeal, dentition Radiographs Lacerations IMF Impressions

Facial Fractures Classification Radiography Occlusion/ dentition 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, Towne’s, R and L lateral oblique views (mandibular series)

Mandible Treatment Restore form and function ORIF 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 Avoid prolonged IMF Within 2 weeks If maxilla cannot be used then mandible first or splints Avoid prolonged IMF 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

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 Rarely needed in children 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 Anterior fracture with one or both condyles Consider reducing one or both condyles first if difficult to control flaring the inferior border Unilateral segmental fracture in one hemi-mandible Close fractures – two plates Separated fractures – long spanning plate

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 Fracture with bony defect Rigid fixation with spanning reconstruction plate Bone graft/ flap within 5 years Soft tissue repair and IMF or ex fix until ready

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%) Symphysis (5.8%) Remove if devitalized o/w IMF or splint Symphysis (5.8%) Often associated with condylar fractures Significant forces cause lateral flaring of posterior segments (often worse with IMF) Parasymphysis (11.6%) Often associated with contralateral fractures Mental nerve Burr/ osteotome may help lessen anterior curvature

Mandible Treatment By Location Body (31.9%) Angle (27.5%) May require external approach Bi-cortical plates placed beneath mental canal Angle (27.5%) Often associated with contralateral Highest complication rate due to third molar teeth and displacing forces

Mandible Treatment By Location Ramus (2.5%) Coronoid process (1.8%) Usually require extraoral approach Often stable due to splinting effect of masseter-medial pterygoid muscle sling unless displacement causes vertical shortening (telescoping) Coronoid process (1.8%) Soft diet usually enough Severe pain may require brief IMF

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 Diet Splints/ IMF Oral washouts +/- 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 Therapeutic rehabilitation Complications 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 - ¾ Assaults – ¼ 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 Subacute Mucocele Sinusitis Chronic Osteomyelitis Abscesses

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