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

2. Facial Fractures Phases Emergency Treatment Airway Edema Teeth BloodFB
Mandible fracture  tongue to pharynx
Stridor, hoarseness, retraction, drooling
ETT
Tracheostomy
Long term IMF
Cricothyroidotomy

3. Facial Fractures Hemorrhage Anterior cranial fossa Midface Lacerations
Nasal
Nasal, zygomatic, orbital, frontal, NOE, maxillary
Reduction (IMF)
Anterior/ posterior packing x hrs
Compression dressing
Embolization
Bilateral external carotid/ superficial temporal ligation
Blood factor replacement

4. Facial Fractures Aspiration Other Low threshold for ETT Eye Brain
Spine

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

6. Facial Fractures Classification Radiography Occlusion/ dentition
Anatomy
Closed v. open
Le Fort
Radiography
CT v. x-rays
Occlusion/ dentition

7. Facial Fractures
Mandible
Anatomy

8. Facial Fractures
Mandible
Anatomy

9. Facial Fractures
Mandible
Anatomy

10. Facial Fractures
Mandible
Anatomy

11. 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

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

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

14. Facial Fractures Mandible Radiography Panorex CT Plain films
PA, Towne’s, R and L lateral oblique views (mandibular series)

15. Mandible Treatment Restore form and function ORIF
Occlusion, TMJ function, cosmesis
ORIF
Exact anatomic reduction
Allows early resumption of mandibular function

16. Mandible

17. 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

18. 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

19. Mandible
ORIF
Lag screw – Anterior

20. Mandible
ORIF
Reconstruction plate – Comminuted body

21. Mandible
ORIF
Two plate/ tension band – Angle

22. Mandible
ORIF
Dynamic compression plate - Condyle

23. Mandible Treatment Contraindications to open Rarely needed in children
Not required
Not candidate
Rarely needed in children
Simple
Heal quickly
Occlusion less established

24. Facial Fractures

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

26. Mandible Treatment by type Complex Multiple or segmental
Often interosseous wires/ reduction clamps/ temporary mini-plates help
Inferior “butterfly” segment
Difficult to reduce

27. 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

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Mandible
Teeth in fracture line

41. Facial Fractures
Frontal bone anatomy – 7 bones

42. Facial Fractures
Frontal bone anatomy

43. Facial Fractures
Frontal sinus anatomy
Middle meatus

44. 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

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

46. Facial Fractures
Frontal Sinus Fracture
Diagnosis
Plain films CT

47. 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

48. Facial Fractures Frontal Sinus Fracture
Complications (Posterior > anterior)
Acute
Epistaxis
CSF leak
Meningitis
Intracranial injury
Hematoma
Subacute
Mucocele
Sinusitis
Chronic
Osteomyelitis
Abscesses

49. END