• Maxillofacial fractures occur when the facial bones are subjected to forces that exceed their impact tolerance

• The introduction of compulsory seat belt legislation in Sweden in 1975 led to a 28% reduction in severe maxillofacial fractures

• As a minimum precaution, protective surgical gloves must always be worn when examining or treating any patient with a suspected maxillofacial injury.

This calls for careful and systematic inspection and palpation of the cranial bones, zygomas, orbits, maxillae, nasal bones and mandible through the overlying soft tissues starting peripherally and working centrally. Any swelling, bruising, tenderness, deformity and crepitus should be identified and noted. Surgical emphysema is occasionally detected following zygomatic and orbital floor fractures if the patient has blown their nose. Patients with midface fractures should be advised not to blow their nose to prevent this complication arising. Temporomandibular joint function is best assessed by simultaneously palpating both condylar heads and assessing for pain and symmetrical vertical and translatory movements.

Ocular abnormalities including subconjunctival haemorrhage, foreign bodies, reduced light and accommodation reflexes, reduced visual acuity, diplopia, opthalmoplegia, enopthalmos, proptosis and telecanthus must be actively sought in every case. Telecanthus is a feature of many, but not all NOE fractures and results from disruption of the medial canthal ligament attachment. It can be extremely helpful to refer to a pre-injury photograph of the patient with a suspected NOE fracture in order to exclude an existing deformity and to help assess their normal intercanthal distance.

The zygomatic complex is best assessed from above and behind the patient. By placing the tips of the index fingers on the zygomatic buttresses and observing their relative positions, any facial asymmetry is readily identified. Enopthalmos or proptosis is similarly recognized by noting any asymmetry in globe/upper eyelid projection.

Cutaneous sensation over the distribution of the opthalmic, maxillary and mandibular divisions of the trigeminal nerve is assessed by the patients’ response to a wisp of cotton wool lightly applied to the skin of the forehead, cheek and lower lip respectively. Facial nerve function is determined by asking the patient to furrow their brow, close their eyes tightly, purse their lips and smile.

Cerebrospinal fluid rhinorrhea is indicative of a fracture in the region of the cribriform plate of the ethmoid, sphenoid or frontal bones together with a tear in the overlying dura and usually occurs within 24 to 48 hours of injury. The diagnosis is usually obvious from the clinical history and the typical appearance of a thin, glairy, sero-sanguinous nasal discharge that tends to form “tram lines” on the facial skin as it evaporates and dries. If there is any doubt in the diagnosis fluid should be sent for quantitative glucose analysis. Glucose levels greater than 30 mg/100ml are indicative of CSF not nasal secretions. Glucose oxidize reagent strips should not be relied on as they not infrequently produce false negative results. Nasogastric tubes must not be inserted into patients with CSF rhinorrhea, as cannulation of the anterior cranial fossa via a disrupted cribriform plate is not unknown!

• All patients who have sustained a high impact maxillofacial injury should be assumed to have a concomitant cervical spine injury until proved otherwise

Securing and maintaining the airway is the first priority. Having donned protective gloves and using a good light, the oral cavity is thoroughly examined for foreign bodies. A finger is inserted along the side of the cheek to the back of the mouth and swept medially and forwards to dislodge any debris. The manoeuvre is performed from both sides of the mouth. A large bore sucker (plastic yankauer) is used to aspirate any blood, mucous and vomitus from the oral cavity and pharynx.

If the maxilla has been displaced posteriorly and is occluding the nasopharynx it should be disimpacted by hooking the index and middle fingers above and behind the soft palate and gently pulling forwards. If the tongue is falling backwards because it has lost its anterior attachment it should be retracted by a 0 gauge suture inserted through the dorsal surface some 2 cm posterior to the tip which is then pulled anteriorly and secured to the side of the face with surgical adhesive tape. If there is any doubt that a clear airway can be maintained orotracheal intubation should be performed and the fashioning of a temporary surgical airway considered. These measures will protect the patients’ airway, facilitate optimal tissue oxygenation and minimize any secondary brain injury due to hypoxia.

Significant bleeding from middle third fractures usually manifests itself as persistent bilateral epistaxis and bleeding that “wells up” in the oropharynx as it runs down from the back of the nasal cavity above.

After disimpacting the maxilla if required, anterior and posterior nasal packs are inserted to tamponade the haemorrhage. A 12 gauge Foley catheter is inserted through each nostril along the nasal floor and gently pushed posteriorly. Extreme caution should be exercized in cases of suspected cribriform plate fracture. When the tip of the catheter becomes visible over the soft palate it should be pulled a short distance into the mouth to ensure that the balloon has passed through the choana. The balloon is inflated and the catheter pulled back through the nose until it impacts against the choana (Fig. 6.9). Ribbon gauze soaked in BIPP (Bismuth Iodoform Paraffin Paste) is then firmly packed into each nostril against the balloon until no more can be introduced. The 2 separate anterior nasal packs should be tied together in the midline. The Foley catheters are tied together over a gauze bolster to protect the nasal soft tissues while maintaining tension on their balloons. Alternatively, they can be secured using a Hollister umbilical cord clamp. It should be appreciated that the paraffin in BIPP can degrade the catheter balloons within 72 hours causing them to deflate.

Anterior and posterior nasal packing occasionally fails to control the bleeding due to laceration of one or both maxillary arteries. In these circumstances the haemorrhage can usually be controlled by direct ligation or packing of the maxillary artery via a transantral (Caldwell-Luc) approach. Ligation of the external carotid artery in the neck as sole treatment for severe midface haemorrhage is seldom effective.

Bleeding from the facial soft tissue is best controlled by direct pressure until such time as definitive surgical exploration and vessel ligation can be performed. However, profuse bleeding from deep lacerations of the tongue, lip and soft palate etc is seldom controlled by direct pressure. While it may be possible to arrest such bleeding using artery clips or sutures in the accident and emergency department care should be taken not to damage adjacent nerves and ducts.

The timing of the repair of maxillofacial injuries in patients with concomitant craniocerebral trauma is controversial. In many cases there is much to be said for performing the definitive repair of the facial fractures simultaneously with the neurosurgical repair of the intracranial injuries. This affords an ideal opportunity to use the same surgical approach (usually a coronal flap) and avoids the need for a second general anaesthetic. It has been shown that early repair of craniofacial fractures in patients with significant craniofacial trauma (ICP = 15 mm Hg or greater) has no negative impact on survival and facilitates early rehabilitation. However, the overriding priority is to prevent further brain injury and patients with a high and/or unstable ICP should be subjected to the minimum surgical and anaesthetic insults in the first few days following their injury.

Although earlier treatment is usually desirable, particularly with compound fractures, a 7 to 10 day window exists for the optimum treatment of mandibular fractures and even longer for middle and upper third fractures (14 days). Providing the maxillofacial fractures are definitively managed within these times in patients with a favourable outcome assessment the final functional and cosmetic results will not be compromized. This does not mean that the maxillofacial surgeon has no role to play during any early short neurosurgical procedures such as the placement of ICP monitoring devices or the evacuation of haematomas. This is an ideal time to fully assess the extent of the maxillofacial injuries and take impressions for study models if required. Discussion with the neurosurgeon at this time concerning placement of craniotomies and bone flaps etc can greatly facilitate future reconstruction. In particular, the maxillofacial surgeon should enjoin his neurosurgical colleague not to throw any bone away but to retain all fragments for future repair and reconstruction.

• Treatment of maxillofacial injuries is divided into emergency (immediate), early (0-14 days) and delayed phases (> 14 days) following injury
• The goals of treatment are life saving, preserve sight and speech, and minimize deformity

Some of the various methods used to treat maxillofacial fractures are listed in Table 6.9. With the advent of internal fixation systems, particularly miniplates and reconstruction plates the use of external fixation systems with the exception of intermaxillary fixation has a rapidly diminishing role in the management of maxillofacial fractures. Nonetheless, external fixation continues to have a role in the management of some grossly comminuted or infected fractures.

Likewise, although internal suspension wires are seldom indicated for definitive treatment, they are extremely useful for supporting and fixing gunning splints and augmenting arch bar fixation in partially dentate jaws. It is important that surgeons who manage maxillofacial trauma are fully conversant with these more traditional fixation methods and not just the modern “high-tech” plating systems (if the only tool in your toolbox is a hammer every problem will look like a nail).

Intermaxillary fixation (IMF) involves securing the upper and lower teeth together in their normal pre-fracture occlusion. For many jaw fractures, if the teeth are placed in the correct occlusion the underlying bone of the mandible and/or maxilla will automatically assume its correct position and any contained fractures will be reduced and immobilized. However, this assumes that there has not been any significant disruption of the jaw/tooth interface. IMF alone is often sufficient treatment but in many cases it will need to be augmented by some other method, typically open reduction and internal fixation (ORIF).

There are several methods of establishing IMF but arch bars are arguably the best. One can use any of the commercially available pre-fabricated arch bars or better still, a custom made one cast by a maxillofacial technician on a model of the patient’s dentition. The arch bar is secured to the mandibular and maxillary teeth by 0.4 mm or 0.5 mm stainless steel interdental wires and then the 2 arch bars are linked together by similar wires or orthodontic elastic bands so establishing the IMF (Fig. 6.10a). Circum-zygomatic and circum-mandibular wires can be used to augment the interdental wires where fixation is sub-optimal because of multiple missing teeth.

If arch bars are not available IMF can be established via interdental eyelet wires (Fig. 6.10b). While these are quick to apply they are not as versatile as arch bars although the incorporation of stainless steel buttons onto the eyelets enables them to be used with elastic IMF which is not possible with the standard eyelet. One of the problems with both arch bars and eyelet wires is the risk of a “sharps” injury. In “high-risk” cases IMF can be established by passing elastic bands around 4 bone screws from a 2 mm miniplate system screwed into the labial cortical plate of the anterior mandible and maxilla.

Despite its almost universal application in the management of maxillofacial fractures there is a significant morbidity associated with the use of IMF. It restricts normal dietary intake resulting in significant weight and protein loss, reduces tidal volume and increases the risk of aspiration of gastric contents should the patient vomit. The wires themselves are uncomfortable and damage the periodontal tissues. Postoperative IMF should be avoided wherever possible in patients who are malnourished or at risk of malnutrition (e.g. patients with eating disorders), epileptic, have severe breathing difficulties such as COAD or asthma and where compliance is likely to be poor such as alcohol and drug abusers.

External fixation systems such as halo, box and Levant frames utilize the principle of craniomaxillary or craniomandibular fixation in order to immobilize facial fractures. Fractures of the midfacial, occlusal or mandibular units are suspended from an intact and rigid cranial unit. In the case of isolated midface fractures they are sandwiched between the intact cranial unit above and mandibular unit below.

Box frames consist of 4 threaded bone pins screwed transcutaneously into the lateral supraorbital rims above and the body of the mandible below. The pins are then linked by 2 vertical and 2 horizontal bars via universal clamps. Other external systems are essentially variations of this scheme. Combinations of pins and bars can be used to build custom external fixation devices to support and control virtually any facial bone fracture.

The principle disadvantage with most, if not all external fixation systems is that they involve closed fracture reduction usually guided by clinical observation of the occlusion and facial form. Because individual fractures are not visualized and anatomically reduced there is a significant margin for error, particularly in re-establishing the correct facial projection following midface fractures. External frames are also cumbersome, unaesthetic, poorly tolerated and prone to accidental dislodgement.

Miniplates have revolutionized the modern management of facial fractures by enabling precise anatomical reduction and fixation under direct vision (Fig. 6.11). True rigid fixation, which is only achievable with compression plate or lag screw systems, is associated with rapid bone healing by primary intention. Non-compression miniplates using monocortical screws are unable to produce true rigid fixation and are actually semi-rigid systems. However, the term rigid fixation in common use usually refers to all types of small plate osteosynthesis systems both compressive and non-compressive and is so used in this chapter.

By rigidly fixing the fractured segments together in their correct position, together with immediate bone grafting where significant skeletal defects exist, the 3 primary dimensions of facial bone reconstruction namely facial width, facial height and facial projection can be restored. The requirement for external fixation is significantly reduced, as is the need for protracted postoperative IMF. The correct application of miniplates is a precise and exacting procedure unforgiving of errors in fracture reduction and immobilization, miniplate adaptation and poor operative technique.

In all cases involving a fracture of a dentate jaw it is mandatory for the correct pre-fracture occlusion to be securely maintained in IMF while the miniplates are applied to the fracture sites. In many situations it is also necessary to initially reduce and control the fractures using stainless steel transosseous wires prior to achieving the final fixation with miniplates. A combination of transosseous wires, miniplates and bone screws may be required to achieve the optimal reduction and fixation of complex fractures.

Nasal fractures are the commonest facial fracture reported in many published series. A history of blunt trauma to the nose, lateral deviation of the nasal bones or septum, visible or palpable deformity, epistaxis, ecchymosis, oedema and small lacerations over the nasal bridge suggest the diagnosis.

It is important to fully examine the nasal cavities which requires adequate suction, illumination and a nasal speculum. Lacerations of the nasal septum especially if sufficient to expose cartilage or bone should be sutured with 5-0 or 6-0 plain catgut. Septal haematomas must be evacuated lest they result in abscess formation or aseptic necrosis. Closed nasal fractures are best treated electively 5 or 6 days post injury to allow any associated swelling to resolve. Simple fractures of the nasal bones can often be treated by digital manipulation under local anaesthesia using intranasal lignocaine spray and external nasal lignocaine infiltration with or without intravenous sedation.

Intranasal manipulation with Asch forceps is usually adequate treatment for a deviated or fractured nasal septum. The forceps blades are slid either side of the septum and pulled upwards and forwards to guide it into its midline position. If one or both nasal bones are displaced medially it may be necessary to use Walsham forceps to manipulate it/them laterally back into position. One blade is slid into the nose while the other (which should be covered with a piece of soft rubber tubing to protect the skin) is applied to the external surface. Using a gentle twisting and lifting movement the displaced nasal bone is repositioned. The nose is then gently packed with BIPP or Vaseline gauze for 24 - 48 hours and a closely adapted external nasal thermoplastic or plaster splint is applied and held securely with surgical adhesive tape for 7-10 days. Even with correct diagnosis and treatment the results of closed reduction are often disappointing with approximately one third of patients having a persistent deformity.

• Simple fractures of the nasal bones can often be treated by digital manipulation under local anaesthesia using intranasal lignocaine spray and external nasal lignocaine infiltration with or without intravenous sedation

These fractures involve the central midface, the nasal bones, the frontal processes of the maxilla and the ethmoid bones and are arguably the most difficult of all facial injuries to treat successfully. Telecanthus is the principal deformity seen in NOE fractures. An intercanthal distance greater than 35 mm is suggestive of a displaced NOE fracture and a distance greater than 40 mm is diagnostic. Telecanthus is invariably due to lateral and inferior displacement of the naso-maxillary buttress or fracture of a plate of bone in the region of the anterior lacrimal crest containing the insertion of the medial canthal ligament. It is unusual for the ligament itself to be divided or avulsed from the bone.

The aesthetic results of closed reduction and external fixation of NOE fractures are frequently disappointing. Optimal treatment of these fractures requires visualization of all fractures followed by open reduction and internal fixation. In the majority of cases a bicoronal flap together with the judicious use of local incisions and any conveniently situated lacerations provides the best access to the fracture sites. The bone fragment containing the medial canthal ligament insertion should be carefully identified, reduced in its correct position and secured with miniplates or wires. If the tendon has been avulsed or is accidentally stripped off the bone a transnasal canthopexy will be required to reattach it. Fine artery forceps are used to identify the tendon through a 4 mm vertical incision sited 3 mm medial to the medial canthus. The tendon is transfixed with a braided 3-0 wire or suture and passed transnasally on an awl posterior to the lacrimal fossa. The transnasal canthopexy rarely produces a perfectly natural appearance to the medial canthus and so accidental stripping of the medial canthal ligament off the bone should be avoided at all costs.

All other fractures are reduced and fixed and any defect greater than 0.5 cm in the orbital floor or walls is bone grafted. Split cranial bone is ideal for this purpose. Wherever possible the bone grafts should rest on sound bone peripherally and be fixed with miniplates or transosseous wires. A dorsal nasal bone graft, which can be cantilevered off the frontal bone, will frequently be required to prevent a postoperative saddle deformity.

Fractures of the frontal sinus frequently coexist with NOE injuries and must be properly managed to reduce the risk of late complications such as CSF leak, meningitis, mucopyocele and brain abscess. Displaced fractures of the anterior wall should be reduced and fixed with miniplates and immediate bone grafting as necessary. If the posterior sinus wall is intact and there is no evidence of a CSF leak it can be managed expectantly. If there is a significant posterior sinus fracture, especially with a concomitant CSF leak the sinus should be cranialized and the dura neurosurgically repaired. Cranialization involves removing all fragments of posterior frontal sinus wall, stripping out all the remaining frontal sinus mucosa, and plugging the nasofrontal ducts with autogenous bone grafts. The insertion of a pericranial or similar flap may be indicated to separate the nasal and cranial cavities.

Significant inferior displacement of the zygomatico-frontal suture produces an antimongoloid slant due to a drop in the level of the lateral canthal ligament. Diplopia is often due to oedema in the extraocular muscles and usually settles within the first few days of injury. Diplopia that fails to resolve suggests an internal orbital fracture and requires further investigation. All patients with zygomatic fractures are at high risk of associated ocular injuries and must have a thorough opthalmic assessment.

The zygoma tends to fracture at or near its 3 main articulation points namely the zygomatico-maxillary suture, the zygomatico-frontal suture and the zygomatico-temporal suture producing what is commonly referred to as a tripod fracture. In reality they are quadrapod fractures because the zygomatico-maxillary buttress will also be involved. Attaining an anatomical reduction at this latter site is fundamental to the management of unstable zygomatic fractures. Inadequate reduction and fixation at the zygomatico-maxillary buttress is responsible for much of the late deformity often associated with fractures managed by closed reduction or single point fixation at the zygomatico-frontal suture.

The indications for treating zygomatic fractures include correction of abnormalities in ocular position and motility, restoration of eye protection, relief of infraorbital nerve paraesthesia, improvement in mandibular opening and the restoration of facial aesthetics. These indications are all relative and their importance varies with factors such as the patient’s age and health. Hence many fractures are treated in young fit and healthy patients in order to restore their facial appearance, but this factor has a lower priority in the elderly or infirm.

Isolated zygomatic fractures associated with significant periorbital oedema and ecchymosis are best treated after a delay of 7-10 days. This not only allows time for the soft tissue swelling to settle and the degree of facial asymmetry to be accurately assessed, but it also provides an opportunity to obtain CT scans in cases of suspected internal orbital wall/floor fracture.

Closed reduction using a Gillies’ temporal approach is adequate treatment for most minimally displaced zygomatic fractures. After making a 2-3cm skin incision at 450 over the temple just anterior and superior to the pinna the outer layer of temporalis fascia is divided. An instrument such as a Rowe or Bristow elevator can then be inserted below the fascia and under the zygomatic buttress. The depressed zygoma is elevated by firmly lifting the elevator in the opposite direction to the force that displaced it (Fig. 6.12).

If the zygoma is unstable following closed reduction or if there has been any significant displacement the fracture(s) should be treated by ORIF using miniplates or transosseous wires (Fig. 6.13). Following elevation using a Gillies approach, all fracture lines and displaced sutures are visualized via appropriately placed cutaneous and mucosal incisions. A mucosal incision in the upper buccal sulcus gives excellent access to the zygomatic buttress facilitating accurate anatomical reduction and miniplate fixation. A “buttress plate” applied in this fashion is the most satisfactory way of preventing late zygoma sag and flat face deformity.

The zygomatico-frontal suture can be approached through a skin incision in the lateral eyebrow (which should not be shaved) or more cosmetically via an upper blepharoplasty incision. Following anatomical reduction a miniplate is placed across the suture. Miniplate fixation at the zygomatico-frontal suture alone is often inadequate to resist displacing forces and consideration should be given to the application of an additional buttress plate.

Numerous approaches have been described to gain access to fractures of the infraorbital margin and internal orbit but they are all variations of the subciliary, infraorbital or transconjunctival incisions. The subciliary incision affords excellent access to the lower half of the internal orbit and orbital margins. The incision is placed approximately 1 mm below the lower eyelashes and extended 1cm laterally and inferiorly at the outer canthus. A thin skin flap is raised above the orbicularis occuli to the level of the inferior orbital rim. An incision is then made directly onto the bone of the anterior maxilla just below the rim so as to avoid opening the periorbita and avoiding the infraorbital nerve. Orbital rim fractures are best stabilized using low-profile or microplates.

Fractures of the orbital floor or walls often occur together with zygomatic fractures and are called impure blow-out fractures. Isolated fractures of internal orbit are called pure blow-out fractures. Pure blow-out fractures can be caused by a direct blow to the globe by an object that is slightly smaller in diameter than the external orbital opening causing a rapid rise in intraorbital pressure. An impact force of 2.08 J (equivalent to a 303 g weight dropped from 70 cm) is sufficient to cause a blow-out fracture by this mechanism. Alternatively, a blow to the orbital rim can cause a shock wave that propagates along the floor of the orbit causing it to buckle and fracture without necessarily fracturing the rim itself. Orbital floor fractures may produce opthalmoplegia and diplopia as a result of incarceration of the inferior rectus, inferior oblique and periorbita (Fig. 6.14). Enopthalmos results from increased intraorbital volume, periorbita incarceration and fat atrophy.

Simple, narrow internal orbital fractures can be treated by overlaying a thin sheet of Silastic after retrieval of any prolapsed periorbita. The Silastic must rest on sound bone all round and must not sag over the fracture. It should be cut to shape so that it lies passively just inside the orbital rim to which it can be secured by a few drops of cyanoacrylate tissue adhesive. Larger defects require bone grafting harvested from the skull, anterior maxilla or iliac crest depending on the volume required.

Retrobulbar haemorrhage is a rare but well recognized complication of midface, zygomatic and orbital floor fractures and occurs following approximately 0.3% of zygomatic and orbital floor repairs. Its incidence is unrelated to the degree of surgical trauma. The usual cause is bleeding from a small branch of the infraorbital artery. The signs and symptoms include decreasing visual acuity, proptosis, diplopia and pain. Failure to recognize and treat retrobulbar haemorrhage early is likely to result in permanent blindness. It is vital that all patients are assessed for this complication on presentation and at frequent and regular intervals postoperatively until discharge. Once the diagnosis is made, medical management should be instituted immediately and urgent arrangements made to return the patient to the operating theatre for orbital decompression. The orbit is explored and all bleeding is arrested and any haematoma evacuated. If a graft was placed in the orbital floor it is removed otherwise a defect is created in the floor to decompress the orbit.

The aim of medical management is to reduce intraocular pressure and so relieve pressure on the short posterior ciliary arteries which otherwise results in ischaemia of the optic nerve head.

Mandibular fractures are traditionally described as being either vertically or horizontally favourable or unfavourable depending on the propensity of the muscular forces acting upon the fractured segments to displace them from their normal anatomical position. Although the principle on which the description is based is useful the nomenclature is confusing because the terms horizontal and vertical refer to the direction from which the fracture is observed and not the direction of the fracture itself. The surgeon needs to assess whether the direction of the fractures and the direction of the muscular pull either side of them will result in adjacent segments being impacted or distracted (Fig. 6.15). All other things being equal a simple, non-displaced “favourable” fracture is likely to require less aggressive treatment than an “unfavourable” one.

For patients with undisplaced favourable fractures who can easily bite into their normal pre-injury occlusion, and who are willing and able to comply with weekly clinical review, it may be permissible to adopt a conservative approach and prescribe a soft diet and analgesics. Minimally displaced fractures can frequently be managed by 4-6 weeks of IMF applied via arch bars or eyelet wires. ORIF is indicated for the majority of displaced fractures and minimally displaced fractures where IMF is contraindicated.

The most favourable site for internally fixing a fractured bone is where the tensile forces acting upon it are at their greatest. Champy et al (1978) applied this “tension band” concept to the internal fixation of mandibular fractures with miniplates. Tensional forces across a fracture at the mandibular angle are best resisted by a superior border miniplate, while the additional torsional forces acting across a fracture anterior to the mental foramen require the application of 2 miniplates approximately 5 mm apart (Fig. 6.16).

After establishing IMF, access to the fracture is achieved via an incision in the labial or buccal sulcus approximately 5 mm below the mucogingival junction. A trans-buccal approach using a trochar as a conduit for drills, screwdrivers and screws facilitates plate application in areas with poor access such as the posterior mandible. The IMF can be released when satisfactory fracture fixation has been achieved.

Occasionally, the access afforded by an intraoral incision is insufficient to enable full exposure and control of the fractured segments and an extraoral approach is required. For posterior mandibular fractures the incision should be placed approximately 3cm below the lower border of the mandible so as to avoid damaging the marginal mandibular branch of the facial nerve. A submental incision is used for symphyseal and parasymphyseal fractures. In severely displaced or comminuted fractures the fragments should first be reduced and stabilized by transosseous wires prior to plate application. Lower border wires inserted via an elective extraoral approach are particularly helpful in controlling lingually displaced fractures.

Teeth in the line of fracture are best left in situ provided that they are firm, not fractured, and have no associated periapical or periodontal infection as they usually facilitate fracture localization and reduction.

In poorly compliant patients whose lifestyle and medical or social circumstances suggest that they are at high risk of further trauma, re-fracture, or post-operative infection, a strong case can be made for utilizing true rigid fixation to produce “safe fixation”.

Fractures of the edentulous mandible present a different set of problems. In simple fractures in a non-medically compromized patient it is often possible to treat the fracture with IMF via gunning splints secured with circum-mandibular wires. However, in many cases IMF will need to be avoided and ORIF will be required. If there is sufficient bulk of mandible then miniplate osteosynthesis is the most satisfactory method but in atrophic mandibles compression/reconstruction plates may be required.

Fractures of the mandibular condyle have traditionally been managed either conservatively or by elastic IMF. Excellent functional outcomes are usually achieved with undisplaced or minimally displaced unilateral fractures managed this way. However, there is increasing evidence that closed reduction of severely displaced, severely telescoped or dislocated fractures frequently results in an unsatisfactory outcome, particularly in bilateral cases. ORIF is indicated for this category of fracture with persistent malocclusions after 3-4 weeks of elastic IMF. Early ORIF should be considered for bilateral fractures. The potential morbidity of ORIF for condylar fractures includes facial nerve paresis, which may be permanent, and avascular necrosis of the condylar head. It is thus not a procedure to be undertaken lightly or by an inexperienced surgeon.

Dislocation of the temporomandibular joint (TMJ) occurs if the condylar head is completely displaced from the glenoid fossa. In the majority of cases the condylar head moves anterior to the articular eminence. Posterior, lateral and superior (central) dislocations are very rare. The clinical features include malocclusion (usually with an anterior open bite), TMJ pain drooling and dysarthria. Beware of misdiagnosing strokes or dementia in the elderly patient who has a dislocated TMJ. The diagnosis can be confirmed by a panoramic tomogram or lateral skull radiograph. While some dislocations reduce spontaneously (subluxations) many require manipulative or even operative reduction. In the majority of cases simple manipulation suffices. The patient should be sat down with the operator standing behind them. The operators thumbs (which should be wrapped in a gauze swab to protect them) are placed on the patients lower molar teeth and the index fingers below the patients chin. Slow, constant downward pressure is exerted on the molars while at the same time pulling upwards and backwards on the chin. The idea is to pull the condylar head onto the crest of the articular eminence and then slip it back into the glenoid fossa. Infiltrating the joint capsule with local anaesthetic before attempting to reduce the dislocation abolishes the neuromuscular reflex spasm maintaining the dislocation and significantly increases the success rate of the procedure. Occasionally, particularly with prolonged dislocations intravenous sedation or general anaesthesia will be required before the dislocation can be reduced. Condylotomy, condylectomy or mandibular osteotomy may even be required when manual reduction fails.

• Beware of misdiagnosing strokes or dementia in the elderly patient

The 2 naso-maxillary and zygomatico-maxillary buttresses maintain the relationship between the maxilla and the cranial base above and the mandible below. Correct anatomical reduction of these 4 anterior buttresses following a LeFort 1 maxillary fracture will ensure that the anatomical relationship between the midfacial, cranial and mandibular facial units is correctly restored. Reconstruction of the posterior buttresses at the pterygoid plates is neither desirable nor necessary.

Following the application of IMF the anterior buttresses are exposed via a horseshoe incision in the maxillary buccal sulcus extending from the first molar tooth on one side to its counterpart on the other. The maxilla is then degloved up to the infraorbital margins superiorly and the maxillary tuberosities posteriorly. All fractures are exposed and anatomically repositioned. Missing buttresses and significant defects are bone grafted using split calvarium. The buttresses and all fractures and bone grafts are then stabilized with miniplates (Fig. 6.17).

A similar approach is adopted for LeFort 2 fractures. Access to the infraorbital rims and orbital floor can be increased by using a subciliary incision. Mobility of the maxilla in the region of the nasofrontal suture will require miniplate osteosynthesis to the frontal bone. Access to this region is via local incisions at the medial canthus, glabella or a bicoronal flap. The management of LeFort 3 maxillary fractures is essentially the same as for panfacial fractures described in the next section.

While the reconstruction of a severe panfacial fracture may at first sight seem a daunting task, it simply requires the surgeon to perform many of the individual facial fracture reductions previously described and then link them all together. However, the order in which the surgery is performed is crucial if predictably good results are to be obtained and mistakes minimized.

In the era of IMF and external fixation an “inside-out” and “bottom-up” approach was favoured, in which the reconstructed mandible acted as the primary template for the remainder of the facial reconstruction which then proceeded in a caudal to cranial direction. Unfortunately, closed fracture reduction and poor fragment control invariably led to errors in reproducing the normal facial width, height and projection. With rigid fixation, correct spatial control of fractured facial bone fragments can be achieved (Figs. 6.18a – 18c and 6.19a – 19b). Table 6.10 details a treatment sequencing system for panfacial fractures. Not all fractures will require every step to be performed but the order of treatment should be adhered to in all cases.

The majority of facial abrasions and lacerations can be adequately managed in properly equipped accident and emergency departments by appropriately trained nursing or medical staff under local anaesthesia. More extensive lacerations requiring in excess of 45 minutes to close are best managed in an operating theatre, while those involving named nerves, arteries and ducts are best dealt with under general anaesthesia. Fine, high quality suturing requires fine high quality instruments and good illumination. It is unacceptable to attempt to repair facial lacerations using instruments designed for general “casualty” use.

The fundamental aim in the management of all facial lacerations is to minimize scarring and its long term cosmetic and psychological sequelae. The soft tissues can be considered as the “fourth dimension” of facial reconstruction and when associated with facial fractures they should be treated following early facial bone reconstruction as soft tissue that heals from a single insult over a correctly reconstructed facial skeleton provides the most natural facial appearance.

Most soft tissue injuries are suitable for immediate primary repair but where there are associated life-threatening injuries and the patients’ condition is unstable, wounds are best covered with sterile saline dressings which are changed frequently until such time as the patients condition stabilizes and definitive repair can safely be undertaken.

• The majority of facial abrasions and lacerations can be adequately managed in properly equipped accident and emergency departments by appropriately trained nursing or medical staff under local anaesthesia

The margins of traumatic lacerations are often shelving, uneven and of questionable viability. If good postoperative results are to be achieved they must be meticulously managed. Under appropriate anaesthesia, wounds are first thoroughly debrided using a suitable antiseptic solution to remove all foreign bodies such as dirt and glass. A soft sterile toothbrush or surgical scrub brush is very effective if used with care. Non-vital tissue should be judiciously excised although irregular, but otherwise viable wound margins are best not converted to a straight line. The extent of any tissue loss should be accurately assessed. Minor losses are inconsequential but more significant ones particularly if full thickness, may require immediate skin grafting or even flap repair.

Wounds should be closed in layers using absorbable sutures for the subcutaneous tissues such that all dead space is eliminated and the wound edges approximated. Final closure of the epidermis using a 5-O or 6-O gauge monofilament suture should evert the wound margins without tension. For the repair of facial lacerations in young children or anyone where it is felt that co-operation with subsequent suture removal will be poor, excellent cosmetic results can be achieved using 6-O plain catgut for epidermal closure. Evenly spaced adhesive suture strips applied at right angles to its long axis provide additional support for the wound. The application of a topical antibiotic such as 1% chloramphenicol ointment prevents desiccation and reduces wound infection.

Deep facial lacerations may transect the facial artery, the facial nerve or the parotid duct (Fig. 6.20). Lacerations around the medial canthus and naso-maxillary angle may involve the lacrimal drainage system. Facial lacerations involving any of these complications should be managed in an operating theatre under general anaesthesia. Under optimal conditions wounds should be thoroughly explored and any associated damage fully documented. The cut ends of any bleeding arteries should be fully exposed and ligated.

If a transected parotid duct is suspected the diagnosis can be confirmed by passing a fine catheter into the duct and gently infusing 3 – 4 cm3 of sterile saline and observing for its emergence into the wound. Transected ducts should be repaired with interrupted 6-O absorbable sutures over a plastic catheter stent to allow free drainage of saliva. The stent is sutured to the buccal mucosa alongside the parotid papilla and removed after 10 – 14 days. Failure to recognize or adequately treat a transected duct will result in a sialocoele and/or salivary fistula, which can prove extremely resistant to treatment.

A laceration that involves the parotid duct may also involve the buccal branch of the facial nerve. If transection of a peripheral facial nerve branch is diagnosed its repair should only be undertaken by a surgeon fully conversant with the local anatomy and skilled in the techniques of parotidectomy and microsurgery. If the transected branch is not readily identifiable via the laceration a formal superficial parotidectomy approach to the main trunk and its branches may be required before it can be located. Immediate microepineural repair using 9-O monofilament sutures offers the best hope of preserving facial animation. The functional and hence aesthetic results of late repairs of undiagnosed facial nerve injuries are poor.

The nasolacrimal sac and duct and the superior and inferior canaliculi are at risk from facial fractures and lacerations in the region of the medial canthus and naso-maxillary angle. Obstruction to the lacrimal drainage system results in epiphora and dacrocystorhinitis. Transection of the inferior canaliculus or lacrimal sac can be confirmed by applying 1 or 2 drops of fluorescein to the lower fornix and observing for the dye in the wound. Repairs to the lacrimal drainage system, especially those involving the lacrimal sac and duct can be complex and should be referred to a surgeon appropriately skilled in oculo-plastic surgery. Significant ocular trauma must always be suspected in these injuries.

Facial fractures in childhood are uncommon accounting for approximately 5% of all facial fractures. In children below 5 years of age the incidence is closer to 1%. Midface fractures in this age group are exceedingly uncommon accounting for less than 0.5% of all facial fractures. The emergency management of facial injuries in children does not differ significantly from the methods previously described for adults.

• Avulsed teeth have an 85-97% chance of being successfully replanted if treatment is timely and appropriate treatment is provided.