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Facial trauma is a fairly common injury.  Most facial trauma is the result of motor vehicle collision, assaults, sporting injuries or falls.  Many times, the facial injury is restricted to the soft tissue resulting in bruising, swelling and discomfort.  However, in harder impact injuries the force may be transferred to the underlying facial bones resulting in a fracture.  


Not all facial fractures need to be treated in the same way one would treat a conventional body fracture (e.g. with a cast).  However, if fractures are significantly displaced then, for function and aesthetics, these may need to be reduced and fixated to maintain their position while they heal.

Often-used terminology in the context of fractures:  

Displaced:  The bones on each side of the fracture are not in alignment as they should be.  Depending on the degree of displacement, surgery may be necessary to reduce and/or fixate the bones.


Fracture:  A break in the continuity of a bone.  The fracture may be compound, where the bone fracture site is communicating with the outside environment (including the mouth).  It may be greensticked such as is often the case with a child's bones where the bone is not completely fractured and is more like a partial break in a wet twig or branch.  A complex fracture is one where there are multiple factors at play (e.g. significant soft tissue injury, possibly missing bone.  Comminuted fractures signify the fracture is not a simple (single break) and there are multiple broken pieces; typically this results from high impact forces (e.g. baseball at high velocity).


Reduce or reduction:  The degree to which a fractured segment of bone is anatomically together as it should be.  Often this can be accomplished without an incison to gain direct access to the bone (termed closed reduction).  If the fracture site needs to be formally opened up to access the bones to reposition them it is termed an open reduction.


Fixation:  Any means by which the bones are held together by a mechanical means to keep them from separating during healing.  If the fracture site was surgically opened up and the fracture directly fixated (e.g. with titanium plates/screws) it is termed interal fixation.  If the fracture is held together by placing wires through the skin and holding these wires together externally it is external fixation.


Maxillomandibular (Intermaxillary) fixation: This is the equivalent of an arm cast (or the best we can do).  It is also commonly known as 'wiring the jaws shut'.  In doing this, the teeth are placed in their maximum intercuspal position (i.e. where they're supposed to fit) and the jaws are wired together.  This allows the bone to heal where they are supposed to such that teeth are working together as they did before the injury.  This type of fixation can often preclude the use of internal fixation and keep you from needing a more invasive surgery. Not every circumstance or person is a candidate for this fixation.




Specific fractures:

Mid-Face Fractures (LeFort fractures):  Studies done in the past by dropping skulls from different heights led Rene LeFort to determine three primary patterns of fractures of the midface (i.e. the maxilla, cheekbones, eye sockets, nasal bones and bones behind them).  In the simplest instance, the maxilla (upper jaw) is disarticulated from the bones behind and above it leaving an upper jaw that is essentially free-floating. In the most severe instance, the midface is disarticulated from the upper skull and eyesockets, nose, maxilla and cheeks are free-floating. These fractures are often the result of blunt force, mid to high energy impact injuries that are spread out (e.g. dashboard injury in a motor vehicle accident or a fall onto the face).  


Orbital Fractures:  The orbit (eye socket) is comprised of a number of bones (seven to be exact).  A not uncommon fracture is the so-called 'blowout fracture' of the orbit.  In this case, a roundish object (e.g. ball, fist) is directed to the eyeball.  As the eyeball's (globe's) pressure and the contents of the orbit increases, there is a weak point in the eyesocket's bones - usually the 'floor' of the orbit - will fracture downwards to create room for the pressure.  If this didn't occur, the eyeball could be directed posteriorly (into the brain) or the eyeball could collapse. This blowout fracture in a sense is nature's protection mechanism.  Depending on the extent of displacement of the floor of the orbital contents, it may need surgery to reconstruct properly to correct: a sunken-in eyeball appearance or to prevent double vision or visual problems.  Usually the incison can be hidden wthin the lid of the eye and healing goes very well.


Zygomatic and Zygomatic Arch Fractures:  The zygoma is the 'cheekbone' and also wraps around to the temple area just in front of the ear.  Fractures to this area can occur in moderate to high impact blunt force trauma as in a fist punch.  Generally, multiple fractures of the zygomatic bone complex (ZMC fractures) need to be corrected through surgery and the placement of small titanium plates.  An isolated fracture of the zygomatic arch (the arm of zygoma that extends back from the cheek to in front of the ear (the bucket handle) can often be repaired with a small, inconspicuous incision allowing the fracture to be "popped out".  Failure to repair this injury can give the individual a sunken-in cheekbone appearance.


Nasal Bone Fractures:  There is one set of paired nasal bones.  These bones are prime targets for being fractured due to their prominent display in the face.  These bones can be displaced or fractured by blunt, midforce trauma (e.g. falls, fists).  More times than not, the nasal bones can be reduced ('reset') by manual reduction without an incision.  If the bone is pushed out, it can be pushed back in from the outside.  Conversely, if it is collapsed inward, it can be pushed back outward with a blunt spatula from the inside of the nose.  The septum can be reduced at the same time and splints/packing are placed.


Mandibular ('jawbone') Fractures:  The mandible is one of the most common facial bone injuries (around half of all injuries).  Injuries to the mandible are common after falls, assaults or sporting injuries.  People should be on the alert to mandibular fractures if:


  • There was a fall on the chin significant enough to result in a bruise or cut.  These injuries can lead to a fracture in the 'neck' of the jaw (the condyle).  Again, this is nature's way of preventing the jaw from being pushed into the brain from an upwardly-backwardly-directed force to the lower jaw.  

  • There was a substantial blow to the jaw on one side.  This often leads to a fracture in the angle of the mandible and sometimes a co-fracture on the opposite side.

  • After the impact/blow (within a very short period of time):

    • the teeth no longer fit together the way they used to;

    • there is numbness or tingling in the lower lip or chin;

    • there is swelling or significant bruising in the floor of the mouth (under the tongue);

    • there is the feeling of crackling or a grating sound around the jaw bone when you move it;

    • there is an inability to open the mouth or when you try to open, the jaw deviates to one side.


More times than not the fracture can be treated in a more conservative fashion.  In compliant, cooperative patients, if the fracture is non-displaced (see above) a non-chew diet for a few weeks may be all that is needed.  If there is some displacement of the fracture or if the patient may not be cooperative, maxillomandibular fixation may be needed.  Finally, if the fracture is significantly displaced or if there is an absence of teeth to wire together, the best choice may be to open the fracture site either via incisions in the mouth or through the neck skin followed by the placement of titanium plates and screws.


Any time a fracture is suspected, it should be investigated as soon as possible.  Fortunately, most fracture situations have a window of time to operate (at least two weeks).  However, some fractures - if they entrap a vital structure (e.g. muscle/nerve entrapment of the eye) - need to be operated on emergently.


Adult versus Pediatric Fractures:

Because children are still growing, we don't want to place a device that may restrict the bone's ability to grow over the long term.  To that end, we often prefer to not place titanium plates that don't go away.  Options for pediatrics may include: resorbable plates and screws, removable wires, temporary maxillomandibular fixation, or no intervention other than supervision.  Adults tend to have more muscular strength to distract or mobilize fracture segments and may be better off having a rigid device such as titanium plates placed.  These plates and other titanium hardware are generally designed to be left in permanently.  The incidence of reactivity (e.g. allergy) to titanium is near-zero.

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