Facial trauma

Dr. Usama Aldaghir

Oral and maxillofacial surgeon
C.A.B.M.S.
 FRACTURES OF THE FACIAL SKELETON

Fractures of the facial skeleton may be divided

into:
➢Those of the upper third (above the eyebrows),
➢The middle third (above the mouth)
➢The lower third (the mandible).
 Fractures of the middle third of the facial skeleton

The facial skeleton can be divided into an upper, middle and lower third.
The lower third is the mandible. The upper third is formed by the frontal
bone. The middle third is the region extending downwards from the
frontal bone to the level of the upper teeth, or if the patient is edentulous
the upper alveolus.
The middle third of facial skeleton is formed by bones which articulate
with each other in immobile sutures. The bones are:
•Two maxillae
•Two nasal bones
•Two zygomatic bones
•Two palatine bones
•Two inferior conchae
•The ethmoid and its attached conchae
•Vomer bone
•Sphenoid bone
The bones of the midface constitute a series of vertical and
horizontal bony struts or 'buttresses', these buttresses of
the face consist of thicker bone that transmits the chewing
forces to the supporting regions of the skull.

The vertical buttresses are the pterygomaxillary,

zygomaticomaxillary, and nasomaxillary buttresses.
The horizontal buttresses are supraorbital or frontal bar,
infraorbital rims, and zygomatic arches.

The skeleton of the midface has been described as a

(crumple zone) that acts as a cushion, absorbing the energy
of any cranially directed impacts coming from an anterior or
anterolateral direction thereby protecting the brain and
conferring a survival advantage.
➢In addition, even trivial blows to the face may:
• cause injuries that compromise the airway;
• directly or indirectly cause a head injury;
• cause injuries to the cervical spine.
 Causes
➢ sporting activities,
➢accidents
➢and intentional violence.
 The middle third
In 1911, René Le Fort classified fractures
according to patterns which he created on
cadavers using varying degrees of force.

These fracture patterns are characteristic of a

unidirectional, low-energy injury rather than the
multi-vector, high-energy mechanisms commonly
observed today.
1\ The Le Fort I fracture effectively separates the
alveolus and palate from the facial skeleton above.

➢Le Fort I fracture (also called Guerin fracture or low

level fracture) is caused by a force delivered above the
apices of the teeth. The fracture occurs at the level of
the piriform aperture and involves the anterior and
lateral walls of the maxillary sinus, lateral nasal walls
and pterygoid plates at the junction of the lower one-
third with the upper two-third. A unilateral maxillary
fracture may also occur, with the fracture coursing
through the palatal suture line or adjacent to it
2\ The Le Fort II fracture is pyramidal in shape.
➢ The fracture involves the orbit, running through the
bridge of the nose and the ethmoids, whose cribriform
plate may be fractured, leading to a dural tear and CSF
rhinorrhoea.
➢ It continues to the medial part of the infraorbital rim
and often through the infraorbital foramen.
➢ It continues posteriorly through the lateral wall of the
maxillary antrum at a higher level than the Le Fort I
fracture to the pterygoid plates at the back.
➢Le Fort II fracture is also referred to as a pyramidal or
sub-zygomatic fracture. This fracture involves the
nasofrontal suture, nasal and lacrimal bones, infraorbital
rim in the region of the zygomaticomaxillary suture,
maxilla, and pterygoid plates half way. It can be unilateral
or bilateral.
3\ The Le Fort III fracture effectively separates the facial skeleton
from the base of the skull

➢ The fracture lines run high through the nasal bridge, septum and
ethmoids, again with the potential for dural tear and CSF leak,
and irregularly through the bones of the orbit to the
frontozygomatic suture.
➢ The zygomatic arch fractures, and the facial skeleton is separated
from the bones above at a high level through the lateral wall of
the maxillary sinus and the pterygoid plates.
➢ Le Fort III fracture is also called craniofacial disjunction; it starts at
the frontonasal suture, runs through the frontomaxillary suture,
over the lacrimal bone, the lamina papyracea of the ethomoid
bone and towards the optic foramen to reach the inferior orbital
fissure, the fracture line divides into two lines. One line passes
around the frontozygomatic suture to separate the zygomatic
bone from the frontal bone. The other line passes posteriorly to
fracture the pterygoid plates at the root, thus separating them
from the cranial base.
 Clinical features
Le Fort I fracture
Malocclusion and mobility of whole of dentoalveolar
segment of upper jaw may be noted.
Hypoesthesia of the infraorbital nerve may be caused by
the rapid development of edema.
Palatal ecchymosis (Guerin sign) is usually noted.
Ecchymosis and tenderness of the zygomaticomaxillary
buttress area.
‘Cracked pot’ percussion sound from upper teeth.
Fractured cusps of teeth.
 Le Fort II fracture
Grasping the anterior maxilla and attempting anteroposterior
displacement facilitates evaluation of the nasofrontal suture
and inferior orbital rims.

Edema is often present overlying the fracture sites.

Mobility of the upper jaw.
Step deformity in the infraorbital rim.
Bilateral cirumorbital edema and ecchymosis (Raccoon eyes)
and subconjunctival hemorrhage may be noted, it results from
the bleeding at the site of fracture, which escapes in different
tissue planes.
Cerebrospinal fluid (CSF) rhinorrhea may be encountered as
the result of a dural tear
Epistaxis is common.
Tenderness over the nasal bridge area and possible
nasal deformity.
Hypoesthesia of the infraorbital nerve is also common
because of direct trauma or rapid edema formation.
Malocclusion is often present in the form of an
anterior open bite and gagging of posterior teeth.
‘Cracked-pot’ sound on tapping teeth.
Difficulty in opening mouth, and sometimes inability
to move the lower jaw
Possible diplopia and enophthalmos in severe cases.
 Le Fort III fracture
Bimanual palpation reveals abnormal mobility at the frontonasal
and frontozygomatic sutures.
Classic dish face deformity and mobility of the zygomaticomaxillary
complex. As the facial bones are disarticulated from the cranial
base the elongation of the face takes place leading to long face.
Facial edema.
Circumorbital ecchymosis and subconjunctival
hemorrhage(Raccoon eyes)
CSF leakage due to the involvement of the cribriform plate leading
to dural tear and CSF rhinorrhea.
‘Cracked-pot’ sound on tapping teeth.
There may be gagging of the occlusion in the molar area.
 Detection of CSF Rhinorrhea
Clinical detection of CSF rhinorrhea may be
complicated by the presence of lacrimal fluid, blood
and nasal secretions. When the blood clots and dries
and the flow of CSF continues, it produces a classical
(tramline pattern). It also forms classical ring around
the clotted blood on the pillow. If the patient is in
supine position it passes in the pharynx giving salty
metallic taste.
Traditional methods for detecting CSF leak include
testing for glucose or protein, but these are neither
sensitive nor specific. Testing the discharge for beta-2
transferrin, a brain specific variant of transferrin, is
accepted as the best available diagnostic method.
It is important to confirm that the patient has sight in
both eyes.
This may be difficult in the very oedematous
patient with marked periorbital oedema, but a pen
torch shown directly through the lids will confirm gross
optic nerve function.
➢ pupil size and reflexes to light should be observed and
recorded,
➢ eye movements.
➢ Diplopia should be checked for by asking the patient to
follow the light of a pen torch in both central and
extremes of gaze.
Diplopia may be indicative of damage to the III, IV
or VI cranial nerves or, more commonly, damage to the
thin orbital plates of bone, particularly the floor of the
orbit.
Imaging
Plain radiographs have only limited role and they are
indicated when three-dimensional imaging (CT scan) is not
available, these may include:
Occipitomental projection The occipitomental view (Water's
view) is useful plain radiograph. Two projections angled at
10° and one at 30° are desirable.
For interpretation of occipitomental radiographs systematic
examination along lines where bone disjunction can be
expected if a fracture has occurred. To facilitate
interpretation 5 curved lines (Campbell-Trapnell lines)
which are frequently used. The occipitomental view may
demonstrate the major areas of fracture discontinuity
including the zygomaticofrontal buttress, the inferior
orbital rim and zygomaticofrontal suture in addition to
haziness of maxillary sinus due to hemorrhage.
Lateral projection
Le Fort type fractures at each level (I, II and III) can be
detected on this view where the fracture line can be seen
passing across the pterygoid plates. It is often the only
plain view that clearly demonstrates a Le Fort I fracture. It
also aids recognition and assessment of any extension of
fractures into the frontal sinus.

CT scan
A CT scan or cone beam CT (CBCT) with multiplanar and 3-D
reconstruction is indicated for visualization and
delineation of the magnitude and comminution of the
midfacial fractures and for the identification of adjacent
fractures, such as those of the maxilla, the naso-orbito-
ethmoidal complex and the skull base.
Submentovertex radiograph for detection of
zygomatic arch fracture.
 Treatment
Observation

Observation is indicated in:

• Non-mobile or minimally mobile linear Le Fort I fracture with
unaffected occlusion.
• Le Fort I, II or III fractures in edentulous patients with atrophic
maxilla provided that they are nondisplaced stable fractures.
• In edentulous patients with minor displacement.
• In cases when general medical conditions do not allow surgical
intervention.
A soft diet is advisable for several weeks. Close follow-up is
required and patients should be compliant.
 Surgical treatment
Reduction
Effective reduction of maxillary fractures depends
on the degree of mobility of Le Fort fractures
following injury; in some situations it may be
possible to reduce low level maxillary fractures
simply by finger manipulation alone otherwise
paired Rowe's disimpaction forceps can be used to
manipulate the fracture into place, also Hayton-
Williams forceps can be used for the same purpose.
The guidance for proper, Reduction is achievement
of satisfactory occlusion and correction of facial
deformity.
 Fractures of the maxilla
The principle of treatment is to restore the
fragments to their original position. To achieve
this, it is usually necessary to reduce the maxilla
first with Rowe’s disimpaction forceps, which
grasp the palate between the nasal and palatal
mucosa.

Considerable force is sometimes required in a series

of downwards, forwards and sideways
movements to mobilise it.

After 2–3 weeks, full disimpaction is often

impossible.
Fixation Applying IMF using interdental wiring or arch bars alone
is insufficient to stabilize the middle third of the facial skeleton
because of the mobility of the lower jaw. After using the mandible
as a guide to accurate occlusal reduction, the middle third must
be immobilized by attaching it to the adjacent facial bones
superior to the fracture line. This can be achieved by either
internal wire suspension or external suspension. These methods,
however, have been superseded by ORIF method.
Methods of internal wire suspension include:
•Pyriform fossa wiring. ( for leforte I)
•Infraorbital rim suspension wiring. ( for leforte I)
•Circumzygomatic wiring. ( for leforte II)
•Supraorbital rim suspension wiring. ( for leforte III)
In case of Le Fort II fractures the pyriform fossa wiring suspension
and infraorbital rim wirings cannot be used for treating as the
fracture line passes above these points. In Le Fort III fractures
internal suspension is not effective as the fracture line is very high
and only supraorbital rim is available for internal suspension.
 Open reduction and internal fixation (ORIF)
Le Fort I fracture Surgical exposure is achieved
through a vestibular incision (gingival sulcus
incision ), this approach allows visualization of the
lateral antral wall and zygomatic buttresses. A Rowe
or Hayton-Williams forceps can then be used to
complete the reduction, if necessary. The patient is
first placed in IMF to reestablish the pretraumatic
occlusal relationship. Fixation with miniplates along
the pyriform (nasomaxillary) and
zygomaticomaxillary buttresses is routinely
provided for stability of this fracture pattern.
 Open reduction and internal
fixation (ORIF)
Le Fort I fracture

Surgical exposure is achieved through a vestibular incision, this

approach allows visualization of the lateral antral wall and zygomatic
buttresses. A Rowe or Hayton-Williams forceps can then be used to
complete the reduction, if necessary. The patient is first placed in IMF
to reestablish the pretraumatic occlusal relationship. Fixation with
miniplates along the piriform (nasomaxillary) and
zygomaticomaxillary buttresses is routinely provided for stability of
this fracture pattern.
Le Fort II fractures
In cases of mobile Le Fort II fractures, the additional fixation
of the nasofrontal suture and the orbital rim is required.
Occasionally exposure can be sufficient using a vestibular
incision, but usually an approach to the orbital rim is required,
this is achieved by one of the following:
•Infraorbital incision
•Subciliary incision.
•Subtarsal or mid-lower lid incision.
•Transconjunctival Incision
•Alternatively a midfacial 'degloving' approach can be
considered for more complex fractures if appropriate, the
technique combines an intraoral vestibular approach with
degloving of the lower half of the nose to allow wide exposure
of the whole maxilla including the nasal skeleton.
Le Fort III fractures
In Le Fort III cases, besides buttress
reconstruction, the fixation of the
frontozygomatic and frontonasal sutures is
required, as well as the stabilization of the outer
orbital frame and the zygoma. Access to the
upper and midface from the cranial base to the
maxillary occlusal level is obtained by using a
coronal scalp flap with an intra-oral vestibular
incision. Additional bilateral approaches to the
infraorbital rims and orbital floors are usually
needed.
Palatal fractures Isolated fractures of the palate are rare, Clinical
examination may reveal laceration of the lip and concurrent
gingival and palatal lacerations. Often,a change in occlusion is also
noted. Diagnosis is confirmed by a maxillofacial CT with axial and
coronal cuts.
Classification
•Type I: Sagittal; if the fracture is located at the midline, it is
considered the median type. The paramedian type describes a
fracture that parallels the midpalatal suture
•Type II: Transverse
•Type III: Comminuted
Treatment
Surgical treatment planning depends on the type of fracture,
presence or quality of the dentition, and concomitant facial
fractures.
Treatment of the palatal fracture in dentate patients should center
on occlusal reduction with IMF and ORIF through facial vestibular
approach. Occlusal splints can be extremely helpful in the
comminuted palatal fracture.
 The zygomatic complex
➢This is the most common fracture of the middle
third of the face, apart from the nose.

➢The fractures occur through points of

weakness :
✓infraorbital margin,
✓the frontozygomatic suture,
✓the zygomatic arch,
✓the anterior and lateral wall of the maxillary
sinus.
The zygomatic complex usually fractures in the region of the
frontozygomatic, the zygomaticotemporal and the
zygomaticomaxillary sutures.
Fractures of zygomatic complex can be classified as:

A/Fractures of the zygomatic body involving the orbit

1. Minimal or no displacement.
2. Inward and downward displacement.
3. Inward and posterior displacement.
4. Outward displacement.
5. Comminution of the complex as a whole.

B/Fractures of the zygomatic arch alone not involving the orbit

1. Minimal or no displacement.
2. V-type in-fracture
3. comminuted
 Clinical features of zygomatic complex fractures
• Flattening of cheek
• Flattening over the zygomatic arch
• Swelling of cheek
• Limitation of mouth opening due to impingement of the
depressed zygomatic bone on the temporal muscle and/or
coronoid process, limiting mandibular excursions and due
to muscle spasm.
• Anesthesia of cheek, temple, upper teeth and gingiva
• Periorbital (circumorbital) ecchymosis and edema
• Sub-conjunctival hemorrhage
• Epistaxis due to disruption of maxillary sinus mucosa
caused by fracture of the sinus wall.
• Crepitation from air emphysema; fracture through a sinus
wall with tearing of the lining mucosa allows air to escape
into the facial soft tissue.
• Tenderness and palpable separation at frontozygomatic
suture
• Step deformity and tenderness of infraorbital margin
• Ecchymosis and tenderness intra-orally over zygomatic
buttress
• Limitation of ocular movement
• Diplopia; bin¬ocular diplopia that develops following
trauma can be the result of soft tissue (muscle or
periorbital) entrapment, neuromuscular injury,
intraorbital or intramuscular hematoma or edema, or a
change in orbital shape, with displacement of the globe
causing a muscle imbalance. The presence of
entrapment of orbital contents by the fracture through
the orbital floor can be determined with a forced
duction test.
• Displacement of the palpebral fissure and unequal
pupillary levels; due to inferior displacement of
Whitnall's tubercle with the attached Lockwood's
suspensory ligament that leads to alteration in the
level of the globe (Hypoglobus or orbital dystopia)
• Enophthalmos defined as the posterior displacement
of the globe that is often due to increase in orbital
volume secondary to interruption of the skeletal
integrity of the bony orbit.
 Imaging
•Occipitomental (Waters') view; it generally delineates the
fracture pattern and displacement of the zygomatic
complex, including isolated fractures of the zygomatic
arch.
•Submentovertex view is helpful for evaluation of the
zygomatic arch and zygomatic projections.
•CT scan; axial and coronal plane CT is the gold standard
for radiographic evaluation of zygomatic fractures. It
allows for detailed evaluation of buttresses of the
midfacial skeleton including the orbit.
 Treatment of ZMC fracture
Zygomatic complex fractures with minimal displacement that are not
causing symptoms do not necessarily require treatment.

The indications for treatment are as follows:

• To restore the normal contour of the face both for cosmetic

reasons
• To re-establish skeletal protection for the globe of the eye.
• To correct diplopia.
• To remove any interference with the range of movement of the
mandible.
• When pressure on the infraorbital nerve results in significant
numbness or dysesthesia
 Reduction
Many zygomatic complex fractures are stable after
reduction without any form of fixation, especially
when:
• The displacement is a medial or lateral rotation
round the vertical axis without separation of the
frontozygomatic suture.
• Recent fractures are more stable than those that
are more than 2 weeks old.
Fractures in which there is disruption of the
frontozygomatic suture and those that are
extensively comminuted are usually unstable after
reduction.
The indirect reduction of a zygomatic fracture can be
achieved by:

The temporal approach (Gillies approach) is

popular and straightforward. It consists of an incision
made in the temporal region and the temporal fascia
is incised, then an instrument is passed superficial to
the surface of the temporalis muscle and deep to the
zygoma. The zygomatic bone or arch can then be
elevated into a correct position using Rowe's or
Bristow's elevator. The position of the bone is
confirmed by palpation of the infraorbital rim and the
cheek prominence using the uninjured side for
comparison.
The percutaneous approach is a rapid method most useful in non-
comminuted fractures with medial displacement and no distraction
of the frontozygomatic suture. The location of the stab incision for
insertion of the bone hook is at the intersection of a perpendicular
line dropped from the outer canthus of the eye and a horizontal line
extending posteriorly from the alar rim of the nostril.
Buccal sulcus approach (Keen approach 1909); an incision is made in
the upper buccal sulcus immediately beneath the zygomatic
buttress and a curved elevator is passed supra-periosteally to
engage the deep surface of the zygomatic bone.
Lateral coronoid approach (Quinn 1977); it is a simple method for
isolated fractures of the arch, this approach consists of intraoral
incision made along the anterior border of the ramus, through
which an elevator is inserted lateral to the coronoid process, and
the arch is elevated while the surgeon palpates extraorally along the
arch.
 Open reduction and internal fixation

It is indicated in:

• Displaced fractures that are not stable after reduction.

• Comminuted fractures.
• Fractures that are more than 2 weeks old.
• When orbital exploration is required due to the presence of
diplopia or enophthalmos.
The open reduction is followed by fixation of the
fracture segments using transosseous wiring or
miniplates and/or microplates. The wires or plates
can be fixed at frontozygomatic suture, infraorbital
rim, the zygomaticomaxillary buttress and rarely at
the zygomaticotemporal suture.
The fractures should be fixed at minimum two
points.
As all fractures of the zygoma, other than those
solely of the arch, involve the orbital floor, it is
essential to apply a forced duction test to ensure
no limitation of movement of the inferior
oblique and inferior rectus muscles.
For this to be done, the lower eyelid is retracted
and the inferior rectus grasped in the lower
fornix. The globe can then be rotated upwards
and should move freely.
Any restriction in movement suggests entrapment
of the infraorbital soft tissues, and the floor of
the orbit should be explored as for a blow-out
fracture
 Incisions for the surgical exposure of the
zygomatic complex

Approaches to the frontozygomatic suture

➢ Lateral eyebrow (also called supraorbital
eyebrow).
➢ Supratarsal fold (upper eyelid) approach gives
an excellent cosmetic result and good
exposure of the fronto-zygomatic suture.
Approaches to the lateral orbital rim,
body and arch of zygoma
➢Lateral canthal incision in a suitable
skin crease lateral to the eye (‘crow's
foot’ crease).
➢Extended preauricular approach to
expose the whole zygomatic arch and
the lateral aspect of the orbital rim.
Approaches to the inferior orbital rim
and orbital floor
➢Infraorbital incision.
➢Subciliary incision.
➢Subtarsal or mid–lower lid incision.
➢Transconjunctival Incision
Approaches to the medial orbital wall

➢Paranasal approach (Lynch incision); is through a

small curved incision over the frontal process of
the maxilla.

➢Transcaruncular approach; it is designed as an

extension of a transconjunctival incision.
All patients who have had operations involving
the orbit should have formal eye observations
in the postoperative period.
The condition of the eye, pupil size and light
reaction should be recorded.
Occasional complications occur, the most serious
of this is a developing retrobulbar haematoma
Increasing proptosis and loss of vision constitute
a postoperative emergency requiring
immediate action to reduce the pressure of the
haematoma.
 Orbital floor fractures
The orbits are described as conical or pyramidal in
shape that consists of 7 bones, the normal orbital
volume is about 30 mL, of which the globe
occupies 6.5 ml.
The orbit consists of an outer and inner frame; the
outer frame is the orbital rim; inferiorly it is
composed of the zygoma laterally and maxilla
medially. Superiorly it is composed of the frontal
bone.
The inner frame is composed of the orbital walls:
•Floor; roof of the maxillary sinus and orbital
plate of palatine bone;
•Medial wall; ethmoidal and lacrimal bones
anteriorly, lesser wing of
•sphenoid with optic canal posteriorly
•Lateral wall; zygoma and greater wing of
sphenoid
•Roof; frontal bone.
 Blow out fracture
Both the lateral wall and the roof are relatively thick; the
most common areas of fracture are the floor and medial
orbital walls. Isolated orbital wall fractures are termed blow-
out or blow-in fractures. Blow-out fractures are further
described as pure, for those that occur in the presence of an
intact orbital rim, and impure, for those with a concomitant
fracture of the orbital rim.
Blow-in fractures are rare; the orbital
wall bone fragments are displaced or
buckled inwards.
 Clinical features

➢ Periorbital (circumorbital) ecchymosis

➢ Subconjunctival hemorrhage
➢ Diplopia; diplopia is a relatively common early clinical
finding after orbital trauma, often simply as a result of
edema affecting the extra-ocular muscles.
➢ Limitation of eye movement especially in upward gaze
,globe retraction on upward gaze
➢Enophthalmos; enophthalmos may not be
clinically apparent immediately following injury
because of swelling of the orbital contents. True
extent of enophthalmos is revealed at around 2–4
weeks following injury when this swelling has
resolved. Enophthalmos clinically obvious to most
patients when exceeds 2mm.
➢Surgical emphysema of eyelids
➢Paresthesia within distribution of infraorbital
nerve
The tethering of the inferior muscles can be further
demonstrated by the forced duction test, which may be
carried out under local or general anesthesia. Fine toothed
dissecting forceps are inserted under the globe of the eye
via the inferior conjunctival fornix and the insertion of the
inferior rectus is gently grasped enabling the globe to be
forcibly rotated upwards and its freedom of movement
compared with the opposite side. Any increased resistance
is readily appreciated and is diagnostic of muscle tethering.

It is essential to measure this interference with orbital

movement by means of a Hess chart and to monitor any
improvement, or lack of it, by repeating the test during the
first 7-10 days after injury.
 Imaging
•Plain radiographs may show evidence of orbital floor or
wall fractures, but are unreliable in excluding such an injury
or determining its extent. Occipitomental view may
demonstrate the classical (hanging drop) appearance of a
large orbital floor defect with herniation of orbital
contents.

•CT has the advantage of better bone visualization.

Coronal, axial and sagittal views may be required to
determine the extent of the defect. Enophthalmos is more
likely to develop where there is loss of the 'posteromedial
bulge' of the orbital floor, best seen in sagittal views. The
posterior limit of the defect also gives an indication of
difficulty of repair.
Hanging drop sign of pure blow out fracture
 Treatment of blow out fracture
• When orbital fractures occur with other
fractures of the midface, the latter must be
repaired first. This is because safe orbital
dissection and repair of orbital defects are
dependent on repositioned key landmarks and
a correctly positioned infraorbital rim to
support an implant. This will not be possible if
the peripheral bones are significantly
displaced.
 Treatment of blow out fracture

Indications
Significant restriction of eye movement (diplopia) with
CT confirmation of entrapment.
Significant enophthalmos.
Large ‘blowout’ defect
Significant orbital dystopia
It is generally accepted that treatment of orbital floor
fractures should be delayed for 7-10 days allowing time for
edema to subside and the true ophthalmic situation to be
revealed. The exception to delayed treatment is in children
and young people with diplopia where exploration should
be performed as soon as possible to prevent persistent
problems.
Treatment consists of direct exploration of the orbital floor
through a suitable lower eyelid or transconjunctival
approach, gentle retrieval of the herniated soft tissues and
reconstructing the bony defect with suitable implant or graft
material that is of a sufficient size to be supported at its
periphery on sound bone.
Reconstructive options for orbital defects
Autografts of fascia, bone and cartilage.
Allograft.
Xenograft.
Alloplastic materials; these can be resorbable
or non-resorbable such as titanium mesh
and sheets of Silastic (medical grade silicone
polymer), Medpor (porous polyethylene) and
PDS (polydioxanone).
 Complications
Retrobulbar hemorrhage
Lower eyelid retraction and ectropion
Persistent edema of lower eyelid
Persistent enophthalmos
Persistent globe depression
Persistent diplopia in vertical gaze
Tissue reaction to implant
Extrusion of implant
Infection and chronic fistula formation
Dacryocystitis
Blindness
 Nasal bone fractures
The nasal bone is one of the most commonly fractured due to
its prominent position and little protection and support. The
nasal bones are relatively thick superiorly where they are
attached to the frontal bone, but are thinner inferiorly where
the upper lateral cartilages are attached. Hence they are
more susceptible to fractures lower down.
According to the force applied, nasal complex fractures can
be divided into three planes:
1. The first plane involves the nasal tip only.
2. The second plane involves the whole of the external nose
anterior to the orbital rim.
3. The third plane is a much more severe injury involving the
medial orbital wall and sometimes the anterior cranial fossa.
These latter injuries are distinguished as fractures of the
naso-orbito-ethmoid complex.
 Clinical features
•Edema over the bridge of the nose.
•Bilateral circumorbital ecchymosis and possibly subconjunctival
hemorrhage, more marked on the medial aspect.
•Deviation of the nose to one side following a lateral injury while
an anterior fracturing force produces a saddle-type depression of
the bridge.
•Epistaxis due to injury to nasal mucosa and Kiesselbach's plexus
or Little's area which is an area of arterial anastomosis present at
anterior inferior nasal septum, linking branches of greater
palatine, superior labial, sphenopalatine and anterior ethmoid
arteries.
•Septal hematoma can sometimes develop as a result of bleeding
into the subperichondrial space. This appears as a dark red
swelling on the septum and results in partial nasal obstruction,
usually within the first 24-72 hours.
•Nasal obstruction due to blood clot, edema of nasal mucous
membrane and the deviated nasal septum.
 Imaging
Isolated nasal bone fractures can be visualized on
soft tissue radiographs of nose, lateral nasal
radiograph and CT scans. The septal deviations
are visualized on occipitomental view or CT scans.
 Treatment
Septal hematoma requires incision and drainage
which should be performed urgently under
topical or local anesthesia. If untreated it can
become infected leading to a septal abscess,
with a risk of intracranial extension, it may also
result in avascular necrosis with loss of cartilage
and a septal perforation. The vast majority of
nasal fractures can be treated by closed
manipulation and simple splinting.
 Reduction
This can be achieved by digital manipulation in
simple fractures. Otherwise Walsham's forceps are
used for manipulating the nasal and the frontal
process of the maxilla bone fragments, the external
blade of the forceps is ideally padded with rubber
or plastic tubing. The vomer and the perpendicular
plate of the ethmoid are then manipulated with
the Asche's septal forceps.
 Methods of immobilization
1. Ribbon gauze packing; such as bismuth iodoform paraffin
paste (BIPP) is lightly packed in the nasal cavity to impart
support and to achieve hemostasis. The disadvantages of
packing are that it obstructs airway, acts as a source of
infection and over-packing may cause displacement of the
nasal bones.

2. Plaster of Paris (POP) splints; it consists of 6-8 layers of

POP bandage cut to produce a strip of plaster across the
bridge covering either side of the nose, with an extension up
to the forehead. When it is firm it is fixed into position with
strips of adhesive tape across the forehead and across the
nasal bridge. The first splint should be replaced by a new
more accurately fitting splint few days later when the
postoperative edema over the nasal region has subsided. A
nasal splint should be left in situ for about 10-14 days in
total.
 Open Reduction and Internal Fixation (ORIF)
ORIF of isolated nasal fractures is a procedure that
is rarely advocated. Indications may include;
grossly displaced fractures where closed
treatment is usually unsatisfactory and when
there is an extensive overlying laceration.
Fractured nasal bones
The nasal bones are the most commonly
fractured bones of the facial skeleton.
Best results are obtained when soft-tissue
oedema has been allowed to settle so that
accurate reduction can be achieved.
Surgery should ideally be carried out within a
week of the injury as, if left any longer,
reduction may become difficult or impossible.
Reduction should be directed first to
repositioning the nasal bones, disimpacting
with Walsham’s forceps

The septum is then grasped with Asch’s forceps,

manipulated until it is straight

It should be remembered, however, that the

nasal septum often cannot be adequately
manipulated into position and may require
formal septoplasty at a later date.
Fractures involving the naso-ethmoidal complex
require open reduction and fixation, and any
disruption of the medial canthal attachments
demands replacement of these structures in
their correct anatomical position.
The nasal bones may need supporting by a pack
within the nasal bridge.
Most packs should be removed at 2–3 days
following the nasal bone reduction. A
protective nasal plaster may be placed and
should be removed at 5–7 days .
Naso-ethmoidal complex fractures

are usually comminuted fractures involving the

nasal bones, frontal processes of the maxilla,
medial and sometimes infraorbital rims and
the maxillary processes/anterior sinus wall of
the frontal bones.
Such injuries can cause significant deformity
and, because of disruption of the medial
canthal ligaments, may cause traumatic
telecanthus.
Frontal bone fractures
The presence of depressed frontal bone fractures and
fractures of the posterior wall of the frontal sinus
demands that neurosurgical collaboration should be
sought.
Access may be through pre-existing lacerations
overlying the area, but excellent access with minimal
morbidity is achieved using the bicoronal scalp flap .
Bone fragments may then be reduced and fixed using
small titanium bone plates and screws .
Any missing bone should be replaced with bone grafts,
thereby avoiding any cosmetic forehead depression
postoperatively.
Complications of fractures of the middle third of
the facial skeleton Early complications

➢ Epistaxis post-reduction bleeding from the nose can occur,

which is usually managed by simple anterior nasal packing.

➢ Ophthalmic complications:
A/ Abrasion of the cornea during surgery; protective shells
should be inserted routinely at the beginning of an operation or
a temporary tarsorrhaphy suture inserted.

B/ Extensive orbital edema or Retrobulbar hemorrhage after

reduction of a fractured zygomatic complex; both can result in a
compartment syndrome of the orbit and loss of eyesight if
untreated by compression and spasm of the posterior ciliary
vessels that supply blood to the optic nerve. It is an emergency
that require immediate management.
 Signs and symptoms of Retrobulbar hemorrhage :
•Pain
•Decreasing visual acuity
•Diplopia with developing ophthalmoplegia
•Proptosis
•Tense globe
•Sub-conjunctival edema/chemosis
•Dilated pupil
•Loss of direct light reflex (Relative afferent
pupillary defect).
• Blindness due to direct injury to the optic nerve.
 Treatment of Retrobulbar hemorrhage
Medical treatment: involves administering
intravenous 20% mannitol (1 gm/kg) and 500 mg
acetazolamide to reduce intra-ocular pressure, and
3-4 mg/kg intravenous dexamethasone to reduce
edema and vascular spasm.
Surgical treatment: it aims to decompress the orbit
through an access incision has been used for initial
treatment of the fracture or through lateral
canthotomy made with sharp scissors. Small soft
drain should be inserted without repair of the
incision performed.
Complications of fractures of the middle third of
the facial skeleton Early complications

➢Inaccurate reduction; especially when

treatment is not by ORIF.
➢Nerve damage involving the infraorbital nerve,
zygomatico-temporal and zygomatico-frontal
nerves. Also coronal approach may result in
damage to the sensory and motor supply of
the forehead.
 Late complications

1. Delayed or non-union: is uncommon, it occurs in fractures

treated by IMF alone. Treatment is by applying miniplates
across the fracture site with or without a bone graft.
2. Malunion: causing cosmetic and functional deformity;
depressed malunion of the zygomatic complex may cause
cosmetic deformity and interference with the coronoid
process of the mandible and restriction of mouth opening.
Malunion of orbital fractures may result in Expansion of
orbital volume which produces enophthalmos that is
sometimes accompanied by diplopia. In Le Fort I, II and III
fractures, the patients may be left with long face or
flattening of the entire profile (dish-face deformity). It may
also cause malocclusion such as retrusion of upper dentition
and anterior or lateral open bite.
3. Residual ophthalmic complications such as
enophthalmos and diplopia; these may result from:
•Deformity of the bony orbit.
•Neurological damage such as damage to the
oculomotor and abducent nerves.
•Damage to the globe itself and its surrounding
soft tissue.
4. Complications associated with paranasal sinuses;
fractures of the middle third of face are usually
associated with comminution of the walls of the
paranasal sinuses, particularly the frontal and
maxillary. This may lead to obstruction of the
ostium and disturbance of drainage leading to
chronic infections.
5. Complications associated with the lacrimal
system; partial or complete obstruction of the
nasolacrimal duct may be a late complication of
Le Fort II type and NOE fractures. The patient
complains of epiphora and may develop
dacryocystitis. If the natural pathway for tears
cannot be re-established by dilation of the duct a
dacryocystorhinostomy operation is done as a
planned procedure.
6. Loss of sensation; such as anosmia or
anesthesia or paresthesia within the distribution
of the maxillary division of the trigeminal nerve.
7. Late problems with internal fixation; Plates or
transosseous wires may become infected,
palpable or visible as projections. In such
situations they need to be removed