Evaluating and treating facial fractures due to trauma, also called maxillofacial trauma (maxilla means upper jaw), requires knowledge of common facial bone fracture patterns along with complete knowledge of normal facial and skull anatomy.
Injuries involving the facial bones range from small, nondisplaced facial fractures (in which the bones are broken but remain in their correct place) that will heal without intervention, to facial fractures that require observation and a soft diet, to facial fractures that need to be treated in order to prevent problems with vision or occlusion (the way the teeth fit together), to complex injuries that require more extensive reconstruction. While the facial skeleton is complex, facial fractures occur in predictable patterns that are treated in distinct ways.
Predictable Patterns of Facial Fractures
- Frontal Sinus Fractures
- Orbital Fractures (fractures of the bones of the eye socket)
- Nasal Bone Fractures (broken nose)
- Nasoorbitoethmoid (NOE) Fractures
- Zygomaticomaxillary Complex (ZMC) Fractures
- Le Fort 1, Le Fort 2, and 3 Le Fort Fractures (fractures of the maxilla or upper jaw) are facial fractures of the midface, which collectively involve separation of all or a portion of the maxilla from the skull base
- Mandible Fractures (fractures of the lower jaw)
Diagnosis and Early Management of Facial Bone Fractures
Patients with suspected facial bone fractures are usually seen in the emergency department. Signs and symptoms of facial fractures include pain, swelling, double vision, facial numbness, and malocclusion (abnormal bite). Definitive diagnosis usually requires imaging, in the form of computed tomography (CT) scan. This aids in both the diagnosis and in treatment planning of the facial fracture.
The majority of patients with facial fractures can be seen in the craniofacial surgeon’s clinic on an outpatient basis. If surgery is needed, it typically occurs 1-2 weeks after the injury. This time period allows for facial swelling from the original injury to decrease substantially, which makes surgery safer and more accurate. However, waiting too long (over 2 to 3 weeks) risks the fractures healing with the bones in the incorrect place (called a malunion). Prior to surgery, the patient is instructed on activity modification, such as a soft diet and limitations in strenuous activity, depending on the location of the fractures.
Certain situations require more urgent care. Examples include open fractures of the mandible, fractures of the frontal sinus and skull base, fractures with injuries requiring surgery from the neurosurgery team, and certain orbital fractures. In addition, patients with extensive injuries to the facial soft tissues may require expedient care. Often, the soft tissue repair is performed at the time of injury and the facial fractures are repaired after the swelling has gone down.
How do pediatric fractures differ from adults?
The pediatric facial skeleton differs in a number of ways from that of an adult. During the first 3 years, the skull grows out of proportion to the facial skeleton, such that the calvarium is 85% adult size by the age of 3. The adult facial skeleton contains a number of hollow areas called paranasal sinuses; these do not begin to develop in children until after 2 years of age. The mandible (lower jaw) and maxilla (upper jaw) in children contain both the primary and secondary (adult) teeth. Finally, the facial bones in children are more elastic and less brittle than adults. Each of these factors make fractures of the midface less common in children, and fractures of the skull and frontal bones more common. In addition, facial fractures in children are less likely to be significantly displaced compared to those of adults. It is important that facial fractures in children be managed by experienced teams in order to minimize disturbances in future facial growth.
Management of Facial Fractures
Frontal Sinus Fractures
The frontal sinus is a hollow space in the frontal bones of the lower forehead. It is lined with mucosa, and is connected to the nose via the nasofrontal ducts. Fractures of the frontal sinus may involve the anterior table (front), the posterior table (back), or both. The anterior table of the frontal sinus comprises the brow prominence of the lower forehead. Displaced facial fractures can therefore result in an obvious indentation and contour deformity. The posterior table of the frontal sinus separates the sinus from the dura mater, the tough membrane which surrounds the brain.
Whether or not a fracture of the frontal sinus needs to be treated depends on: 1) the degree of displacement of the anterior table 2) whether or not the drainage through the nasofrontal ducts has been disrupted 3) the degree of displacement of the posterior table and 4) the presence of other injuries to the skull or brain.
Because the anterior table of the frontal sinus is such a noticeable facial attribute, displaced fractures can lead to abnormalities of the normal contour of the brow region. Nondisplaced fractures (with a near-normal bone position) can be managed with light activity until the fracture heals. Displaced fractures often require surgical repair. Surgery involves fracture reduction (placing the bones back into their normal positions) and using titanium miniplates and screws to hold the bone in the correct position. If there is no laceration over the fracture, access to the bone is usually accomplished through a coronal incision, which is a zigzag incision over the top of the scalp. This allows for the scar to be hidden in the hairline, with minimal visible scarring once the hair regrows.
If the nasofrontal ducts are injured, impairing drainage from the sinus to the nose, there is risk for a mucocele, which can be painful, infected, or damage the surrounding bone. In order to prevent this, the frontal sinus is obliterated. This is an operation in which all of the mucosa (lining) is removed, and the sinus is filled with bone or fat.
When there is a significantly displaced fracture to the posterior table of the frontal sinus, there is essentially exposure of the intracranial contents (brain and surrounding membranes) to the nasal cavity. When combined with an injury to the dura mater (outer, thick covering of the brain), this can lead to a cerebrospinal fluid leak or serious infections. The cerebrospinal fluid acts as a buffer and protection system to the brain. Persistent leakage through a tear in the dura and displaced fractures can lead to headaches, infection, and other problems. For this reason, repair of significantly displaced frontal sinus fractures is recommended. Repair, termed cranialization of the frontal sinus, involves coordination between the neurosurgery and craniofacial surgery teams. The surgery involves a coronal incision (through the scalp), a craniotomy (temporary removal of part of the skull), removal of the posterior table of the frontal sinus, packing the nasofrontal ducts with bone graft, and covering the defect with a pericranial or other flap (deep layers of the scalp).
Nasal Bone Fractures
The nasal bones are among the most fractured bones in the human body. Although the diagnosis may be fairly obvious, we generally recommend imaging (CT Scan) to determine whether there are fractures to other facial bones, as well as the extent of the nasal fractures. The severity and displacement of nasal fractures may be difficult to assess at the time of injury due to swelling.
Fractured nasal bones benefit from repair if there is displacement sufficient to create a deformity or affect breathing. Repair of most nasal fractures involves a 15-30 minute procedure called a closed nasal reduction. This usually involves a general anesthetic. The bones are shifted back into place and held in place by a splint. If there is also a fracture of the nasal septum (center of the nose dividing the left from right), this may also be reduced and splinted at the time of surgery.
Nasoorbotiethmoid (NOE) Fractures
Nasoorbitoethmoid, or NOE, facial fractures involve the nasal bones as well as the lacrimal, ethmoid, maxillary, and frontal bones. This is the area of the face behind the nose, where the inner eyelids attach to the facial skeleton (the medial canthal tendon). Fractures to this region may result in decreased nasal projection (flat, sunken-in, or “saddle” nose) and telecanthus (widening of the distance between the eyelids and a blunted appearance of the inner eyelids). These are among the most difficult facial fractures to correctly treat and require a surgical team experienced in facial fracture repair. Inadequate treatment can result in persistent increased width between the eyelids and a saddle-nose deformity.
Surgical Treatment for Nasoorbotiethmoid (NOE) Fractures
Surgery typically involves multiple incisions, including eyelid incisions, upper gingivobuccal sulcus incisions (in the mouth), and coronal incisions (across the scalp, ultimately hidden by the hair). Larger fractures can be reduced (put in the correct position) and fixed using titanium miniplates and screws. Comminuted fractures (in multiple small fragments) may require bone grafting and special anchors and sutures to place the medial canthal tendons in the correct position.
The orbit, or eye socket, is actually composed of seven facial bones: the frontal, zygomatic, lacrimal, maxillary, ethmoid, palatine, and sphenoid bones. It contains not only the eyeball (orbit), optic nerve (nerve responsible for vision), and extraocular muscles (muscles that move the eye), but also nerves that provide eye and eyelid motion and sensation to the forehead and face. The orbit is divided into the orbital roof (top of the orbit), medial orbital wall (inner orbit adjacent to the nose), lateral orbital wall (outer wall of the orbit), and orbital floor (bottom of the orbit). Symptoms and management of orbital fractures depends on location.
Orbital Roof Fractures
Fractures of the top of the orbit, or orbital roof, usually result from a high-energy traumatic impact. While orbital roof fractures may be isolated injuries, they are frequently accompanied by other fractures of the skull or facial skeleton. These fractures may be associated with injuries to the dura (tough membrane surrounding the brain), retrobulbar hematoma (bleeding within the eye socket), ptosis (drooping of the eyelid), injury or entrapment of extraocular muscles, and injuries to the eye. Evaluation of these injuries often involves members of the neurosurgical and ophthalmology teams, as well as the craniofacial surgeon.
Management of orbital roof fractures depends on the presence of other injuries, as well as the size of the fracture and degree of displacement. Most isolated orbital roof fractures do not require repair and can be followed over time. Young children with fractures to the orbital roof and tears of the dura mater may be at risk for developing a growing skull fracture, or increase in the size of the fracture over time, which is monitored by routine checkups after the injury. Large displaced fractures and fractures associated with injuries to the brain or other facial or skull bones often require repair.
Orbital Floor and Medial Orbital Wall Fractures
The orbital floor (bottom of the orbit) and medial orbital wall (inner orbit, behind the nose) are composed of very thin bone, which separates the orbit from the hollow paranasal sinuses. Blunt force trauma to the orbit (from fist, car accident, baseball, etc.) can cause this thin bone of the orbital floor to fracture and shatter. This is actually beneficial- the dissipation of force from the thin bones of the orbit fracturing may protect the eyeball (or globe) from serious injury.
Diplopia (double vision) is common after fractures of the orbital floor and medial orbital wall. The extraocular muscles are responsible for movement of the eye. They can become injured with orbital fractures limiting the motion of the eye and causing double vision. In particular, the inferior rectus muscle allows the eye to look down. It sits on the orbital floor, and may be injured with an orbital floor fracture, or herniate into the maxillary sinus below the fracture. Occasionally, the muscle can become entrapped within the fracture, necessitating surgical release. The medial rectus muscle allows the eye to look inward. It may become similarly injured with fractures to the medial orbital wall.
Large orbital floor fractures may lead to eventual enophthalmos (sinking back of the eye) and diplopia (double vision). Large fractures of the orbital floor or medial orbital wall increase the volume (overall size) of the orbit. Once the initial swelling resolves, the eyeball may sink back into the orbit, which can lead to double vision.
Orbital floor fractures in younger children may behave differently than in adults. While adult orbital floors tend to shatter with injury, the bones of the orbital floor in children are more elastic and less brittle. Occasionally, when pediatric orbital floors fracture, the bone snaps back into place, trapping the inferior rectus muscle within the fracture. This is called a “trapdoor fracture” and can lead to ischemia (lack of blood supply) to the inferior rectus muscle and permanent double vision. In order to prevent this, trapdoor fractures are taken to the operating room within 1-3 days for repair.
Nondisplaced or minimally displaced medial orbital floor fractures may be treated with observation and do not require surgery. Large fracture size that puts patients at risk for enophthalmos and evidence of muscle entrapment are indications for surgery. Surgery involves an incision within the lower eyelid either through the skin or the conjunctiva (eyelid lining). The bones of the orbital floor/medial wall are too thin and brittle to be repaired directly. Instead, the defect is repaired by covering it with a thin implant made of titanium or synthetic material.
Zygomaticomaxillary Complex Fractures
Zygomaticomaxillary Complex (ZMC) facial fractures are fractures the zygoma (cheekbone) and its surrounding facial bones. ZMC fractures are usually the result of a blunt injury to the cheek, such as from a car crash or a fight. This bone is not fractured in one place, but in all four attachments of the zygoma to the facial skeleton. ZMC fractures often involve fractures to the orbital floor, which may need to be repaired depending on the size of the fracture. The fracture is often accompanied by an injury to the infraorbital nerve, which provides sensation to the cheek, upper lip, and side of the nose. Numbness is usually temporary, but may take months to resolve. If displaced, ZMC fractures result in a lack of cheek projection and an increased width. This leads to a flat, wide cheek if unrepaired.
Surgical Treatment for Zygomaticomaxillary Complex (ZMC) Fractures
Treatment for ZMC fractures is recommended when the fractures are displaced. Surgery involves incisions though the lower eyelid skin or lining (conjunctiva), the upper gum line (gingivobuccal sulcus), and the upper eyelid. The bones are reduced (put back in to the proper place) and fixed into place using titanium miniplates and screws.
Fracture of the zygoma may only involve the zygomatic arch, which defines the side of the upper cheek. If indented or displaced, these fractures may be treated with a small incision through the mouth or the hairline and reduced or “knocked out”. These fractures do not require fixation with plates and screws.
Maxillary (Upper Jaw) Fractures (Le Fort Fractures)
Fractures to the maxilla (upper jaw) are often classified as Le Fort fractures. They are typically the result of significant blunt force trauma. Le Fort fractures involve a fracture in the junction of the maxilla to the skull base (pterygomaxillary junction) along with fractures across the upper jaw or bones above it. The level of the transverse fractures determines whether the fracture is termed a Le Fort 1, Le Fort 2, or Le Fort 3 fracture. This may be accompanied by fractures to the palate, as well. These fractures separate the upper jaw from the skull and from the rest of the facial skeleton. This may result in a disruption of the relationship between the upper and lower teeth, which is called malocclusion. The bite may feel “off”, or the patient may be able to connect the upper and lower teeth only in certain areas.
Surgical Treatment for Maxillary Fractures (Le Fort Fractures)
Treatment of Le Fort fractures depends on the amount of displacement and the presence of malocclusion. Nondisplaced fractures, in which the bones remain in their correct position, may be treated with a soft diet and activity restrictions. Minimally displaced fractures, in which the bones are only slightly out of place, may require a period of maxillomandibular fixation (MMF) or “wiring the jaws together”. In this procedure, typically done under general anesthesia, thin metal devices called arch bars are secured to the upper and lower teeth with small wires. The upper and lower teeth are then held together with rubber bands or wires, which allows the lower jaw to act as a splint as the maxillary (upper jaw) fractures heal, such that the teeth end up contacting correctly after the fractures heal. The length of MMF ranges from 2 to 6 weeks.
Displaced fractures, in which the bones are in the incorrect position, require more extensive surgery to correct. In addition to MMF, the fractures are exposed depending on whether they are Le Fort 1, 2, or 3 fractures. Le Fort 1 fractures require an incision in the upper gumline (gingivobuccal sulcus incision). With Le Fort 2 fractures, lower eyelid incisions are added through the eyelid skin (subtarsal incision) or through the eyelid lining (transconjunctival incision). Le Fort 3 fractures require the addition of incisions either through the upper eyelids or a coronal (scalp) incision. The bones are reduced (put into the proper position) and fixed using titanium miniplates and screws.
Mandible (Lower Jaw) Fractures
Fractures to the lower jaw, or mandible, result from strong blunt force trauma. Examples include car crashes, fights, bicycle accidents, and falls. The mandible is divided into the condyles (where the mandible meets the temporomandibular joints or TMJs), ramus (vertical part of the mandible), body (horizontal part of the mandible which bears the teeth), angle (where the ramus connects to the body), and parasymphysis (front of the mandible). Fractures may occur in any of these areas. Often, the lower jaw is fractured in multiple places.
Patients with mandible fractures experience pain and swelling, and may feel that the upper and lower teeth no longer fit together properly. This is called malocclusion. A nerve called the inferior alveolar nerve travels through the mandible and gives sensation to the lower teeth, gums, and lower lip. It is often injured during a mandible fracture and may lead to numbness in these areas. This is usually temporary, but may take months to resolve.
Surgical Treatment for Mandible Fractures
Treatment of mandible fractures depends on the amount of displacement, as well as the presence of malocclusion. Minimally displaced fractures, in which the bones are broken but stay in the correct location, may be treated with a soft diet and regular check-ups. Minimally displaced fractures, in which the bones are slightly in the wrong location, accompanied by malocclusion may be treated by a period of maxillomandibular fixation (MMF) or “wiring the jaws together”. As in fractures of the maxilla (upper jaw), this procedure involves attaching thin metal devices called arch bars to the upper and lower teeth using small wires. The upper and lower teeth are then connected using rubber bands or wires. The upper teeth then act as a splint to allow for the mandible fractures to heal in the correct orientation, resulting in a correct bite. The length of MMF ranges from 2-6 weeks.
Open Reduction and Internal Fixation (ORIF) of Displaced Mandibular Fractures
Displaced fractures, in which the bones are not in their anatomically correct location, require open reduction and internal fixation (ORIF), possibly along with a period of MMF. The bones are approached through incisions, the location of which depends on the location of the fracture. Fractures of the parasymphysis, body, and angle can be approached by incisions on the inside of the mouth (gingivobuccal sulcus incisions). Very small incisions on the outside of the face may be needed for screw placement. Fractures to the ramus and condyles may require incisions on the neck (Risdon), behind the mandible (retromandibular), or in front of the ear (preauricular). The bones are then reduced, or placed into their correct positions, and fixed together using titanium plates and screws.
Open Repair of Subcondylar Fractures
Fractures of the condyles or just below (subcondylar fractures) deserve special mention. The facial nerve is a nerve responsible for the motion of the muscles of the face. Approaching condylar or subcondylar fractures for repair risks injury to the facial nerve, which can lead to paralysis of that side of the face. There are safe techniques to reach these fractures for repair. However, open repair of these fractures is reserved for severely displaced fractures, in which the bones are significantly out of place and fractured on both sides of the mandible (bilateral fractures). The majority of condylar and condylar fractures are treated with MMF, occasionally with placement of a splint between the upper and lower teeth to preserve the height of the mandible.
In cases of certain severe mandible fractures, the above techniques are not adequate for management. Examples include severely comminuted fractures (fractures in many pieces, or a “shattered mandible”), open fractures with a loss of soft tissue, contaminated or very dirty fractures, and fractures that have become infected. In these cases, treatment with plates and screws may not be safe, and may risk infection or further problems with healing. These fractures may be treated with an external fixation device. With this technique, the bone fragments are held in to the correct position by screws (or “posts”) connected to a rod on the outside of the face for a period of 6-8 weeks. After the bones have had an opportunity to heal or the infection has been treated, the fractures may then be treated with traditional titanium plates and screws.
Frequently Asked Questions
I have facial fractures that need to be treated using plates and screws. Will I scar?
All incisions result in scars, but the incisions used in facial fracture management are designed to be camouflaged. Incisions in the eyelids tend to heal very well and are often difficult to notice. Access to the upper and lower jaws uses incisions inside the mouth, which are not visible from the outside. Coronal or scalp incisions are performed within the hair in a zigzag fashion. This tends to hide the scar within the hair, even when the hair is wet.
I am going to need to have my jaws wired shut to treat my fractures. Will I lose weight?
Yes. Maxillomandibular fixation (MMF) is usually performed with rubber bands rather than wires, but the patient will still be unable to open their mouth and the majority of the diet will be in liquid form. The amount of weight loss depends on the patient and the weight at the time of the injury. Most patients can expect to lose 10-20 pounds. We will give diet advice often with the aid of a nutritionist to minimize the weight loss, and maximize nutrition for healing.
My face is numb after my facial fractures. Will this improve?
The nerves that provide sensation for the face travel through the facial skeleton. They are frequently injured with facial fractures. The inferior alveolar nerve exits the skeleton just below the orbit, or eye socket, and provides sensation to the cheek, upper lip, and side of the nose. It may be injured with orbital floor, ZMC, or Le Fort fractures. The inferior alveolar nerve travels through the mandible and provides sensation to the lower teeth, gums, and lower lip. This nerve may be injured with a mandible fracture. Typically, these nerves are “bruised” but not disrupted. Recovery of the nerve generally occurs at a rate of about an inch per month, after a month lag time. Recovery thus takes several months. During recovery, patients may experience tingling or “paresthesias”.
If you would like more information, please contact the Craniofacial Team of Texas by calling 512-377-1142 or toll free 877-612-7069 to schedule an appointment or complete an online appointment request.