Australian Dental Journal, August, 1982 227

Volume 27, No. 4

The management of fractures of the facial skeleton

Eric Carter, F.R.A.C.D.S.

Formerly 0 f Royal Newazstle Hospiiul, Newcastle, New South Wales

AHXI K N r-A retrospective survey of 366 patients admitted to the Royal Newcastle Hospital for the treatment of maxillo-facial injuries is reported. The facial fractures were classified into four groups on anatomical grounds and the causes and incidence of injury are stated. Patient management is outlined and the techniques employed and the results obtained are discussed.

(received .for publication August, 1980. Revised January, 1982.)

Introduction

The Dental Unit of the Royal Newcastle Hospital provide\, amongst other servies, an after-hours on-call emergency service in which the Oral Surgery Section is responsible for the treatment of fractures of the maxillo- facial skeleton. Patients with multiple injuries are treated i n close co-operation with members of the Department of Anaesthesia, Surgery and Orthopaedics.

A retrospective survey of 366 patients seen personally between January 1979 and July 1980 for the management of injuries to the maxillo-facial skeleton was undertaken i n order to determine the types of injuries and to assess the efficacy of the treatment provided.

Findings

Thc average age of patients presenting was 27.4 years, males compri\ing 84 per cent of the series. These findings are similar to experience elsewhere.'

The injuries were divided into four groups on the basis of \itc namely: mandibular fractures, central middle-third fracturcs. lateral middle-third fractures (zygoma and /ygomatic arch) and whole face fractures and the iiicidcncc o f cach type is \een in Fig. I ,

The causes of injury are shown in Fig. 2 which clearly illustrates that motor vehicle accidents were the most

'

common cause of such injuries. Figure I reveals that they were also the most serious for no less than 63 out of 65 patients who sustained central middle-third injuries were injured in motor vehicle accidents, a finding similar to that recorded over a seven year period at the Royal Melbourne Hospital.' Five patients, three of whom were motor cycle riders, died from associated head injuries and were excluded from this survey. Seventy-two percent of these road traffic accidents occurred in the inner city area in which two-fifths of the population served by the hospital reside.

Study of Fig. 1 also reveals that sporting injuries, most of which were sustained whilst playing Rugby football, were the major cause of lateral middle-third fractures being responsible for 41 of the 65 cases.

' Steidler NE. Cook RM, Reade PC. Incidenceand management of major middle third fractures at the Royal Melbourne Hospital. A retrospective study. Int J Oral Surg 1980;9:92-8.

' Luce EA, Tubb TD, Moore AM. Review of lo00 major facial fractures and associated injuries. Plast Reconsir Surg IY7Y;63: I ,26-30.

' Nakannira T, Gross CW. Facial fractures. Analysis of five years experience. Arch Otolaryngol 1973;97:288-90.

' Turvey TA. Midfacial fractures: a rcrrospective analysis of 593 case\. J oral Surg 1977;35:887-91.

Australian Dental Journal, August, 1982

indicated when either submandibular swelling or supraglottic oedema caused obstruction of the airway. Associated injuries necessitated tracheostomy in eight other patients.

One-third of the patients in the series had injuries of such a severity as to necessitate admission for in-patients care whilst the remainder were given immediate supportive care before being treated on an out-patient basis. When facial fractures were the sole injury, the average duration of stay in hospital was only four days.

With the exception of nine patients who either failed to return for follow-up appointments or were travellers and referred to colleagues practising closer to their homes, all patients were reviewed in the out-patients’ department at weekly intervals for a minimum period of six weeks. The post-operative complications experienced by them are listed and are discussed below.

229

Fractures of the mandible The most common injury experienced was mandibular

fracture whicl\ occurred in a total of 221 patients in 66 of whom bilatcral fractures were present (Fig. I ) . Fifty-scven of these patients were admitted for in-patient care, twenty-Fix of whom sustained either bilateral or multiple fractures. An extra-oral approach was used to provide access to the fracture site in 39 patients.

Acrylic dental cap splints were used to obtain inter- maxillary fixation in 149 patients. I n six instances such splints required recementing, on cach occasion within the first weeh of placement and in these circumstances the period of fixation was increased to eight weeks. Unauthorixd voluntary release of fixation by two patients wa\ followed by Ggns of infection and mal-union in each caw. The healing period for these patients was troubled ;IS no aniount of advice could change either their attitude or their lack o f co-operation. Both patients who released their fixation experienced mal-union and had an occlusal di5crepancy after splint removal. Both patients refused further trcattnent.

Acrylated arch bars with eyelet wiring or interdental wiring alone where required were used for fixation in thirty-two patients and whilst these appliances proved to be just as effective as dental splints in the long-term placement of them was time consuming.

When the severity of mandibular fracture necessitated open reduction, lower border wiring was the method favoured and the technique employing four bur holesS proved to be the most effective. In my opinion, the advantage this technique offers over plating is that it enables minor fragments to be supported in apposition to the major fragments whilst providing rigid fixation and being adaptable to any site.

‘ Broil\ K, Boering G. Fractures of the mandibular body treated by stable internal lixarion: a preliminary report. J oral Surg 197O;28:4O7- 1.

Trans-osseous wires were inserted in 26 patients whilst plating of the bony segments was used in five others in whom open reduction was required. One plating proved to be unsuccessful after the patient released his inter- maxillary fixation one week post-operatively and infec- tion supervened. This plate was found to be loose and

T A M t: 1 Complications experienced by 221 patients with mandibular fractures

Mal-union . . . . . . . . 3 Non-union , . . _ . . , _ I Occlusal discrepancy . . . . 3 Infection . . . . . . . _ 7 Plate loss . . . , . . . . I Salivary fistula . . . . . . I

projected through the original extra-oral incision and was removed. The use of an external jaw appliance, similar to an orthodontic harness, which provided a reasonable degree of support, was followed by clinical union after three months.

Whenever comminuted fractures of the mandible are present, or, following the removal of loose fragments of bone during debridement of the wound, lower border wires can be regarded as but merely approximating the segments. When an oral tube is utilized it is suggested that the lower splint be first firmly wired to the teeth of the arch using the study models as a guide, prior to open reduction being performed. Elastics can then be used to gently re-establish the occlusion following removal of the tube. Per-alveolar wires were used on a number of occa- sions t o secure the lower splint and thus guarantee accurate alignment of the lower arch prior to open reduction, a technique which was found to give very satisfactory results.

Table 1 details the post-operative complications which occurred in this group of patients.

Lateral middle third fractures In 54 patients with fractures of the zygomatic bone the

fracture was reduced in 30 with a Rowe’s zygomatic elevator introduced via an intra-oral buccal incision. A Bristow’s elevator was employed utilizing a temporal approach in 16 patients and the remaining six patients, in whom marked displacement or comminution was present were treated by direct wiring inserted via external incisions.

Packing of the maxillary sinus with gauze soaked in Whitehead’s varnish with primary closure to stabilize the reduced segment was required in only seven patients. Four of these patients requiring open reduction needed packing of the maxillary sinus in order to support its collapsed lateral wall and the body of the malar bone.

An oro-antral fistula occurred in one patient in whom antral packing was employed and this was closed suc-

230 Australian Dental Journal, August, 1982

each occasion the central segment was found to be displaced in a medial and downwards direction adjacent to the coronoid process of the mandible. Additional radiographs proved helpful in both instances. Oblique axial views in addition to an antero-posterior thirty degree fronto-occipital projection" were of particular

cessfully with an undercut buccal mucoperiosteal flap some five months after the initial operation. In one case persistent sinusitis was treated by a radical antrostomy twelve months after reduction of a fractured zygoma via the temporal approach. Two fragments of dead bone were found lying in the thickened antral lining at this second operation.

Whilst the elevation of a fractured zygomatic bone is often considered to be a simple procedure it may be followed by serious complications and the possibility of intra-orbital haemorrhage must never be forgotten. Use of an intra-oral incision proved very effective whenever comminution to the zygomatico-maxillary buttress was suspected. Firm intra-oral palpation under general anaesthesia was found to be of value in the determina- tion of the degree of comminution of the zygomatico- maxillary buttress. When the force producing the fracture is particularly severe it is not unusual to find fragments of the maxillary wall lying within the sinus cavity proper. Should packing be required access to the maxillary sinus is facilitated and examination and, i f necessary, reconstruction of the orbital floor is possible. An ade- quate intra-oral incision facilitates accurate relocation of the fragments especially in the region of the infra-orbital foramen.

Packing of the maxillary sinus with gauze soaked in Whitehead's varnish was utilized to support the fractured body of zygoma in seven cases in one of which an oro- antral fistula developed. Subsequent to this experience, support was obtained by insertion of the bulb of a Foley's catheter with exit via a nasal opening in all cases in which severe comminution of the lateral wall of the maxillary sinus was encountered.

An ophthalmic opinion was sought for all patients who presented with diplopia associated with fractures of the zygomatic bone. Detailed examination of the orbital floor by tomography was undertaken for each patient and when obvious defects were noted radiographically, exploratory operations were performed at the time that the malar was elevated. Of the four patients showing radiographic defects of the orbital floor, only two required the inser- tion of an implant. The other two patients each had a comminuted fracture which, although sagging, was essentially intact. However, i t was significant that there was considerable loss of orbital contents into the maxillary sinus in all four patients.

Zygomatic arch fractures

For simple depressed fractures of the zygomatic arch, either a small skin incision in the temporal region sited above the hair line, or, an intra-oral incision was used lo permit the introduction of an elevator, the extra-oral approach being preferred because of the ease of access it provides.

Reduction proved quite difficult in two patients in whom complete separation of the central segment was encountered as part of a crush injury of the arch. On

T A I % I I 2 Complkarions experienced with 65

lateral niiddle-third ,jiructures

Prolonged paraesthesia. . . . 5 Transient d ip lop ia . . . . . . 6 Persistent diplopia. . . . . . I Oro-antral fistula . . . . . I Chronic sinusiti9 . . . . I Restricted mandible moveiiiciit . . I

value. The fracture site was exposed via a high pre- auricular incision similar to that employed for access to the temporo-mandibular joint' in order to minimix the risk of damage to the sensory and motor innervation of the face. Direct wiring of the fragments using fine wire and small burs proved to be a delicate operation necessary to avoid stripping of the muscle attachment. A jaw support was used for two weeks post-operatively to minimize mandibular movement which might induce stress on the re-constituted arch. The use of this device was considered to be justified in view of the success of both operations.

Diplopia

Diplopia was experienced pre-operatively by I2 patients sustaining a fracture of the Lygornatic bone. Defccts of the orbital floor were identified radiographically i n f o u r of these patients and exploratory operations were carried out at the time the fractured segment was elevated. T'wo patiets required synthetic implants placed via an inferior orbital incision and two ohers were treated succc\sfully by the insertion of a pack to support the depresscd orbital floor. One patient experienced persistent diplopia on upward gaze subsequent to the placement of a synthetic implant and a subsequent incision failed lo reveal the cause or to rectify this complication.

Transient post-operative diplopia persisted for ;in average period of eight days in six patients. The incidence of post-operative complications is recorded in Tahlc 2 .

Central middle-third injuries

The central middle-third injuries which occurred wcrc all variations of the cla\\ical Le Fort type fracrurc

' Maclhnald M. Plain radiography 0 1 lac ia l Iraiiiia. I lie Radiographer 1977 Sepi:XI -4.

' Al-Kayar A , Bramley P . A modified prc-auricular approach to the temporo-mandibular joint and nialar arch. H r .I 0 r ; i l Surg 1979-80; I 7 3 I - 103.

Australian Dental Journal, August, 1982 23 I

II+I Le Fort1 4% 17%

Fig. 3.-lncidence of central middle-third fractures: 65 patients.

patterns with the high level (Type 111) presenting more often than the mid level (Type 11) or low level (Type 1) fracture a finding which differs significantly from that observed in the Melbourne survey.' The incidence is shown in Fig 3. The high incidence of severe injuries is related to the fact that all but six of these injuries were sustained in motor vehicle accidents. The reason for the high incidence of Le Fort 111 fractures is obscure but might possibly be attributed to the speeds at which the accidents occurred; as no record of these is available this is no more than a clinical impression.

Cerebro-spinal fluid rhinorrhoea Cerebro-spinal fluid rhinorrhoea was detected in 22 pa-

tients who had sustained a central middle-third injury. Reduction and fixation of the dislodged central segment sealed the leak effectively in all but three of these patients in whom surgical repair of the dura mater was necessary. Whenever the presence of cerebrospinal fluid rhinorrhoea was either recognised or suspected the patient was given courses of both penicillin ( 1 million units/6 hourly) and sulphadiazine (1 g r a d 6 hourly) as a prophylactic measure. On five occasions, the complication was not recognized until the patient had been an in-patient for four days.

Fixation Cranio-maxillary fixation was employed for five to six

weeks for all central middle-third injuries with release of intermaxillary fixation on the tenth day when no mandibular fractures were present. Although various methods were employed, the technique which proved to be the most effective in our hands and caused the least inconvenience to the patient was the Levant frame.8

Supra-orbital pins It is a wise precaution to suspect cerebro-spinal fluid

rhinorrhoea in all cases of severe central middle third injury.9 Its presence may not be readily evident and indeed may not be detected for several days after manipulation of the middle-third segment. The use of

TABU 3 Complications experienced with 65

central m iddle-l hird injuries

Persistent C.S.F. rhinorrhoea . . 3 Lachrymal drainage defect . . 3 Persistent diplopia., . . . , 1 Occlusal discrepancy . . . . 2

supra-orbital pins as an anchorage for cranio-maxillary appliances offers an advantage whenever radiographic examination of the anterior cranial fossa is necessary. The suspension apparatus can either be removed quite simply on numerous occasions or left in position even when tomograms are required. When properly placed, this method of fixation provides adequate stability, minimal scarring and does not impede the investigations of the neuro-surgical or radiologic teams as do the more bulky cranio-maxillary apparatus. The incidence of post-operative complications recorded in the treatment of central middle-third injuries is recorded in Table 3.

Full face fractures Patients with full face fractures required lengthy and

careful assessment prior to surgery. Dental impressions proved invaluable for treatment planning especially when segments of the maxillae were missing. The mandibular arch was used as a template for alignment of the middle- third segment and in all cases cranio-maxillary fixation was employed prior to reduction of nasal or lateral middle-third fractures.

Lessons learned from experience Initial assessment of the patient with facial injury must

include careful examination of the oral cavity for loose teeth and broken or dislodged dentures. It is my experience that injury to the tongue frequently occurs in high velocity accidents and can easily be overlooked. The admitting clinician must be aware that persistent haemor- rhage from the naso-ethmoid region may not be readily obvious when the patient is supine. Persistent swallow- ing or vomiting of fresh blood may indicate the need for packing of the nasal cavity to prevent continuing blood loss. The introduction of a Foley's catheter can prevent

' Levant BS, Cook RM, MacFarlane W1. Experience with the levant frame for cranio-maxillary fixation. Br J Oral Surg 1973;l1:30-5.

' Matras H, Kuderna H. Combined cranio-facial fractures. J Maxillofac Surg 1980;8:52-9.

232 Australian Dental Journal, August, 1982

the development of life threatening exsanguination. Intra- nasal sprays of cocaine should not be used in the presence of an associated head injury.

During the initial examination and admission of two patients injured in motor vehicle accidents, a rapid deterioration in physical condition was noted but the cause was not immediately obvious. Life-threatening epistaxis was finally identified and both cases were successfully treated in the accident reception area by the insertion of nasal packs.

It should never be forgotten that every mandibular fracture must be regarded as being compound to the mouth and so antibiotic prophylaxis is indicated in an endeavour to prevent infection and this is particularly so when definitive treatment is delayed for any reason.

Maintenance of the airway, especially in the un- conscious patient, requires constant attention and its importance must be repeatedly emphasized when the accident reception area is busy. Positioning the patient so that the head is slightly elevated, if fully conscious, or turning him onto his side if not, will help keep the airway clear. Constant vigilance is essential for those patients who must be nursed on their back particularly when associated cervical spine injuries are suspected and suction apparatus should always be close at hand. Oral airways, such as the Guedel, are often rejected by patients with facial fractures. Patients in coma arising from an associated head injury should always have the airway protected by the introduction of a cuffed endotracheal tube.

Early involvement of the dental team in the manage- ment of the victims of trauma who had sustained facial fractures proved invaluable. Taking impressions of the dental arches as soon as possible following admission allowed time for thorough preparation assisting adequate treatment planning and liaison with the dental technicians when splints were required.

Pain is not a prominent feature of facial fractures unless the fracture site is disturbed by muscle action either on swallowing, talking or worse by excessive manipulation of the fragments. The early application of an effective jaw support (for example, a roller bandage) is recommended whilst the use of local anaesthesia greatly alleviates discomfort from an unstable mandibular fracture.

Lacerations of the soft tissues which extend to the bone should be repaired immediately. Closure of skin wounds within eight hours of injury promotes rapid healing and minimal scar formation. When glass or round gravel is present, meticulous debridement under general anaesthesia must be undertaken and should ideally be performed by those expert in soft tissue surgery.

The use of general anaesthesia to facilitate the reduction of facial fractures invokes all the problems of a shared airway. Nasal intubation allows accurate inter- maxillary fixation and helps ensure minimal post-

operative occlusal problems. On occasions, however, oral intubation may be required in the presence of fractures of the frontal base of the skull or a crush naso-ethmoidal injury and in these circumstances the correct apposition of the maxillae is rendered more difficult. Thorough preoperative assessment of study models and precision in the fabrication of interlocking splints is essential i f the correct occlusion is to be re-established. Delay in the reduction of the displaced middle-third injury may pro- ve to be of value, for it allows facial swelling to subside and known land-marks to be palpated to aid relocation of the central segment. Intermaxillary elastics can be employed to provide the final adjustments following extubation.

Teeth present in the line of fracture have been the subject of great debate and were present in 104 of the 221 mandibular fractures. Thirty six of these were removed because they were either displaced or obviously damaged and the remaining 68 were left in situ. In only four of the latter cases was there evidence of infection which could be attributed to the presence of such a tooth and these teeth were removed surgically without the splint being released and healing occurred without further complication.

The routine practice of removing teeth from a mandibular fracture line does not appear to be mandatory for successful healing to occur. The policy adopted of removing only those teeth which were obviously damaged by the injury and all unerupted teeth dislodged into a fracture line appears to be sound. As stated by James et al,'" teeth in the fracture line often seem to aid fixa- tion and so doctrinal sacrifice of them would appear to be unwarranted.

The maintenance of rigid intermaxillary fixation is considered to be of great value mindful that the use of plates and wires for osteosynthesis without additional fixation has been advocated by several authors.s ' I

However, i t is my experience that despite having obtain- ed the most accurate reduction with rigid intra-osseous fixation, i t is wise to play safe and to use supplementary intermaxillary fixation whenever teeth are present. Two of the three patients in this series who presented with mal-union following apparently rigid intra-osseous fixa- tion had released their intermaxillary fixation without authority thus allowing movement at the fracture site.

Acrylic cap splints proved reliable in establishing post healing occlusion and their ease of application seems to outweigh the advantages of interdental wiring and arch bars.

In the immediate post-operative period patients often react violently and this is usually associated with recovery

lo James RB, Fredrickson C , Kent JN. Prospecrive study of man- dibular fractures. J Oral Surg 1981;39:275-81.

" Bechers HL. Treatment of initially infected mandibular frac- tures with bone plates. J Oral Surg 1979;37:310-13.

Australian Dental Journal, August, 1982

from anaesthesia. However, it is well to bear in mind that unexplained restlessness may indicate hypoxia and that this risk could be of particular significance when intermaxillary fixation has been employed. Other signs include dyspnoea, mental confusion, tachycardia, and hypertension. Careful attention to the monitoring of vital signs, including the measurement of arterial blood gas levels, aids early detection of any deterioration in the pa- tient’s condition thus enabling steps to be taken to prevent progress towards eventual respiratory failure and death.

Restraint of the hyperactive patient is always essential but particularly so when external apparatus is in position and in such circumstances it is wise to restrain the arms until the patient has recovered from the effects of anaesthesia. This is particularly so when the injuries sustained are accompanied by cerebral irritation. Sand- bags applied on either side of the head proved to be superior for this purpose to any other form of restraint and especially so during the night hours when apparatus can be easily damaged whilst the patient sleeps. Such precautions avoid the need to replace external fixation apparatus. Prolonged restraint and regular supervision is virtually mandatory in order to prevent children tampering with appliances.

Surgical manipulation of the mid-face may cause epistaxis and varying degrees of obstruction of the nasal airway hindering and possibly preventing breathing via this route. A properly secured naso-pharyngeal airway is helpful in the early stages. Almost every patient will complain of discomfort when an airway has been in place for about 24 hours and so i t should be removed the moment that there is no longer any danger of respiratory obstruction

Post-operative vomiting proved to be a relatively rare complication but its effects on an airway which is already compromised must never be forgotten. Correct position- ing of the patient before he or she leaves the recovery room i s vital-fluids must be able to drain from the side of the mouth rather than pool in the oro-pharynx. Adequate suction must be readily available at all times. Nausea should be treated promptly with antiemetics and in this regard the use of Droperidol (0.1 mg/kg intramuscularly) has proved effective. The immediate release of fixation should never be regarded as the first step in the management of airway complications for its replacement is both time consuming and tiring. Thus, whilst the routine placement of wire-cutters on the post-operative instruction sheet is advisable i t must be

233

‘ 2 Go\\ A N , Chau K K , Mayne LH. Intermaxillary fixation: how practical i \ emergency jaw release? Anaesth Intensive Care 1979;7:253-7.

emphasized in nursing training programmes that they should be used with discretion.” Constant reassurance of the patient in the immediate post-operative period is to be encouraged.

Conclusions

In the successful treatment of maxillo-facial injuries, the assessment of the damage sustained, the surgical management and post-operative follow-up will always re- main the concern of a number of medical disciplines and therefore early consultation between various specialities is to be encouraged to ensure the best result for the patient. Of paramount importance in dentistry.

Emphasis has not been placed on the psychological problems relating to various degrees of loss of body image which must accompany every severe facial injury nor to the value of the specialized care provided by dietary consultants and nursing personnel. Respect for the abilities of allied professions and early involvement of all in an inter-disciplinary team approach eliminates many management problems.

This survey clearly indicates that no one specialist, regardless of whether he be dental or medical, should work alone but rather should work in willing coopera- tion with others.

Post-operative occlusal problems can be avoided if the dental team is consulted early; in-patient management can be trouble-free if treatment planning is coordinated and based on the individual needs of the patient, not those of an individual specialist. Thus the dental surgeon must clearly understand the problems which may be en- countered by other disciplines involved in the total management of the patient.

The opinions expressed herein are based upon first hand experience. They may be of interest and value to clinicians called upon to manage patients with maxillo-facial injuries and stimulate thought and discussion concerning this important field of clinical practice.

Acknowledgements

1 am indebted to Professor G. L. Howe, Dean of Dental Studies, University of Hong Kong and Dr 0. F. James, Director of Anaesthesia and Intensive Care, Royal Newcastle Hospital, New South Wales, for their guidance and encouragement in the preparation of this paper.

Department of Oral Surgery and Oral Medicine, University of Hong Kong,

2/F, The Prince Philip Dental Hospital, 34 Hospital Road,

Hong Kong.

I