‫ حسنين احمد‬.

‫د‬/‫جامعة بغداد‬/ ‫كلية طب االسنان‬/ ‫المرحلة الخامسة‬

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. These vertical pillars are further supported by the horizontal
buttresses;

The horizontal buttresses are supraorbital or frontal bar, infraorbital rims, and
zygomatic arches. Joining these buttresses together is lamellar thin bone. This
framework results in fairly predictable patterns of fracture.

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.
The Le Fort classification

In 1901, Rene Le Fort described the classical fracture patterns of the midface and
determined three main levels of fractures as interruption of buttresses and lamellar
bone structures in the mid-facial architecture. These fracture patterns are
characteristic of a unidirectional, low-energy injury rather than the multi-vector, high-
energy mechanisms commonly observed today. However, this system is popular
because it provides a simple, anatomically differentiated system for the general
classification of mid-facial injuries.

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.

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.

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

Examination should include firmly grasping the maxillary arch with the finger and

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thumb facially and palatally and attempting displacement of the maxilla in three
dimensions, as well as compression and expansion of the maxillary arch.

• 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 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, although a classical Le Fort II fracture does not include the
cribriform plate of ethmoid so CSF rhinorrhea does not take place, unless there
is associated fracture of cribriform plate of ethmoid.

• 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

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 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 syndrome.
• Facial edema.

• Circumorbital ecchymosis and subconjunctival hemorrhage.

• 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.

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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. These views
will demonstrate uncomplicated middle third fractures with sufficient detail to
determine a treatment plan. 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.

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.

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 • 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.

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.

• Infraorbital rim suspension wiring.
• Circumzygomatic wiring.
• Supraorbital rim suspension wiring.

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) The current method of choice is
internal fixation with miniplates, microplates, three-dimensional meshes, and screws.
With this method, it is possible to fix even the smallest fragments and to stably bridge

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areas of comminuted fragments in the buttress regions until the fractures have
consolidated. 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 pyriform
(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, but up to 8% to 13% of Le
Fort fractures are complicated by concomitant palatal fractures. Clinical examination
may reveal laceration of the lip and concurrent gingival and palatal lacerations. Often,

7
a change in occlusion is also noted. Diagnosis is confirmed by a maxillofacial CT with
axial and coronal cuts.

Classification
Several classification systems have been suggested for palatal fractures. A simplified
classification system classifies the palatal fractures into:

• 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 fractures

The zygomatic complex usually fractures in the region of the frontozygomatic, the
zygomaticotemporal and the zygomaticomaxillary sutures. It is unusual for the
zygomatic bone itself to be fractured, but occasionally it may be especially due to high
energy injuries. Sometimes the bone may even be comminuted. The arch of the
zygoma may be fractured in isolation from the rest of the bone.

Fractures of zygomatic complex can be classified as:

Fractures of the zygomatic body involving the orbit

1. Minimal or no displacement.

2. Inward and downward displacement.

3. Inward and posterior displacement.

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4. Outward displacement.

5. Comminution of the complex as a whole.

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; binocular 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

9
 inferior displacement of Whitnall's tubercle with the attached Lockwood's
suspensory ligament that leads to alteration in the level of the globe.
• 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

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 and 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.

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 • 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.

Indirect reduction of a zygomatic fracture can be achieved by:

The temporal approach (Gillies approach) is popular and straightforward. The

operation depends on the fact that the deep Temporal fascia is attached along the
superior surface of the zygomatic arch, while the temporalis muscle passes beneath
the arch to be attached to the coronoid process and anterior ramus. 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.

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 • 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.

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

Midtarsal incision is placed in a natural crease approximately half way between the
lash margin and the orbital rim.

Subciliary (lower blepharoplasty) incision is placed in a suitable skin crease parallel to

the free edge of the lid 2-3 mm away from the margin.

Transconjunctival approach through the lower fornix has the obvious advantage of an
invisible scar.

Approaches to the medial orbital wall

Paranasal approach (Lynch incision); is straightforward approach to the medial orbit

12
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.

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.

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.

In blow-out fractures, the fragments of bone are displaced downwards into the antral
cavity and the periorbital fat tends to herniate through the defect, this has the effect of
interfering with the action of the inferior rectus and inferior oblique muscles
preventing upward movement and outward rotation of the eye with resulting diplopia
in these directions of gaze. If a large enough amount of orbital fat is displaced through
the orbital floor defect it may result in enophthalmos.

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

13
 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.

Treatment

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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.

Indications

1. Significant restriction of eye movement (diplopia) with CT confirmation of

entrapment.
2. Significant enophthalmos.
3. Large 'blowout' defect
4. Significant orbital dystopia

Relative contraindications

1. Visual impairment
2. Anticoagulant medication
3. Patient unconcerned
4. Proptosis
5. An already 'at risk' globe
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. If stabilization is
required this can be performed by using microplates or by simple wiring to the orbital
rim.

Reconstructive options for orbital defects

Autografts of fascia, bone and cartilage, Allograft, Xenograft, Alloplastic

15
 materials; these can be resorbable or non-resorbable such as titanium mesh
and sheets of Silastic (medical grade silicone polymer), Medpor
(porouspolyethylene) 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.

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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

17
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.

Naso-orbito-ethmoidal complex fractures

The naso-orbital-ethmoid (NOE) fracture represents a significant diagnostic and

reconstructive challenge. This region houses the lacrimal apparatus, medial canthal
ligament, and anterior ethmoidal artery.

The NOE fractures are typically noted to be unilateral, bilateral, simple, or

comminuted and are likely to have with different fracture presentations bilaterally.
They may occur as an isolated injury or in conjunction with other major facial
fractures.

Classification

A commonly used classification system of NOE fractures is based on their relationship

to the central fragment at the site of medial canthal tendon attachment:

Type I; the simplest form of NOE fracture involves single central fragment bearing

18
the canthal ligament.

Type II; comminuted central segment with medial canthal ligament still attached to a
bone fragment.

Type III; comminuted central segment with detached medial canthal ligament.

Clinical features

• Bruising or laceration of skin of the nose

• Bilateral circumorbital ecchymosis and edema
• Subconjunctival hemorrhage.
• Epistaxis
• Deformity of nose and inter-orbital area
• Crepitus of bones of nasal complex
• Unilateral or bilateral telecanthus, generally speaking, an inner intercanthal
measurement greater than 35 mm is indicative of canthal displacement.
• rounding of the medial canthus of the eye.
• Airway obstruction
• Septal deviation
• Cerebrospinal rhinorrhea
• The damage to the cribriform plate of ethmoid results in damage to the
branches of the olfactory nerve and loss of smell sensation (anosmia).

Imaging Plain radiographs provide insufficient detail of damage. CT scans (axial and
coronal views) provide a much more complete picture and are an essential
investigation for the accurate assessment of this type of injury.

Treatment Effective treatment depends primarily on accurate replacement and

fixation of the medial canthal ligaments and restoration of the nasal bridge anatomy.
Closed reduction by manipulating the fragments and external splinting using acrylic
buttons or small lead plates held in place with transnasal wires are usually
unsatisfactory. Secondary deformity is difficult to correct owing to scarring and
displacement in the medial canthal area. ORIF using transosseous wiring or
miniplates and microplates offers the best option of restoring the anatomy of this area;

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the surgical procedure includes the following steps:

• Surgical exposure.
• Identification of the medial canthal tendon and tendon-bearing bone
fragment.
• Reduction and reconstruction of the medial orbital rim.
• Reconstruction of the medial orbital wall.
• Transnasal canthopexy.
• Reduction of septal fractures.
• Nasal dorsum reconstruction and augmentation.
• Soft tissue adaptation.

Occasionally the canthal ligament may be avulsed from the bone, or the fragment may
be too small to plate in position. In this situation a transnasal canthopexy should be
carried out using fine wire or a braided stainless steel suture. Where the medial wall
of the orbit is Missing or extremely comminuted it is advisable to combine this with a
bone graft or titanium mesh to help anchor the soft tissue.

Approaches for surgical exposure of the NOE fractures

1. Through existing laceration

2. Local skin incisions for exposure of the nasal bridge and frontonasal region:
3. H-shaped incision across the bridge.
4. Z-shaped incisions in the medial canthal areas.
1. Midline vertical incision from the forehead across the glabella.
6. Extended W-shaped incision from above or beneath the medial aspect of one
eyebrow across the nasal bridge to above or beneath the opposite eyebrow.

Disadvantages of local incisions:

• May result in unsightly scar

• Limited access
• Fracture lines may extend beyond the area of the surgical exposure and
accurate reduction can be compromised.

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7.Coronal flap The coronal flap gives excellent exposure of the whole of the upper
part of the facial skeleton and has largely replaced the local incisions because of the
good visualization it gives of the frontal bone, naso-ethmoid region, superior orbital
margins, lateral orbital margins and both zygomatic arches.

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. 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:

• 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)

Treatment

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

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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.

• Blindness due to direct injury to the optic nerve.

Abrasion of the cornea during surgery; protective shells should be inserted routinely
at the beginning of an operation or a temporary tarsorrhaphy suture inserted.

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:

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 • 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

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