Fracture of the facial bones-Nose,Maxilla,Mandible,Zygomatic

FRACTURE OF THE FACIAL BONES

Fractures of the facial bones may be divided as follows:

A. Fractures of upper third-Above Supraorbital Ridge

• Frontal Sinus,Supra-orbital Ridge,Frontal bones

B. Fracture of Middle third-Between supra-orbital ridge and upper teeth

• Nasal Bones and Nasal Septum
• Naso-orbital
• Zygomatic bone
• Floor of Orbit
• Maxilla

C. Fractures of lower third

• Mandible
• Alveolus
• Temporomandibular joint

FRACTURE OF NASAL BONES

• Nasal fracture is the most common facial fracture, and the third most common fracture of the skeleton overall.
• Aetiology:Direct trauma to the nose or Face,Head injury

Types:

• Depressed-when the injury is from front
• Angulated-due to injury from side

Clinical features:

• External Nose may be swollen and deformed.Crepitus may be felt.
• Epistaxis,Nasal Blockage

Investigations:

• Radigraph of the Lateral view of the nose shows Fracture of Nasal bone with or without Displacement
• Treatment:Reduction of fracture required if the fracture fragment is displaced.

FRACTURE OF MAXILLA

It is classified into 3 types : 

Le Fort I (transverse)–

• Fracture runs above and parallel to the plate. It crosses lower part of nasal septum, maxillary antra and the pterygoid plates.

Le Fort II (pyramidal) fracture–

• Passes through the root of nose, lacrimal bone, floor of orbit, upper part of maxillary sinus and pterygoid plates on both the sides.

Le Fort III (craniofacial dysjunction)–

• There is complete separation of facial bones from the cranial bones. 
• The fracture line passes through root of nose, ethmofrontal junction, superior orbital fissure, lateral wall of orbit, frontozygomatic and temporozygomatic sutures and the upper part of pterygoid plates.

Clinical features:

• Depneding on the type of fracture,the following features are seen:
• Nose-Nasal bridge collapses,Epistaxis,Nasal obstruction,CSF Rhinorrhea
• CSF Rhinorrhea Occurs in fracture of maxilla in Le Fort type II and type III (as cribriform plate is injured here) and also in naso-ethmoid fracture
• Maxillary sinuses-Step deformity of the infra-orbital margin,Numbness of the cheek
• Eyes-Subconjunctival hemorrhage,Diplopia,Epiphora
• Face-Dish-face deformity with the flattening of the face
• Malocclusion of the jaws

Investigations;

• Radiograph  and CT scan of Facial bones(more precise)-reveals the fractures and displacement.

Treatment

• After the Oedema of the soft tissue subsides,the fractures are reduced under general anesthesia.
• Maintainence of reduction is performed by splints,rods,bars,or continuous traction

FRACTURE OF ZYGOMATIC BONE

• Zygoma fracture is also known as tripod fracture.

Clinical features :

• Considerable swelling over zygomatic arch is common 
• Flattening of malar prominence.
• Step-deformity of infraorbital margin.
• Anaesthesia in the distribution of infraorbital nerve.
• Trismus, due to depression of zygoma on the underlying coronoid process.
• Oblique palpebral fissure, due to the displacement of lateral palpebral ligament.
• Restricted ocular movement, due to entrapment of inferior rectus muscle. It may cause diplopia. 
• Periorbital emphysema, due to escape of air from the maxillary sinus on nose-blowing.
• The mucosa of the maxillary sinus may be lacerated and cause epistaxis on that side.
• Fracture of the zygoma may or may not be painful to palpation and running a finger along the zygomatic arch may give a feel of a depressed fracture or a small dimple.

Investigations;

• Radiograph  and CT scan of Facial bones(more precise)-reveals the fractures and displacement.

Treatment

• Zygomatic arch is to be elevated.Reduction is performed by an external incision or via Caldwell -luc approach.Wiring or packing the maxillary antrum maintains the reduction of the fracture.

FRACTURE OF MANDIBLE

• Condylar process fractures of the mandible are most common account for 35% of all the fractures of mandible. They are followed by angle, body and symphysis in decreasing order of frequency.

Clinical features

• Pain,Swelling,Deformity with trismus or malocclusion of teeth

Treatment:

• The fracture is reduced and fixed by:
• Closed reduction or Open reduction.