Introduction:-

Fracture means break in the continuity of the bone and facial fracture refers to any kind of broken bone in the area of the face. Facial fracture can occur singly or in combination with other fractures or injuries. Facial fractures can pose plastic surgeons considerable challenges during treatment. Reconstruction and repair of facial fractures requires specialised skills and reconstructive materials such as bone grafts, skin flaps etc. Facial fracture repair is carried out by specialised plastic surgeons known as oculoplastic or maxillofaciary surgeons.

Facial fractures are most commonly caused by impact injuries as a result of sporting trauma, motor accidents, falls and physical combat injury. Facial fractures tend to be common due to sport injuries. Pan-facial fractures are also likely in the case of extensive injury or trauma.Fracture of facial bones, especially the jawbones, frontal sinus etc. require a considerable amount of force. The surgeon developing the treatment plan for the fracture reconstruction should also take into account the mechanism of trauma into consideration.

Alternative Nomenclature:-

  • Maxillofacial Fractures
  • Naso-Orbital-Ethmoid Fracture

Classification & Types:-

One system of facial fracture classification is the Le Fort system of classification. Under the Le Fort system, fractures are classified as :

  • Le Fort Type 1 – This is a type of horizontal maxillary fracture, which results in the separation of the teeth from the upper face.
  • Le Fort Type 2 – This is a fracture which is pyramidal in nature with the teeth forming the base of the pyramid and the nasofrontal suture as the apex
  • Le Fort Type 3 – In this type of fracture, the bones fracture in such a way as to result in a craniofacial dysjunction.

Other ways of classifying fractures involve classifying them on the basis of location

  • Nasal Fracture – This is a fracture of the nasal bones
  • Jaw fracture or Mandibular Fracture – Fracture of the jawbones is known as a mandibular fracture.
  • Midface fracture or Maxillary Fracture – Fracture of the bones making up the midface (from the lips to the eyes) is known as a midface fracture.
  • Eye socket fracture or Orbital Fracture – The bones that make up the hollow surrounding the eyes are known as the orbit. Any fracture of these bones is known as an orbital fracture.
  • Temporomandibular joint – Fracture of the joint connecting the cheekbone and the jawbone is known as a temporomandibular joint fracture. This may lead to dislocation of the jaw, and angled jaw.
  • Frontal Sinus fracture – The fracture of the frontal sinus or forehead bone is known as a frontal sinus fracture.
  • Cheek bone fractures or Zygoma Fracture – Fracture of the zygomatic bone, or the cheek bone is known as a zygomatic fracture. Implants may be used to reconstruct the cheek.
  • Naso-ethmoidal fractures – Nasoethmoidal fractures include fractures occurring in the bones of the nasal, orbital and cranial cavities. Any fractures occurring in the sasal, orbital, lacrimal, maxillary, ethmoid or sphenoid bones is known as a naso-ethmoidal fracture.
  • Panfacial fractures – Fractures involving the lower, middle and upper part of the face are known as panfacial fractures. These require extensive reconstruction involving the chin, cheek and jaw. Implants and grafts may be required.

Causes & Risk Factors:-

All kind of vehicle crashes (automobile, bike, motor etc.), sport injuries, accidental falls, gunshot wounds, seizures, injury due to blunt objects, falls on ground, combat injuries etc.

Symptoms and signs:-

Some of the symptoms can be specific for the particular bone fractures while other can be common for all the bone. Some of the symptoms may get high lightened even with soft tissue injuries with no facial fractures too.

Some of the common symptoms are:-

  • Pain in the chin, cheek and face area, swelling and bruising in the face
  • A fractures nose may show symptoms like swelling, tenderness, deformity, bleeding from nose. Severe injury to the nose may lead to injury to the bones inside the nose like ethmoid bone fracture which can cause persistent nose bleed or discharge of clear nasal fluid.
  • A jaw fracture or mandibular fracture may show symptoms like mandibular pain and tenderness, difficulty in occlusion and pain, bruising under the tongue.
  • Midface fracture may cause pain and tenderness in the cheek, difficulty and pain in closing the mouth, some visual problems, bruising in and around the eyes. Some the patients suffering these types of injuries may suffer from breathing difficulty and may require assistance in respiration like a tube inserted down the throat.
  • Cheek bone or zygomatic fracture can manifest as flattening of the cheeks, visual problems, pain with jaw movements, blood in and around the eye an altered sensation under the eye of the affected side.
  • Eye Socket fracture can very well manifest as sunken eye or enopthalmos, visual problems like particularly upward gaze or double vision, alteration of sensation underneath the eye.
  • TMJ (Temporomandibular Joint) dislocation can lead to jaw being pulled out of place, inability to close the mouth. This joint is place below the temporal bone under the ears where the end of the jaw meets it.
  • Alarming symptoms in case of facial fractures are clear nasal fluid discharge, persistent nose bleed, hearing problems, jaw dislocation, no sensation or altered sensation in the face area, difficulty to close mouth, visual problems, open wounds etc.

Investigations:-

  • X-Rays are taken out for facial fractures. Particular type of facial fracture may be visible in particular type of radiographic view. Sometime dental X-Ray may also be used for the condition.
  • Computed Tomography (CT) is often used for better visualisation of the fractures as well as for examination of the soft tissue injury or accumulation of blood in the area. Angiography can also be used to locate the source of the bleeding.

Diagnosis:-

Diagnosis of the particular type of facial fracture depends upon the information of the injury was sustained, the physical examination and investigations. Injuries sustained to other parts of the body along with facial fractures also need to be considered especially in cases of vehicular accidents.

Complications of Disease:-

Some of the complications which can happen in cases of facial fractures are deformation in the face area, chronic breathing problems, difficulty in swallowing and chewing, problematic eye sight etc.

Treatment Options:-

  • Self-care
  • Ice packs can be used upon the area to help with the pain and the swelling
  • If there is any bleeding area, direct pressure needs to be applied onto it.
  • Medical help should be called immediately.
  • Treatment of the facial fractures aims to bring back the natural architecture of the face and leave any traces of the facial injuries. Fractures can be manages by using metal screws and plates or they may be required to be wired up together. Sometime bone grafting may be required to bring about the near natural cosmetics of the face by filling the missing sections if the bone and to provide structural support to the other parts.
  • Open wounds are sutured and nasal packing may be given to nose bleeds. In case of severe trauma, open airway needs to be ensured. Infection may take severe turn in cases of facial fractures hence good antibiotic coverage also with pain medication is needed.

Complications of Treatment:-

  • Complications of medical management:Antibiotics may create additional stomach problems and long term use of pain killers may bring on addiction.
  • Complications of surgical care:In many cases the cosmetic aspect comes second. In this case there may be disfiguration and cosmetic surgery may be necessary in the future.

Prognosis:-

If treated timely it has excellent prognosis if the patient is under good care.

Prevention:-

In order to prevent this condition one should take extra care during high risk activities such as playing sports, alcohol use. The seatbelt as well as the sport protective face gear are necessary.

References:-

http://www.emedicinehealth.com/facial_fracture/article_em.htm

http://www.ncbi.nlm.nih.gov/pubmed/22614719

http://www.ncbi.nlm.nih.gov/pubmed/22613286

http://www.ncbi.nlm.nih.gov/pubmed/22610701


About Dr. Debraj Shome

Debraj Shome-2
Debraj Shome, MD, DO, DNB, FRCS (Glasgow), FICO (USA), MNAMS, MBA (Healthcare Management, Vanderbilt University, USA), is Consultant Facial Plastic Surgeon, Oculoplastic Surgeon & Cosmetic Surgeon at Nova Specialty Surgery, Mumbai, India..Read more

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