Classification of Maxillofacial Injuries Notes

Fracture Principles And Maxillofacial Injures

A fracture is a structural break in the normal continuity of bone. This also includes hairline fractures.

Dislocation

A dislocation is a total disruption of a joint with no remaining contact between articular surfaces, e.g. anterior and posterior dislocations of the shoulder.

Read And Learn More: Clinical Medicine And Surgery Notes

Subluxation

Subluxation is a disruption of a joint with some contact between articular surfaces.

Sprain

A sprain refers to a painful condition due to the tearing of a ligament, e.g. ankle sprain due to a tear in the lateral ligament.

Mechanism of Injury

1. Direct violence: A fractured tibia or fractured mandible can occur due to a fall.
2. Indirect violence: Fracture clavicle due to fall on outstretched hand.
3. Traction injuries: Examples—When there is traction on the ligament, attached to the medial malleolus, the bone may fracture. Also, patellar fractures can occur due to the powerful contraction of the quadriceps.
4. Compression fractures occur due to falls from a height, on the heels. It may be associated with an impacted fracture of a vertebral body.

Types of Bones

1. Tubular bone
2. Cancellous bone

Types of Fracture

1. Closed or simple: When there is no communication between the site of fracture and the exterior it is described as closed or simple.
2. Open or compound: When there is a wound leading down to the site of fracture or communication between the fracture site and the exterior it is described as open or compound.

Fracture Classification

1. Depending on the etiology (pathogenesis) of fractures

1. Traumatic fractures
2. Pathological fractures
   1. Tumors
      • Giant cell tumors
      • Secondaries in bone
      • Bone cysts
   2. Infections
      • Acute osteomyelitis
   3. Metabolic bone diseases
      • Hyperparathyroidism
      • Osteoporosis
      • Paget’s disease
      • Multiple myeloma, etc.
3. Stress fractures
   1. This is common in metatarsal bones, particularly the second metatarsal bone, due to prolonged marching. Hence, it is also called a ‘march fracture’.

Injury

• Direct: Fracture at the same spot.
• Indirect: Fracture away from the spot.
• Muscular: Fracture due to contraction of muscles

2. Depending upon the plane of the fracture surface

1. Transverse
2. Spiral
3. Oblique
4. Comminuted
5. Compression.

3. Special fractures

1. Depressed fracture: This type of fracture is common in skull bone. It results due to a sharp localized blow, due to which a segment of cortical bone is depressed. It needs to be treated with elevation of the bone outwards.
2. Fracture-dislocation: Anterior dislocation of the shoulder along with a fractured neck of the humerus is a classical example of this. Fracture-dislocation gives rise to very severe pain and continues unless dislocation is reduced.
3. A fracture involving a joint: These cases have to be treated properly, otherwise joint stiffness and late osteoarthritis can occur.
4. Complex fracture: These fractures involve major vessels or nerves, for example
   • Fracture of the humerus can be associated with radial nerve injury.
   • Fracture of the lower end of the femur can be associated with injury to the popliteal artery.

Special Fractures

• Depressed—common in skull bones
• Fracture—dislocation
• Complex fracture with neurovascular damage

Healing of a Fracture

1. Stage of hematoma formation

Every fracture is associated with some amount of bleeding. Bleeding is due to tearing of the periosteum or injury to the soft tissues in the vicinity of the fracture or from endosteal vessels (periosteal and endosteal vessels).

• There is a disruption of the Haversian system of the bone.
• If the opposition is good without displacement, minimum hematoma occurs.
• If the displacement is much, a large hematoma occurs, as in cases of fractured femur.
• Like any other injuries in the body, within a few hours, inflammatory exudate is formed around and between the broken ends of the bone.
• These events take about 1–2 days.

2. Cellular stage

Similar to what happens in wound healing, there is a rapid cellular activity in fracture healing. The fusiform fibroblasts invade the clot soon. The clot will be replaced by fibrous and vascular tissue (fibrovascular tissue-granulation tissue).

• Osteoblasts also proliferate which are derived partly from the periosteum and partly from a cortical layer of the bone.
• Gradually there is metaplasia of the fibroblasts to chondroblasts which results in islands of cartilage.
• Eventually, osteoid tissue is formed.
• Thus by 2 weeks of time, granulation tissue is formed.

Fracture In Children

• Interferes with the growth of bone if it involves a physical plate.
• Greenstick fracture is commonly incomplete.
• Healing time is lost.
• Joint stiffness is rare.

Sources Of Bleeding From Fractures

• Bone ends
• Soft tissues
• Marrow vessels

3. Stage of callus formation

• Callus refers to new bone at the site of fracture. When blood supply is good, new bone formation occurs fast. The cells responsible for callus are derived from the periosteum.
• If the blood supply is poor, instead of callus, cartilage may be formed, which later gets calcified.

Types of Callus

1. An external callus is the callus that helps to bridge the gap between the fracture ends.
2. An intermediate callus is the one that unites the callus.
3. An internal callus is the one that seals the fracture site.

4. Stage of new bone formation

• Osteoclasts remove the external and internal callus. Slowly trabeculated lamellar bone replaces fibrous bone.
• Then new Haversian systems are formed.
• Then by 8–12 weeks of time, the bony union between the fragments takes place.

5. Stage of remodeling

• Similar to collagen remodeling which takes place in bearing wound healing, bone remodeling takes place through muscular and weight stresses. The remodeling process can continue upto a year or so.
• Remodeling corrects the minimal deformity.
• It is seen better in children.

Surgical Anatomy Of The Maxillofacial Region Introduction

The face is the most prominent and expressive part of the human body. The framework of the face is formed by intricate interdigitation of multiple delicate and compact bones.

For an easy understanding of the facial skeleton, it can be divided into the following.

• Lower third
• The middle third, and
• Upper third.

Surgical Anatomy Of The Mandible

1. The mandible is the most prominent, sturdy, and mobile bone in the facial skeleton, having a horseshoe shape.
   • It has direct relation with the base of the skull, through the head of the condyle by forming a joint with the glenoid fossa.
2. The outer cortical plate of the body of the mandible is thickest in the region of mental prominence and in the third molar region.
   • The ramus is formed by two thin layers of cortical bone with a central core of cancellous bone.
   • The junction between the body and the ramus of the mandible constitutes a line of structural weakness.
3. The slender neck of the mandibular condyle is an area of anatomical weakness and gets easily fractured due to direct or indirect violence.
4. The presence of teeth in the bone constitutes a source of weakness, especially those with long roots like the canines and the ones embedded within the bone.
5. Fractures occurring in teeth-bearing regions always compound into the oral cavity and the tooth in line of fracture constitutes a potential source of infection.
6. Fractures at the angle of the mandible are influenced by the pull exerted by the medial pterygoid, masseter, and temporalis muscles.
   • The factors which influence the displacement of fractured segments are:
     • Direction and magnitude of impact The site of fracture
     • The direction in which the fracture line runs
     • The pull exerted by the muscles attached to the jaw
     • Presence or absence of teeth in both fragments.
7. The mandible has mainly two sources of blood supply—centrally by the inferior dental artery and peripherally by the periosteal blood supply. As the age advances, the central blood supply gets reduced due to narrowing of blood vessels, which eventually may disappear. Then, the mandible will only have the periosteal blood supply Open reduction in old age may be avoided as that will curtail the periosteal blood supply.

Surgical Anatomy of the Middle Third Area

The middle third of the facial skeleton is formed by a complex articulation and interdigitation of multiple bones.

1. The middle third of the facial skeleton is formed by the articulation of the following bones.
   • Two maxillae
   • Two zygomatic bones
   • Two zygomatic processes of temporal bones
   • Two palatine bones
   • Two nasal bones
   • Two lacrimal bones
   • The vomer
   • The ethmoid and its attached conchae
   • Two inferior conchae
   • Pterygoid plates of the sphenoid.
2. The frontal bone and the body of the sphenoid with which the middle third articulates are at an angle of about 45° to the occlusal plane of the upper teeth. They form an inclined plane, which slopes downwards and backward.
3. When there is a fracture of this bony complex they are displaced along this inclined plane to a variable degree.
4. If the middle third of the facial skeleton is pushed downwards and backward as a result of fracture, it can force the mandible downwards producing posterior gagging of the teeth, and an anterior open bite.
5. In cases of fracture of isolated nasoethmoidal complex or LeFort 2 and 3 fractures, communication of the ethmoid may result in a dural tear in the region of the cribriform plate of the ethmoid leading to CSF rhinorrhoea.
6. Fracture of the zygomatic complex or LeFort 2 occurring either unilaterally or bilaterally, injury to the infraorbital nerve may occur, resulting in anesthesia or paresthesia in the region supplied by this nerve.
7. The protection offered to the globe of the eye by the zygomatic prominence and the compact ring of bone that forms the optic foramen, rupture of the globe, or tearing of the optic nerve is fortunately rare.
8. The suspensory ligament of Lockwood which normally maintains the level of the globe of the eye is inserted laterally into the Whitnall’s tubercle.
   • Hence, an alteration in the position of the globe of the eye may occur in zygomatic or LeFort 3 fractures due to the separation at the frontozygomatic suture.
9. Fracture of the orbital floor may result in herniation of the orbital contents into the maxillary sinus.
   • It will result in restriction of movement of the inferior rectus and inferior oblique muscles leading to diplopia.

Primary Care In Maxillofacial Injuries Respiratory Obstruction Causes

1. Obstruction of the nasal and oral airway by blood clots, vomitus, saliva, bone, teeth, dentures, and foreign bodies or inhalation of any of these.
2. In bilateral parasymphyseal fractures of the mandible, a bodily backward displacement of the tongue and its attachments can lead to closure of both the nasopharynx and oropharynx.
3. A downward and backward displacement of the fractured maxillae can occlude the oronasopharynx.
4. Airway obstruction may occur as a result of a large hematoma formation on the floor of the mouth or due to pharyngeal or laryngeal edema or surgical emphysema.

Primary Care In Maxillofacial Injuries Respiratory Obstruction Management

1. Clearing the room and nasopharynx from blood clots, mucus, broken teeth, dentures, or other foreign bodies with the help of powerful suction and wet swabs.
2. If the tongue falls backward, it is unfavorable.
3. By disimpacting maxillae, obstruction due to the fractured maxillae can be relieved.
4. In a patient with maxillofacial injury semiprone or lateral position is preferable. This will maintain a clear airway by allowing drainage of blood, saliva, and CSF.
5. If the airway is becoming considerably compromised, endotracheal intubation should be carried out.
6. In certain situations, a tracheostomy has to be done to secure a clear airway as in an extreme emergency situation.

Control of Haemorrhage

Severe hemorrhage is associated with soft tissue laceration of the maxillofacial region. If there is severe bleeding from the inferior alveolar artery, immediate open reduction and control of bleeding should be carried out.

Severe bleeding from the palatine vessels can be controlled by inserting a deep suture down to the bone to include the vessel and the mucoperiosteum in a single bite.

In extreme cases, ligation of the external carotid artery or one of its branches may be necessary.

Bleeding from middle 3rd and lower 3rd fracture

Immediate management

• Anterior/posterior nasal packs
• Temporary stabilization of the fracture
• Temporary cauterization of the bleeder
• Selective angiogram and embolization
• Ligation of the external carotid artery.

Control Of Pain And Infection

If the maxillofacial injury is associated with severe pain, suitable analgesics/antibiotics should be administered.

It should, however, be remembered that the use of powerful analgesics such as morphine is contraindicated as they depress the cough reflex and respiratory center and also mask pain which can be diagnostically important, e.g. from a ruptured spleen.

It can also interfere with pupillary reaction. Immunity against infections like tetanus should be boosted by giving an injection of tetanus toxoid even if the patient was previously immunized.

Clinical Examination Of The Maxillofacial Region

After instituting the life-saving measures, a systematic examination of the patient should be carried out.

History Of Injury

1. History of injury
   • Mode of accident at the site
2. Date and time of injury
   • Recent injury
   • Old injury
3. Mode of injury
   • Road traffic accident/fall
4. Level of consciousness
   • Disoriented
   • Confused
   • Well-oriented
   • Influence of alcohol.

General Examination Maxillofacial Region

1. Examination of cranium
   • Laceration
   • Bony damage
2. Examination of eyes/pupillary reflex.
3. Examination of cranial nerves.
4. Examination of neck, chest, abdomen, upper and lower extremities.

Maxillofacial Region Local Examination

Examination of the lower third of the face

• Lower third facial deformity
• Swelling of the lower third of the face
• Contour of step defect of the lower border of the mandible
• Deviation of the mandible on opening
• Limitation of mouth opening
• Paresthesia of the lower lip
• Occlusal-derangement
• Sublingual ecchymosis

Examination of the middle third of the face

1. Gross edema of the face
2. Circumorbital ecchymosis
3. Contour defects
4. Massive hematoma/ecchymosis
5. Cerebrospinal fluid leaks from the nose and ear
6. Alteration in the level of the globe
7. Extraoral/intraoral laceration
8. Paresthesia of middle 3rd of face
9. Posterior gagging of occlusion
10. Midpalatal split
11. Occlusal movements:
    • Upwards
    • Downwards
    • Lateral
12. Difficulty in opening mouth.
13. Diplopia:
    • Horizontal—Monocular
    • Vertical—Binocular
14. Step defect of frontozygomatic suture, infraorbital margin, zygomatic arch,
    zygomatic buttresses.
15. Mobility at LeFort 1, 2 & 3 levels, dentoalveolar level.

Classification Of Fracture Mandible

1. Fractures of the mandible can be classified into simple, compound, comminuted, pathological condyle, and green stick.
2. Anatomical classification:
   1. Dentoalveolar fracture
   2. Condylar fracture
   3. Coronoid fracture
   4. Ramus fracture
   5. Angle
   6. Body (horizontal portion up to premolar)
   7. Symphyseal region fracture.

Clinical Features Of Mandibular Fractures

Mandibular Fractures Clinical Features

• Mobility of dentoalveolar segment
• Subluxation on avulsion of teeth
• Horizontal/vertical split of tooth
• Occlusal derangement
• Change in the alignment of the tooth
• Laceration of gingiva.

Mandibular Fractures Management

• Reduction of dentoalveolar segment
• Place the jaws in centric occlusion
• Stabilizing with arch bar or interdental wiring
• Soft diet for 3 weeks.

Condylar Fracture

Condylar Fracture Classification

• No displacement of the fracture
• Displacement of fracture
  • Anterior overlap
  • Posterior overlap
• Deviation
• Dislocation
• Intracapsular fracture
• Extracapsular fracture.

Condylar Fracture Clinical Features

Fracture Of Ramus/Angle Of Mandible

Fracture Of Ramus/Angle Of Mandible Clinical Features

• Swelling of the angle of the mandible
• Ecchymosis of buccal/lingual mucosa
• Step defect of the lower border of the mandible
• Occlusal discrepancy
• Tenderness of angle.

Fracture Of Ramus/Angle Of Mandible Management

• Closed reduction of fracture with an intermaxillary fixation for 4–6 weeks.
• Open reduction of fracture and fixation using titanium/stainless steel plates/transosseous wiring
• Intraoral approach (favorable fracture) (buccal sulcus approach)
• Extraoral approach (unfavorable fracture) (submandibular incisors/Ridson’s incisors).

Fracture Of Symphysis Of Mandible Clinical Features

• Step defect of the lower border of the mandible-anterior aspect
• Discrepancy in occlusion
• Sublingual ecchymosis
• Mobility of mandible
• Inability to close mouth
• Drooling of saliva.

Fracture Of Symphysis Of Mandible Management

1. Closed reduction with intermaxillary fixation for 4 weeks
2. Open reduction —Vestibular intraoral approach.

Fracture Of Middle Third Classification

1. Fractures not involving occlusion

1. Central Region
   • Fractures of the nasal bones and/ or nasal septum.
   • Fractures of the frontal process of the maxilla
   • Fractures of types ‘a’ and ‘b’ which extend into the ethmoid bone (nasoethmoid).
   • Fractures of types ‘a’, ‘b’, and ‘c’ which extend into the frontal bone
     (fronto-orbito-nasal dislocation).
2. These can be generally grouped into nasal complex fractures.
3. Lateral regions: Fractures involving the zygomatic bone, arch and maxilla
   (zygomatic complex) excluding the dentoalveolar component.

2. Fractures involving the occlusion

1. Dentoalveolar
2. Subzygomatic
   1. LeFort 1 (low-level)
      • Unilateral
      • Bilateral
   2. LeFort 2 (pyramidal)
      1. Unilateral
      2. Bilateral
3. Suprazygomatic: LeFort III (high level or craniofacial dysfunction):

• Unilateral
• Bilateral.

Nasoethmoidal Complex Fracture Classification

1. Isolated nasoethmoidal and frontal region injury without other facial bone fractures.
   • Bilateral
   • Unilateral.
2. Combined nasoethmoidal and frontal region injury with other fractures of mid-face.
   • Bilateral
   • Unilateral.

Signs and Symptoms of Nasoethmoidal Complex Fracture

• Bleeding from nose
• Subconjunctival on ecchymosis (nasal side).
• CSF rhinorrhoea
• Traumatic telecanthus Saddle nose
• Crepitus over nasal bridge.

Management of Nasal Complex Fractures

Purpose

Active and functional airways and proper shape of the nose.

• Walsham’s forceps and Asch’s septal forceps are used.
• The padded blade is held internally and externally.
• The nasal bone is gently manipulated to reduce the pavement in the proper position.
• Asch’s septal forceps to reduce the septum.
• An intranasal splint or nasal pack is used to stabilize the fragment.

Zygomatic Complex Fracture Classification

1. Fracture stable offer deviation:

1. Zygomatic arch medially displaced.
2. Rotation around the vertical axis
   • Medial
   • Lateral

2. Fractures unstable after reduction

1. Zygomatic arch inferiorly displaced.
2. Rotation around a horizontal axis
   • Medial
   • Lateral

3. Dislocation en bloc

• Inferiorly
• Medially
• Posterolateral

4. Comminuted fracture

Signs and Symptoms of Zygomatic Complex Fracture

1. Flattening of cheek
2. Swelling of cheek
3. Periorbital hematoma
4. Subconjunctival hemorrhage
5. Tenderness of zygomatic buttress intraorally
6. Diplopia/enophthalmos
7. Lowering of pupil level
8. Epistaxis
9. Tenderness and step deformity of frontozygomatic and intraorbital margins.
10. Paraesthesia of cheek
11. Trismus
12. Limitation in mandibular movement
13. Hooding of globe.

Management of Zygomatic Complex Fractures

• Closed reduction —Gillies temporal approach.
• Open reduction and fixation
• 2-point or 3-point fixation of the facial buttress
  • Frontozygomatic
  • Zygomatic buttress
  • Infraorbital.

Approaches

• Intraoral (vestibular)
• Extraoral
  • Lateral eyebrow incision
  • Infraorbital incision
  • Hemicoronal/bicoronal incision.

Gillies temporal approach—reduction of zygomatic arch/zygoma

About 2 cm long incision is made between the two branches of the superficial temporal artery parallel to the anterior branch. The incision is deepened to reach the temporal fascia which is a white glistening membrane.

The fascia is incised and an elevator is introduced beneath the zygoma and the fragments are gently manipulated into the proper position. Originally, Bristow’s periosteal elevator was the one that was used for the purpose. Rowe, in 1966, devised a special elevator (Rowe’s zygomatic elevator).

This elevator has a blade, an oval handle like the Bristow’s elevator, and a lifting handle having the same length as the blade. The limiting hinge is designed in such a way that during lifting the handle and blade lie parallel to one another. Here the lifting can be done without undue pressure.

An audible snapping is usually heard when the zygoma gets reduced into position. Defects in the arch or other parts can be corrected by moving the elevator underneath and manipulating it.

The orbital rim, zygomatic arch, etc. can be palpated to ensure the correction of step deformity. After proper reduction, the incision is closed in layers. For about three weeks no pressure should be applied over the zygomatic area. So, the patient is instructed not to lie on the affected side.

Classification/Clinical Features Of Middle Third Fracture LeFort 1 Fracture (Guerin’s Fracture)

The fracture line runs horizontally above the floor of the nasal cavity. It involves the lower third of the septum, the palate, the alveolar processes of the maxillae, and also the lower third of the pterygoid plates of the sphenoid.

This particular fracture is also known by different names—low-level fracture, floating fracture, or horizontal fracture of the maxillae.

Signs and symptoms of LeFort 1 Fracture

1. Floating maxilla
2. Swelling of the upper lip
3. Posterior gagging of occlusion
4. Bleeding from nose
5. Ecchymosis of the palatal region (molar area)
6. Derangement of occlusion.

LeFort 2 Fracture

• This is otherwise called a pyramidal fracture because of the nature of the fracture lines.
• The top portion of the pyramid is at the nasal bones and the fracture line runs laterally involving the lacrimal bones, the medial wall of the orbit, and the infraorbital border, fracturing through or medial to the infraorbital foramen and runs backward beneath the zygomaticomaxillary buttress through the lateral wall of the maxillary sinus. It also fractures the pterygoid plates.
• The zygoma remains intact with the base of the skull.

Signs and Symptoms of LeFort 2 Fracture

1. Gross edema of the soft tissue of the middle 3rd of the face.
2. Bilateral circumorbital ecchymosis
3. Bilateral subconjunctival ecchymosis
4. Deformity of nose
5. Bleeding from the nose with/without nasal obstruction
6. Dish face deformity of the face
7. Retropositioning of maxilla with posterior gagging
8. Mobility of upper jaw at LeFort 2 level
9. Limitation of ocular movements
10. CSF rhinorrhoea, appreciated for its salty taste
11. Tenderness and separation of infraorbital margin and zygomatic buttress.

LeFort 3 Fracture

• This fracture is often called craniofacial disjunction and it actually separates the entire facial bones from the cranial base.
• The fracture runs parallel to the base of the skull. This is sometimes termed high-level fracture or transverse fracture.
• The fracture line runs through the nasal bone and continues posteriorly involving the lacrimal bones and the full depth of the ethmoid bone, and runs around the optic foramen, involves the inferior orbital fissure, the pterygomaxillary fissure, and the lateral orbital wall involving the frontozygomatic suture, LeFort 3 fractures zygomatic arch also.

Signs and Symptoms of LeFort 3 Fracture

1. Tenderness and separation at pentozygomatic suture and zygomatic arc.
2. Lengthening of face
3. Enophthalmos
4. Hooding of eyes
5. CSF rhinorrhoea
6. Tilting of the occlusal plane
7. Mobility of the whole facial skeleton as a single block.
8. Depression of ocular levels.

Mid-palatine Split

This is an uncommon occurrence since the bone is very strong at the suture interface. However, the central split of the palate may be seen along with any of the LeFort fractures. (LeFort classification is based on the experimental study of Rene LeFort in 1901.

He inflicted experimental trauma to the faces of cadavers and then dissected them to find out the fracture lines and broadly classified the fractures into three groups.)

Definitive Management Of The Mandibular Fractures Closed Reduction And Indirect Skeletal Fixation

1. Dental wiring (direct, eyelet or ivy loop, continuous or multiple loop, Risdon wiring).
2. Arch bars
3. Cap splints
4. Gunning type splints
5. Pin fixation.

1. Dental Wiring

This method is used when the patient has a satisfactory complement of teeth in both jaws for proper stabilization in centric occlusion. This provides a rapid method of immobilization.

0.35 mm soft stainless steel wire has been found very effective in dental wiring.

Direct wiring is done on individual teeth and the upper and lower jaws are fixed in occlusion (intermaxillary fixation). For better grip, the wire can be applied in a clove hitch form around the teeth. Direct wiring is a simple method.

The disadvantages are that the individual tooth is wired and for releasing the fixation all the wires are to be removed. These problems are overcome in interdental eyelet wiring.

Interdental eyelet wiring is probably the widely accepted method of intermaxillary fixation.

• The method of placing the eyelet wire is shown in the diagram. Care should be taken to place the wire in the cervical region to get better stability. The wires are pushed down to achieve this end.
• About five eyelets are placed in the upper jaw and five in the lower jaw. Intermaxillary fixation is achieved by connecting the eyelets by wires and tightening.
• The fixation is started first at the molars and works to the anterior region alternating the sides. If the anterior region is tightened first a posterior open bite may result. No free ends of wires should be projecting out to injure the soft tissues.

Multiple loop or continuous wiring has been advocated by Stout (1943). He described this method as placing elastic traction to reduce the fracture. An 80 cm long, 0.5 mm diameter S.S. soft wire is used for this purpose.

2. Arch Bars

• Many varieties of arch bars are available, e.g. Winter, Jelenko, and Erich types.
• All these types are effective when prefabricated arch bars are not available. A 3 mm half-round German silver bar with notches grooved to prevent slipping of wires can be used as an arch bar.

The major indications of the arch bars are the following.

1. When there are not enough teeth for dental wiring.
2. Uncomplicated dentoalveolar fractures.
3. Along with the internal skeletal suspension in the middle third fractures.
   When the jaw requires reduction into an arch form before intermaxillary fixation.
4. When the body fracture is associated with condylar fracture early mobilization is recommended.
5. The method of fixation of the arch bar is illustrated in the figure.

Risdon wiring is the other method used when an arch bar is not available. In this method, the two wires tied on the posterior teeth are used in the place of the arch bar.

This type of wiring is specifically indicated in the midline and paramedian fractures of the mandible as it affords a reducing force towards the ‘symphysis’.

3. Cap Splints

• Cast silver cap splints or acrylic cap splints can be used. The former one is more stable but requires a longer laboratory procedure.
• Cap splints are indicated when very few teeth are present on the main fragments. The impression-taking, fabrication, and fixing of cap splints is a very lengthy procedure and can be done only in well-equipped centers.

4. Gunning Type Splints

• These splints are indicated in fractures of the edentulous mandible. These splints are retained in position ‘of circumferential wiring or by peralveolar wiring.
• This method is contraindicated in unfavorably displaced fractures lying outside the denture-bearing area and in cases of severe fracture displacement. Extreme resorption of alveolar ridges complicates this technique.
• In the maxilla instead of a peralveolar pyriform aperture, prenatal or circumzygomatic wirings are suitable alternatives.
• If the patient is already wearing a denture, the same can be suitably modified. It is always advisable to give gutta-percha lining for the slint to minimize injury to the soft tissues.
• Hooks are incorporated into the splints for the placement of intermaxillary elastics and wires. The upper splint is fixed to the alveolus by using an awl to pass 0.5 mm S.S. soft wire through the alveolus high up in the canine area on each side.
• The wires are passed and tightened over the splint. The lower splint is fixed to the mandible by circumferential wiring.
• An awl is pushed through the skin beneath the chin to the mouth to the lingual side of the jaw at the canine region and the wire is withdrawn and the awl is passed to the buccal side, keeping the awl close to the bone.
• The wire is released from the awl and the awl is removed. The wire is tied and tightened around the splint.
• Intermaxillary fixation is achieved by placing elastic bands or wires on the hooks attached to the buccal aspect of the splints.

Open Reduction And Direct Skeletal Fixation

1. Transosseous wiring or osteosynthesis

• Upper border
• Lower border

2. Plating

• Compression plates
  • Dynamic
  • Eccentric
• Non-compression plates

3. Lag screw fixation
4. Titanium/stainless steel mesh fixation.

• Intramedullary pinning.

Management Of Middle Third Fracture Direct/Internal Fixation Of Maxilla

Direct Osteosynthesis

1. Transosseous wiring at fracture:
   1. LeFort 1 (alveolar/midpalatal)
   2. LeFort 2 (orbital rim/zygomatic buttress)
   3. LeFort 3 (dentozygomatic and pentonasal)
2. Miniplates:
   1. Stainless steel plate/titanium plate
   2. Microplate
   3. Compression plates
      • Dynamic
      • Eccentric
   4. Polyglycolic acid resorbable plates
3. Transfixators with Kinschnes wire or Steinman pin.
   1. Transracial
   2. Zygomatic septal.

2. Suppression wires to the mandible

1. Frontal
   1. Central
   2. Lateral
2. Circumzygomatic
3. Zygomatic
4. Infraorbital

3. Support

1. Antral pack
2. Antral balloon.

External Fixation Of Maxilla

1. Craniomandibular
   • Box frame
   • Halo frame
   • Plaster of Paris head layer
2. Craniomaxillary
   • Supraorbital pins
   • Zygomatic pins
   • Haloframe

Internal Suspension

Internal suspension for stabilization of the middle third fracture is of the following types.

1. Circumzygomatic suspension
2. Zygomatic suspension
3. Infraorbital suspension
4. Pyriform aperture suspension
5. Frontal
   • Central
   • Lateral.

1. Circumzygomatic Suspension

This technique is used in subzygomatic fractures where the zygoma is intact. The wire is passed around the zygomatic arch.

Technique

• An Obwegeser bone awl is pierced extraorally at the point of the junction of the temporal and frontal processes of the zygomatic bone.
• It is directed beneath the zygoma intraorally in such a way as to enter the oral cavity in the buccal sulcus at the first molar region.
• The wire is attached and the bone awl is withdrawn to a level where its tip lies just above the arch without emerging from the skin.
• The awl is then passed over the lateral aspect and directed downwards to enter the oral cavity at the original point in the buccal sulcus.
• Instead of a bone awl a wide-bore spinal needle can also be used for the purpose. The wire is sawed so as to cut through the soft tissue and come in contact with the zygomatic bone.
• The wire is then fixed to the arch bar or splint, either to the maxilla or mandible in the premolar area.

2. Zygomatic Suspension

The inferior ridge of the zygomatic buttress is used for suspension. The area is approached through the buccal sulcus.

3. Infraorbital Suspension

• A small hole is drilled through the lower border of the orbit and the wire is suspended from the border.
• The area is approached through a 2.5 cm, semilunar incision beneath the orbit.
• The intraoral approach through the buccal sulcus above can also be used for this purpose.
• A cm incision is placed above the canine fossa. During the drilling of the hole and threading the wire, the eyeball should be well protected by malleable retractors.

4. Pyriform Aperture Suspension

• A2 cm transverse incision is placed above the lateral incisor and the bony pyriform aperture is exposed.
• A drill hole is made 1 cm from the free border to the lateral side. The wires are then fixed to the appropriate loop or splint on the arch. This method is useful in cases of LeFort I type of fractures.

5. Frontal Suspension

1. Lateral
   • An incision is made in the lateral border of the eyebrow to expose the zygomatic process of the frontal bone just above the frontozygomatic suture. The Aburr hole is drilled about 5 mm above the suture line.
   • The wire is passed and both the ends together are passed downward and forward behind the zygomatic bone using a Rowe’s zygomatic bone awl to emerge in the buccal sulcus near the first molar tooth.
   • A pullout wire is incorporated at the region where the wire passes through the bone hole. This facilitates easy removal of the wire after the completion of the treatment.
   • This type of suspension is used in cases where the fracture is supra-zygomatic.
2. Central
   • This method was introduced by Kufner (1970). A 2 cm incision is made horizontally on the forehead just above the frontal sinus.
   • A Roger Anderson pin is introduced in an oblique downward direction engaging the inner table of the skull. A 2 cm subcutaneous tunnel is created below the pin.
   • An awl is passed through the vestibule of the cavity in the upper canine region passes lateral to the pyriform margin of the nose in front of the lacrimal gland and emerges through the subcutaneous tissue tunnel.
   • The two ends of the wire (looped around the pin) are engaged in the awl and withdrawn.
   • The same procedure is repeated on the opposite side and wires are pulled to remove any slackness.
   • After the reduction of the fracture, the wires are fixed to
     the maxillary or mandibular splints or loops for fixation.

Duration of Treatment

• The duration of treatment varies depending on the site of the fracture, the condition of each case, and the treatment modality.
• As a general rule, the intermaxillary fixation (IMF) has to be kept in position for a period of three to four weeks in children and adolescents.
• In adults, the period of IMF is 5 to 6 weeks. In old patients and in infected cases the period of fixation has to be increased from 7 to 10 days more.

Complications

In properly treated maxillofacial injuries complications are comparatively rare. The complications are seen as follows.

1. Anesthesia
   • Anesthesia of the lower lip occurs in cases of neuropraxia, axonotmesis, or neurotmesis of the mandibular nerve.
   • This may occur in the fracture of the body of the mandible. Neuropraxis will usually recover in a period of a few weeks.
   • If the nerve is severed it may take about 1 to 2 years for recovery. If the infraorbital nerve is involved, anesthesia occurs in the region of the lower eyelid, lateral part of the nostril, upper lip on the affected side, and the anterior teeth.
2. Malunion and deformities
   • Deformities of the face occur if the reduction is not satisfactory or malunion occurs. In the case of the mandible, functional remodeling takes place very rapidly in a matter of months.
   • Proper remodeling does not take place in the instance when the fracture at one side of the genial tubercle is malpositioned.
   • This results in a marked asymmetry. In the middle third injuries, improper reduction can result in flattening of the face, dish face deformity, and anterior open bite with gagging of the molar teeth.
   • Anterior open bite with gagging of the molar teeth occurs in bilateral condylar fractures.
3. Infection
   • Infection is a very rare complication. It occurs if the root stumps are left in the fracture line or in cases where the general resistance of the patient is poor. Infection can also occur when there is improper fixation causing mobility at the fracture site.
4. Superior orbital fissure syndrome
   • Trauma to the zygomatic complex sometimes may damage the contents of the superior orbital fissure.
   • Haematoma or aneurysm within the fissure affects the 3rd, 4th, and 6th cranial nerves, resulting in ophthalmoplegia, ptosis, proptosis, and a fixed dilated pupil.
   • Unless the nerve is traumatized there is complete or partial recovery.
5. Nonunion and delayed union
   • Nonunion is comparatively rare in the maxillofacial region. However, non-union or delayed union occurs in the following conditions:
     1. If a tooth has been left in the fracture line.
     2. The fracture is infected due to some other reasons.
     3. Inadequate immobilization.
     4. Patients debilitated by systemic diseases and deficiencies. Delayed union or non-union can be treated and cured by removing the cause (infection and presence of teeth in the fracture line), freshening the bone ends, and rewiring. If there is bone loss, grafting also may have to be done.
6. Derangement of the occlusion
   • In a satisfactorily performed treatment, occlusal derangement is minimal and this gets corrected by itself as the patient starts using the teeth. If there is a persistence of traumatic occlusion selective grinding is done. If occlusal derangement is severe in neglected fractures refracturing of the fragment and correction is performed.
7. Ankylosis of the temporomandibular joint
   • This is comparatively higher in young children. The chances are higher if there is an intracapsular fracture. Prolonged immobilization also may result in ankylosis of the temporomandibular joint.
8. Other complications
   • Diplopia, enophthalmos, strabismus, etc. are certain other complications associated with injuries of the orbit. A deviated nasal septum may result in a blockade of the nares.
   • Damage to the nasolacrimal duct results in epiphora. Anosmia occurs if the olfactory nerve is affected due to the comminution of the cribriform plate of ethmoid.