38 Maxillofacial injuries

RICHARD P JUNIPER Introduction Injuries to the face are common but the majority is relatively minor A fe! are major and com"le#$ re%uirin& e#actin& techni%ue and infinite care in mana&ement It must be remembered al!ays that an intact and unscarred face is im"ortant to the !ell'bein& of the individual$ and thus all injuries$ ho!ever trivial$ should be treated thou&htfully and sym"athetically$ !ith every effort al!ays to "roduce an o"timal outcome In addition$ even trivial blo!s to the face may( )cause injuries !hich com"romise the air!ay* )directly or indirectly cause a head injury +a fall to the &round so ban&in& the head$ for instance,* )cause injuries to the cervical s"ine Injuries to the face and facial bones result from both s"ortin& activities and accidents$ and intentional violence -he major injuries in the "ast !ere as a result of road traffic accidents$ but the com"ulsory !earin& of seat belts$ car air ba&s$ head restraints and laminated !indscreens have reduced all of these &reatly Ho!ever$ the reduction in dama&e from this source has been almost matched by the increase in deliberate injury from bodily violence !here ."uttin& the boot in/ has become a fashion !ith a""allin& results Clinical effects -he mouth and nasal "assa&es are the u""er air!ay$ and lacerations and fractures of the facial s0eleton may &ive rise to immediate or delayed res"iratory obstruction Immediate obstruction may arise from inhalation of tooth fra&ments$ accumulation of blood and secretions$ and loss of control of the ton&ue in the unconscious or semiconscious "atient -o avoid this$ the "atient should al!ays be nursed in the semi' "rone "osition +1i& 23 4, !ith the head su""orted on the bent arm$ and never lyin& on their bac0 Dama&ed teeth$ blood and secretions can then fall out of the mouth and &ravity "ulls the ton&ue for!ard As the "atient is manoeuvred into the correct nursin& "osition$ the nec0 should be su""orted and held in a neutral "osition 5 a "rotective collar is advisable until a fracture of the cervical s"ine has been e#cluded Under no circumstances should the chin be "ulled u" to strai&hten the air!ay An intracranial injury should al!ays be considered as a "ossibility$ ho!ever minor the injury to the face Initial haemorrha&e after a facial injury can be dramatic 6ustained bleedin& is unusual but emer&ency sur&ery to stabilise the facial fractures and control bleedin& may be re%uired -he most li0ely causes of circulatory failure in a bad facial injury are accom"anyin& s0eletal injuries or a ru"tured viscus$ and these should al!ays be actively sou&ht for in the shoc0ed "atient 7edema is a "articular feature of all fractures of the facia s0eleton and tends to develo" !ithin 895:9 minutes -hus$ "atient !ith a shattered face may a""ear to have a cho0e air!ay immediately after the blo!$ but that air!ay may ra"idly chan&e and become occluded by s!ellin& of the ton&ue facial and "haryn&eal tissues -his "roblem must al!ays be borne in mind !hen the middle third of the face is involved$ In ;e 1ort III fractures +see belo!, the facial bones may be thrust do!n!ards and bac0!ards alon& the base of the s0ull As it does so$ the "osterior teeth of the u""er and lo!er ja! contact first and the mouth is held o"en &ivin& the im"ression of a &ood air!ay +1i& 23 <, As s!ellin& su"ervenes$ the soft "alate and the ton&ue may s!ell to meet$ so closin& the "haryn&eal air!ay

and leadin& to acute res"iratory obstruction +1i& 23 2, =henever this is sus"ected$ the .&olden hour/ must be used to insert an oro"haryn&eal air!ay$ even thou&h the "atient may a""ear conscious and unobstructed If this is not done an emer&ency tracheostomy may have to be underta0en later !ith &reat ris0 to the "atient E#amination of the injuries -he e#amination of the "atient should be under a &ood li&ht !ith consideration of the air!ay and other collateral injuries al!ays in mind It is easy to be deviated from e#aminin& the !hole "atient by the dramatic effects of the facial injury -he ra"id onset of oedema may ma0e the e#amination of the face and routine head injury observations difficult 5 occasionally it is im"ossible to "rise the eyelids a"art to e#amine the "u"il$ for instance ;acerations should be e#"lored &ently first and$ if necessary$ cleaned usin& sterile saline$ a%ueous antise"tic solution and>or dilute hydro&en "ero#ide 7nce the "attern and e#tent of soft'tissue injury has been established$ attention should be &iven to the hard tissues Re&ardless of the a""arent site of the injury$ the !hole head should be e#amined visually and by "al"ation startin& !ith the vault of the s0ull A blo! to the face may result in the head bein& thro!n bac0 a&ainst a hard object and a bruise or laceration on the occi"ut missed -he face should be e#amined from in front Any asymmetry and dis"lacements should be noted$ althou&h oedema may ma0e this difficult ?entle "al"ation$ usin& both hands and !earin& sur&ical &loves$ &ives the most information in searchin& for ste" deformities -enderness over sites of 0no!n !ea0ness and "otential for fracture +see belo!, is a very &ood &uide for the "ossibility of fracture of the bone beneath A suitable system is to e#amine from above do!n!ards 5 the su"raorbital and infraorbital rid&es$ the nasal brid&e$ the @y&omas$ includin& the @y&omatic arch -he mandible should then be e#amined startin& at the condyles bilaterally and then follo!in& the "osterior and lo!er border of the mandible as far as the midline All middle third injuries are accom"anied by bleedin& from the nose$ and ;e 1ort II and III injuries fre%uently have a cerebros"inal fluid +C61, lea0 !ith anterior or "osterior C61 rhinorrhoea All fractures of the ma#illa lead to mucosal tears !ith bleedin& from the nose A "articularly useful si&n in the fractured @y&oma is the fre%uent subconjuctival haemorrha&e !hich !ill be found to have no "osterior border !hen the "atient is as0ed to loo0 to the o""osite side +1i& 23 A, -his &ives a "ositive indication of a fracture of the bone behind -he "atient should then be e#amined intra orally !ith &ood illumination* a "en torch is insufficient -he li"s should be "arted and the occlusion of the teeth e#amined -he u""er and lo!er teeth normally .fit/ to&ether even if the occlusionis naturally irre&ular if they do not a fracture of the ja!s is li0ely All fractures of the alveolus +the bone holdin& the teeth, tear the &in&iva and are com"ound into the mouth( the e#aminer should loo0 for sites of bleedin& A haematoma in the floor of the mouth is a &ood indication of a fracture of the mandible$ "articularly in the edentulous case -he chee0s$ throat and ton&ue should be e#amined at the same time Bovement of the ja! should be tested deviation from the midline at rest or on o"enin& su&&ests a fracture of the side to !hich the ja! is deviatin& If a fracture of the ma#illa is sus"ected$ the u""er dental arch should be &ras"ed bet!een inde# fin&er and thumb of one hand in the molar re&ion$ !hile the other is "laced on the forehead A &entle "ull on the ma#illa for!ard and bac0!ard$ or side to side$ !ill reveal movement bet!een the e#aminin& hands =ith the mandible$ &entle mani"ulation across the sus"ected site of a fracture !ill confirm the "resence of the fracture if .s"in&in&/ is felt and seen Confirmation of a fractured @y&oma may be

made by "al"atin& the fractured antral !all above the u""er molar teeth in the buccal sulcus -he facial e#amination should be com"leted by testin& for sensation over the face Anaesthesia or "arasthesia su&&ests a fracture "ro#imally alon& the "ath of the nerve -hus$ anaesthesia of the chee0 and u""er li" su&&ests a fracture &oin& throu&h the infraorbital foramen$ !hile anaesthesia of the lo!er li" su&&ests a fracture of the mandibular body It is im"ortant to confirm that the "atient has si&ht in both eyes -his may be difficult in the very oedematous "atient !ith circumorbital haematoma$ but a "en torch shone throu&h the lids !ill confirm that the o"tic nerve is intact =here "ossible$ vision should be chec0ed for di"lo"ia by as0in& the "atient to follo! the li&ht of the "en torch in both central and e#tremes of &a@e Di"lo"ia may mean that there is dama&e to the thin orbital "lates of bone$ "articularly the infraorbital "late All findin&s should be recorded accurately$ "referably !ith dia&rams to include measurements of lacerations and dis"lacements Photo&ra"hs of the initial injury can be very hel"ful if liti&ation is li0ely to follo! Investi&ations Clood tests Caseline full blood "icture and serum electrolytes should be recorded$ and the blood should be &rou"ed !hen it is thou&ht that much bleedin& has occurred and more bleedin& is li0ely Radio&ra"hs Posteroanterior occi"itomental radio&ra"hs ta0en at 49 and 29de&ree are the best initial radio&ra"hs to illustrate the site and dis"lacement of the ma#illa* an o"a%ue antrum is a &ood indication that there may be a fracture of the ma#illa A "anoramic oral radio&ra"h +ortho"antomo&ram, is the radio&ra"h of choice for the mandible as it sho!s the !hole bone from condyle to condyle If the "atient cannot be "ositioned in the machines to achieve these vie!s$ radio&ra"hs should !ait until the "atient is fit enou&h Poor radio&ra"hs can be misleadin&$ and treatment can only be carried out on &ood ones -he orbital floor may be visualised best by a com"uterised tomo&ra"hy +C-, scan in the coronal "lane$ and may also be used to identify the "resence and site of other middle third fractures If a C- scan is to be made$ al!ays consider includin& the u""er cervical s"ine in addition to the face 1ractures of the facial s0eleton 1ractures of the facial s0eleton may be divided into those in the u""er third +above the eyebro!s,$ the middle third +above the mouth, and the lo!er third +the mandible, 1ractures tend to occur throu&h "oints of !ea0ness 5 the sutures and foramina$ and in thin unsu""orted hone -he u""er third -he "atterns of fracture of the s0ull tend to be random but there are "oints of !ea0ness$ mainly involvin& the frontal sinuses and the su"raorbital rid&es -he middle third 1ractures of the middle third of the face have been studied e#tensively and RenD ;e 1ort in 4:4 4 classified fractures accordin& to "atterns !hich he created on cadavers usin& various de&rees of force -he ;e 1ort classification is used e#tensively today throu&hout the !orld =hile ;e 1ort classified the fractures from su"erior to inferior$ the custom today is that the classification runs inferiorly to su"eriorly +1i& 23 E, -he;e 1ort I fracture effectively se"arates the alveolus and "alate from the facial s0eleton above -he fracture line runs throu&h "oints of !ea0ness from the "yriform

a"erture$ throu&h the lateral and medial !all of the ma#illary sinus runnin& "osteriorly to include the lo!er "art of the "tery&oid "lates -he ;e 1ort II fracture is "yramidal in sha"e -he fracture involves the orbit$ runnin& throu&h the brid&e of the nose$ and the ethmoids !hose cribriform "late may be fractured$ leadin& to a dural tear and C61 lea0 It continues to the medial "art of the infraorbital rim$ throu&h the infraorbital foramen and throu&h the infraorbital fissure -he orbital floor is al!ays involved It continues "osteriorly throu&h the lateral !all of the ma#illary antrum at a hi&her level than the ;e 1ort I to the "tery&oid "lates at the bac0 -he nasal se"tum is dis"laced and lateral !alls of the nose are fractured -he ;e 1ort III fracture effectively se"arates the facial s0eleton from the base of the s0ull 5 the fracture lines run hi&h throu&h the nasal brid&e$ se"tum and ethmoids$ a&ain !ith the "otential for dural tear and C61 lea0$ and irre&ularly throu&h the bones of the orbit to the fronto@y&omatic suture -he @y&omatic arch fractures$ and the facial s0eleton is se"arated from the bones above at a hi&h level throu&h the lateral !all of the ma#illary sinus and the "tery&oid "lates -he nasal se"tum !ill he fractured and may be dis"laced -hese fractures are seldom confined e#actly to this classification and may be combinations of any of the above -he @y&oma -his is the most common fracture of the middle third of the face a"art from the nose$ as the "atient turns the chee0 to a""roachin& dan&er -he fractures occur thou&h "oints of !ea0ness 5 infraorbital mar&in$ the fronto@y&omatic suture$ the @y&omatic arch and the anterior and lateral !all of the ma#illary sinus -ears on the mucosa of the antrum lead to bleedin& from the nose -he infraorbital "late of bone is al!ays involved to a &reater or lesser e#tent and may cause entra"ment of the orbital contents Clo!'out fractures of the orbit Direct trauma to the &lobe of the eye may "ush it bac0 !ithin the orbit -he &lobe is a fairly robust structure and as it is thrust bac0!ards$ the "ressure increases !ithin the orbit and the !ea0er "lates of bone may fracture$ !ithout necessarily fracturin& the bones of the orbital rim 6uch injuries can occur !here a "ointed object hits the &lobe of the eye 5 for e#am"le$ a bent elbo! of a standin& man inadvertently bein& thrust into the orbit of a "erson sittin& A fin&er deliberately thrust into the eye may have the same effect -he !ea0est "late of bone$ commonly the infraorbital "late$ ru"tures and the orbital contents herniate do!n!ards into the ma#illary antrum 7n rebound$ as the "ressure !ithin the orbit is reduced$ the small fractured "ieces of bone may entra" the orbital contents$ "articularly the inferior obli%ue and inferior rectus muscles$ leadin& to failure of the eye to rotate u"!ards Eno"hthalmos and "rofound di"lo"ia can follo! althou&h initially both may he concealed by oedema Anaesthesia over the distribution of the infraorbital nerve may be an im"ortant clue to the blo!'out fracture Pain is e#"erienced on movements of the eye as the entra""ed muscle is stretched -here may be eno"hthalmos althou&h this may be mas0ed in the early sta&es by oedema Any fracture that may involve the orbital floor +;e 1ort II and @y&omatic bone, must be considered a "otential for orbital content entra"ment too 1ractures of the mandible -hese are usually as a result of blo!s from the side or from the front to the lo!er third of the face -he condylar nec0 is the !ea0est "art of the bone and is the most fre%uent site of fracture +1i& 23 8, !hile other fractures tend to occur throu&h un eru"ted teeth +the im"acted !isdom tooth, or !here the roots are lon& +the canine tooth, Clo!s from the side may fracture at the "oint of injury but$ as the force is transmitted to the

base of the s0ull via the condylar nec0$ this may fracture first Clo!s from the front may cause fracture in the midline and fractures of both condyles Individual shar" blo!s !ith a blunt instrument may fracture a se&ment a!ay from the mandible Clo!s from belo! may cause the mandible to be thrust u"!ards fracturin& the alveolus and teeth as they hit their fello!s in the ma#illa 1ractures of the mandibular body may also fracture the teeth in the fracture line Buch has been made in the "ast of the .butterfly/ fracture of the mandible Here a se&ment of mandible in the midline is detached from the rest of the mandible !ith fractures in the canine re&ions -he se&ment of bone ta0es on the a""earance of a butterfly$ and this !ill include the anterior insertion of the ton&ue +&eniohyoid and &enio&lossus, Conce"tually$ the ton&ue may fall bac0 and occlude the air!ay 1irst$ the fracture is e#tremely rare$ and second$ the "atient can still control the ton&ue$ if allo!ed to by a &ood nursin& "osition +see above, -reatment 6oft'tissue injuries 1acial soft tissues have an e#cellent blood su""ly and heal !ell -hey should be sutured as soon as "ossible after the injury after careful e#"loration$ dDbridement and cleanin&$ "articularly !here &lass or "lastic may be embedded -he tissues should be meticulously clean and scrubbed$ as retained dirt may cause tattooin& and hy"erto"hy of the scar Bany lacerations may be closed usin& local anaesthesia$ injectin& into the ed&es of the !ound If the "atient is due to have a &eneral anaesthetic and there is a delay$ the !ounds should be closed in advance by local anaesthesia -issue sufficiently traumatised to have lost its blood su""ly should be removed !ith a shar" scal"el$ and the ed&e to !hich it is to be a""osed trimmed to fit as a""ro"riate ?reat care should be ta0en to re"lace tissues very accurately$ "articularly in cosmetically im"ortant landmar0s such as the vermillion border of the li"s$ the eyelids and nasal contours Haemostasis is im"ortant Buscle and underlyin& layers should be brou&ht to&ether !ith absorbable sutures so that the ed&es of the !ound lie "assively !ithin < mm of their final "osition -hen fine monofilament sutures +E'9 or 8'9, are used to brin& the !ound ed&es to&ether +1i& 23 F, All sutures should be "laced so as to avoid com"romisin& the blood su""ly of the a"ices of small fla"s Gacuum drains are used !here there is concern over dead s"ace beneath the !ounds -he lacerations should be covered by antibiotic ointment and this should be re"laced t!o to three times "er day -his "revents the sutures causin& scarrin& of the s0in Intravenous de#amethasone 3 m& t!ice daily for < days and broad's"ectrum antibiotics should be "rescribed 6utures may be removed from the third day 1acial nerve injury -he facial nerve may be severed in the de"th of a lateral facial !ound If this is sus"ected$ "rimary re"air should be attem"ted$ "articularly !here clinical si&ns su&&est that a main division is involved ;ocatin& the divided branches in oedematous and dama&ed tissue may be e#tremely difficult Pro#imal and distal fla"s in relatively normal adjacent tissue may have to be raised to identify the nerve on each side of the laceration -he severed nerve may then be traced to!ards the laceration and the ends a""ro#imated usin& an o"eratin& microsco"e$ and the nerve and laceration sutured Attem"t at "rimary re"air is al!ays !orth!hile$ althou&h e#tremely difficult$ as secondary re"air is &enerally unsatisfactory Parotid duct ;acerations in the same vicinity as those that transect the facial nerve may also transect the "arotid duct -he su&&ested mana&ement is to insert a small cannula in the "arotid duct from !ithin the mouth and then "ass it distally until it a""ears in the

!ound -he "osition of the duct is identified and the "ro#imal end may be found from the site of the distal end as the tissues are a""ro#imated and the cannula runs into it -he laceration of the facial tissues may be sutured in the normal !ay avoidin& any tendency to dis"lacement across the ends of the duct 6ome advise that the "arotid duct is sutured side to side to avoid stricture -!o days of intravenous de#amethasone +3 m& t!ice a day, should follo! the sur&ery Antibiotics are recommended -he lacrimal a""aratus -he lacrimal a""aratus may be involved in dama&e to the eyelids and nasal bones in ;e 1ort II and III injuries -he tissues are &enerally &rossly oedematous and the mani"ulation re%uired to reduce the fractures adds to the difficulties of identifyin& the cannaliculae Bost sur&eons do not attem"t re"air "rimarily but refer to an a""ro"riate "lastic or o"hthalmic sur&eon if e"i"hora become a "roblem later 6ur"risin&ly$ fe! "atients suffer e"i"hora after a year has ela"sed from the injury Injuries to the facial bones -he fractured nose -his is the most common fracture of the face Cest results are achieved !hen oedema has been allo!ed to settle so that accurate reduction can be achieved Reduction of oedema may be assisted by intravenous or intramuscular de#amethasone 3 m& t!ice daily "reo"eratively Ho!ever$ sur&ery should not be left for lon&er than a !ee0$ as reduction may become difficult or im"ossible Accurate reduction al!ays re%uires a &eneral anaesthetic and an endotracheal tube A throat "ac0 should al!ays be inserted Reduction should be directed first to re"ositionin& the nasal bones$ disim"actin& !ith =alshams/s force"s !ith the e#ternal blade covered !ith rubber tubin& so as to avoid dama&e to the s0in -he nasal bones are first ta0en laterally to disim"act them$ and then medially to re"osition them It is !ise to start on the side o""osite to the blo! !hich bro0e the nose -he se"tum is then &ras"ed !ith Asch/s force"s$ mani"ulated until it is strai&ht$ and then "ositioned in the &roove of the nasal crest and vomer Asch/s force"s may be used to "ull the disim"acted nasal bones for!ard to their "revious un fractured "osition If there is a su&&estion that the insertion of inner canthi has been involved$ or the nasal bones have been thrust into the ethmoid sinuses$ then o"en reduction may be re%uired +see treatment of ;e 1ort III, -he nasal bones may need su""ortin& by a "ac0 !ithin the nasal brid&e -his is best done usin& ribbon &au@e inserted into the fin&er+s, of a rubber sur&ical &love "reviously "laced beneath the reduced nasal bones +to reduce the discomfort of "ac0 removal at 2 days, A "rotective nasal "laster may be "laced and removed at 4 !ee0 1ractures of the ma#illa -reatment of fractures of the ma#illa should be underta0en in a ma#illofacial unit -hey al!ays re%uire a &eneral anaesthetic &iven throu&h a cuffed nasotracheal tube Careful intubation is re%uired ensurin& that the tube is directed "osteriorly$ not su"eriorly$ on insertion Correctly "laced tubes are of no ris0 to the cranial base ho!ever e#tensive the fracture 7ccasionally it may be necessary to be&in the o"eration !ith an oral tube$ and then transfer to a nasal tube once the ma#illas reduced and held 1inal "ositionin& of a concomitant fractured nose may be left until the end of the o"eration$ just after the nasal tube has been removed Conversely$ if it is necessary to leave in a naso"haran&eal air!ay$ a second air!ay should be inserted in the other nostril$ so as to 0ee" the nares e%ually distended A tracheostomy may be re%uired occasionally -he "rinci"le of reducin& and stabilisin& fractures of the frontal and facial bones is that the sur&eon starts at the to" and !or0s do!n =here there are e#tensive lacerations$these may be used$ "erha"s !ith small e#tensions$ to a""roach the fracture

lines =here there are no convenient lacerations$ fractures of the frontal bone and su"raorbital rid&es and fractures of the nasal root may be a""roached throu&h a coronal incision at the vault of the s0ull$ hi&h in the hair line -he incision is ta0en from just in front of each ear across the vault of the s0ull and reflected for!ards until the su"raorbital rid&es are e#"osed -he su"raorbital nerve is identified and freed and the fla" e#tended as re%uired -he nasal root$ the lateral orbital rim and @y&omatic arch may be e#"osed throu&h this route All of the fractured bones may be reduced and held by stainless steel or titanium mini"lates or micro"lates and !ires$ under direct vision Cone deficiencies in this area or in the infraorbital "late may be made u" !ith free cranial cortical bone &rafts$ !ith the donor sites available throu&h the coronal incision =here the nasal bones are s"read$ leadin& to an orbital hy"erteleorism$ the root of the medial canthal li&aments may be identified and sutured to the o""osite side to restore canthal !idth =hen the stabilisation of the u""er "art of the face is com"lete$ attention may be &iven to the midface Incisions in the lo!er eyelid +ble"horo"lasty incisions, or lo!er conjunctival sac are used to e#"lore fractures of the infraorbital mar&in -hese also &ive access to the orbital floor and are used to treat blo!'out fractures -he rim may be fi#ed usin& mini"lates or micro"lates or !ires as above$ and the floor of the orbit reconstituted !ith bone$ titanium or allo"lastic material accordin& to choice$ held by !ires or scre!s -he lo!er "art of the ma#illa is a""roach throu&h a &in&ival sulcus incision above the ma#illary teeth as far bac0 as the second molar 1ractures may be identified !ith ease throu&h this route and fi#ed !ith "lates or !ires -he dental arch is restored to its ori&inal sha"e as far as "ossible so that it matches the "revious occlusion !ith the lo!er teeth -o achieve accurate location$ dental arch !ires or eyelet !ires +see belo!, may need to be inserted =here this is antici"ated$ the necessary !irin& is done before the main "art of the o"eration is commenced -he "rinci"le of treatment is to restore the fra&ments to their ori&inal "osition -o achieve this$ usually it is necessary to reduce the ma#illa first !ith Ro!e/s disim"action force"s !hich &ras" the "alate bet!een the nasal and "alatal mucosa Considerable force is sometimes re%uired in a series of do!n!ard$ for!ard and side!ays movement to free it$ "articularly !here the o"eration has been delayed After 2 !ee0s$ full disim"action is often im"ossible =ith the advent of mini"lates and micro"lates$ indirect fi#ation !ith "ins and halo frame is seldom used If the fra&ments are multi"le and the !hole restored ma#illa remains unstable$ e#ternal fi#ation may be the only ans!er -hen the "rinci"le is that the mandible is fi#ed to the cranium$ !ith the ma#illa as a sand!ich bet!een the t!o Cranial fi#ation is by a halo or su"raorbital "ins$ and mandibular fi#ation is by "ins inserted in the body on each side All of the "ins are connected to&ether !ith connectin& bars secured by universal joints =hen the teeth of each ja! are fi#ed to&ether !ith interma#illary fi#ation +see belo!, the antero"osterior "osition of the face is li0ely to be correct -he vertical dimension is adjusted throu&h the connectin& bars fi#ed by universal joints on to the "ins -his means that the ja!s are fi#ed to&ether durin& recovery$ and careful attention should be &iven to advisin& the recovery staff on ho! to release the a""aratus in an emer&ency 1ractures of the mandible 1ractures of the mandible fre%uently are reduced and then fi#ed !ith interma#illary fi#ation +IB1, IB1 is a means of s"lintin& the u""er and lo!er arches of teeth to&ether 1irst$ eyelet !ires or arch bars are fi#ed to the u""er and lo!er teeth Eyelet !ires consist of a small loo" about A mm in diameter t!isted in the centre of a len&th

of 9 2E'mm stainless steel !ire Each loo" is threaded bet!een and around "airs of teeth$ and t!isted to&ether on the buccal side$ !ith one of the ends &oin& throu&h its o!n loo" -his ma0es very secure fi#ation 1our or five eyelets are re%uired for each dental arch -hese are most suitable !here there is a full$ or near full$ arch of teeth in each ja! =here there has been tooth loss !ith irre&ular &a"s around the mouth$ then arch bars may have to be used -hese are "refabricated len&ths of stainless steel ta"e or !ire$ !ith hoo0s comin& off at 3549'mm intervals -hese are !ired to individual teeth so that there are t!o arch bars o""osin& one another in each ja! IB1 is a""lied bet!een the loo"s of the eyelet !ires or the hoo0s of the arch bars In the "ast$ custom'made silver ca" s"lints !ere used$ cemented to the o""osin& ja!s -hese are rarely used no! 1or future comfort of the "atient$ it is very im"ortant to restore the dental occlusion to its ori&inal "osition =ith sim"le minimally dis"laced fractures$ eyelet !irin& is all that is re%uired +1i& 23 3, -his may be achieved !ithout &eneral anaesthetic Undis"laced fractures and fractures of the mandibular condyle may re%uire no active treatment Dis"laced fractures$ or fractures !hich have mar0edly disturbed the occlusion$ !ill re%uire a &eneral anaesthetic A cuffed nasotracheal tube is re%uired !ithout a throat "ac0 +a throat "ac0 may ma0e it difficult to achieve the correct occlusion, 1ractures of the body of the mandible may be e#"lored throu&h intra oral or e#tra oral incisions accordin& to the access re%uired$ and the fractures reduced and fi#ed !ith mini"lates and>or !ires Any fractured teeth should be removed and also those "reviously com"romised by e#tensive caries or infection It is unnecessary to remove healthy teeth in the fracture line -o be sure of achievin& a correct occlusion it is !ise to use tem"orary intrao"erative IB1 -here are occasions !hen the best results can be achieved !ith IB1 alone In this event$ it is necessary to remove the IB1 durin& recovery$ so as not to ris0 com"lications involvin& the air!ay IB1 may be inserted after 4< hours !hen the "atient has recovered from the &eneral anaesthetic It is retained for 25A !ee0s 1ractures of the edentulous mandible &enerally are "lated usin& mini"lates In the atro"hic mandible$ the raisin& of "eriosteum should be 0e"t to a minimum as the blood su""ly to the ja! may be com"romised =here there is fear that the blood su""ly may be seriously disadvanta&ed by the insertion of "lates$ ?unnin&/s s"lints may be constructed -hese re%uire dental im"ressions and are then constructed in the laboratory In effect$ these are li0e u""er and lo!er dentures$ but !ith the teeth re"laced !ith "lastic in !hich hoo0s are "laced +the "atient/s dentures may be used, Each s"lint is !ired to the res"ective ja! the mandible$ !ith !ires &oin& around the mandible +circumferential !ires, and the ma#illa$ !ith !ires &oin& around the @y&omatic arches -he circumferential !ires around the mandible are sited to stabilise the fracture line -he hoo0s "laced on the buccal surfaces of the "lastic arch are used to a""ly IB1 !hen the "atient has recovered from the anaesthetic -he IB1 is released after A58 !ee0s 1ractures of the mandibular condyle may cause disturbance to the occlusion !ith deviation of the mandible to the side of the fracture In unilateral fractures$ this disturbance may correct s"ontaneously in a fe! days If it is still "resent at 49 days$ or !here both condyles are fractured$ o"en sur&ery may be re%uired to one of the condyles to "revent an anterior o"en bite develo"in& -he o"en bite occurs due to the vertical "ull of the muscles of mastication shortenin& the ramus -he "osterior teeth contact first and the anterior teeth remain a"art 1unctionally and cosmetically$ this is very undesirable and is almost im"ossible to counteract by secondary "rocedures

6im"ly to fi# the mandible in IB1$ !ith or !ithout "osterior bloc0 to overcome the tendency to o"en bite$ is insufficient Direct sur&ical a""roaches to the condylar nec0 are difficult o!in& to the "arotid &land and facial nerve lyin& in close "ro#imity Preauricular incisions combined !ith incisions at the lo!er border of the mandible do &ive access but reduction of the bones is difficult throu&h these a""roaches A sim"le and effective a""roach is via a tan&ential incision at the an&le of the mandible that &ives access to the bone beneath$ bet!een the facial and cervical branches of the facial nerve -he an&le of the mandible is identified and the "eriosteum raised u" both sides of the ramus as far as the fracture line Access to the dis"laced condyle is achieved by removin& the "osterior border of the mandible !ith a vertical subsi&moid cut$ runnin& from the si&moid notch of the mandible do!n to the an&le of the ja! -he condyle may then be removed and offered u" to the e#cised se&ment of mandible -he t!o bone fra&ments are located and fi#ed to&ether !ith mini"lates outside the body -he restored bone is then returned to the "atient and secured to the distal mandible !ith a mini"late 1ractures of the @y&oma 6econd to the fractured nasal bone$ this is the most common fracture of the ma#illa Dis"lacement is usually "osteriorly$ but it is im"ortant to assess the actual dis"lacement by studyin& the occi"itomental radio&ra"hs Bost fractures may be reduced by the ?illies a""roach -his entails an incision in the hairline su"erficial to the tem"oral fossa about 4E mm lon&$ at AEde&ree to the vertical It is dee"ened do!n to and throu&h the tem"oral fascia A channel is "re"ared behind the fascia and do!n to the body of the @y&oma and arch A Cristo!/s or Ro!e/s elevator is then inserted beneath the body of the @y&oma or arch$ accordin& to the site of fracture Considerable force is a""lied in the o""osite direction to that calculated to have been delivered by the blo! !hich caused the fracture After reduction$ the "osition of the @y&oma can be chec0ed by "al"atin& the bony "rominences of the arch$ and the lateral and inferior orbital rims As all fractures of the @y&oma involve the orbital floor$ it is essential to a""ly a forced duction test to the &lobe to ensure that the inferior obli%ue or inferior rectus muscle is not tra""ed 1or this to be done "ro"erly$ the lo!er eyelid should be retracted and the inferior rectus muscle &ras"ed in the lo!er forni# -he &lobe can then be rotated u"!ards and should move freely Any restriction in movement su&&ests entra"ment of intra orbital tissues and the floor of orbit should be e#"lored as for a blo!'out fracture +see belo!, It is essential to !arn the anaesthetist that this manoeuvre is bein& done$ as it can lead to a severe bradycardia 6hould the fracture seem unstable$ direct !irin& or "latin& may be necessary -he fronto@y&omatic suture should be e#"osed by a small incision just behind the lateral "art of the eyebro! and visualised Dis"lacements may be reduced and &enerally the fracture becomes stable once this fracture is fi#ed 7ccasionally it is necessary to e#"lore and fi# fractures of the infraorbital rim +see above, If the fra&ments are very unstable o!in& to comminution$ "ac0in& the antrum via a Cald!ell5;uc incision in the mouth may be necessary -he antrum should be first e#amined usin& a fibre'o"tic li&ht source$ !ith "articular attention &iven to the orbital floor -hen$ !ith the orbital floor reduced and "rotected$ and the body of the @y&oma su""orted by an assistant$ the antrum may be "ac0ed from above do!n !ith a <'inch ribbon &au@e soa0ed in =hitehead/s varnish ?reat care must be e#ercised not to over"ac0 the antrum and dis"lace the orbital contents -he incision is closed !ith a tail of ribbon &au@e sutured into the !ound to allo! draina&e -he "ac0 is removed at 2 !ee0s

All "atients !ho have had o"erations around the orbit should be observed formally at 4E'minute intervals for :54< hours -he condition of the eye$ the "u"il si@e and the a""reciation of li&ht should be recorded 7ccasional com"lications arise$ the most serious of !hich is a develo"in& haematoma in the "eri orbital tissues or the cone bet!een the ocular muscles Increasin& e#o"hthalmous and loss of vision constitute a "osto"erative emer&ency re%uirin& immediate action to reduce the "ressure of the haematoma Clo!'out fractures -he mechanism has been e#"lained above -he floor of the orbit is a""roached either throu&h a ble"horo"lasty incision in the lo!er eyelid or throu&h the inferior forni# Hee"in& su"erficial to the tarsal "late of the lo!er lid$ the infraorbital mar&in is identified and the "eriosteum raised$ bein& careful not to dis"lace the delicate fra&ments of bone constitutin& the fracture -he "eri orbital tissues are &ently se"arated from the bones of the fracture and freed so that no tra""in& remains -he a"e# of the orbit should not be e#"lored for fear of dama&e to the o"tic nerve or s"asm of the retinal artery Defects of the orbital floor may be made u" !ith bone from the cranium +see above, or the o""osite antral !all$ titanium mesh$ or other suitably ri&id materials Reinforced silastic sheet is no lon&er thou&ht ade%uate -he materials are fi#ed !ith !ires$ scre!s or "lates and the !ound is closed ?eneral 1ractures of the facial s0eleton are almost al!ays com"ound and "ro"hylactic antibiotics are im"ortant Penicillin and metronida@ole sin&ly or in combination are ideal for those "atients !ho are not aller&ic -he ce"halos"orins are an alternative =here there is the "ossibility of a C61 lea0 from a dural tear above a fractured cribriform "late of the ethmoidbone +;e 1ort II and III,$ suitable antibiotics !hich cross the blood5brain barrier +chloram"henicol$ for e#am"le, should be &iven to avoid the ris0 of menin&itis or later intracranial abcess All "atients !ith fractures of the facial s0eleton benefit from intrao"erative and "osto"erative de#amethasone$ to reduce s!ellin& Interma#illary fi#ation ma0es it im"ossible to che! It is im"ortant that the "atient receives the advice of a dietician so that hi&h calorific value food may be ta0en throu&h the IB1 It is sur"risin& ho! "atients find a !ay to ta0e fluid and semi'solids throu&h clenched teeth In the badly injured$ "arenteral feedin& may be re%uired It is !ise to leave a naso&astric tube in "lace$ inserted at the time of o"eration$ for as lon& as food cannot be ta0en normally Dislocation of the mandibular condyles Dislocation of the mandibular condyles is a relatively uncommon condition and occurs usually after a !ide o"enin& of the mouth 7ccasionally it may accom"any a blo! to the face$ "articularly a blo! to the ja! !ith the mouth already o"en -he "atient is unable to close the mouth as thecondyles have translated in front of the articular eminence and s"asm of the closin& muscles tra"s them there It may be very "ainful An attem"t should be made to reduce the dislocation by manual mani"ulation -his is achieved by standin& in front of and above the seated "atient and &ras"in& the mandible !ith &loved hands !ith the thumbs on the occlusal surfaces of the teeth$ and the inde# and middle fin&ers belo! the lo!er border of the mandible It is !ise to !ra" the thumbs each in a &au@e s%uare 6udden do!n!ard and bac0!ard movement is a""lied bilaterally !ith an assistant su""ortin& the head If this fails$ one re"eat attem"t concentratin& on one side at a time may then succeed Reduction may be assisted by injectin& local anaesthetic around both joints 7ccasionally it may be

necessary to sedate the "atient !ith intravenous mida@olam or even resort to a &eneral anaesthetic 1urther readin& Ro!en$ N ; and =illiams$ J ; +eds, +4:3E, 1racture of the 1acial 60eleton$ Churchill ;ivin&stone$ Edinbur&h