What are facial fractures?

The word “fracture” just means “break”, so facial fractures are broken facial bones. Facial fractures can occur singly (such as a broken nose) or in a combination (such as occurs in a severe motor vehicle accident).

The following will explain some of the basic information about the most common types of facial bone fractures:

Frontal Sinus Fractures
    In the lower part of the central forehead there is a pair of sinuses called the Frontal Sinuses. These are cavities in the bone, filled with air, that are connected by a duct to the inside of the nose. This is the weakest part of the forehead, where the bone is thinnest. As a result, trauma to the forehead tends to result in fractures that involve this area rather than the upper forehead where the bone is thicker.

    Frontal sinus fractures vary in severity. If the frontal sinus breaks, the bone is pushed inwards, resulting in a “dent” in the forehead. However deep the dent is initially, it will get deeper when the swelling resolves. Treatment involves making an incision in the scalp and elevating the depressed bone fragments or replacing them with bone from another location. If the fracture is more severe it will result in an indentation AND blockage of the drainage into the nose. Treatment involves the same approach and manipulation of the depressed bones, but also obliteration of the sinus. If the sinus is not obliterated, it may collect mucous and a mass called a “mucocele” can develop which requires additional surgical procedures. Finally, if the injury is the most severe, there may be a forehead deformity, obstruction of sinus drainage AND injury to the underlying covers of the brain. This can result in leakage of the brain fluid (cerebrospinal fluid or CSF).

Nasal Fractures
    Broken noses are very common. They can occur from relatively minor trauma, such as falling against a door or being hit with an elbow in a basketball game. Of course they can also occur as part of a much more complex pattern of facial injury.

    If you suspect you have a nasal fracture, look at yourself in the mirror. If the nose is swollen but not pushed to the side or the bridge is not caved in, you probably don’t need any treatment. In other words, having a broken nose doesn’t mean that you need treatment. If, on the other hand, the nose is pushed over to the side, it will require treatment or it will heal in the wrong position. By the same token, if the bridge is crumpled and there is a “saddle” nose, surgical correction will be required.

    If the nose is pushed to the side and the injury is seen by a plastic surgeon in the first few days, a “closed reduction” may be recommended. This means that the nose is manipulated and molded back to the midline. A splint is applied.  Sometimes this closed reduction will result in a normal appearing nose and prevent the need for additional surgery in the future. Sometimes, however, the crookedness is not completely corrected by the closed reduction, and additional procedures are required several months later.

Naso-orbital-ethmoid Fractures

    These injuries occur when the nose is subjected to severe trauma from the front, rather than from the side. This usually requires a high velocity injury such as a car accident. The nose crumples, the bridge collapses, and the area directly behind the nose, along the inner walls of the eye sockets, also crumples.

    These injuries are always severe and require a significant procedure under general anesthesia to correct them. Frequently, additional surgical procedures are required. Some of the problems that have to be corrected in these injuries are: a crushed nasal bridge, a frontal sinus fracture (see above) with leaking CSF, and displacement of the inner corners of the eyes.

Orbital Fractures
    The orbit is another word for the eye socket. The orbit is the bony box that the eye lives in. The most common fracture of the eye socket occurs when the patient is hit in the eye, such as by a punch or a baseball. The pressure on the eye causes the surrounding bone to break. The bone tends to break where it is weakest which is usually the floor of the eye socket. This type of fracture is called a “blow-out” fracture, because the floor of the orbit is blown outward. In the case of the floor of the eye socket, the bone is pushed downwards into the maxillary sinus.

    Do blow-out fractures have to be treated? The answer is “not always”. However, if the fracture is severe and the volume of the eye socket is increased by the blow-out, the eyeball may gradually sink backwards over the ensuing several months. If you think of an ice cube floating in a glass of liquid, it is a helpful image. Think of the glass as the eye socket and the ice cube as the eyeball. If the liquid and ice cube are placed in a glass of larger diameter, the ice cube will float closer to the bottom of the new glass. By the same token, when the eye socket becomes enlarged by an injury, the eyeball sinks backwards.

Cheek bone Fractures

    Cheek bone fractures go by many names. They can be called zygoma fractures, tripod fractures, quadripod fractures, trimalar fractures, and orbitozygomatic fractures. The cheek bone, like the nose and chin, are prominent parts of the face and tend to be the recipient sites of trauma. The main problem with a cheek bone fracture is that it makes the face look lopsided.

    Like other facial fractures, just having a cheek bone fracture does not mean you need surgery. If the cheek bone is depressed enough to cause a visible deformity, then surgery is indicated. The other problem is that the cheek bone also forms part of the eye socket, so fractures of the cheek bone also involve fractures of the eye socket (see above).

`    Surgical correction of a zygoma fracture involves making 2-3 incisions where they won’t show in order to get access to the bone. Usually incisions are made inside the lower eyelid and inside the mouth in order to expose and repair the fracture. The bone is usually held together with titanium plates and screws.

Upper jaw fractures
    The other term for upper jaw fractures is “maxillary fractures”. Upper jaw fractures occur in many forms. The three most common types are called the Le Fort I, Le Fort II and Le Fort III fractures. These names refer to the pattern of the broken bones, with Le Fort I being the mildest and Le Fort III being the most severe.

    Jaw fractures require treatment, like cheek bone fractures, but have the additional problem of involving the teeth. If the upper jaw is fractured, the patient will notice that his/her bite (dental occlusion) is abnormal. During the surgical repair, the teeth are wired together to re-establish the correct relationship between the upper and lower teeth and then the bones are repaired with plates and screws.
    Depending on the situation, the jaw wiring may be removed before the end of the procedure. In other cases, the jaw wiring is left in place for several weeks.

Lower Jaw Fractures

    Lower jaw fractures, or mandible fractures, are also common injuries. Like upper jaw fractures, the injuries cause the teeth to be misaligned. Unlike upper jaw fractures, however, lower jaw injuries are more likely to heal incorrectly because the bone is much thicker than the upper jaw and prone to problems such as infection.

    The treatment of mandible fractures depends on where in the lower jaw the fractures occur. Because the mandible is like a ring, it usually breaks in more than one place.

    Like upper jaw fractures, the teeth are wired together during the procedure. The bone is then repaired, usually with plates and screws, and then the teeth are usually unwired. To assure a good alignment of the teeth, however, it is usually necessary to place rubber bands between the upper teeth and lower teeth over the next several weeks to guide the teeth into the correct position.