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884
Section 9
Plastic and Reconstructive Surgery
tions, and local fl aps that are beyond the scope of this
chapter. As with all facial injuries, the choice of primary
versus secondary reconstruction is based on the extent
and the mechanism of the injury. If primary reconstruc-
tion is not possible, mucosa can be closed to skin until
defi nitive reconstruction is performed.
SUMMARY
Management of soft tissue trauma can be challenging
and requires a fi rm understanding of the common
mechanisms of injury, biologic principles of healing,
and the most successful reconstructive techniques.
Careful planning for each repair and precise execution
of technique ensure the best possible result in even the
most devastating of injuries. Patients should be made
aware at the initiation of treatment that some injuries
will benefi t from revision or secondary reconstruction
even after appropriate primary surgical correction has
been performed.
References
1. Hollander JE, Singer AJ, Valentine S, et al: Wound registry:
Development and validation. Ann Emerg Med 25:675-685,
1995.
2. Gassner R, Tuli T, Hachl O, et al: Cranio-maxillofacial trauma: A
10 year review of 9,543 cases with 21,067 injuries. J Craniomaxil-
lofac Surg 31:51-61, 2003.
3. Singer AJ, Mach C, Thode HC Jr, et al: Patient priorities
with traumatic lacerations. Am J Emerg Med 18:683-686,
2000.
4. Eppley BL, Sood R: Facial burns. In Booth PW, Eppley B, Schmel-
zeisen R (eds): Maxillofacial Trauma and Esthetic Reconstruc-
tion. Edinburgh, Churchill Livingstone, 2003, pp 429-444.
5. Callaham M: Controversies in antibiotic choices for bite wounds.
Ann Emerg Med 17:1321-1330, 1988.
6. Morgan JP 3rd, Haug RH, Murphy MT: Management of
facial dog bite injuries. J Oral Maxillofac Surg 53:435-441,
1995.
7. Sacks JJ, Sattin RW, Bonzo SE: Dog bite–related fatalities from
1979 through 1988. JAMA 262:1489-1492, 1989.
8. Lackmann GM, Draf W, Isselstein G, Tollner U: Surgical treat-
ment of facial dog bite injuries in children. J Craniomaxillofac
Surg 20:81-86, 1992.
9. Palmer J, Rees M: Dog bites of the face: A 15 year review. Br J
Plast Surg 36:315-318, 1983.
10. Diphtheria, tetanus, and pertussis: Recommendations for vaccine
use and other preventive measures. Recommendations of the
Immunization Practices Advisory Committee (ACIP). MMWR
Recomm Rep 40(RR-10):1-28, 1991.
11. Osmond MH, Klassen TP, Quinn JV: Economic comparison of a
tissue adhesive and suturing in the repair of pediatric facial lac-
erations. J Pediatr 126:892-895, 1995.
12. Toriumi DM, O’Grady K, Desai D, Bagal A: Use of octyl-2-cyano-
acrylate for skin closure in facial plastic surgery. Plast Reconstr
Surg 102:2209-2219, 1998.
13. Quinn J, Wells G, Sutcliffe T: Tissue adhesive versus suture wound
repair at 1 year: Randomized clinical trial correlating early, 3-
month, and 1-year cosmetic outcome. Ann Emerg Med 32:645-
649, 1998.
14. Maw JL, Quinn JV, Wells GA, et al: A prospective comparison of
octylcyanoacrylate tissue adhesive and suture for the closure of
head and neck incisions. J Otolaryngol 26:26-30, 1997.
15. MacGillivray RF, Stevens MR: Primary surgical repair of traumatic
lacerations of the lacrimal canaliculi. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 81:157-163, 1996.
16. Hartstein ME, Fink SR: Traumatic eyelid injuries. Int Ophthalmol
Clin 42:123-134, 2002.
17. Blanchaert RH Jr: Surgical management of facial nerve in -
juries. Atlas Oral Maxillofac Surg Clin North Am 9(2):43-58,
2001.
18. Myckatyn TM, Mackinnon SE: The surgical management of facial
nerve injury. Clin Plast Surg 30:307-318, 2003.
PEARLS
• Copious irrigation, conservative débridement, a
hemostatic fi eld, and careful preparation set the
stage for successful wound closure.
• Precise suturing with everted wound edges yields the
most predictable healing and the best aesthetic
results.
• Planning closure and local fl aps to respect the
RSTLs optimizes aesthetic healing.
• Discuss revision possibilities at the initial repair by
highlighting the likelihood of revision in severe
wounds.
PITFALLS
• Do not consider performing very complex closures in
the emergency department setting because patient
cooperation, optimal lighting, and quality
instrumentation will probably improve the outcome.
• Do not perform defi nitive closure of an extensive
gunshot wound at the fi rst visit because most will
require additional débridement.
• Inspect areas with complex anatomy carefully
because injury to specialized structures is much
better managed defi nitively at the initial repair than
at a secondary procedure.
• Postoperative wound care and protection are
important to avoid complications and to discuss the
expectations of healing or revision.

Chapter 92
Fractures of the Mandible
Mark W. Ochs
The mandible is the second most commonly fractured
bone in patients sustaining facial trauma.1 When a man-
dibular fracture is detected, additional fractures of the
mandible or midface should be sought out. Failure to
do so will inevitably result in an incomplete or undesir-
able treatment outcome. The mandible is the thickest
bone of the maxillofacial complex. Therefore, with pan-
facial fractures, adequate mandibular restoration to full
continuity often serves as the reference and pillar to
re-establishing normal facial contours and projection.
Mandibular fractures are classifi ed by their ana-
tomic location (Fig. 92-1): symphysis/parasymphysis,
anterior (between the canine teeth), body (between the
canine and second molar), angle (in the third molar
region up to the level of the lower occlusal plane), and
ramus (at the posterior mandibular vertical compo-
nent, excluding the condylar process and coronoid).
Condyle fractures are further subdivided into subcon-
dylar—below the sigmoid notch (the U-shaped junction
of the condyle and the coronoid) and coursing down
into the ramal area, the condylar neck (at or above the
sigmoid notch), and intracapsular—the condylar head,
or articular surface. Dentoalveolar fractures are con-
fi ned to a tooth or a segment of teeth and their sur-
rounding bone but do not extend down or through the
inferior border of the mandible.
These same fractures are also classifi ed as open or
closed. By defi nition, any fracture in a tooth-bearing
area is an open fracture. Mandibular fractures will often
course along or parallel the tooth roots in the anterior
region, thereby resulting in a new gap between the
adjacent teeth, a gingival tear, or a heavier radiodense
line along the tooth root. With multirooted posterior
teeth, the fracture can traverse along a mesial or distal
root surface or involve the tooth itself. Generally, frac-
tures of the ramus, condyle, and coronoid are closed
unless severe displacement or a penetrating-type injury
has occurred. Edentulous mandible fractures, particu-
larly the body, can be open because of an intraoral tear
of the thin overlying mucosa.
Fractures of the posterior body, the angle, and the
ramus can be classifi ed as favorable or unfavorable
based on the direction (the orientation) of the fracture
line and the net effect of the masseteric muscle pull
under function (Fig. 92-2). Favorable fractures are
angled such that with masseteric closing force, the frac-
ture is further reduced or supported. Unfavorable frac-
tures are further distracted by this same force.
General knowledge of the dentition and occlusion
is necessary to adequately access and treat mandible
fractures. The full adult dentition consists of 32 teeth,
including the third molars and wisdom teeth (Fig.
92-3). The teeth are numbered sequentially, starting
with the maxillary right third molar (no. 1) and moving
forward to the other molars, bicuspids, canines, and
incisors and all the way across to the left maxillary third
molar (no. 16). The left mandibular third molar is next
(no. 17), and numbering continues forward and across
the midline to the right mandibular third molar (no.
32). It is prudent practice to routinely “count teeth”
and assess for any missing or splayed teeth with con-
comitant open sockets, gingival tears, or bleeding.
These are all telltale signs suggestive of a fracture. The
primary dentition also has a nomenclature that uses
capital letters (Fig. 92-4).
When discussing a particular surface or a relation-
ship to a tooth, a set of terms is used: mesial refers to
the anterior surface (in front of or toward the midline),
distal refers to the posterior surface (or away from the
midline), lingual identifi es the inner surface or tongue
side, and buccal/labial/facial all refer to the outer
surface or the cheek side.
885

886
Section 9
Plastic and Reconstructive Surgery
The most widely used classifi cation system for
describing maxillary and mandibular intraoral bite rela-
tionships is the Angle system. An Angle class I occlusion
is characterized by the maxillary canine being just distal
to or behind (half a tooth) the mandibular canine, and
the mesial buccal (front) cusp of the maxillary fi rst
molar is slotted in the buccal groove of the mandibular
fi rst molar (Fig. 92-5).
Although Angle class I is the most common and
desirable occlusal relationship, it is not present in all
patients before injury. Classifi cation may be different
on the right versus the left side. When evaluating a
patient with a mandibular fracture, it is important to
ask the patient or family whether a preexisting maloc-
clusion was present, specifi cally, “Were your upper
teeth in the front overlapping your lower teeth?” (class
I). Additionally, one may ask, “Was your lower jaw
Condyle
Ramus
Angle
Body
16%
26%
29%
2%
1.5%
Symphysis
22%
Alveolar
process
3.5%
Coronoid
process
Figure 92-1. Anatomic classifi cation and percent distribution of
mandibular fractures in dentate adult patients.
A
B
Canine
Incisors
Incisors
Lingual
Mesial
Labial
Distal
Buccal
Mandible
Maxilla
Canine
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Bicuspids
Bicuspids
Molars
Molars
Canine
Incisors
Incisors
Mandible
Maxilla
Canine
F
E
D
C
B
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
A
Molars
Molars
Figure 92-2.
A, Favorable mandibular
angle fracture. With the muscular pull of the
temporalis and masseter and the minor infl u-
ence of the digastrics and suprahyoid muscu-
lature, there is a tendency toward further
fracture reduction or stabilization. B, Unfa-
vorable mandibular angle fracture. With these
same muscular forces there is a tendency
toward gapping at the superior border and
rotation of the proximal or angle segment
upward. This bony step can also be palpated
intraorally.
Figure 92-3. Adult/permanent dentition with numbering system
and descriptors that help accurately describe the relationship of an
injury or abnormality relative to the dentition.
Figure 92-4. The pediatric/primary dentition with alphabetic
designations.

Chapter 92
Fractures of the Mandible
887
Class I occlusion
Class II occlusion
Class III occlusion
Figure 92-5. Angle’s classifi cation of occlusion. In class I occlusion,
the mesial buccal cusp of the maxillary fi rst molar fi ts into the buccal
groove of the mandibular fi rst molar. In class II occlusion, the man-
dibular fi rst molar is distal relative to the maxillary fi rst molar, a con-
sequence of mandibular retrusion. If the mandible is prognathic
(class III occlusion), the mandibular fi rst molar is completely in front
of the maxillary fi rst molar.
recessive/receding or did it jut out?” (class II or class
III, respectively). Finally, ask “Did your front teeth not
come all the way together or were they gapped verti-
cally?” (indicating an anterior open bite). These queries,
along with appropriate radiographs, help avoid sur-
prises and struggles in the operating room when
attempting to align the fractures and re-establish the
habitual occlusion. Wear facets on the teeth and inter-
digitation of the bite are useful aids in determining
more precise fracture alignment.
PATIENT SELECTION
Patients with mandibular fractures may have the classic
signs and symptoms: pain, trismus (diffi culty opening),
swelling, malocclusion, gingival tear, ecchymosis of the
fl oor of the mouth, bony crepitus on functioning, and
paresthesia or anesthesia of the lower lip and chin
(cranial nerve V3 distribution).2 The most common
initial complaints are pain and malocclusion. The
paresthesia or anesthesia is generally due to swelling
or a direct injury to the inferior alveolar nerve cable
somewhere along its course through the mandibular
canal from the lingula/medial midramus to the mental
foramen (exiting below and between the apices of
the mandibular bicuspid teeth). This would be indica-
tive of fracture of the body, angle, or ramus. Focal pre-
auricular pain during active jaw motion or palpation is
suggestive of a condylar or subcondylar fracture. Floor
of the mouth ecchymosis is typically seen with sym-
physeal fractures, especially in edentulous elderly
patients.
Unless there is gross fracture displacement in a thin
individual, it is diffi cult and painful to palpate a bony
step. A more productive maneuver is to gently fl ex the
mandible across the suspected fracture site to detect
mobility, gapping of teeth, or widening of a gingival/
mucosal tear.
PREOPERATIVE EVALUATION
AND PLANNING
Once a clinical diagnosis of a mandibular fracture is
established, it is important to query the patient about
any preexisting malocclusion; any previous fractures,
injuries, or surgery involving the jaws or the temporo-
mandibular joints; and any previous orthodontic treat-
ment (generally indicates a class I or more favorable
occlusion, but not always). After the initial clinical
examination and history, selective radiographs can be
obtained to determine the specifi c location, extent, and
characteristics of the fracture. The radiographic studies
must fully evaluate the entire mandible because multi-
ple fractures are fairly common. A parasymphyseal or
body fracture will often have an associated contralateral
subcondylar fracture. The two best initial radiographic
studies are a panoramic tomogram (Panorex) and an
open-mouth reverse Towne view to further assess con-
dylar fractures.3 If the fi ndings are equivocal or the
study is not diagnostic, it can be repeated or additional
mandibular views can be taken, such as posteroanterior
(best for the symphyseal area), lateral (images the body
and angle well), or oblique (visualizes the body, angle,
and ramus well and the condylar neck less reliably).
The quality and diagnostic accuracy of the mandible
series can be diminished if a portable study is performed
or the patient is in a cervical collar, which hampers
positioning and leads to structural overlap. In any event,
if more defi nitive imaging is required, a computed
tomography (CT) scan with axial cuts ranging from 5
to 1.5 mm is indicated. Intravenous contrast enhance-
ment is not indicated and provides no additional

888
Section 9
Plastic and Reconstructive Surgery
information in the acute trauma setting. Direct coronal
views can be helpful in ascertaining the exact pattern
and alignment of condyle fractures, particularly intra-
capsular ones. Three-dimensional reformatting is gen-
erally unnecessary and adds further expense. If there is
any suspicion of maxillary, midfacial, or skull fractures,
the axial CT scan should be continued through these
regions as well.
Once all the radiographic studies have been
reviewed, it is often helpful to re-examine the patient
so that issues such as suitability and number of teeth for
arch bars, soft tissue swelling, and associated lacerations
can be incorporated into the surgical treatment plan
and the approaches to be used.
The timing of treatment of mandibular fractures
depends on many factors, but in general it is better to
treat a fracture as soon as possible. Evidence shows that
the longer an open or a compound fracture is left
untreated, the greater the incidence of infection.4 Anti-
biotics have been shown to decrease the risk of wound
infection in patients with mandible fractures.5 Antibiot-
ics with appropriate activity against oral bacteria can be
initiated upon diagnosis and administered for several
doses after surgery. Grossly contaminated wounds or
open defects may warrant longer therapy. In addition,
delay of several days or weeks makes ideal anatomic
reduction of a given fracture diffi cult, if not impossible,
particularly for condylar and subcondylar fractures.
Furthermore, progressive edema 2 or 3 days after
surgery frequently makes surgical access and soft tissue
dissection more diffi cult.
However, treatment of facial fractures is frequently
delayed for several reasons. In many cases, other more
serious or life-threatening injuries are present, and the
patient is not neurologically or hemodynamically stable
enough to undergo general anesthesia and a surgical
procedure. Moreover, it is highly desirable to have the
cervical spine cleared of any injury and to have the
cervical collar removed before surgery, especially with
any extraoral approaches and open treatment of
condyle fractures. Infrequently, excessive soft tissue
edema or anticoagulation requires a 3- to 4-day delay in
surgical treatment.
The primary goals of treatment of mandibular frac-
tures are to restore continuity of the mandible and
return to the patient’s habitual functioning occlusion.
In addition, consideration should be given to maintain-
ing acceptable facial and dental aesthetics and minimiz-
ing neurosensory or facial nerve impairment. During
the treatment and healing phases it is also important
to maintain adequate nutritional status and minimize
patient discomfort and inconvenience. Therefore,
patients with neurologic injuries, preexisting mental
disabilities, or seizure disorders may not be suitable
candidates for closed treatment and the use of postop-
erative maxillomandibular fi xation (MMF). Finally, pre-
operative assessment of the patient’s nasopharyngeal
airway should be undertaken because nasoendotracheal
intubation and intraoperative interdental fi xation are
almost always necessary for treatment of a dentate man-
dibular fracture. Septal deviation, turbinate hypertro-
phy, bleeding, and coagulopathies are several factors to
be considered.
SURGICAL APPROACHES
Fractures of the mandible can be treated in either
closed or open fashion. The surgeon needs to consider
the adequacy of the teeth with regard to number, the
amount of decay or periodontal disease present, exten-
sive crown and bridge work, and opposing dentition to
maintain the bite relationship. Generally, a patient
must have the majority of teeth in all four quadrants of
the mouth for closed treatment and 6 weeks of MMF to
be effective. Circumdental wiring and arch bars may
only add further stress to an already compromised
dentition.
The decision whether to treat a mandibular frac-
ture by either open or closed means may be heavily
infl uenced by concomitant injuries and fractures at
other mandibular sites or associated facial bones.6,7
More extensive concomitant facial injuries may prompt
opening and rigid plating of all mandible fractures to
restore facial proportions and projection or to assist in
closed reduction or a period of postoperative MMF for
less stable midfacial fractures.
Most mandible fractures can be opened and plated
from an intraoral or extraoral approach. In general, it
is easiest to approach and plate parasymphyseal frac-
tures transorally. Condyle fractures, when opened, are
best approached extraorally via a modifi ed submandib-
ular or retromandibular dissection and, very infre-
quently, via a preauricular dissection. The decision to
open a mandibular body, angle, or ramus fracture,
either intraorally or extraorally, should be based on a
specifi c fracture pattern, soft tissue swelling, ease of
access, and the surgeon’s preference. Surgical planning
should take into account these factors and the possibil-
ity of combined approaches such as an intraoral vestibu-
lar incision and percutaneous drilling and screwing
through a cannula.
Arch Bar Application
Proper treatment of mandibular fractures in dentate
patients usually begins with the application of prefabri-
cated arch bars. The teeth are gently brushed with a
preparative solution and rinsed to clear any clots or
debris. A moist throat pack is then inserted to prevent
loss of any wire trimmings into the hypopharynx. It is
helpful to infi ltrate a local anesthetic with 1:100,000
epinephrine throughout the maxillary and mandibular
vestibule because annoying oozing can occur in patients
with preexisting gingival infl ammation. The segment of
arch bars is cut to appropriate length for at least fi rst
molar–to–fi rst molar engagement (preferable to include
the second molars) around the arch. The arch bar is
gently bent into a curve and preadapted to the dental
arch at the level of the necks of the teeth and the free
gingival margin (Fig. 92-6). Usually, posterior teeth
(bicuspids and molars) are ligated to the arch bar with
24-gauge stainless steel wire, and anterior teeth are
secured circumdentally with 26-gauge wire. It is easiest

Chapter 92
Fractures of the Mandible
889
to start with the fi rst bicuspids because they have a
bulbous shape that is favorable for seating of the wires
below the height of contour. As the wires are tightened,
the arch bars should be held in proper anteroposterior
alignment and snug against the cervical margins of the
anterior teeth. One limb of the wire is passed under the
bar and one over the bar on return from the lingual
pass and twisted in a clockwise direction while fully
seating the wire around the neck of the tooth with a
forked wire director (see Fig. 92-6B). This is most
important for canine and anterior teeth, which are
slender and have minimal undercuts to resist dislodge-
ment when the MMF wire loops are tightened to bring
the patient into full occlusion.
The wires should lie on the surface of the teeth and
not pass through or around the interdental papillae
(see Fig. 92-6C). When fractures of the mandibular
body or parasymphyseal region are present, a wire may
be looped around the teeth adjacent to the fracture site
and gently tightened until proper fracture alignment
has been achieved (see Fig. 92-6D). Placement of the
arch bar can then continue distally to the site of the
fracture; the fracture must be properly reduced at the
superior mandibular surface. If the arch bar interferes
with reducing a fracture, it can be sectioned at the
fracture site to allow proper alignment. After the arch
bars have been placed in stable fashion on both the
maxillary and mandibular dentition, MMF is performed
(see Fig. 92-6E). It is important to not overtighten the
MMF wires, especially with fractures of the parasymphy-
seal region, because the inferior fracture gap will widen
(see Fig. 92-6F and G) and result in “lingual version” of
the mandibular dentition.
When the dentition is inadequate to completely
stabilize an arch bar, the arch bar may be further
secured with circum-mandibular wiring for the man-
dibular arch bar and wiring of the piriform aperture
or circumzygomatic wires for the maxillary arch bar
(Fig. 92-7). The skeletal fi xation wires provide added
stability.
Several important considerations must be kept in
mind for proper placement of arch bars. A circumden-
tal wire should not pass through the interdental papilla
of the gingiva because necrosis of this important struc-
ture can occur. The wires should be carefully positioned
directly adjacent to the tooth and slid beneath the
gingiva to avoid gingival necrosis. Before tightening the
wires around the bars, the two ends of the circumdental
loop should be adjusted so that they are of equal length
and form an isosceles triangle. If the ends of the wire
are of equal length, they will fi rmly anchor the arch bar
to the teeth as the wires are carefully twisted under
tension. Wire twisting is always performed in a clockwise
direction so that other surgeons will know which direc-
tion to twist for tightening or removal postoperatively.
Dental and Dentoalveolar Fractures
Teeth can be individually fractured through the crowns
at various levels. Management of fractures of the teeth
is individualized according to the severity of the injury.8
B
A
C
Incorrect
Correct
Figure 92-6. Technique of placement of arch bars and maxillo-
mandibular fi xation (MMF). A, The arch bar is cut and bent to the
appropriate length and shape of the dentition, including all stable
teeth, for fi xation. B, The arch bar is fi xed to the posterior teeth with
24-gauge circumdental wire and to the anterior teeth with 26-gauge
circumdental wire. It is often helpful to start in the bicuspid regions
because these teeth have undercuts that engage the circumdental
wires well and seat the arch bar at the cervical margin of the teeth.
The wires pass above the bar on one side of the tooth and below the
bar on the other side and are then twisted in a clockwise direction.
C, The wires should pass between the tooth and the interdental
papilla to avoid strangulation of these structures.

890
Section 9
Plastic and Reconstructive Surgery
D
E
F
G
Figure 92-6, cont’d D, A bridal
wire is passed around the fi rst and
second bicuspids with a left mandibu-
lar body fracture to aid in reduction
and stabilization. This is done before
fi xation of the arch bar and allows the
arch bar to be secured to the mandi-
ble in an already reduced position.
E, MMF, or wire loops, are placed
between the upper and lower arch
bars to maintain dental occlusion
during fi xation of the fracture. F and
G, Overtightening the MMF wires in
the presence of a symphyseal or para-
symphyseal fracture will cause the
inferior border of the fracture to splay
apart with accompanying lingual
version of the occlusal surface. If this
is not detected, adequate reduction of
the fracture is not possible.
Even if the pulp is exposed and the tooth is fractured
off at the base of the crown, these teeth should be
maintained and can be restored with endodontic treat-
ment (root canal) and crowns. Teeth that have been
subluxated or dislodged should be manually reposi-
tioned within the socket and dental arch. It is usually
best to secure the injured tooth or segment of teeth to
the adjacent dentition with a braided wire and bonding
agents (such as cured resins, which are used by ortho-
dontists to apply brackets to the teeth). If a dental
specialist is not available for assistance, temporary sta-
bilization with less tightly applied arch bars can suffi ce
until more defi nitive treatment is rendered. Overtight-
ening the circumdental wires merely serves to extrude
and extract the injured or subluxated teeth. Large den-
toalveolar fracture segments (four or more teeth) are
more amenable to arch bar stabilization or miniplating
(or both). Totally avulsed teeth need to be reimplanted
within 1 hour for a reasonable prognosis. The tooth
should be bonded to the adjacent teeth. Teeth that
have sustained root fractures are not usually salvageable
and should be removed.

Chapter 92
Fractures of the Mandible
891
B
A
Figure 92-7. A, When the maxillary dentition is inadequate for fi xation, suspension wires can be passed through the piriform aperture and
tied directly to the arch bar, or circumzygomatic wires can be passed and an intermediate loop of wire can engage the lower arch bar or be
secured to a circum-mandibular wire (B), which can also help retain a lower arch bar with inadequate dentition. Generally, 24-gauge wire is
used for skeletal fi xation wires, and lighter wire (26-gauge) is used for any intermediate loops that lock the skeletal fi xation wires to each
other.
Symphyseal and Parasymphyseal Fractures
Either an intraoral or an extraoral approach can be
used for symphyseal and parasymphyseal fractures. The
intraoral approach requires less tissue stripping and is
quicker. Once the arch bars are in place, fairly snug but
not overtightened MMF should be instituted to avoid
splaying of the inferior border. The MMF is secured
before soft tissue dissection and the mandible sup-
ported, which offers resistance when undermining the
periosteum and mentalis muscle. Dissection should be
carried out to the inferior border. A toe-up Obwegeser
or symphyseal retractor aids in stabilization and retrac-
tion. With the lip retracted and stretched slightly, the
vestibular mucosal incision should be 1 cm away from
the mucogingival junction. This will allow stronger mul-
tilayered closure of both muscle and the mucosa and
will also help avoid postoperative oral dehiscence with
plate exposure. In addition, the incision heals more
comfortably within the depth of the vestibule. Once
adequate exposure is gained for plating (usually a 3- to
4-cm incision), the fracture can be gently splayed by
inserting a Freer or periosteal elevator and twisting
lightly. The fracture margins should be irrigated and
gentle curettage performed to remove all debris,
trapped muscle, small bone fragments, clot, or fi brin.
This is especially important for fractures that are being
treated more than 48 hours after injury. The MMF is
then snugged and tightened while placing gentle inward
extraoral pressure on the bilateral angle or body regions.
Inward bilateral angle pressure helps prevent inferior
and labial bone gapping. Generally, a superior four- to
six-hole tension band plate (2.0-mm system) is adapted
and secured with monocortical screws (4 to 5 mm in
length) (Fig. 92-8). Before fi xating the plate, the
occlusion and fracture alignment should be checked. A
previously placed bridal wire (see Fig. 92-6D) can assist
B
A
Figure 92-8. A, Transoral approach and plating of a symphyseal
fracture. A superior monocortical tension band plate (2.0-mm system)
and a heavier inferior border fracture plate (2.7-mm system, bicorti-
cal screws) can be used. B, The patient was treated with arch bars,
was maintained in maxillomandibular fi xation (MMF) during frac-
ture reduction plating, and underwent an extraoral approach for the
treatment of a left subcondylar fracture. On the release of the MMF
wires, the occlusion was checked and found to be stable and repro-
ducible. The arch bars were then removed and soft tissue closure
performed.

892
Section 9
Plastic and Reconstructive Surgery
in gaining fi rm interdental contact. The superior mono-
cortical plate should be placed below the roots of the
incisor and canine teeth. The outline of the roots may
be visible, or placement of the plate 22 to 24 mm (inci-
sors) or 26 mm (canine) below the incisal edges pro-
vides safe clearance. Generally, an ideal and safe place
for plating is at the level of the greatest concavity of the
mandible, where the alveolar process meets the chin.
The screw holes should be carefully centered and a drill
guide used. The circumdental and MMF wires will not
resist displacement caused by improper eccentric
drilling.
When an inferior border plate is adapted, I gener-
ally use a slightly heavier fracture plate (or compression
plate) for this purpose—one that cannot be bent with
fi nger pressure alone. Slight judicious contouring of
any gross bony irregularities (preexisting irregularities,
not improperly reduced fracture margins) facilitates
plate adaptation and optimal contact with the facial
cortical bone. A four- or six-hole plate with a small
center span is ideal because most fractures have some
degree of obliquity. It is best to avoid traversing the
fracture line with the bicortical screws. With the MMF
secure and the superior tension band plate in place, the
fracture is stationary and maintains its position while
adapting and securing the heavier inferior border plate,
which will more readily resist movement and mastica-
tory and functional force during healing. Once adapted
and fl ush to the bone, it is helpful to overbend the
heavier fracture plate slightly in the central portion so
that it is raised 0.5 mm off the bone surface.9 During
screw tightening, this will help minimize unfavorable
lingual gapping and posterior fl aring or widening of
the mandible (see Fig. 92-6). These heavier plates are
generally secured with 2.3- to 2.7-mm-diameter screws
systems. It is important to use drill guides because
eccentric hole placement will cause a shift in the bone
fragments and malocclusion. It is sound surgical prac-
tice to place at least two screws on each side of the
fracture line within each plate (i.e., a minimum of four
screws per plate). This prevents pivoting and rotational
movement. A single, nonrigid 2.0-mm plate can be used
for fracture stabilization if the patient is being main-
tained in MMF for 6 weeks because of other facial frac-
tures. In addition, some surgeons prefer to use 2.0-mm
plates for both the superior tension band and the infe-
rior bicortical plate. It is possible to use a lag screw
technique without a plate for oblique fractures of the
symphysis, but this method is rather technique sensi-
tive, and any minor drilling malalignment will result in
a noticeable and unforgiving malocclusion, usually with
a step in the dental arch.
After rigidly fi xating the fracture, if there are no
other mandibular fractures to treat, the MMF wires (not
the circumdental wires) can be cut and removed and
the occlusion checked. It is best to push upward on the
bilateral angles externally to gently seat the condyles
during closure. If the result is satisfactory and stable,
muscular closure is performed with several 4-0 Vicryl
(braided polyglactin) sutures, and the mucosa is closed
with 3-0 or 4-0 chromic suture in a running horizontal
mattress stitch. If the arch bars are not to be main-
tained, they should be removed before soft tissue
closure. In general, I do not leave arch bars on postop-
eratively unless the patient is to be maintained in MMF
or if there is some need for elastic guidance. Arch bars
without MMF are inadequate to provide stability at the
alveolar level and should not be relied on to serve as a
superior tension band or to provide “fi xation.”
If an extraoral approach is to be used, the 4- to 5-cm
curvilinear incision line should be placed in the sub-
mental region so that it is not visible from the frontal
view. The incision should be centered around the point
at which the fracture crosses the inferior border of the
mandible.
Body Fractures
Fractures of the mandibular body are readily exposed
via an intraoral mucosal approach. There are scant
muscle attachments and little tissue thickness to tra-
verse during dissection. The mucosa and deeper tissues
are infi ltrated with local anesthetic and a vasoconstric-
tor to minimize bleeding and optimize visualization.
Reinjection during surgery is more advisable than
cautery, especially in proximity to the mental nerve. As
previously described, the 5- to 6-cm mucosal incision is
made 1 cm lateral or inferior to the mucogingival junc-
tion. Along the anterior extent a mucosal-only incision
is made, and blunt dissection with small curved hemo-
stats helps identify and free the mental nerve from the
anterior or labial fl ap of soft tissue. The mental nerve
exits the mandible between the root tips of the bicuspid
teeth. This nerve should be preserved and protected
throughout the procedure. It is best to perform dissec-
tion with the teeth in MMF because MMF allows more
lateral and inferior posterior retraction of the lip,
cheek, and commissure of the mouth. A toe-up Obwe-
geser retractor beneath the inferior border of the man-
dible helps provide excellent retraction and visualization.
Excessive torquing on the obwegeser retractor or body
retractor can cause the fracture segments to splay later-
ally. A single heavier fracture plate can be readily
adapted along the typically fl at, broad surface of the
body’s inferior border. The lower edge of the plate
should be even with the lowest edge of the mandibular
inferior border (Fig. 92-9) to allow proper drilling and
bicortical screw placement and avoid injury to the infe-
rior alveolar nerve. Generally, the anterior screws are
easily placed transorally, and because of the limits of
cheek and lip retraction, added safety is provided by
angling slightly inferiorly as one proceeds medially. If
necessary, a trocar, cannula, and guard can be used to
percutaneously drill and place screws in the posterior
plate holes. These are done last because the plate is
already stabilized and held in place with the anterior
screws. Therefore, the surgeon can concentrate on cen-
tering the hole with the aid of a drill guide within the
cannula and create a perpendicular path for screw
insertion. In most instances there is adequate room
above the inferior alveolar canal and below the tooth
root apices for a monocortically fi xated tension band
plate (Fig. 92-9B). If the fracture is located more toward

Chapter 92
Fractures of the Mandible
893
A
B
C
D
Figure 92-9. Right body and left subcondylar fracture of the mandible. A, Panoramic radiograph demonstrating a slightly oblique fracture
of the right mandibular body with mild displacement and vertical overlap of the left subcondylar segment. Note that there is inadequate denti-
tion, particularly in the left posterior maxilla, to re-establish a proper vertical dimension through maxillomandibular fi xation (MMF) alone.
B, A transoral approach to the right body fracture was made after placing the patient in MMF. A superior monocortical tension band, four-hole
miniplate was applied above the mental nerve, and a four-hole heavier fracture plate was applied at the inferior border, with the distal screws
angled inferiorly to avoid the inferior alveolar nerve canal. C, Left submandibular/retromandibular approach to the displaced subcondylar
fracture. Note that the inferior edge of the proximal segment is laterally displaced. This is quite classic because the pull of the lateral pterygoid
on the condylar head displaces it forward and medially. When dissecting subperiosteally, this segment often falls underneath the dissection
and must be palpated and retrieved from the superior fl ap. D, The reduced left subcondylar fracture, which was fi xated with a ladder plate
and a locking 2.0-mm system. Intraoperatively, the MMF and arch bars were removed, and the patient was allowed to ingest a soft diet.
the anterior body region, the monocortical superior
plate must “straddle” it above the mental foramen.
Remember that the mental nerve has a genu as it exits
the mandible. The nerve courses upward and posteri-
orly several millimeters as one proceeds anteriorly.
Therefore, the inferior alveolar canal and nerve are
slightly below the level of the mental foramen. A pan-
oramic radiograph is invaluable in assessing this rela-
tionship and clearance relative to the nerve canal and
root apices. The occlusion should be checked frequently
during fracture reduction and fi xation to help ensure
restoration of preinjury alignment.
If the extraoral approach is chosen, a transverse
incision is made at least two fi nger breadths below the

894
Section 9
Plastic and Reconstructive Surgery
E
F
Figure 92-9, cont’d E, A lateral cephalogram taken the fi rst postoperative day shows good preservation of the posterior vertical dimension
and projection of the mandible. F, Panoramic radiograph demonstrating postoperative reduction and fi xation of the right body and left sub-
condylar fractures.
inferior border of the mandible and carried down
through the platysma and then the fascia overlying the
submandibular gland to protect the marginal mandibu-
lar branch of the facial nerve. It is usually helpful to
have a nonparalyzed patient and a nerve stimulator to
test any questionable branches or nerve-like structures.
The mandible is then exposed by excising the perios-
teum on its inferior border. Elevation of the periosteum
allows wide exposure of the mandible and placement
of mandibular reduction clamps when necessary. The
extraoral approach may provide better exposure if the
mandibular body is comminuted. After the mandible
is plated, the MMF is again released, the occlusion is
checked, and the arch bars are removed before tissue
closure.
Angle Fractures
Mandibular angle fractures are often associated with an
impacted or partially erupted third molar (wisdom
tooth). Nondisplaced fractures can be treated in closed
fashion with 6 weeks of MMF. No MMF plus a soft diet
as the sole treatment is not recommended because
malunion or unfavorable occlusal changes will develop
in a signifi cant proportion of patients. Completely
impacted third molars that do not interfere with frac-
ture reduction may be left in place. In fact, removal may
cause excessive distraction of the segments and a sig-
nifi cant bony void. If a tooth is partially erupted or
fractured or interferes with reduction, it should be
removed completely. Removal may include vertical sec-
tioning of the tooth with a fi ne (1.5 mm) fi ssure burr
and high-speed (100,000 rpm) drill with copious irriga-
tion. The tooth fragments can then be split and elevated
out independently. Either intraoral or extraoral expo-
sure can be used. Arch bars are placed before soft tissue
surgery. The intraoral approach is similar to that
described for a body fracture, except that it is located
somewhat more superior along its posterior extent and
overlies the external oblique ridge (Fig. 92-10). If a
partially erupted third molar is being removed, the inci-
sion should course along the lateral exposed crown
(the sulcus) and fade back out to the lateral oblique
ridge posteriorly to allow primary closure of the tooth
socket. Wider tissue dissection with subperiosteal strip-
ping is needed to facilitate lateral retraction and visual-
ization. It is sometimes easier to perform the soft tissue
dissection and fracture reduction before placing the
patient in MMF. A straight or gently curved monocorti-
cal miniplate is usually placed along the lateral aspect
just beneath the external oblique ridge (see Fig.
92-10B). Screws can be inserted either transorally or
percutaneously, depending on soft tissue stretch and
access. Another miniplate or heavier fracture plate is
typically applied along the inferior border, often angling
upward at the posterior extent but still below the infe-
rior alveolar nerve canal. When placing the cannula
and trocar percutaneously, it is best to fi rst sound the
proposed skin puncture site with a long anesthetic
needle and see whether it corresponds to the fracture
line or the center of the planned percutaneous screw
placement (Fig. 92-11). Sounding helps avoid the neces-
sity of making additional stab incisions and replacing
the cannula at a different site. I do not prefer to use
preformed mandibular angled fracture plates trans-
orally. They are diffi cult to adapt, and any eccentric
drilling of the screw holes within the plate tends to
create exaggerated unfavorable vectors and displace-
ment of the bony segments.
If the angle fracture is approached extraorally, a
skin incision is made approximately 2 to 2.5 cm below
the inferior border of the angle and carried slightly
upward toward the earlobe at the posterior extent (Fig.
92-12). The incision should be of adequate length
(5 cm) to allow retraction and exposure while plating.

Chapter 92
Fractures of the Mandible
895
A
B
Figure 92-10. Left angle fracture of the mandible. A, Incision line for a transoral approach to the fracture. B, A six-hole tension band plate
is adapted along the external oblique line. There is no center span in this plate and the central plate holes were too close to the fracture line,
so no screws were placed in them. Doing so may have caused crazed lines or the screws may have traversed into the fracture line itself. The
inferior border angle plate is usually applied via a percutaneous approach with cannula and a drill guide.
B
A
Figure 92-11. Left mandibular angle fracture. A, After intraoral dissection and placing the patient in maxillomandibular fi xation, a 25-gauge
anesthetic needle was used to sound the proposed percutaneous stab incision site, which was then stretched slightly with a small hemostat and
a cannula with a trocar was inserted and a cheek guard placed. B, The operator is then able to view the fracture and plate transorally while
using the percutaneous access to drill and, as seen here, to place screws along the lateral cortex of the mandible.

896
Section 9
Plastic and Reconstructive Surgery
Blunt dissection with slight undermining of the deep
subcutaneous layers is performed. The platysma is
divided at the lower extent of the dissection, as is the
superfi cial layer of the deep cervical fascia, while testing
for the marginal mandibular branch of the facial nerve
(Fig. 92-12B). This branch is just inferior to the tail of
the parotid gland. The incised layers and skin fl aps are
retracted superiorly to expose the pterygomasseteric
muscle sling and the periosteum of the mandible. This
is incised and widely dissected subperiosteally. The frac-
ture is then gently débrided, irrigated, and reduced
while placing the patient in MMF. A four- or six-hole
straight or gently curved monocortical (2.0 mm) plate
is applied superiorly just below and along the external
oblique lines. A four- or six-hole heavier mandibular
plate is then applied bicortically along the inferior
border and below the inferior alveolar canal (see Fig.
92-10B). After all fractures are plated, the MMF should
be released and the occlusion checked. The wound is
then irrigated and closure performed with continuous
locking 4-0 Vicryl in the platysma and interrupted
buried sutures subcutaneously. The cuticular layer is
closed with interrupted or continuous 5-0 or 6-0 nylon.
Suction drains are rarely indicated, and a gentle pres-
sure dressing or facial support helps prevent postopera-
tive hematoma formation.
Ramus, Condyle, and Coronoid Fractures
Coronoid fractures are uncommon and usually associ-
ated with a zygomatic complex fracture that has been
driven inward. Coronoid fractures do not require closed
or open treatment. They heal uneventfully on their
own, except if an overlying zygomatic complex is not
properly reduced and is in close proximity, thereby
risking fi bro-osseous union of the entire coronoid and
zygomatic complex fracture.
A
B
Platysma
Digastric
Dissection
plane
Parotid
C
Figure 92-12. External approach
to a mandibular angle fracture.
A, The skin incision is centered
around the fracture and designed
so that it is just inferior to the angle
of the mandible, parallel or within
cervical skin creases (dashed line).
By making the skin incision high in
the neck, the length of the incision
can be minimized (approximately
4 to 5 cm). The platysma muscle
will be cut more inferiorly in the
neck at the traditional level (dotted
line) to preserve the marginal man-
dibular branch of the facial nerve.
B, Cross section through the region
of the mandibular angle showing
the avascular plane of dissection
that allows easy access to the man-
dibular angle. The facial nerve
branches are protected by initially
dissecting inferiorly into the neck.
The dissection then proceeds to
the digastric muscles, where the
point of dissection is deep to the
facial nerve. The mandibular peri-
osteum is incised on the inferior
border of the mandible. C, Expo-
sure of a reduced fracture through
an extraoral approach.

Chapter 92
Fractures of the Mandible
897
Ramus fractures can be treated satisfactorily by
closed reduction and 6 weeks of MMF. Transoral
approaches for plating are diffi cult. The external skin
incision plus approach for ramus fractures is similar to
that for angle fractures but with more extension supe-
riorly and with subperiosteal dissection and retraction.
Y plates, L plates, and “box” or “ladder” plates allow
several screws to be placed in the proximal superior
segment closer to the fracture line and decrease the
need for further superior dissection and retraction (see
Fig. 92-9E and F).
Condylar and subcondylar fractures can be treated
with 2 to 4 weeks of MMF. If the fracture is intracapsular
(head of the condyle), 2 weeks is appropriate to limit
the risk for ankylosis.10 When a unilateral subcondylar
fracture is associated with other mandibular fractures,
open reduction with rigid fi xation of the coexisting
mandibular fractures is indicated so that the subcondy-
lar fracture can be mobilized and returned to function
at 2 to 4 weeks (Fig. 92-13).
Open reduction and plating of condyle fractures
may be indicated11 and is necessary in the following
situations:
1. Displacement of the condylar head into the middle
cranial fossa
2. When
condylar
displacement
prevents
re-
establishment of proper occlusion
3. With lateral or severe displacement of the condylar
head out of the fossa
4. When a foreign body, such as a bullet or bone frag-
ment, is lodged within the temporomandibular joint
capsule
5. Open fractures with extensive soft tissue injuries
(gunshot wounds) in which early function can help
minimize fi brosis
B
C
D
A
E
Figure 92-13. A, A young man was evaluated for pain and malocclusion with shift of the lower jaw to the left and premature occlusal contact
on the right posterior teeth. An open-mouth reverse Towne view (B) and a Panorex view (C) demonstrate the left condyle fracture with overlap
and a right body fracture gapping between the second bicuspid and fi rst molar. D, The patient underwent placement of arch bars, maxillo-
mandibular fi xation (MMF), and a transoral approach to the right body fracture with placement of a heavy fracture plate along the inferior
border. Adequate reduction and posterior vertical dimension were re-established by keeping the patient in 2 weeks of MMF. E, Postoperative
occlusion at 6 weeks. The bars were removed at week 4. Between weeks 2 and 4, some light box elastics were placed on the right side and ante-
rior arch bar regions to help guide the occlusion.

898
Section 9
Plastic and Reconstructive Surgery
Other relative indications include bilateral condyle
fractures associated with midfacial fractures or bilateral
condyle fractures in an edentulous patient. In these
situations, open reduction of one or both condylar frac-
tures greatly aids re-establishment of proper facial
dimensions. When signifi cant displacement has resulted
in the loss of posterior vertical height, open reduction
with rigid fi xation is usually recommended (see Fig.
92-9). Severely comminuted intracapsular condyle frac-
tures are not amenable to plate-and-screw fi xation and
result in only more soft tissue trauma. These patients
should be treated with 2 weeks of MMF and then guided
(elastic) function as necessary for several more weeks.
When open reduction of a condyle fracture is per-
formed, it is generally through a skin incision similar to
that for angle fractures, with a posterior tail that is
within 2 cm of the ear lobe. Infrequently, condyle frac-
tures are exposed through a preauricular incision to
allow retrieval of a medially displaced condylar head.
The preauricular incision is usually performed in
conjunction with the submandibular/retromandibular
angle approach so that reduction and plating of the
fracture are possible without excessive inferior retrac-
tion and stretch from above, which might place the
facial nerve and superior branches at risk. Condyle frac-
tures (adult or pediatric) should not be approached
intraorally. Careful planning and multiple techniques
are often needed, even with extraoral approaches.
Treatment of mandible fractures should be undertaken
by surgeons familiar with the surgical approaches, and
it is benefi cial to have another surgeon assisting. Judi-
cious stripping and muscular refl ection for 1 to 1.5 cm
on the medial surface of the inferior angle will greatly
improve the ability to retract superiorly. In addition, a
channel or toe-up Obwegeser retractor placed in the
sigmoid notch will enhance visualization and access to
the condyle fracture. Plate confi gurations that allow
several screws to be inserted within the condylar seg-
ments close to the fracture line will facilitate plating
(see Fig. 92-9D).
Endoscopically assisted reduction plus plating of
condyle fractures has been advocated by several authors,
but it has limitations and has not been shown to be
more effi cacious or to have less risk than traditional
approaches.
Pediatric mandible fractures (≤6 years of age) are
usually best treated with closed techniques involving the
use of skeletal fi xation wires and sometimes acrylic
interocclusal splints (Fig. 92-14). Because of immature
bone, limited bone stock, and developing permanent
tooth buds, children’s mandibles are diffi cult to plate
effectively,12 especially condyle fractures.
Multiple Fractures
With comminuted mandible fractures, I fi nd it easier to
piece together the larger, more stable fragments with
miniplates and then consolidate and rigidly fi xate the
entire complex with a larger spanning fracture or
reconstruction plate (Fig. 92-15). Locking screws that
engage the plate itself help improve stability and mini-
mize distraction of segments during screw tightening
because it is virtually impossible to adapt the large plate
in full passive contact with all the bony segments.
When deciding whether to use an intraoral versus
an extraoral approach for plating, the surgeon should
take into consideration several factors. More posterior
fracture locations, any comminution, and edentulous
fractures are better suited to extraoral approaches.
Thin edentulous bilateral body fractures are best
treated via an extraoral approach.13 After the chin
segment is dissected at the inferior extent of the man-
dibular border, a portion of the mentalis is stripped and
a single bicortical screw is inserted in the midpoint of the
chin with 3 to 4 mm exposed beneath the head. A large
Kelly clamp is then used to grasp the screw shaft and
retract anteriorly to make the tissue planes more identifi -
able and the posterior subperiosteal dissection easier. A
long-span rigid plate with three to four screws in the
symphysis and three to four screws in the angle provides
more reliable rigid fi xation and predictable healing
without any secondary procedures (Fig. 92-16).
When treating comminuted or edentulous mandi-
ble fractures or when drilling at an angle to avoid vital
structures, locking screw systems help prevent displace-
ment of the segments and provide excellent rigidity.
When drilling screw holes for these or any rigid plating
systems (>2-mm external thread diameter, 1.5-mm
burr), the drill guide should be used to properly align
the bony hole within the plate hole and thus prevent
defl ection with screw tightening (see Fig. 92-16E).
POSTOPERATIVE MANAGEMENT
Patients treated by open reduction and plating of man-
dibular fractures should be placed on a soft diet that
does not require chewing for several weeks and then
advanced to a normal diet only after 6 weeks. Even then,
tough foods such as raw carrots, bagels, and the like
should be avoided for several more weeks.
If the fracture has been treated in closed fashion
and the patient is in MMF, oral hygiene is especially
important. The patient should be instructed to brush
the teeth and arch bars daily and to perform oral saline
rinses. Soft dental wax can be given to the patient to
place over any sharp or prominent areas. Wire tails
should be bent inward to minimize lip and cheek irrita-
tion. Wire cutters should be given to the patient at the
bedside and on discharge from the hospital so that the
MMF (the vertical wires) can be cut in the event of an
airway emergency. Nutrition consultation should be
considered for patients with planned periods of 4 to 6
weeks of MMF. The MMF and circumdental wires can
be removed in the offi ce under local anesthesia, some-
times supplemented with intravenous sedation. The
MMF wires should be released fi rst, before intravenous
sedation, in case airway access or support is needed.
Patients with open mandible fractures are usually placed
on antibiotics at the time of diagnosis, through surgery,
and for several postoperative doses. Prolonged antibi-
otic therapy or broad-spectrum antibiotics are not
indicated and have not been shown to provide any
benefi t.

Chapter 92
Fractures of the Mandible
899
B
E
D
C
A
Figure 92-14. A 5-year-old patient was an unrestrained passenger in a motor vehicle accident. A, Non–contrast-enhanced axial computed
tomography scan demonstrating multiple intracapsular fractures of the bilateral condyles. Additional lower cuts also revealed a right symphysis
fracture through the developing permanent canine tooth bud. B, After nasally intubating the patient in the operating room, dental molds were
taken and stone casts poured. The lower cast, seen here, was sectioned at the displaced fracture line of the right parasymphysis and reduced
relative to the maxillary dentition. C, An acrylic splint was then fabricated to index these adjustments. The acrylic splint was inserted after
placing bilateral 24-gauge skeletal wires at the piriforms and circum-mandibularly. Care was taken to not pass the right circum-mandibular wire
within the fracture line of the right parasymphysis. The patient was maintained in skeletal and maxillomandibular fi xation for 2 weeks. The
intermediate 26-gauge wires were then cut and the patient allowed to function. D, A panoramic radiograph taken 2 weeks after removal of the
skeletal suspension wires shows good maintenance of the entire dentition and no developing open bite. Both condyles are beginning to re-form.
E, Occlusion 6 months after surgery showing vertical overlap and good interdigitation.

900
Section 9
Plastic and Reconstructive Surgery
B
A
C
D
G
E
F
Figure 92-15. Twenty-four-year-old woman involved in a motor vehicle accident. A, Non–contrast-enhanced axial computed tomography
(CT) scan showing comminution of the inferior border of the mandible. B, A panoramic radiograph obtained before the CT scan shows com-
minution of the right parasymphysis, a left body fracture, and a right condyle fracture with numerous craze lines. C, The patient had a large
laceration of the chin and submental region that was extended 2 to 3 cm along the left mandibular angle region. First, monocortical miniplates
and a locking screw system were used to piece the bony fragments together. The larger spanning rigid plate was then adapted to the inferior
border and locking screws inserted. D, Postoperative panoramic radiograph showing maxillomandibular fi xation, which was maintained for 2
weeks to treat the right condyle fracture in closed fashion. E, Three months’ postoperative facial appearance. F, Submental view of the healed
laceration. The patient declined to have any revision surgery for this. G, Left lateral view of the fi nal occlusion.

Chapter 92
Fractures of the Mandible
901
B
A
D
C
E
F
Figure 92-16. A 54-year-old institutionalized, mentally challenged man with spina bifi da was referred for nonhealing and infection of bilateral
edentulous body fractures. A, A lateral mandibular radiograph shows that the patient had previously undergone open reduction and internal
fi xation of the fractures and that miniplates had been applied to the lateral surface and the inferior border. The plates were fairly short in
span and placed in an unfavorable compression zone, so during function the fracture would tend to gap superiorly. B, Right oblique view
showing complete loss of fi xation and osteolysis. C, Left oblique view demonstrating similar fi ndings and screws backing out. D, The patient
underwent wide extraoral exposure and débridement of the fi brous and granulation tissue on all bony margins. The right body fracture is seen
reduced and a rigid reconstruction plate (2.3-mm system) was positioned and held with self-retaining clamps. E, A drill guide was used and
locking screws inserted in the sound bone at least 4 to 5 mm away from the fracture site. F, Frontal view of the fully fi xated mandible.

902
Section 9
Plastic and Reconstructive Surgery
G
I
H
Figure 92-16, cont’d. G, Submental view. H, Postoperative lateral
mandibular radiograph showing excellent projection and contours.
I, Anteroposterior radiograph demonstrating symmetry and normal
contours.
PEARLS
• Use drill guides with the more rigid plating systems
to help prevent subtle shifting of segments.
• During application of rigid fi xation, continuously
recheck the occlusion to make sure that tightening
of the last screw did not distract the bony segments.
• Mandible fractures in the pediatric age group are
often best treated with closed techniques.
• Place the patient in maxillomandibular fi xation
before plating any fractures.
• Remove arch bars at the end of surgery unless they
are necessary for postoperative interdental fi xation
or elastic guidance.
• Plates that are not placed perpendicular to the
fracture line can cause vertical defl ection during
screw tightening and may be less stable.
• Mucosal incisions that are less than 1 cm away or
close to the mucogingival junction do not allow
suturing of the muscle layer, which is a risk for
wound dehiscence and plate exposure.
• Intraoral approaches to condylar, subcondylar, and
ramal fractures often result in a prolonged
frustrating attempt at plating and lead to
suboptimal alignment.
PITFALLS
• Lack of copious irrigation while drilling screw holes
may result in overheated or necrotic bone that does
little to stabilize fi xation screws and can result in
microscopic or gross mobility of the fi xation and
fracture before healing.
• If a tooth is left in the line of fracture or if the tooth
itself is fractured or grossly decayed, it may limit
bony reduction or result in a postoperative infection.
References
1. Thaller SR: Management of mandibular fractures. Arch Otolar-
yngol Head Neck Surg 120:44-47, 1994.
2. Chacon GE, Larsen PE: Principles of management of mandibular
fractures. In Miloro M (ed): Peterson’s Principles of Oral and
Maxillofacial Surgery, 2nd ed. Hamilton, Ontario, BC Decker,
2004, pp 401-443.
3. Chacon GE, Dawson KH, Myall RW, Beirne OR: A comparative
study of two imaging techniques for the diagnosis of condylar
fractures in children. J Oral Maxillofac Surg 61:668-672, 2003.
4. Zallen RD, Curry JT: A study of antibiotic usage in compound
mandibular fractures. J Oral Surg 33:431-434, 1975.
5. Chloe RA, Yee Y: Antibiotic prophylaxis for facial fractures. A
prospective, randomized clinical trial. Arch Otolaryngol Head
Neck Surg 114:1114-1122, 1988.

Chapter 92
Fractures of the Mandible
903
6. Ellis E, Moos KF, El-Attar A: Ten years of mandibular fractures:
An analysis of 2,137 cases. Oral Surg 59:120-129, 1985.
7. May M, Tucker HM, Ogura IH: Closed management of mandibu-
lar fractures. Arch Otolaryngol 95:53-57, 1972.
8. Leathers RD, Gowans RE: Management of alveolar and dental
fractures. In Miloro M (ed): Peterson’s Principles of Oral and
Maxillofacial Surgery, 2nd ed. Hamilton, Ontario, BC Decker,
2004, pp 383-400.
9. Tucker MR, Ochs MW: Basic concepts of rigid internal fi xation:
Mechanical considerations and instrumentation overview. In
Tucker MR, Terry BC, White RP, Sickels JV (eds): Rigid Fixation
for Maxillofacial Surgery. Philadelphia, JB Lippincott, 1991, pp
30-53.
10. Mathog RH, Rosenberg Z: Complications in the treatment of
facial fractures. Otolaryngol Clin North Am 9:533-552, 1976.
11. Zide MF, Kent JN: Indications for open reduction of mandibular
condylar fractures. J Oral Maxillofac Surg 41:89-98, 1983.
12. Amaratunga NA: Mandibular fractures in children—a study
of clinical aspects, treatment needs, and complications. J Oral
Maxillofac Surg 46:637-640, 1988.
13. Marciani RD: Invasive management of the fractured atrophic
edentulous mandible. J Oral Maxillofac Surg 59:792-795, 2001.

Chapter 93
Fractures of the Upper Facial and
Midfacial Skeleton
Mark W. Ochs
Depending on the point of impact and the degree of
force, the upper facial and midfacial bones can sustain
isolated or characteristic fracture patterns. A single
blow from a fi st to the midface often results in a dis-
placed nasal fracture, the most common midfacial frac-
ture, or in a tripod fracture of the zygomatic complex
(ZMC). The midfacial bones tend to fracture in areas
where they are thin and weak, such as the nasal bones,
the anterior maxillary sinus wall, the orbital fl oor,
the medial walls, and the nasal-orbital-ethmoid (NOE)
complex. Suture lines also provide a natural cleavage
plane for fractures to occur. If the facial bones are
struck in strong thicker areas, the force is transmitted
to the suture lines or thinner bony areas.
When severe or multiple midfacial fractures occur
or when such fractures are associated with lacerations
or penetrating injuries, signifi cant hemorrhage can
occur. Patients are often brought by emergency medical
personnel on spine boards and in cervical collars. These
restraints can lead to airway compromise, so measures
to suction and control hemorrhage are essential. A sig-
nifi cant number (>5%) of patients with frontal sinus or
multiply displaced midfacial fractures will have an injury
to the cervical spine.1 When the airway needs to be
secured, emergency tracheostomy or cricothyrotomy
is generally the safest and most predictable course of
action. It is diffi cult to perform direct laryngoscopy
while maintaining in-line cervical spine traction. Fiber-
optic intubation (either nasally or orally) is usually
hampered by blood obstructing the view. Attempts at
“blind nasal intubation” should be undertaken only by
skilled individuals once a fracture of the NOE complex
and possible fracture of the cribriform plate (with their
potential for false passage into the anterior cranial
fossa) have been excluded.
Control of hemorrhage can be accomplished by
injection of local anesthetic containing vasoconstrictors,
tacking sutures, localized packing, and less frequently,
direct clamping of vessels. Blind clamping or electrocau-
tery should not be undertaken in injured areas along
the course of the facial nerve. Some blood loss during
facial fracture surgery is unavoidable, but the use of
injected vasoconstrictors and topical agents with nasal
packing will greatly reduce oozing throughout the surgi-
cal procedure. Local infi ltration may be repeated as
often as necessary if the vasoconstrictors wear off. Bleed-
ing vessels should be ligated or cauterized. The patient
must be kept warm and the proper coagulation mecha-
nism should be evaluated. The anesthesiologist must
make every effort to maintain normotension or a systolic
blood pressure of 110 mm Hg or lower. This should be
done only when appropriate and neurologically and
systemically tolerated by the patient.
Before general anesthesia, a gross visual acuity
check of both eyes and assessment of facial motion must
be made. This information is invaluable when corre-
lated with computed tomography (CT) during treat-
ment planning.
Goals of treatment of facial fractures are to restore
the patient to the preinjury facial form with normal
function. Re-establishment of the proper anterior facial
projection without abnormal widening of the face is
essential.2 There is a tendency for a broad, fl at face to
occur as a result of blunt force and the direction of
displacement. Severe midfacial fractures are often asso-
ciated with multiple fractures of the mandible, which
further compounds this situation.
Precise repositioning plus fi xation prevents maloc-
clusion and shortening of the midface. Horizontal rela-
tionships are maintained by buttresses at several levels,
905

906
Section 9
Plastic and Reconstructive Surgery
including the supraorbital rims and frontal bone, the
zygomatic arch, the infraorbital rims, the nasal bones,
and the maxillary alveolus. These horizontal relation-
ships determine facial width, malar projection, occlusal
relationships of the maxillary dentition, orbital posi-
tion, and the width of the base of the nasal pyramid.
In addition to anatomic repositioning of the facial
skeleton, surgical treatment must also consider the
importance of restoring function, including an intact
blood-brain barrier; mucociliary clearance of the
frontal, maxillary, and ethmoid sinuses; nasal breath-
ing; lacrimal drainage; dental occlusion; and conjugate
movement of the extraocular muscles. The latter
depends on establishing proper orbital volume and
position of the globe.
PATIENT SELECTION AND PREOPERATIVE
EVALUATION
Although each anatomic entity will be discussed sepa-
rately, the surgeon should bear in mind that midfacial
fractures are frequently multiple, have associated soft
tissue injuries, and may be accompanied by neurologic
injuries.
Maxilla
Direct blunt force trauma to the maxilla results in
several classic fracture patterns that are designated by
a Le Fort classifi cation (Fig. 93-1). A Le Fort I fracture
is a horizontal maxillary fracture of the horseshoe-
shaped dentoalveolar complex (above the tooth roots)
through the midmaxillary sinus and base of the lateral
nasal walls. A Le Fort II fracture is a pyramidal break of
the nasomaxillary complex with separation at the fron-
tonasal junction, through the inferior orbital rims, and
then laterally along the anterior maxillary sinus wall,
below the zygomatic buttresses. To clinically differenti-
ate a Le Fort I from a Le Fort II fracture, the examiner
should grasp the anterior maxillary teeth and alveolar
ridge while stabilizing the forehead with the opposite
hand. Anterior-posterior, or side-to-side, force should
be applied to the anterior maxilla while observing for
symmetrical motion of the entire maxilla (Le Fort I
versus an isolated dentoalveolar fracture) or the maxilla
and nasal complex together (Le Fort II). Complete
craniofacial dysjunction is termed a Le Fort III fracture.
Here, the entire facial complex, including the zygo-
matic buttresses, moves with applied maxillary force.
Generally, Le Fort fracture patterns are not “pure” and
have additional lines of fracture (i.e., dentoalveolar
component), comminution, combinations (such as Le
Fort I and III levels), or associated midfacial fractures
(i.e., ZMC or orbit). Typically, the direction of the force
fracturing the maxilla displaces the maxilla upward and
back. This results in an anterior or lateral open bite and
malocclusion. The face is fl attened and elongated.
Patients sustaining Le Fort fractures demonstrate
malocclusion, severe bilateral facial and periorbital
edema, epistaxis, and ecchymosis (especially in the
maxillary vestibule). These patients will often have par-
esthesia of the midface because of edema and pressure
on the infraorbital nerves. Palpation of the maxillary
vestibule, orbital rims, and nasal complex can reveal
bony steps or detect motion while manipulating the
maxilla. Edema and pain while palpating can readily
mask these deformities. Tears in the gingiva or palatal
mucosa should be sought because they are indicative of
segmental fractures of the dentoalveolar complex and
may alter the treatment plan. Traumatic open gaps in
the dental arch should be accounted for either by an
avulsed and missing tooth or by displacement or splay-
ing of the fractured maxillary segments. Any watery or
clear rhinorrhea should be collected and sent for β2-
transferrin assay to determine whether a cerebrospinal
fl uid (CSF) leak is present.
If there is strong clinical suspicion of a maxillary
fracture, fi ne-cut (1.5 mm) axial CT scans through the
entire facial complex offer the best imaging informa-
tion for surgical planning and have replaced plain
radiographs such as a Waters view, which offer little
precise information. It is advisable to carry the CT scan
through the mandible because there are invariably
mandibular injuries such as condylar fractures that can
be diffi cult to diagnose clinically or with plain fi lms.
Intravenous contrast material in the setting of acute
facial trauma does not provide any additional detail and
is not indicated.
Zygoma
Fractures of the ZMC are the second most commonly
occurring facial fracture. They typically occur as a result
of lateral blunt force, such as a blow to the face with a
fi st. These fractures are also termed “tripod” fractures
because they are breaks along the zygomaticofrontal
Le Fort III
Le Fort II
Le Fort I
Figure 93-1. Le Fort classifi cation of midfacial fractures. A Le Fort
I fracture courses along the base of the nasal septum and fl oor or the
midmaxillary sinus walls with separation at the pterygoid plates. A Le
Fort II fracture traverses along the anterior maxillary wall and through
the medial orbital rim, coupled with the nasal complex. A Le Fort III
fracture has breaks at the zygomatic frontal sutures, frontonasal junc-
tion, zygomatic arches, and pterygoid plates. In essence, the entire
midface is separated from the cranium (craniofacial dysjunction).

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
907
and zygomaticomaxillary junction (infraorbital rim and
anterior sinus wall) and the zygomatic arch.3 Usually,
the zygomatic buttress is driven medially inward, infe-
rior, and slightly posterior. There will be fl attening of
the malar projection, but this can be masked by edema.
Frequently, clinical signs and symptoms include infe-
rior displacement of the lateral canthus, tenderness of
the frontozygomatic suture (located 1 cm above the
lateral canthus), lateral subconjunctival hemorrhage,
pain or limitation while opening the mouth, paresthe-
sia of the cheek/lip, midfacial edema, and limited
range of ocular motion (secondary to an orbital fl oor
component). Palpation of the inferior orbital rim may
reveal a step at the mid or medial half of the rim. Visual
acuity should be assessed to rule out the possibility of a
retrobulbar hematoma. Limited opening of the mouth
is generally mild and due to the pain associated with
masseteric muscle pull. However, with severe displace-
ment of the ZMC, there can be direct impingement of
the coronoid process and marked limited opening
(1 cm interincisally). In anticipation of oral intubation
for surgical repair, it is helpful to ask the patient to
deviate the mandible to the contralateral side of the
ZMC fracture and to assist the individual with opening.
This often clears the path for the ipsilateral coronoid
and allows adequate opening.
Isolated fractures of the zygomatic arch are usually
due to a focused blow, such as with an elbow or a hard-
ball, directly to the midarch. Typically, there are three
separate vertical fracture lines with inward displace-
ment in a V- or W-shaped pattern (Fig. 93-2). An inden-
tation and tenderness in the area directly over the
fracture may be noted or camoufl aged by edema. Mild
limited opening because of muscular pain is often
present.
Radiographic imaging of fractures of the ZMC can
initially include a Waters view to look for opacifi cation
or an air-fl uid level in the maxillary sinus or a teardrop
sign in the maxillary sinus caused by sagging of the
periorbital contents through the orbital defect. Separa-
tion or widening of the zygomaticofrontal suture line is
often diffi cult to ascertain except with extreme displace-
ment. Axial CT offers the best views to determine the
direction and degree of displacement of the ZMC.
Direct coronal views or, less ideally, reformatted images
can provide additional details of the orbital fl oor com-
ponent if repair of this area is contemplated. Minimally
displaced or nondisplaced fractures of the ZMC will
heal uneventfully with sinus precautions, deconges-
tants, and antibiotics, if indicated. In patients with mini-
mally displaced or nondisplaced isolated fractures of
the ZMC, orbital fl oor, or anterior maxillary wall, one
should not operate for V2 paresthesia alone. The infra-
orbital nerve does not need to be decompressed, and
“surgical exploration” will only further traumatize the
nerve and not hasten recovery. Surgical repair is
directed toward realignment, restoration of midface
form, and unrestricted motion of the globe and
mandible.
Isolated zygomatic arch fractures can be imaged
with a submental vertex or “jug-handle” view. These
inexpensive plain radiographs are adequate for plan-
ning surgical treatment. If further images are to be
obtained, an axial CT scan is the image of choice. Iso-
lated arch fractures are usually treated by open reduc-
tion through limited incisions in the temporal area,
lateral aspect of the brow, or transorally and then not
plated. Therefore, early operative intervention (prefer-
ably within the fi rst 24 to 72 hours) is desirable to
improve stability of the reduction and prevent the frag-
ments from sagging back inward.
Orbit
Isolated fractures of the orbit constitute 10% of all
facial fractures. If one includes fractures of the orbit
that extend outside the confi nes of the orbit into the
facial skeleton, the incidence approaches 40% to 55%.
Fractures involving the orbit can be classifi ed as ZMC,
NOE, or internal orbital fractures.4 Internal fractures of
the orbit can occur in numerous patterns and can be
described as linear, blowout, and complex. Linear frac-
tures maintain periosteal attachments and do not gen-
erally result in a defect, but they can cause entrapment
or impingement of the extraocular muscles or the
capsulopalpebral fascia (Tenon’s capsule). This most
commonly occurs with linear fractures of the orbital
Figure 93-2. Isolated fracture of
the right zygomatic arch. The
diagram shows an inferior view of a
classic fracture pattern with three
breaks that typically occurs after a
focused blow with a blunt object.
The submental vertex radiograph
reveals an inwardly displaced frac-
ture of the right zygomatic arch
and a normal left zygoma.

908
Section 9
Plastic and Reconstructive Surgery
fl oor, especially in pediatric patients, whose facial bones
are more pliable and momentarily expand or displace
open at the time of impact and then snap back closed
and entrap soft tissue. These patients will have fi rm,
fi xed limitation on upgaze or, more commonly, on
downgaze. The patient may exhibit head tilting, nausea,
and episodic bradycardia. Early repair (within 24 hours)
and freeing of entrapped tissue are essential to prevent
ischemia and fi brosis of the tissues with long-term
restriction. Any equivocal entrapment or ocular restric-
tion can be assessed by topically anesthetizing the globe
and performing forced duction by grasping the inser-
tion of the inferior rectus muscle through the lower
eyelid fornix and attempting to move the globe superi-
orly and inferiorly.
Blowout fractures of the orbit are the most com-
monly occurring orbital injury and are limited to one
wall, with the defect being less than 2 cm in diameter.
Blowout fractures most frequently occur in the anterior
or medial part of the orbital fl oor; however, they can
occur in the medial wall or orbital roof, where they can
be manifested as blow-in fractures. Orbital fl oor blowout
fractures occasionally cause entrapment and limited
ocular motility, but they more commonly result in
expansion of the orbital volume with sagging of the
orbital contents into the maxillary sinus. Initially,
enophthalmos may not be apparent, but with clearance
of hemorrhage and resolution of edema, the condition
may become evident.
The decision to undertake surgical repair or recon-
struction of these defects is based on functional limita-
tions or cosmetic deformity.5 Defects of 25% or less of
the surface area without entrapment generally heal
uneventfully without any intervention. Repair of inter-
mediate defects involving 25% to 50% of the surface
area is based on the degree of displacement, the amount
of volume expansion, and any coexisting enophthal-
mos, even with edema. Larger or comminuted defects
(>50%) with signifi cant disruption are best treated by
early repair (within 7 days) because some degree of
enophthalmos or diplopia is the norm when left unre-
paired. Fractures of the lateral wall rarely result in
entrapment or volume changes since this area is well
supported laterally by the bulky temporalis muscle. The
lateral wall is most frequently fractured at the junction
of the zygoma and greater wing of the sphenoid (one
third of the way back from the rim), and it is usually a
component of a ZMC fracture. Medial wall fractures
rarely cause entrapment but can result in signifi cant
volume changes with a shift of orbital content into the
ethmoid air cell spaces. In this instance, repair and
reconstruction are usually indicated.
Exploration, repair, or reconstruction of fractures
of the orbital roof (or any combination of such proce-
dures) may be indicated if a dural tear is suspected or
to prevent the development of a “pulsatile globe.” This
inward and outward movement of the eye is due to the
arterial pulsations and respiratory fl uctuations that
occur in the overlying cerebral hemisphere. The pulsa-
tile globe phenomenon often becomes apparent after
resolution of edema and hematoma in unrepaired
defects of the roof of the orbit and causes persistent
blurred or double vision.
Complex fractures consist of extensive fractures
that affect two or more orbital walls; they often involve
the posterior orbit and may involve the optic canal.
Superior orbital fi ssure syndrome or orbital apex
syndrome can occur.6 The former consists of dysfunc-
tion of cranial nerves III, IV, V, and VI as a result of
compression by bone fragments or hematoma. Orbital
apex syndrome consists of superior orbital fi ssure
fi ndings with the addition of injury to the optic nerve.
High-dose systemic steroids, blood pressure control,
and elevation of the head of the bed can be palliative.
Surgical intervention with decompression is based on
correlation of CT with physical fi ndings, the degree of
optic nerve compromise, and the patient’s neurologic,
hemodynamic, and systemic stability. Retrobulbar
hematoma can be treated on an emergency basis by
performing a lateral canthotomy or inferior cantholysis
(or both) and evacuating the clot by inserting a small
curved hemostat along the lateral orbital wall and
spreading it. A small Penrose drain can then be
inserted.
Fractures of the orbital complex are usually associ-
ated with fractures of the facial skeleton outside the
orbital framework (Le Fort II or III fractures or frontal
sinus fractures) and are classifi ed as combined fractures.
A systematic approach to assessment of both orbits will
further defi ne the functional and anatomic defects asso-
ciated with injuries to the orbit. The initial ophthalmic
evaluation should include a periorbital examination
and testing of visual acuity, ocular motility, pupil
responses, and visual fi elds, as well as a funduscopic
examination. The eyelids and periorbital areas should
be inspected for edema, ecchymosis, lacerations, ptosis,
asymmetric lid droop, injury to the canaliculus, and
disruption of the canthal tendon.
Once the clinical assessment is complete, fi ne-cut
(1.0 to 1.5 mm) axial CT images can be correlated with
abnormalities or defi cits. Direct coronal images are
benefi cial in evaluating defects of the walls of the sinus,
and three-dimensional reformatting can be useful in
patients with complex facial trauma or in instances of
delayed or secondary repair. Magnetic resonance
imaging has been used to identify wood or nonmetallic
foreign bodies in penetrating injuries. These objects
can be misdiagnosed by CT as intraorbital air and
should be suspected when the apparent air collection
within the post-traumatic orbit does not resorb
rapidly.
The timing of any orbital repair is based on the
urgency of the clinical fi ndings (optic nerve compro-
mise or muscle entrapment), the extent of the defects,
associated facial fractures, or the patient’s medical con-
dition and health (Fig. 93-3). Early repair (within 5 to
7 days) offers the best results. Interval repair (within 7
to 14 days) can be undertaken once the edema and
hematoma have resolved, a clear functional or cosmetic
reason to intervene exists, and the patient is stable
enough to undergo surgery with general anesthesia.
Late repair (after 14 days) generally yields suboptimal

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
909
outcomes because of malunion and unfavorable soft
tissue adaptation.
Nose
Fractures of the nose are the most common fracture of
the face and are usually due to blunt force trauma.
Lateral or oblique blows to the nose cause inward
depression of the area of impact and lateral bowing of
the contralateral side. A concomitant fracture of the
nasal septum may accentuate the C-shaped deformity
of the nasal dorsum. The degree of displacement can
be masked by soft tissue swelling. Direct anterior force
to the nasal bridge creates a depression of the nasal
bridge and splaying of the nasal bones overlapping the
frontal process of the maxilla (Fig. 93-4). Higher-energy
impacts in this area can result in fracture of the ethmoid
sinuses and NOE fractures. Frontal sinus and anterior
basilar skull fractures are commonly associated with
NOE fractures.
Fractures of the nose are primarily diagnosed by
clinical examination. Patients sustaining a nasal frac-
ture typically have epistaxis, nasal airway obstruction,
localized pain, and an altered appearance of the nose.
Physical examination requires proper lighting, suction,
and intranasal application of vasoconstrictors by either
aerosol spray or cotton pledgets. External signs of
trauma such as lacerations, ecchymosis, or deviation of
the nasal bridge should be noted. Edema often masks
more subtle nasal fractures, and follow-up examination
in 3 to 5 days is advisable if there are equivocal signs of
nasal fracture. All areas of the nasal bones and cartilage
should be palpated lightly to detect any bony crepitus,
steps, focal tenderness, or loss of support. Once the
internal nares have been adequately cleared of clots
and the vasoconstrictor has taken effect, speculum
examination may reveal mucosal tears, septal deviation
and hematoma, and protrusion of fractured bony seg-
ments or displaced cartilage intranasally.
The patient should be questioned regarding any
preexisting nasal trauma, deformity, or septal deviation
because many of these patients will have previously sus-
tained a fracture. Signifi cant or obstructive nasal septal
deviation with pink, fi rm, normal overlying mucosa is
suggestive of chronic septal deviation and not an acute
injury. The point of attachment of the upper lateral
cartilage to the nasal bones should be carefully assessed
for disruption or detachment.
Plain radiographs of the nasal bones are seldom
useful in the diagnosis or treatment decision making
related to isolated nasal fractures. Normal suture lines
and old healed fracture lines may be indistinguishable
from acute fractures. In addition, fractured or displaced
cartilaginous structures are not visualized by plain
radiographs. If the need for a radiographic diagnosis
exists, CT is the preferred imaging modality. CT scans
clearly delineate the hard and soft tissue nasal struc-
tures, and signs such as lack of mucosal edema or asym-
metric inferior turbinate size and shape suggest a
previous injury or chronic nasal septal deformity.
Acute nasal bleeding is best managed by topical
measures: vasoconstrictors, external pressure, ice com-
presses, and elevation of the head of the bed. More
severe bleeding is managed by nasal packing.
The need for reduction of nasal fractures and sta-
bilization is based on the patient’s cosmetic appearance
and the patency of the nasal airway. Nasal fractures
elevated and reduced within the fi rst 48 hours are
Functional deficit
(-) Forced duction
test
Enophthalmos or
inferior dystopia
Normal globe
position
Muscle entrapment
on CT
Connective tissue
implingement only
on CT
Strabismus surgery
Surgical exploration
Younger
normotensive
patient
Serial examinations,
eye exercises, and
steroids for 7-10 days
Steroids and follow
clinically for 14 days
Mechanical restriction
or persistent diplopia
within 30 degrees of
primary gaze
Resolution of mechanical
restriction and diplopia
within 30 degrees of
primary gaze
Enophthalmos or
inferior dystopia
No globe position
changes
No evidence of
neuromuscular
injury
No surgery
Orbital floor reconstruction
No surgery
Emergency
exploration
Evidence of
neuromuscular
injury (by forced
generation and
retraction test)
Elderly or
hypotensive
patient
Younger
normotensive
patient
Follow clinically
with serial examinations
> 50% floor
defect or
soft tissue prolapse
< 50% floor
defect
Surgical
exploration
(+) Forced duction
test
Cosmetic deformity
Orbital Floor Fracture
Figure 93-3. Management of a
fracture of the orbit fl oor. The two
primary indications for surgical
intervention are to restore normal
function of the globe and extra-
ocular muscles and to repair a
cosmetic deformity that would
be noticeable. CT, computed
tomography.

910
Section 9
Plastic and Reconstructive Surgery
generally very stable. However, it may be necessary to
wait 3 to 5 days to allow resolution of edema so that
evaluation and proper alignment can be achieved. Most
simple nasal fractures can be reduced with closed tech-
niques under local anesthesia or intravenous sedation
in an ambulatory setting.
Nasal-Orbital-Ethmoid Complex
Impacts of higher force to the nasal complex can result
in fractures of the nasal bones, splaying, and posterior
displacement into the ethmoids (Fig. 93-4C). Clinical
signs of a fracture of the NOE complex are severe
edema, telecanthus, lack of nasal projection, persistent
epistaxis, occasionally CSF rhinorrhea, and periorbital
ecchymosis. Blurred or altered vision may be present
and is usually due to the edema and not to ocular
restriction.
Fine-cut (1.0 to 1.5 mm) axial CT scans should be
obtained to fully evaluate fractures of the NOE complex.
Even with overlying lacerations, the medial canthal
tendons are still usually attached to the bony anterior
lacrimal crest.7 The telecanthus is due to lateral dis-
placement of the central portion of the frontal process
of the maxilla. These segments are typically rotated
outward and inferiorly displaced. The canaliculi should
be evaluated for possible disruption.8 If uncertainty
exists, exploration of the wound plus repair under
general anesthesia is warranted. Any copious, watery, or
clear drainage should be collected and sent for β2-
transferrin assay to determine whether CSF rhinorrhea
has resulted from fracture of the cribriform plate or
anterior basal skull.
Open nasal fractures and coexisting septal fractures
are best treated under general anesthesia because of
patient comfort, the degree of manipulation required
for reduction, and the possibility of excessive bleeding
during instrumentation. An oropharyngeal pack is
helpful to have in place so that clots do not pool in the
hypopharynx. NOE fractures require open reduction,
internal fi xation, and often transnasal wiring under
general anesthesia.
Frontal Sinus
Fractures of the frontal sinus occur almost exclusively
in adults. The frontal sinuses are two separate bony
cavities formed either by invagination of the nasal cavity
into the frontal bone or by extension of superior eth-
moidal air cells into the same area. The frontal sinus is
not radiographically evident until 6 years of age and
becomes fully formed around the age of 15 years. The
frontal sinus drains into the middle meatus of the nasal
cavity via a foramen or ostium (85%) and less frequently
through the frontal nasal ducts. Five percent of the
adult population have either a unilateral frontal sinus
or almost no frontal sinus. The anterior sinus wall, or
outer table, is relatively thick and resistant to fracture.
The posterior table is thin membranous bone with
adherence to the surrounding dura and periorbita. The
frontal sinus wall and ducts are lined with cuboidal
respiratory epithelium that invaginates into small bony
D
A
B
C
Figure 93-4. Patterns of fractures
of the nose. A, Bowing or C-shaped
deformity caused by direct lateral
force. The ipsilateral nasal bones are
depressed. B, Greater force causes
fractures of the nose and deviation
of the septum with lateralization
of the contralateral nasal bones.
C, Comminution secondary to more
midline and heavy force with frac-
ture of the septum results in loss of
anterior
projection
and
dorsal
support. D, Fracture of the nasoeth-
moid complex caused by an extreme
anterior
impact.
The
fractures
extend posteriorly to involve the
medial orbital walls with typical splay-
ing of the medial canthal tendons.

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
911
depressions. These depressions (foramina of Breschet)
allow venous drainage of the sinus mucosa. After trauma
or incomplete removal of the mucosa, mucocele forma-
tion may arise from these remnants.
Fractures of the frontal sinus require high-impact
force such as that experienced by passengers in a motor
vehicle accident without safety restraints. Fractures of
the frontal sinus account for less than 15% of fractures
of the mid and upper portion of the face. The majority
of the time these fractures are associated with overlying
lacerations of the forehead. Palpation and inspection
through an open laceration of the forehead can reveal
a depressed deformity or bony ledge indicating a frac-
ture of the frontal sinus. It is common to have associ-
ated nasal, NOE, and orbital and maxillary fractures.
Intracranial injuries such as cerebral contusion, sub-
dural hematoma, epidural hematoma, dural tear, intra-
parenchymal bleeding, pneumocephalus, and CSF leak
are also often associated. A hyperextension injury or a
fracture of the cervical spine should be considered in
this high-risk group.
When fracture of the frontal sinus is suspected, an
axial CT scan (1.5- to 3.0-mm cuts) should be obtained
to assess the fracture and the degree of displacement
of the anterior and posterior tables. Displacement of a
frontal sinus fracture is defi ned as overlap by the amount
of thickness of the adjacent cortical bone. Intermediate
distinctions such as mild or moderate are confusing and
have no clinical relevance. Both the anterior and pos-
terior tables should be categorized as fractured or not
involved and displaced or nondisplaced. A displaced
posterior table (overlapped fracture margins) is often
associated with tears of the dura or cerebral injury
requiring neurosurgical intervention.
Management of fractures of the frontal sinus should
follow a logical decision-making process, as outlined
in Figures 93-5 and 93-6. Open fractures of the frontal
sinus require emergency exploration and treatment.
Open fractures can be treated by primary cutaneous
repair and delayed treatment of the injury to the frontal
sinus, if necessary. A fractured frontal sinus usually fi lls
with blood and mucus after trauma. Prophylactic anti-
biotics that cover most sinus microorganisms (ampicil-
lin with clavulanate) or a fi rst-generation cephalosporin
is generally recommended. Patients with involvement
of the posterior table and displacement are often
administered a broader-spectrum antibiotic that can
cross the blood-brain barrier. Cervical immobilization
should be maintained until cervical spine injury can be
defi nitively excluded. Sinus decongestants are of poten-
tial benefi t and should be considered in patients with
frontal sinus trauma.
Defi nitive treatment of fractures of the frontal sinus
depends on the extent of the fracture.9 If the drainage
system of the sinuses is signifi cantly compromised, oblit-
eration or cranialization is generally recommended. If
only the anterior table is fractured and nondisplaced,
surgical treatment is not usually necessary. A displaced
fracture of the frontal sinus that is extensive enough to
create a cosmetic deformity can be accessed directly
through the fracture or via a liberal sinusotomy. The
mucosal lining is then completely removed by curettage
and drilling to deter formation of a mucocele, typically
years later. The nasofrontal ducts can then be obliter-
ated with fascia or bone grafts and the frontal sinus can
be obliterated with autologous fat, bone, pericranium,
or alloplastic material.
If only the anterior table is displaced without
involvement of the nasofrontal ducts, primary repair
without obliteration can be performed. Signifi cant
involvement or displacement of the posterior table
usually requires direct exploration, with repair or cra-
nialization depending on the degree of damage.10
Smaller frontal sinuses in young patients can be cranial-
ized by simply removing the posterior wall of the sinus,
smoothing the edges, removing the mucosal lining, and
obliterating the frontonasal ducts. Such treatment in
Displaced
No
Yes
Observe
Nasofrontal duct
involved
No
Yes
Reduction & fixation,
sinus preservation
Reduction & fixation,
sinus obliteration
Anterior Table Fracture Only
Figure 93-5. Fracture of the frontal sinus with appropriate
management.
Displaced Posterior Table
No
No
Yes
No
Yes
Yes
CSF leak
Observe
Allow up to 7 days
for resolution. If
persistent leak, then
consider cranialization
No
Yes
Nasofrontal duct
involved
Reduction & fixation
of anterior table,
sinus obliteration
Reduction & fixation
of anterior table,
sinus preservation
CSF leak
Anterior/Posterior Table Fracture
Figure 93-6. Fracture of the frontal sinus involving the posterior
table requires further evaluation, and more treatment options exist,
depending on the alignment of the posterior table and whether a
cerebrospinal fl uid (CSF) leak is present.

912
Section 9
Plastic and Reconstructive Surgery
older patients and those with large frontal sinuses may
predispose to the development of chronic subdural
fl uid accumulations. With displaced fractures of the
posterior table, the presence of associated tears of the
dura requiring neurosurgical management is the rule
rather than the exception.
SURGICAL APPROACHES
Airway Management
Special consideration should be given to secure the
airway when repair of midfacial and panfacial fractures
is undertaken.11 A coordinated strategy and discussion
of issues that affect the airway, such as the complexity
of the injury, the length of the procedure, the surgical
approach, the use of intraoperative or postoperative
maxillomandibular fi xation (MMF), and the route and
method of intubation, should take place between the
surgeon and anesthesiologist. Cervical collars, Mayfi eld
head holders, and the direction of the anesthetic tube,
including the method of securing it, should also be
considered. Patients with isolated nasal or zygomatic
fractures should be orally intubated. Patients with Le
Fort I–level fractures can be safely intubated nasally
with a standard tube or nasal RAE tube. Cervical spine
precautions may necessitate that intubation be per-
formed fi beroptically. Patients with Le Fort II, Le Fort
III, and NOE fractures may not be suitable for nasal
intubation as a result of the need to repair or manipu-
late the nasal bones and septum. Oral intubation is
often not possible because of full dentition and the
need for MMF during surgery to re-establish the occlu-
sion and align the fracture segments. If adequate eden-
tulous space exists for insertion of the oral endotracheal
tube between the teeth in MMF, this is an option. The
tube can be secured to the sound adjacent teeth with
26-gauge circumdental wire. Passing the tube distal to
the second molars in a fully dentate patient is often not
satisfactory because of kinking of the tube, interference
with surgical access, or potential displacement during
surgical manipulation and turning of the head. In this
instance or when concern for violation of the cribri-
form plate exists, a tracheostomy should be performed
at the start of the procedure and a reinforced cuffed
endotracheal tube placed, its position confi rmed, and
the tube secured with suture.
Sequencing of Treatment
Generally, arch bars are fi rst applied to the maxillary
and mandibular dentition as described in the previous
chapter.
An intact mandible provides an excellent reference
for re-establishing proper midfacial projection and
transverse alignment with the use of MMF. It is often
preferable to then open all fracture sites that require
reduction and plating. It is usually easiest to start plating
around points of broad, solid bony contact such as the
frontozygomatic sutures, frontal sinus, zygomatic arches,
and zygomatic buttresses along the posterior maxilla.
The thinner piriform rims, anterior maxilla, and nasal
bones are fi xated last. If the mandible is fractured, it is
still best to place arch bars fi rst, apply MMF, and then
re-establish mandibular continuity by anatomic reduc-
tion and plating of the more anterior fractures (sym-
physis) and progressively working to the more posterior
fractures, with condyles treated last. If both condyles
are fractured, it is benefi cial to open and plate at least
one side to help re-establish proper posterior vertical
dimension and a stable hinge axis point. When a patient
is edentulous in one or both arches, best-fi t anterior
reduction plating is practical. If dentures exist, they can
be secured to their respective arch by circum-mandibu-
lar wiring or screwing to the palate through holes pre-
drilled in the lateral palatal shelves of the denture itself.
In most instances, dentures interfere with surgical
access, are ill-fi tting or unstable, and do not greatly aid
in fracture reduction. Repair or reconstruction of inter-
nal orbital fractures and defects is generally performed
last because stable and aligned orbital rims help guide
and stabilize the repair.
Maxillary/Le Fort Fractures
Le Fort I fractures are approached through a maxillary
vestibular incision placed 1 cm from the outstretched
mucogingival junction from fi rst molar to fi rst molar.
Distal extension beyond this point invites herniation of
the buccal fat pad and additional bleeding. Subperios-
teal dissection is then accomplished with minimal strip-
ping and soft tissue refl ection on the inferior (or
dental-bearing) segment that will just permit plate and
screw placement. Infi ltration of the maxillary vestibule
with local anesthetic containing a vasoconstrictor mini-
mizes oozing, and placing the patient in MMF before
incision helps stabilize the maxillary segment and facili-
tates soft tissue dissection. Subperiosteal placement of
toe-up Obwegeser retractors along the lateral maxillary
“pockets” provides excellent “hands-free” exposure.
Once the entire anterior maxillary fracture line is
exposed with adequate areas for plating, the MMF is
rechecked and tightened slightly, if needed, because of
stretching of the wire. Any debris or small free-fl oating
piece of bone is removed, and the fracture is reduced
by applying upward vertical pressure on the mandibular
angles bilaterally. Digital pressure in the submental
region or chin often provides what appears to be
improved reduction of the fracture, but at the expense
of slight distraction of the condylar heads from the
fossae. Plating in this position results in an immediate
anterior open bite on release of the MMF wires, or it
can occur postoperatively when the patient’s mastica-
tory muscles seat the mandibular condyles. Therefore,
it is best to plate and fi xate the maxilla with slight ante-
rior wall contact irregularities because the fractured
heavier posterior maxilla and pterygoid regions may
not allow complete vertical reductions either. With the
condyle seated by applying constant pressure to the
angle region, the maxilla is fi xated with 1.7- or 2.0-mm
miniplates in the piriform and zygomatic buttress
regions.12 Generally, four plates are applied, and L
shapes seem to work the best because two screws can be

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
913
placed in the inferior segment of each plate without
violating any tooth roots (Fig. 93-7). Irrigation should
be used during drilling to prevent overheating of the
thin maxillary bone. Placing the anterior plates 2 to
3 mm laterally from the edge of the piriform rims and
slightly medially inward allows engagement of both the
anterior maxillary and lateral nasal walls and thus pro-
vides improved stability.13 Screws 4 to 5 mm in length
are the norm. Once all plates are placed, the MMF wires
(not the arch bars and circumdental wires) are cut and
removed, and the occlusion is checked by applying
intermittent mild pressure on the mandibular angles.
The circumdental wires and arch bars are removed only
after adequate fracture reduction and fi xation are con-
fi rmed and the surgeon is confi dent that there will be
no need for a period of postoperative MMF or elastic
guidance.
For closure, a nasal cinch suture that engages the
underside or inner aspects of the alar bases is placed
and secured to draw the ala together to the preinjury/
presurgical position. Closure of the muscular layer is
then performed on each side with several interrupted
4-0 Vicryl sutures (braided polyglactin suture, Ethicon).
The maxillary mucosal incision is closed with 3-0 or 4-0
chromic suture in a running horizontal mattress stitch.
The pack should be removed from the throat and an
orogastric tube passed. The area should be suctioned
and then the tube withdrawn before extubation.
Treatment of a Fort II fracture is similar to treat-
ment of a Le Fort I fracture but usually requires higher
medial dissection for plating. Generally, plating of the
frontonasal or high medial nasomaxillary fracture lines
is unnecessary. However, if comminution or lack of sta-
bility dictates the need to fi xate in this region, access
via a coronal incision is preferred over an “open-sky”
approach (H shaped; combined medial brow and gla-
bellar and lateral nasal incisions). Sometimes an exist-
ing laceration can be accessed and extended slightly for
plating. Fixation of the frontonasal junction with bilat-
eral smaller plates along the lateral nasal/medial orbital
rim contours is less palpable than fi xation with a mini-
plate directly over the midforehead and nasal dorsum.
Le Fort III fractures generally require both a maxil-
lary vestibular incision (because there are usually
additional maxillary lines of fracture) and a coronal
approach to access and fi xate the frontonasal, zygomati-
cofrontal, and zygomatic arch fractures. The coronal
incision is a wavy line that is placed approximately 2 cm
posterior to the hairline (midline) and extended pos-
teriorly and then inferiorly in the preauricular region
(Fig. 93-8). The wavy line facilitates “turning the fl ap
Figure 93-7. Le Fort I fracture repair. The right maxillary vestibu-
lar incision was made 1 cm above the mucogingival junction. Arch
bars were secured and the patient placed in maxillomandibular fi xa-
tion. The anterior maxillary bony reductions appear slightly off, but
this is typical because it is usually impossible to fully reduce a frac-
tured posterior maxilla with the condyles seated by pressure at the
angles of the mandible. The maxilla is fi xated with miniplates and
2.0-mm screws in the areas of heaviest bone: the buttress (left) and the
piriform rim (right). No attempt is made to “reconstruct” the anterior
maxillary wall defect, and it should heal uneventfully. Any free bone
fragments should be removed from the sinus.
A
B
Figure 93-8. Design of a coronal fl ap. A, The preauricular incision
is not extended below the lower edge of the tragus. Going below and
deep to this invites injury to the main trunk of the facial nerve. At
the superior extent of the auricular attachment the incision is curved
posteriorly for about 0.5 cm to help avoid cutting the superfi cial
temporal artery (STA). The STA can generally be left intact and
refl ected forward with the coronal fl ap. B, A soft wavy line rather than
a straight side-to-side incision allows ease in turning the fl ap over.

914
Section 9
Plastic and Reconstructive Surgery
over” and has the added benefi t of being less noticeable
when the hair is wet, such as during swimming, and
when mild hair loss has occurred. The incision is carried
through skin, subcutaneous connective tissue, galea
aponeurotica, and loose areolar tissue in the midline
and extended laterally in the supraperiosteal plane to
the superior temporal line bilaterally.
The subgaleal plane of dissection is contiguous with
a plane deep to the parietotemporal fascia in the area
of the temporalis muscle. Dissection is carried anteri-
orly to the frontal bone, and a horizontal incision is
made through the periosteum approximately 2 to 3 cm
superior to the orbital rim (Fig. 93-9). This incision is
carried laterally to the superior temporal line and is
joined with the preauricular area inferiorly through the
superfi cial layer of the deep temporal fascia to protect
the temporal branch of the facial nerve (Fig. 93-10).
The frontal branch or superior division of the facial
nerve courses in a plane superfi cial to the deep tempo-
ral fascia approximately 1 to 2.5 cm from the tragus
along the zygomatic arch. This approach provides access
to the entire medial, lateral, and superior orbital frame.
Closure may include suspension of the cut temporal
fascia over the temporalis muscle and should include
deep closure of the galea aponeurotica, subcutaneous
tissue, and skin. Miniplates secured with 3- to 4-mm-
length screws are adequate for fi xation (Fig. 93-11). It
is desirable to use burrs with drill stops (ledges that
prevent drilling beyond predetermined depths) when
working around the orbital rims. The lateral canthal
Figure 93-9. Frontal view of a refl ected bicoronal fl ap. The peri-
cranium is cut horizontally 2 to 3 cm above the superior orbital rims.
The supraorbital nerves were in notches (not foramina) and were
freed for full exposure of the nasal complex and superior medial
orbital walls. Reduction of the fractures of the nose and orbit com-
pletely reduced the telecanthus, and therefore transnasal wiring was
unnecessary.
Figure 93-10. Left coronal view of the incision through the super-
fi cial layer of the deep temporal fascia just below the temporal line.
The dissection should be deep to this layer to protect the frontal
branch of the facial nerve and be confl uent and deep to the perios-
teum of the zygomatic arch to protect the superior division of the
facial nerve.
Figure 93-11. Left lateral view of a bicoronal dissection and plating
of the arch and lateral orbital rim. Note that clean refl ection of the
superfi cial temporal fascia along with the arch periosteum led to a
safe and dry fi eld.
attachments to the internal orbit (Whitnall’s tubercle)
should not be disturbed during dissection and there-
fore do not require reattachment.
Skeletal suspension wires from the intact portion of
the facial bones (frontal or circumzygomatic) can aid
in stabilizing the maxillary fractures or can be used
as a sole means for accomplishing closed reduction
by securing them through intermediate wires to the

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
915
mandibular arch bar or circum-mandibular wires (Fig.
93-12).
After repair of any Le Fort fracture (I, II, or III),
the nasal septum should be inspected to make sure that
it is not subluxated or laterally displaced. The nasal
septum can be repositioned or slightly trimmed at the
inferior aspect, if necessary, to allow positioning in the
midline. Once the fractures are reduced and fi xated, a
forced duction test of both eyes should be performed
to rule out entrapment of muscle because the majority
of these fractures have an orbital component.
Zygomatic Fractures
Isolated fractures of the zygomatic arch are best repaired
within 72 hours of the injury. In this time frame the
arch tends to reduce easily, with excellent indexing and
stability and no need for internal fi xation or external
splints. Fractures of the arch can be approached through
a limited lateral brow incision with blunt dissection
down to the supraperiosteal plane or via a Gillies
(2.5-mm oblique temporal hairline) incision and avoid-
ance of the superfi cial temporal artery.14 The temporal
fascia is exposed, and a Freer elevator is used to create
a small pocket between the fascia and temporalis muscle.
With either approach, a blunt stout instrument (curved
Kelly clamp, urethral sound, or Rowe zygomatic eleva-
tor) is inserted beneath the arch. It is often helpful to
palpate with the opposite hand intraorally in the poste-
rior buccal sulcus to detect a slight defl ection from the
tip of the instrument. The arch is then elevated with
lateral and superior force while taking care to not lever
off any other facial bones. An audible crack or pop
indicates that the fracture has been reduced, and palpa-
tion of a convex contour confi rms the reduction. The
subcutaneous and skin layers are closed, and the patient
is advised to avoid contact to the area for several weeks.
A maxillary vestibular (buccal sulcus) approach can be
used, but it might be accompanied by bleeding from
the masseter muscle and has the risk of inferior/lateral
orbit violation if the arch elevator is overinserted
beneath a moderately depressed arch fracture.
Fractures of the ZMC can be approached by a
variety of incisions: lateral brow, modifi ed blepharo-
plasty, hemicoronal, transconjunctival, infraciliary, and
maxillary-vestibular. The degree of injury and the dis-
placement often dictate which areas of the ZMC must
be accessed and fi xated.15,16 Although a single miniplate
at the frontozygomatic suture may suffi ce for healing,
it may not provide absolute rigidity to maintain malar
projection and ideal contours. Typically, at least two
points of fi xation and plating are used to achieve rigid-
ity. We generally prefer plating at the frontozygomatic
suture because it is easily indexed and has heavy bone
stock for fi xation. The second area of fi xation can be
either across the zygomatic buttress (maxillary vestibu-
lar incision) or at the infraorbital rim. The latter is
chosen when exploration of the orbital fl oor or recon-
struction is anticipated (Fig. 93-13). These approaches
and materials for repair are fully discussed in the next
section.
Before plating any fracture lines, all sites are
exposed, and the ZMC is reduced to satisfaction in each
area.17 The ZMC is then fi xated with miniplates (1.7- to
2.0-mm systems) while taking care to maintain the
plates several millimeters away from the orbital rim so
that they will not be visible or palpable. If associated
facial fractures (Le Fort, frontal sinus) or comminution
exists, it may be necessary to obtain direct access to the
entire zygomatic arch for fi xation and stabilization.18
This is accomplished via a coronal or hemicoronal
approach. Care should be exercised to not “overele-
vate” the arch at its midpoint. The zygomatic arch has
a slight curve at its anterior and posterior extents but is
fl at in the middle. Overprojection of the arch should
be avoided because it causes a tumor-like protrusion
postoperatively that will persist.
Orbit
Once it has been determined that a patient requires
surgical intervention for a fracture of the orbit, several
factors must be considered when selecting the surgical
approach and method of reconstruction. The primary
consideration is to determine which walls need to be
repaired. Associated facial fractures, lacerations, and
surgeon preference are other important factors.
Three basic incisions provide access to the orbital
fl oor: infraorbital, subciliary, and transconjunctival
(Fig. 93-14). The subciliary and transconjunctival inci-
sions, because of their superior aesthetics, are the most
commonly used today.19,20 In the subciliary approach,
the skin is incised several millimeters below the
lid margin in a skin crease and dissected from the
Figure 93-12. Skeletal suspension wires as seen on a lateral cepha-
logram. Bilateral frontal suspension wires (24- and 26-gauge “pullout
wires”) and circum-mandibular wires (24 gauge) were passed with
awls and secured to arch bars to support and immobilize a Le Fort I
fracture. The frontal and circum-mandibular suspension wires were
secured to each other with a 26-gauge intermediate wire loop. Open
treatment was not performed because of cervical spine injury and the
patient’s critical status. A tracheostomy had been performed previ-
ously to secure the airway.

A
B
E
F
C
D
Figure 93-13. Severely displaced fracture of the left zygomatic complex. A, Axial computed tomography (CT) scan showing the buttress
driven inward to the posterior maxillary sinus and approaching the pterygoid plates. The cursor arrow overlies the area of impact, and a depres-
sion is seen despite tremendous soft tissue swelling. B, Slightly inferior CT scan demonstrating the fractured posterior zygomatic arch compo-
nent with probable mechanical impingement on the tip of the coronoid process. Diffi culty opening the mouth for oral intubation should be
anticipated and evaluated. The soft tissue swelling “masks” the degree of bony displacement. C, Facial appearance as the patient was prepared
for surgery urgently because of a tense left periorbita and decreased vision in the left eye. She was taking warfarin (Coumadin) for atrial fi bril-
lation and suffered signifi cant localized bleeding and in essence “a compartment syndrome” of the orbit. D, The left lateral brow incision was
fi rst undertaken and the entire zygomatic complex grossly reduced. A miniplate was fi xated with 1.7-mm-diameter, 3 mm-long screws after the
inferior orbital rim and zygomatic buttress were exposed and reduced. E, Orbital rim plated after transconjunctival retroseptal dissection and
inferior cantholysis. The rim was stabilized with a miniplate and 1.3-mm-diameter screws. F, The fl oor of the orbit had been almost completely
destroyed. It was reconstructed with a 0.85-mm-thick sheet of Medpor (high-density porous polyethylene) that was fi xated inferolaterally to the
intact fl oor ledge with a single 5-mm-long, 1.7-mm-diameter screw to prevent migration or “unfl exing” of the gently curved Medpor. Forced
duction of the globe should be performed at this stage to ensure that none of the orbital contents have become entrapped or tethered by the
repair or fi xation.

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
917
G
I
H
J
Figure 93-13, cont’d. G, Maxillary vestibular view of the reduced
zygoma and resultant anterior maxillary wall defect that was not recon-
structed. The Medpor orbital fl oor repair is visible from below. The
patient’s edentulous maxillary ridge can be seen in the lower left area.
H, The zygomatic buttress was fi xated with a miniplate and 1.7-mm-
diameter screws. I, Postoperative axial CT scan obtained the following
day showing symmetrical alignment. J, Facial view 1 month after
surgery.
B
A
Figure 93-14. Inferior lid approaches. A, Subciliary dissection with the initial skin incision just below the lash line through orbicularis oculi
muscle and staying anterior to the orbital septum and carried inferiorly to the rim. The periosteum is incised several millimeters below the rim
(level of the arcus marginale and orbital septum attachment) and then refl ected to gain access to the orbital fl oor. B, Lower eyelid skin crease
approach to the inferior orbital rim and fl oor. After incising the skin, the inferior dissection is performed anterior to the orbicularis oculi
muscle.

918
Section 9
Plastic and Reconstructive Surgery
orbicularis oculi for a few millimeters before splitting
the muscle fi bers down to and anterior to the orbital
septum. Division of skin and muscles at different levels
helps prevent direct scarring and retraction of the
eyelid. The dissection is then carried down to the orbital
rim, the periosteum is incised 2 mm below the orbital
rim (below the arcus marginale), and the dissection is
extended posteriorly along the orbital fl oor to elevate
the orbital contents and reduce the fl oor fractures. One
can safely dissect 30 mm back along the fl oor because
the optic canal is 40 mm from the anterior lacrimal
crest and is superiorly and medially located. After repair
is complete, several tacking sutures can be placed in the
periosteum at the rim, and only the skin is closed with
cutaneous 6-0 nylon suture.
The transconjunctival approach has two variations:
retroseptal and preseptal. The retroseptal approach is
a more direct approach to the orbital fl oor, but it
exposes the extraconal fat, which can obstruct the sur-
geon’s view. For this reason the preseptal approach is
preferred. To avoid excessive tension and stretching of
the lower eyelids, many surgeons prefer to start by per-
forming a lateral canthotomy (3-mm skin incision in a
crow’s foot line) and inferior cantholysis, which consists
of division and release of only the inferior leafl et of the
lateral canthus (Fig. 93-15). The lid is then held out and
forward with fi ne forceps, and the palpebral conjunc-
tiva and inferior lid retractors (smooth muscle that is
an extension of the capsulopalpebral fascia) are under-
mined and incised 2 to 3 mm below the inferior edge
of the tarsus. If one undermines and incises at the
depth of the fornix and aims toward the caruncle (small
yellow mound of tissue) medially, injury to the tarsus
and inferior canaliculus can be avoided.
The dissection is then carried inferiorly along the
plane superfi cial to the septum (to avoid herniation of
fat) down to the orbital rim, and the periosteum is
incised on the facial aspect. After orbital repair the
periosteum is approximated with several fi ne inter-
rupted sutures. The conjunctiva is closed with several
6-0 fast-absorbing gut sutures. If there is any uncertainty
in reapproximating the correct layers, do not suture.
Tacking the orbicularis oculi to the periosteum of the
orbital rim will result in acute ectropion, lid retraction,
and a “hound dog eyes” appearance. If this occurs, have
the patient vigorously massage the area to stimulate its
release. If the situation does not resolve within several
weeks, reopen the site and release it. It may be advisable
to place a reverse-Frost (modifi ed tarsorrhaphy suture)
for 24 hours. Reattachment of the inferior leafl et of the
lateral canthus is accomplished with 4-0 Mersilene
double-armed suture on an S-2 needle. The needles are
passed internally to externally along the lateral orbital
rim (cut margins) to ensure proper insetting of the
lid.
Access to the superior orbital rim and the fronto-
zygomatic suture can be achieved with an eyebrow
incision, an upper blepharoplasty incision, or coronal
dissection. The eyebrow and blepharoplasty incisions,
because of their excellent aesthetics, are most often
used. The coronal incision is used when extensive facial
or skull fractures are present. The eyebrow incision is
placed on the lateral aspect (1.5 cm) above the brow
and parallel to the hair follicles. Sharp dissection with
electrocautery can be carried down through the subcu-
taneous tissue, orbicularis oculi muscle, and perios-
teum. This provides excellent access to the lateral
rim and plating at the frontozygomatic suture, which
is 1 cm above the lateral canthus. The upper blepharo-
plasty incision is similar to the brow incision, but
slightly more inferior and more horizontal. It is placed
in one of the skin creases of the upper eyelid and
carried through the subcutaneous tissue, orbicularis
oculi, and periosteum. A 1.0- to 1.5-cm incision is all
that is necessary because of the mobility and laxity of
the lid tissues. Closure requires suturing of the perios-
teum and skin.
Access to the medial orbital rim and superior aspect
of the medial orbital wall can be obtained through a
coronal (see Fig. 93-9) or a lateral nasal incision. Access
to the inferior medial orbital wall can be achieved via a
transconjunctival approach. The lateral nasal approach
involves a vertical, 1.5-cm curvilinear incision approxi-
mately 0.5 to 1.0 cm anterior to the medial canthus.
Care must be taken to not place the incision too close
to the medial canthus, which can result in scar contrac-
ture and “webbing.” Dissection is carried through the
skin, subcutaneous tissue, orbicularis oculi, and perios-
teum. The periosteum can then be refl ected posteriorly
and superiorly to the medial orbital rim and wall. The
medial canthal tendon, which envelopes the lacrimal
sac, lies posterior and inferior to the incision. A single
subcutaneous suture and multiple interrupted skin
sutures are all that is required for closure.
The goal of primary reconstruction of internal frac-
tures of the orbit is restoration of mobility and function
of the globe, re-establishment of normal volume, and
elevation of prolapsed soft tissues from the paranasal
sinuses.21 Isolated linear fractures are reduced, and any
entrapped soft tissues are freed. No grafting is required,
but a piece of Gelfi lm or fi ne (0.85 mm) Medpor
(porous polyethylene, Porex Surgical) can be laid over
the site if the surgeon is concerned about impingement
or risk of re-entrapment.22
Blowout and larger defects can be reconstructed
with a variety of materials: split calvarial bone, Medpor,
and titanium mesh. The graft should not extend all the
way to or over the inferior orbital rim. This creates a
posterior ramping effect on the globe and does not
restore the normal contours of the orbital fl oor. The
orbital fl oor dips down several millimeters immediately
behind the inferior rim and has a gentle concave curve
from side to side and anterior to posterior. Overgraft-
ing with excessive reduction of orbital volume or placing
the graft too anterior with posterior sloping tends to
prop the globe too far superiorly and creates a vertical
dystopia with the possibility of persistent enophthal-
mos. Attempts should be made to rest the graft on
intact bony ledges and to position the graft beyond the
equator of the globe posteriorly. The grafts can be
secured with screws or sutures, depending on the nature
of the reconstruction (Fig. 93-16). Unsecured grafts can

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
919
B
C
E
F
A
D
Figure 93-15. Transconjunctival preseptal approach. A, The palpebral conjunctiva and inferior lid retractors are incised below the inferior
edge of the tarsal plate. The inferior dissection is anterior to the septum to avoid herniation of orbital fat into the operative fi eld. B, Left lateral
canthotomy incision. Generally, it is only 5 to 7 mm in length and carried through the orbicularis oculi muscle. C, Inferior cantholysis performed
with tenotomy or iris scissors. It is helpful to angulate the tips of the scissors slightly downward to ensure division of only the inferior canthal
tendon and leaving the superior leafl et intact. The tips of the scissors are just superfi cial to the periosteum of the rim when the cut is performed.
The cut lateral edge of the lid is grasped with 0.5-mm pickups, and additional “snipping” of the canthal attachments is performed until the lid
can be adequately mobilized for the following step. D, The lid is gently held outward at two points by the assistant while the surgeon undermines
the palpebral conjunctiva and inferior lid retractors (smooth muscle). This is toward the depth of the fornix, and the tip of the blunt scissors
is pointed medially toward the caruncle. E, These same layers are then divided. F, Desmarres retractors are used to refl ect the lower lid inferi-
orly. A Lucite lid plate or malleable retractor rests on the inner edge of the rim to retract the septum and orbital contents inward during inci-
sion of the facial periosteum several millimeters below the rim.

920
Section 9
Plastic and Reconstructive Surgery
I
G
H
Figure 93-15, cont’d. G, The fracture of the zygoma has been
reduced and the rim aligned and fi xated with a miniplate and 1.7-mm
screws. H, Generous access as a result of inferior cantholysis and a clean
fi eld secondary to the preseptal approach. I, Postoperative appearance
at 6 weeks.
migrate forward to the rim and be palpable or angle
and protrude into the paranasal sinuses.
Fractures of the orbital fl oor should not be over-
treated. If there are no fi rm fi ndings—entrapment,
greater than a 50% fl oor defect with orbital herniation,
acute enophthalmos—allow the edema to resolve,
reevaluate the wound, and intervene only if a functional
defi cit or cosmetic deformity warrants repair.
Nose
Nasal and septal fractures should be repaired as soon
as possible but can be delayed 7 to 10 days to allow reso-
lution of edema and reassessment. Closed reduction is
all that is required for most nasal and septal fractures.
It can be accomplished under topical anesthesia, local
anesthesia, intravenous sedation, or general anesthesia.
Topical anesthesia and vasoconstriction are achieved
with the insertion of cottonoids (0.5 × 3 inches) or
cotton pledgets saturated with 2% to 4% lidocaine
and the vasoconstrictor of choice (1 : 50,000 epineph-
rine, 1 : 10 dilution of 0.25% phenylephrine [Neo-
Synephrine], 0.05% oxymetazoline). These objects are
inserted high into the nasal vault between the nasal
bones and septum, at the base of the septum, and at
the lateral inferior turbinates.
It is benefi cial to inject local anesthetic at each site
(0.5 mL) along the lateral nasal bones, at the infraor-
bital nerve externally, and at the base of the anterior
septum. Even if general anesthesia is used, the local
anesthetic with vasoconstrictor facilitates direct vision
and minimizes bleeding and postoperative pain. After
waiting a full 10 to 15 minutes for the vasoconstrictive
action, the pledgets are removed. A blunt elevator
(Goldman elevator, knife handle) is inserted a prede-
termined amount with the thumb pressed against the
external skin overlying the nasal bone to be elevated.
Slight thumb pressure allows rotational or twisting
motion as the nasal bone is elevated and aligned (Fig.
93-17). The nasal bones and dorsum are then inspected
and palpated for midline alignment, projection, and
symmetry. In general, the nasal bone fractures are
reduced fi rst, and then the nasal septum is inspected
with a speculum and aligned as needed. Asch forceps
are inserted bilaterally into the nasal cavity; they can be
placed higher in the nasal vault to provide additional
anterior force and elevation of the nasal bones or, more
commonly, along the base and midseptum to bring the
structures into midline. The reduced septum should
provide support to the overlying nasal bones and allow
a patent bilateral nasal airway. After fi nal inspection of
the nasal bones and septum, internal silicone splints
can be placed bilaterally along the septum, and a 3-0
silk transfi xion suture should be passed through both
splints and the anterior septal cartilage to secure
them.
The nasal skin is then dried and “defatted” with
alcohol wipes and a small amount of topical adhesive

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
921
A
B
C
D
E
F
Figure 93-16. A, Frontal view of a 53-year-old man who had fallen from a tree and sustained a fracture of the zygomatic complex (ZMC)
and a ruptured left globe. He had been treated at another center by open reduction and internal fi xation of the left ZMC, enucleation of the
globe, and insertion of a 12-mm hydroxyapatite (HA) sphere. He complained that his prosthesis would dislodge and that his left “eye” appeared
sunken in and down. B, Submental view showing signifi cant left enophthalmos (>10 mm). The HA implant sphere was too small and the orbital
volume was too large. C, The left orbit was reconstructed with a titanium mesh plate that served as a scaffold for multiple calvarial split-
thickness grafts. The grafts were placed posteriorly and laterally behind the equator of the HA globe. D, To restore lower lid length and recon-
struct the fornix, a free mucosal graft was harvested from the buccal aspect of the mouth and inset and the form supported by 6-0 Prolene
sutures and a Telfa bolster. E and F, Postoperative coronal computed tomography scans demonstrating the reduced orbital volume with mesh
and grafts in place.

922
Section 9
Plastic and Reconstructive Surgery
G
H
I
Figure 93-16, cont’d G, Fornix and anterior projected mucosalized
HA sphere 6 weeks after surgery. H, New and thinner prosthesis (eye
contact lens) with a red dot that helps the patient orient it for insertion.
I, Facial appearance 2 months after the procedure.
solution applied, followed by porous paper tape or
Steri-Strips. A thermoplastic splint can then be trimmed,
heated, and adapted to the external nasal contours and
secured with adhesive tape. These coverings are gener-
ally left in place for 1 week. Compound nasal fractures
should be repaired earlier. Direct access to the bones
through the laceration may allow wiring or plating for
stabilization if necessary. Closed reduction is accom-
plished with a similar sequence and protocol. External
splinting, even over sutured lacerations, is acceptable.
Attempts should be made to close mucosal lacerations
over the nasal and septal cartilage with absorbable 5-0
suture.
Nasal-Orbital-Ethmoid Complex
NOE injuries result in signifi cant aesthetic deformities.
Injuries to the nasal airways and lacrimal system can also
occur. Injuries to the lacrimal system can be managed
by placing small silicone tubes (Crawford tubes) within
the superior and inferior canaliculi down through the
lacrimal sac, retrieving them intranasally with a Craw-
ford hook below the inferior turbinate, and then tying
them together. Repair of NOE injuries is recommended
within the fi rst week after injury because soft tissue col-
lapse and readaptation cause permanent thickening of
this region. Medial rectus entrapment with NOE inju-
ries is uncommon. The primary defects that occur with
NOE injuries are splaying of the nasal bones, posterior
displacement with lack of support, and lateral canthal
displacement.
Isolated medial orbital wall defects are best
approached directly through lateral nasal incisions.
Approaches to the inferior orbital rim and fl oor, such
as the subciliary or transconjunctival approaches, are
often necessary for fi xation of displaced segments of
bone or fi xation of graft material (alloplastic or autog-
enous bone) to stable bone. Coronal approaches may
be necessary when there are associated frontal sinus
fractures; however, these approaches offer limited
access for isolated NOE fractures.23 Access through any
combination of overlying laceration, coronal incision,
or lateral nasal incision is generally required to ade-
quately treat these injuries (Fig. 93-18).
Traumatic telecanthus should be treated by direct
fi xation techniques with 1.0- to 1.7-mm plating systems.
External splinting rarely yields satisfactory results. With
NOE fractures, the medial canthal tendons usually
maintain their attachments to the bony segments.
Proper reduction plus fi xation of the bony skeleton to
the surrounding stable bone (maxillary, orbital, or
frontal) often corrects the telecanthus deformity. With
more severe injuries it is often necessary to perform
transnasal fi xation. A fi ne stainless steel wire (30 gauge)
can be directly secured or sutured to the canthal tendon
for this purpose (Fig. 93-19). The wire is inserted just
posterior and superior to the lacrimal fossa by a wire-
passing burr or curved needle. The two limbs of the
wire can then be twisted gradually around a short
section of plate in the opposite orbit to adjust and “fi ne-
tune” the canthal position. Avoid nasal packing to

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
923
A
B
C
D
Figure 93-17. Reduction of a frac-
ture of the nose. A and B, The bowed
or C-shaped deformed nasal complex
is reduced with a blunt elevator.
C and D, Reduction of fractures
of the nose that are telescoped is
accomplished with Walsham and
Asch forceps.
stabilize or align the nasal septum. The packing tends
to bow the nasal bone reduction out and creates a per-
manently full and broad-appearing nose. If the septum
is not in the midline, realign the septum surgically or
trim the base and stabilize with thin Silastic internal
splints bilaterally. Inadequate narrowing of the nasal
bones when treating NOE fractures leads to persistent
telecanthus and lack of nasodorsal projection. Transna-
sal wiring during the initial repair avoids this complica-
tion, which is extremely diffi cult to correct later.
If nasal dorsal strut grafts, such as split calvarial
bone or alloplast, are being contemplated, the health
and adequacy of the overlying soft tissue and skin must
be assessed. If maceration or signifi cant soft tissue devi-
talization is present, secondary reconstruction of the
nasal dorsum is advisable (Fig. 93-20). The decision
whether to perform immediate reconstruction or delay
grafting is made on an individual case basis. Before
undertaking any secondary reconstruction of an NOE
injury, it is helpful to obtain a CT scan with three-
dimensional reformatting. This aids greatly in surgical
planning, preparation, and selection of graft materials
(Fig. 93-21).
Frontal Sinus
The coronal approach provides the best access for
repair of fractures of the frontal sinus. Only extensively
large and degloving lacerations permit adequate direct

924
Section 9
Plastic and Reconstructive Surgery
A
C
D
E
B
Figure 93-18. A, An elderly trucker struck the bridge of his nose on
the steering wheel during a rollover accident. Portions of the commi-
nuted nasal-orbital-ethmoid fracture and splayed nasal bones were pal-
pable through the overlying laceration. B and C, Axial computed
tomography scans demonstrating the typical posterior depression and
outward splaying of the nasal bones with ethmoid disruption and a frac-
tured buckled septum. D, Microplates with 1.2-mm screws were used to
meticulously piece all the fragments into place. No transnasal wiring was
necessary because the medial canthal tendons remained attached to the
bony lacrimal crests and were reduced with the fracture repair. E, Sutured
laceration and narrowed canthi at the end of the procedure.

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
925
A
B
C
D
Figure 93-19. Fracture of the nasal-orbital-ethmoid complex repaired
with miniplates and the medial canthi reduced and narrowed with trans-
nasal 30-gauge wires sutured to the tendons.
Figure 93-20. A, Facial appearance of a woman with a fracture of the nasal-orbital-
ethmoid complex, laceration, and wound breakdown because of a postoperative infec-
tion. The nasal dorsum is sunken in with a saddle deformity, and there is the appearance
of telecanthus despite an intercanthal distance of 29 mm. B, Right oblique view
showing a short, upturned nose. C, A split-thickness calvarial graft was contoured and
plated on the underside with 1.7-mm screws so that they would not be palpable with
any graft remodeling or soft tissue thinning. D, The graft is inset via a coronal
approach after bluntly developing a soft tissue pocket that extends down to the cepha-
lad extent of the medial crura of the lower lateral cartilages. This length is beyond
the native nasal bones, and it is necessary to adequately restore proper projection of
the dorsum and tip without the nares being fully visible from the frontal view.

926
Section 9
Plastic and Reconstructive Surgery
E
F
Figure 93-20, cont’d. E, Facial view 6 weeks after surgery. No canthopexy or scar revision was performed, yet the scars are less noticeable
because they are stretched over a smooth convex framework and the canthi appear narrower as a result of proper anterior projection and
volume of the nasal dorsum. F, Right oblique view.
A
B
Figure 93-21. Three-dimensional computed tomography scans. A and B, Reformatted frontal and lateral views of a young man who was
assaulted with a pipe and sustained a fracture of the nasal-orbital-ethmoid complex that was not repaired at his local hospital because of severe
brain injury and a questionable chance for survival. These images greatly aid in preoperative planning for secondary reconstruction. The healed
fracture edges have remodeled and smoothed, so osteotomizing or attempting to “reduce” the segments generally leads to a poor result. Reduc-
tion and recontouring of any excess or full areas and grafting onto stable areas for projection and contour with debulking of scarred soft tissue
yield a better result. Several revision procedures should be anticipated.

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
927
exposure. Smaller lacerations should be repaired and a
coronal approach undertaken. During refl ection of the
coronal fl ap, any free or loose anterior bone fragments
should be preserved on the back table and oriented for
later replacement and reconstruction. Displaced frac-
tures of the anterior table should be elevated and the
sinus fl oor, ostia, and posterior wall inspected. Patency
of the nasofrontal ducts or foramen may be diffi cult to
discern visually. Saline or methylene blue can be irri-
gated into the openings with an 18-gauge angiocatheter
and then observed to emerge from the middle turbi-
nate or collect in the posterior pharynx, thereby con-
fi rming patency. If the posterior table and nasofrontal
ducts are free of injury, the anterior table can be reas-
sembled and fi xated with low-profi le miniplates (1.0- to
1.7-mm systems) or titanium mesh. Mesh is useful in
covering noncritical defects (<1.0 cm in diameter).
With larger defects, though rarely necessary, consider-
ation should be given to harvesting split calvarial grafts
and recontouring.
If the posterior table is fractured, one should deter-
mine radiographically and clinically whether the frac-
ture is displaced. Displacement is defi ned as a discrepancy
that is equal to or greater than the thickness of the
adjacent fractured bony edges. The fracture is either
displaced or nondisplaced. Intermediate terms, such as
mildly displaced or angulated, are confusing and do not
help direct clinical decision making. Displaced frac-
tures warrant neurosurgical consultation. Oftentimes
an osteotomy of a larger section of the frontal bone or
the entire frontal bar (including the supraorbital rims)
must be carried out and removed to permit adequate
visualization and access for management of cerebral
injuries and dural repair (Fig. 93-22). Care should be
A
B
C
D
Figure 93-22. A, Lateral view of a young man whose left face was impaled by a crane hook and who then fell several stories from a steel
building frame. His cervical spine was stabilized and he was orally intubated. A tracheostomy was performed. B, Computed tomography scan
revealing a displaced frontal bone fracture with intracranial air. C, The maxilla and arches are fractured with comminution of the right maxilla.
D, There are bilateral displaced angle fractures of the mandible and a right subcondylar fracture not seen on this lower cut.

928
Section 9
Plastic and Reconstructive Surgery
E
F
G
H
I
J
Figure 93-22, cont’d. E, The neurosurgeon osteotomized the frontal bone and skull beyond the areas of fracture to gain adequate access
for dural repair without excessive retraction on the injured frontal lobes, which could lead to further edema. A lyophilized dural patch was
inset over the torn right frontal area and the margins sealed with fi brin glue. F, The skull vault was pieced back together and plated ex situ
with a 1.7-mm system. The right superior orbital rim is in the right lower corner of the fi eld. G, A large portion of the anterior cranial fossa
was free fl oating. It was retrieved during dural inspection and repair, “preplated” so that it could be slid between the frontal lobes and right
orbit, and then fi xated to the reconstituted skull when it was placed back in position. H, Cranial vault fi xated and burr holes covered. Note
that several small holes (1.5 mm) were made bilaterally to aid in the suspension of dural tacking sutures to discourage epidural blood accumu-
lation. I, Fixated right zygomatic arch as viewed from above. J, The right zygoma and orbit were repaired through the gaping cheek exit wound
with 1.7- and 1.3-mm miniplates. The right canaliculi were intubated before conservative excision of devitalized tissue margins and deep repair
of the eyelid and cheek wound.

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
929
K
L
M
N
Figure 93-22, cont’d. K, Inferior view of the plated right subcondylar fracture, which was accomplished through the submandibular entry
wound after placing arch bars and wiring the patient into maxillomandibular fi xation. L, Next, the oblique fracture of the right angle and pos-
terior body is fi xated with a 2.0-mm tension band plate and a bicortical inferior border plate. M, An extraoral approach was used to plate the
left angle. N, Intraoperative appearance of the revised entrance and exit wounds and a head wrap being placed.
taken to avoid entry into and damage to the sagittal
sinus, which will result in severe hemorrhage. In cases
in which there is severe cerebral contusion with antici-
pated postoperative edema or a moderate or small
frontal sinus, cranialization of the frontal sinus is pre-
ferred. Cranialization involves complete removal of the
posterior wall of the sinus, removal of all sinus mucosa,
and smoothing of the bony margins (Fig. 93-23). Any
dural tear is repaired primarily or patched with fascia,
lyophilized dura, synthetic patch, or pericranium.
Tissue sealants such as fi brin glue can be used to help
reinforce the repair. Dural tacking sutures to the overly-
ing reconstructed anterior table can help prevent acute
or chronic subdural fl uid accumulation. Before reas-
sembling and plating the anterior table, the sinus
mucosa in the nasofrontal ducts should be refl ected
downward into the nasal cavity and the orifi ce obliter-
ated with local bone fragments, harvested temporalis
muscle, or free pericranium.
If the nasofrontal ducts are fractured or obstructed,
the patient is at risk for the development of sinusitis,
meningitis, or osteomyelitis.24 If the ducts are injured
or if the frontal sinus is to be obliterated with grafted
fat (harvested from the abdomen), bone, pericranium,
or acceptable alloplastic material, or cranialized, the
ducts should be obstructed and sealed off as described.
Obliteration of the nasofrontal duct is necessary to seal
off the frontal sinus or intracranial space from nasal

930
Section 9
Plastic and Reconstructive Surgery
O
P
Q
R
S
Figure 93-22, cont’d. O, Postoperative lateral cephalogram showing restored facial dimensions. P and Q, Three months after repair, Z-plasty
of the medial canthal scar and mechanical dermabrasion of the cheek wound were performed. R, Facial appearance 6 month after injury. He
had returned to full-time construction work without disability. S, Occlusion.
contamination. Sinus obliteration is undertaken to
eliminate dead space, discourage fl uid accumulation,
and provide an additional barrier between the nasal
cavity and the brain.
When obliteration of the nasofrontal duct and sinus
and cranialization are undertaken, it is critical to remove
all remnants of sinus membrane and mucosa. Vigorous
use of the curette and sometimes curettage with a round
diamond burr are required for complete removal.
Mucosal remnants can lead to mucocele formation and
infection many years later. With more limited unilateral
sinus injuries or with limited access through a lacera-
tion via endoscopic visualization to ensure that no free
fragments are located within the sinus, lateral nasal
incisions (Lynch) and elevation of the anterior frac-
tures can be performed. This should be attempted only
by an individual skilled in functional endoscopic surgi-
cal techniques and only for mild unilateral injury.

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
931
B
A
D
C
Figure 93-23. Steps in cranialization of a fractured frontal sinus. A, The dura is repaired and the posterior sinus wall is removed through a
bicoronal approach. B, Mucosal remnants are removed by burring the anterior wall and fl oor. C, The nasal frontal ostia are plugged. D, The
anterior table is reconstructed with microplates, and the brain accommodates and fi lls the space.
POSTOPERATIVE MANAGEMENT
The postoperative course and regimen are dependent
on the variety and severity of the facial fractures. Routine
orders include cold compresses for the face, elevation
of the head of the bed, decongestant nasal sprays, and
wire cutters at the bedside if the patient is maintained
in MMF. Instructions on how to cut the wires in case of
emergency are useful. However, if the arch bars are left
in place, soft wax can be given to the patient to place
over any wire causing irritation, and nutrition consulta-
tion is also advisable. For patients not in MMF but who
have undergone repair of Le Fort fractures, a soft diet
that does not require chewing is recommended for 4
to 6 weeks. The patient should be instructed in
oral hygiene and saline rinses. Perioperative steroids
administered intravenously can greatly aid in reduction
of soft tissue swelling. Methylprednisolone (125 mg
intravenously every 6 hours) is preferable over dexa-
methasone (8 mg intravenously every 8 hours). This
regimen should not be confused with the high-dose
steroids that are given to patients with traumatic optic
neuropathy and visual compromise. In these instances,
intravenous methylprednisolone (3 mg/kg) and subse-
quent doses of 1.5 mg/kg every 6 hours are adminis-
tered to reduce edema and optic nerve compression.25
Evaluation of visual acuity should be performed fre-
quently within the fi rst 24 hours after any orbital surgery.
Even with signifi cant periorbital edema the eyelids
should be separated and pupillary reactivity and ade-
quate vision confi rmed. Any equivocal or worrisome
fi ndings should prompt an emergency ophthalmic con-
sultation. Occasionally, proptosis or chemosis of the
bulbar conjunctiva with exposure develops. Lubrication
of the eye should be applied frequently (every 2 hours)
to avoid desiccation or ulceration. Any lid retraction or
ectropion should be assessed and managed by direct
massage, steroid injection, or surgical revision. Pares-
thesia and dysesthesia of the supraorbital and infraor-
bital nerves are common after injury and repair. Unless
surgically transected, most will recover fully within 3 to
6 months.
Blurred vision and mild diplopia are common after
fractures of the orbit and usually resolve when the
edema subsides. Marked diplopia or decreased vision
should be evaluated on an emergency basis by an oph-
thalmologist. Evacuation of a retrobulbar hematoma,
high-dose steroids, and other sight-preserving maneu-
vers can be performed as indicated. Serial examinations
are important for early detection of decreased vision.
Any persistent clear or watery fl uid from the nose
should be evaluated with a β2-transferrin assay to rule
out CSF rhinorrhea. Radionuclide studies can be per-
formed to localize the source of the CSF rhinorrhea,
and transnasal endoscopic patching of the CSF leak
along with placement of a lumbar drain for 3 to 5 days
is usually successful.
Perioperative antibiotics are frequently used in the
care of patients treated for facial fractures. Intravenous
antibiotics are usually given before and for 24 hours
after surgery. Beyond this time, there is no proven
benefi t of intravenous antibiotics. Antibiotics should
provide gram-positive and staphylococcal coverage.
Amoxicillin with clavulanate and clindamycin are good

932
Section 9
Plastic and Reconstructive Surgery
fi rst-line choices. Sinus precautions should be instituted
in patients who have undergone repair of maxillary or
ZMC fractures. Early wound infections are often due
to nonviable bone, breakdown of soft tissue, retained
tooth fragments in the line of fracture, or mobility
across fracture lines. Attempts should be made to ascer-
tain the cause and direct therapy toward the same.
Simply administering antibiotics fails to completely
resolve the infection and delays the necessary inevitable
treatment of débridement, surgical drainage, or refi x-
ation of fractures.
Late infections (>6 weeks) are usually due to para-
nasal sinus obstruction and possibly a devitalized maxil-
lary tooth requiring extraction or root canal therapy.
Clinical examination, local sensitivity, and radiographic
imaging can help identify the source, and appropriate
treatment can be rendered.
Pressure dressings can be applied to suit the
patient’s needs, particularly with coronal fl aps, or when
extensive soft tissue stripping has been performed.
Suction drains can be placed beneath the coronal fl aps
and maintained for 24 hours. Generally, drains are
unnecessary, except in the presence of excessive oozing
during closure.
Postoperative radiographs can be useful in assess-
ing the adequacy of reduction, alignment of fi xation,
and skeletal relationships. They also serve as a baseline
if future occlusal changes, shift in segments, or infec-
tion or loosening of hardware occurs. These radio-
graphs can include Panorex, a posteroanterior or lateral
cephalogram, a Waters view, or skull fi lms. Follow-up
CT scans are generally required for complex orbital
repairs and frontal sinus repairs with intracranial injury.
Patients should avoid strenuous physical activity for 6
weeks and avoid contact sports for an additional period
if warranted by the injury.
Malocclusion discovered immediately after surgery
or within the fi rst week is usually due to improper
reduction of the fractures and fi xation in that position.
The most common postoperative malocclusion is an
anterior open bite deformity caused by upward pres-
sure on the chin with displacement of the condyles
while plating midfacial fractures. If the anterior open
bite is slight (less than 2 mm), vertical elastic traction
on the arch bars may resolve the situation satisfactorily.
A large open bite must be addressed by revision surgery
with plating in the correct anatomic position while
seating the mandibular condyles. Excessive amounts of
box elastics to close malocclusions can lead to loss of
fi xation, nonunion, and damage to the teeth.
Malocclusion that occurs later (during the healing
phase) is usually due to loss of fi xation, use of plates
with inadequate rigidity, or backing out of screws
because of overheated bone at the time of surgery or
infection. The patient may also be overactive and eating
a normal diet, or infrequently the patient sustains addi-
tional facial trauma and may not report it to the surgeon.
Grasping the maxillary complex to detect mobility and
comparing current radiographs with ones taken imme-
diately postoperatively may reveal loss of fi xation or
shift of the bony segments. Generally, reoperation plus
reapplication of fi xation is required to address this situ-
ation. Meticulous passive plate adaptation and the use
of locking screw systems can help avoid torquing seg-
ments and misalignment.
PEARLS
• A thorough preoperative evaluation with a logically
sequenced treatment plan helps avoid complications
and unfavorable outcomes.
• The patient’s imaging studies must be reviewed
personally by the surgeon, who should correlate any
radiographic fractures with the physical fi ndings.
• When grafting defects of the orbital fl oor,
reconstitute the defect and restore the normal
orbital fl oor contour, which is not fl at.
• Do not operate on nondisplaced ZMC, isolated
anterior maxillary wall, or orbital fl oor fractures for
the purpose of improving V2 paresthesia or
anesthesia.
• When treating moderate or severely displaced ZMC
fractures, accessing at least two fracture points and
fi xating them along both areas aids in reduction
and helps ensure proper alignment and adequate
postoperative stability.
PITFALLS
• Nasal and zygomatic arch fractures treated after 48
hours of injury do not reduce as precisely and tend
to be less stable and drift back into the injured
position.
• When closing eyelid incisions, either infraciliary or
transconjunctival, improper reapproximation and
suturing unlike layers will result in lid tethering and
possibly ectropion.
• Serial perioperative visual acuity checks or patient
complaints indicating decreased vision must be
taken seriously and should prompt immediate
evaluation and appropriate treatment.
• Early postoperative malocclusion (<24 hours) is
usually due to fi xation of fracture segments that
were improperly aligned.
• Later postoperative malocclusion is probably due to
nonunion or shift of bony segments secondary to
inadequate fi xation, infection, or excessive use.
References
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Hamilton, Ontario, BC Decker, 2004, pp 435-444.

Chapter 93
Fractures of the Upper Facial and Midfacial Skeleton
933
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