Craniofacial Trauma: Health Sciencies Cooperation Monographies

Craniofacial Trauma Dr.
Alberto Musolas
Dr. Pierre Quinodoz
Health sciencies cooperation monographies
Craniofacial trauma
Health sciences cooperation monographies
Dr. Alberto Musolas

Plastic, Reconstructive and Aesthetic Surgery.
Fundación Cirujanos Plástilos Mundi, Spain.
Agence Suisse pour le Développement et la Coopération, Suisse.
Dr. Pierre Quinodoz
Plastic, Reconstructive and Aesthetic Surgery.
Agence Suisse pour le Développement et la Coopération, Suisse.
Craniofacial.indd 1 22/01/10 13:22

Craniofacial trauma
Health sciences cooperation monographies.
1st. Edition, 2010.
Edited by Alberto Musolas
Publication of this book has been possible thanks to the

sponsorization of Dr. Gilberto Chechile, and Instituto Médico
Tecnológico (Barcelona, Spain).
Thanks especially to Jordi Grifoll as representative of
Hermes Editora General S.A.U., who has selflessly taken
care of all the technical aspects of this publication.
This book is published with the aim of cooperation in mind,

and should be freely distributed to hospitals, physicians and
organizations working or involved in health cooperation
programs in undeveloped areas.
Its sale is expressively not permitted.

Prologue
Craniofacial trauma related to undeveloped countries represents three main challenges;
prepare physicians to be able to treat facial fractures from the less severe forms to most
complicate ones, combine the teaching of the most advanced procedures with the most
modern technology with the tools and capacities of third world hospitals and train young
surgeons (future active members of NGOs) from fully developed countries to learn and
work with procedures and tools that are not longer seen in their countries.
Meeting by meeting, book by book, the most modern techniques and procedures are pre-
sented, and the more precision instruments and devices are available to surgeons in devel-
oped countries. Research and teaching always emphasizes the news trends, and beside
this, great advances in anaesthesiology and Intensive Care units play a very active role in
the favourable outcome of our patients..., and meeting by meeting and book by book, the
gap between first world surgery and third world surgery, is increased.
Excellent publications (and very expensive), from highly recognised specialist, full of illustra-
tions and schemes about techniques and materials, that rarely, if ever, fit the undeveloped
countries standards, are of little use in these regions..., when available, for local surgeons.
This manual represents the experience of plastic surgeons involved with the practice of
Craniomaxillofacial trauma in Europe as well as in Third world countries. It do not pretend
to be the last word in the most modern techniques but a useful and practical book that will
assist the physician and / or surgeon in their solitude in the desert or forest with a wide
variety of resources (variety that represents from almost nothing of nothing to the modern
titanium miniplates) and will help young surgeons to understand that current X-ray films
and wire ligatures, could still be more than just an acceptable option.
With the idea of full cooperation to assist the local population, also is in our mind to spread
the knowledge of our specialty between all the surgeons, physicians and even paramedics,
that is why this manual will be given free as donation to everyone working with patients and
facing emergencies in undeveloped countries and to the participants in plastic surgery
workshops around the third world. To facilitate access to all our manuals they could also be
freely discharged from the web page of the Spanish foundation Cirujanos Plastikos Mundi.
This book also represents the knowledge, experience and work of others surgeons in their
respective publications. In order to be highly didactic, we add to our own material, many of
their draws and schemes that had been directly taken from them with the respective refer-
ences. That is why they are also recognised as intellectual authors of that manual and so
the merits.

The aim of cooperation is to share knowledge and experience, and sharing means profes-
sional as well as spiritual enrichment for both parts. In such a way this manual is also the
result of the sharing experiences of the authors with surgeons from Africa, Europe, Asia,
South America and USA.
Finally we have to credit the invaluable help of Jordi Grifoll, for that first quality edition, the
collaboration of Daniela Weber, Dr. Joseph Mª Costa, Dr. Javier Beut, and very specially,
the economic support of Dr. Gilberto Chechile whose Instituto Médico Tecnológico has
made possible with their funds to print these manuals. If these manuals could be freely
distributed to those working in undeveloped areas it should be thanks to them.
Dr. Alberto Musolas

Dr. Pierre Quinodoz

Craniofacial Trauma
1. Introduction
2. Initial evaluation
3. Head injury
4. Local evaluation and management of Craniofacial trauma
5. Management of wounds and open fractures
6. Approaches to the craniofacial skeleton
7. Principles of bone healing
8. Principles of Bone grafting in facial fractures
9. Techniques and elements for bone fixation
10. General approach to Facial Fractures
11. Frontal sinus fractures
12. Fractures of the orbit
13. Fractures of the Zygoma
14. Fractures of the Nose
15. Fractures of the Naso-Orbital-Ethmoidal complex
16. Fractures of Maxilla
17. Fractures of Mandible
18. Facial fractures in Children
19. Summary

Chapter 1
I ntroduction
Craniofacial trauma is as old as the human race. What has changed over the last decades
is the speed in which many of these traumas occurred, the way in which they are explored
and diagnosed (CT scans, 3D scans), and the way they are treated with the extensive use
of miniplates and screws.
Fractures and traumas over the facial skeleton since recent times had been always pro-
duced, more or less, at low speed. It means that most of the fractures, despite its impor-
tance and consequences, results in more or less big fragments. These big fragments are
much easily brought together and stabilized, even with wire, than the very small fragments
found in high speed traumas. The result of a high speed trauma are great comminute frac-
tures involving one or several facial bones, soft tissues injuries in the form of open wounds
and / or loss of tissues, and associated injuries in other regions.
As has been said before, during the last decades CT scans has made diagnosis of fractures
very easy and accurate, craniofacial techniques has provided access to the facial skeleton
through aesthetically acceptable incisions, plates and screws has given long term stability
and better bone healing, and better knowledge of local flaps has allow immediate sot tissue
repair, but this high technology is rarely available in undeveloped countries, so...
The reality in undeveloped areas is that the only thing you will surely
have is your own knowledge, skill and experience.
It means that one must relay on the old principles of surgery as, anatomical exploration, physi-
cal exam, clinical evaluation, simple X-ray films, etc., etc. to do a consistent diagnosis. Finally, the
way to obtain a good result depends on your skill, experience and ability to stabilize the bones
fragments in the more anatomic and functional position with the minimum technology.
This manual, though mentioning and presenting the more actual trends, is addressed to
manage craniofacial trauma in undeveloped conditions with limited resources at hand,
more than to be the last word in craniofacial trauma surgery with the most advanced instru-
ments and devices that could be available in fully developed areas and hospitals.
Craniofacial Trauma [ 7 ]

Chapter 2
Initial evaluation
Between 50 to 70% of patients that had suffered a craniofacial trauma have other associ-
ated injuries that could be even more important than the fractures themselves. So, evalua-
tion began with a coordinated and systematic evaluation of all areas, local or general, in
order to detect the priorities in management.
Management of Cranio-facial trauma begins with a coordinated and

systematic evaluation of all areas, involved or not.
Regional problems associated with craniofacial trauma may include a vast form of damage
everywhere; however, vital damage must be first detected and treated consequently. A sys-
tematic evaluation is so the most important principle when facing a craniofacial trauma and it
must done properly and with certain mandatory priorities with revision and management of:
2.1 Cervical spine injuries
Over 10% of patients with craniofacial trauma will have some type of cervical spine injury,
so until proven otherwise all the patients must be considered to have this type of injury and
treated in consequence, in order to proceed immediately to treat the vital compromises.
2.2 Airway compromise
Airway is always the second concern in traumas over the craniofacial region. Fractured teeth,
fractured segments of the maxilla or mandible, displaced midfacial fractures, fracture of the
larynge, blood or even foreign bodies, may interfere or occlude the upper airway tract, so
immediate attention must be addressed to ensure an open airway flow. A clear upper airway
could be maintained, if necessary with a careful endotracheal intubation or if needed by
emergency, by coniotomy or tracheotomy.
2.3 Hemorraghe
Is the third problem to be treated immediately after the airway flow has been secured.
Open or even closed injuries may bleed profusely and be the cause of considerable blood
loss. In fact this is the main cause of shock after trauma, so said, gain prompt access to the
vascular system and start with fluids replacement is mandatory. Frequently these haemor-

rhages come from the nose or posterior pharynx. Posterior nasal packing (see fig. 87) and
reduction of fractured bones are the best way to reduce or stop bleeding. Ligature of the
external carotid artery is rarely needed.
2.4 Open or closed head injury
High speed or high energy facial trauma usually causes a varying degree of head damage.
This is best evaluated using the Glasgow coma scale together with a pupil examination.
Special attention must be paid to the possibility of intracranial hemorrhages that may cause
subdural hematomas with a wide variety of neurological damage and not rarely, dead. That
is why special mention should be paid to the neurological exploration, care, observation
and if needed, intervention. The Glasgow Coma Scale is a neurological exam which aims
to give a reliable, objective way of recording the conscious state of a person, for initial as
well as continuing assessment. A patient is assessed against the criteria of the scale, and
the resulting points give a patient score between 3 (indicating deep unconsciousness) to
15 (completely awake). See below in chapter 3.
2.5 Thoracic, Abdominal and Orthopaedic injuries
Though thoracic and abdominal traumas are not very commonly associated, orthopaedic
injuries and long bone fractures use to be present at the same time. Management of these
injuries is done after the patient has been completely stabilized and ready to sustain com-
plex and long surgical procedures.
[ 10 ] Craniofacial Trauma

Chapter 3
Head Injury
Facial injuries are usually accompanied by cranial, and the subsequent brain, trauma. The
anatomy, morphology and special conditions of the brain and their components inside the
cranium makes that the consequences of even a blunt and lesser impact over this area
could become dramatic.
Over the last decades, the mortality due to severe head injuries has been dramatically re-
duced (from 50% to 36% in well documented series). These achievements are mainly
due to the advances and application of well established protocols in the areas of emer-
gency medical services and the units of critical or intensive care.
3.1 Classification of Head Injury
Head injury could be classified in different ways:
• By Mechanism:
- Closed injury (High velocity and low velocity).
- Penetrating Injury (Gunshot wounds and other injuries).
• By severity:
- Mild: Glasgow Coma Scale 13-15.
- Moderate: GCS 9-12.
- Severe: GCS 8 or less (comatose).
• By morphology:
- Skull fractures:
• Vault: Linear or stellate, depressed or not.
• Basilar: With or without CSF leak, and with or without nerve VII palsy.
- Intracranial lesions:
• Focal: Epidural, subdural or intracerebral.
• Diffuse: Mild concussion, classic concussion and diffuse axonal injury.
The American Association of Neurology describes three mechanisms of cranial trauma:
• Impact of an object to the cranium (penetrating or not).

• Impact of the cranium against an object (penetrating or not).
• Mechanism of forward and backward impact.

As for the cranium the direct impact from an object could be more severe with higher local
damage, for the brain the third mechanism is much more frequent and could be also much
more devastating as the brain is push in a forward and backward movement hitting several
times the inner surface of the frontal and occipital bones.
After a cranial traumatism some lesions, isolated or associated, could result.
• Scalp and skull: simple open wounds to complete avulsions. Simple lines of fractures up
to complex sinus fractures (see below).
• Intracranial lesions. From the simplest contusion to the most severe closed head trauma
with intracranial haematomas. This haematomas, depending on their localization could
be epidural, subdural, subaracnoideal and intraparenquimatose.
3.2 Physiopathology of the traumatic Brain Injury
The cranium has three main components:
• Brain tissues (aprox. 85%).

• Blood (7%).
• Cerebral Spinal Fluid CSF (8%).
The delicate equilibrium between these components keeps the brain properly functioning.
Any change in the proportions of one, two or all the components result in disarray with
severe or fatal consequences.
So said, is important to know some concepts and data affecting the normal physiopathol-
ogy in the traumatic injured brain.
3.2.1 ICP, Internal Cranial Pressure. The three components joint together in a closed
space. The proper relationship between their mass and volume keep them under a more
or less constant Internal Cranial Pressure in order to accomplish their functions (Normal ICP,
about 10 mm Hg or less). When the mass and volume of one or two of them varies, the
others should adapt themselves in order to keep the Internal Cranial Pressure (ICP) be-
tween normal rates. The most widely used methods for measuring it are the ventriculos-
tomy or intraventricular catheter. The highest incidence of patients with intracranial hyper-
tension in which monitoring is advisable are those with abnormal CT scans and / or unable
to follow orders.
3.2.2 CBF, Cerebral Blood Flow. Brain flow makes reference to the vascular irrigation of
the cerebral tissues. Some mechanisms allow the self regulation of the cerebral blood flow
(CBF) that should be constant under a normal Medial Arterial Pressure (50-150) (MAP). If
the MAP increases a local vasoconstriction occurs, on the contrary if the Medial Arterial

Pressure decrease, a vasodilatation is the reaction. The Cerebral Blood Flow (CBF) is also
sensible to the changes in the PaO2 and PaCO2.
• If PaO2 is over 120mm Hg, the CBF decrease.

• If the PaO2 is less than 50mm HG, the CBF increases.
Regarding to the PaCO2:
• If the normal PaCO2 increases, for each mm HG of PaCO2 the CBF increases approxi-
mately about 3 %.
3.2.3 CPP, Cerebral Perfusion Pressure. This pressure makes reference to the pressure
needed for the brain to be irrigated. This pressure is the result of the Mean Arterial Pressure
minus the Internal Cranial Pressure. Today is considered more useful to check the CPP
rather than the ICP. It seems that CPP less than 60 mm Hg is generally associated with a
poor outcome. So to keep the brain perfectly irrigated is much better to have CPP higher
than 80 mm Hg. This is the reason to control and act on the mean arterial pressure and the
Internal Cranial Pressure and it means to keep the PaCO2, PaO2 and CIP between their nor-
mal rates.
3.2.4 Compensating mechanisms. As has been previously mentioned one of the most
important factors is the Internal Cranial Pressure. To keep that pressure under functional
levels, some mechanism has been developed and kept functioning until the moment in
which the proper pressure is re-established or fails completely.
At the beginning, when the internal pressure stars to rise, the cerebral spinal fluid decrease
by a mechanism of resorption.
If the ICP continues growing, a vasoconstriction is established in order to decrease the in-
ternal pressure.
If the ICP continue rising, the former mechanism fails and the ICP could not be restore by
itself and the arterial pressure start rising trying to keep the brain well vascularized, but this
Hypertension could trigger the Cushing effect (hypertension, bradicardy and abnormal
breathing), with the final effect of increasing progressively the ICP.

Physiopathology of ICP
Primary lession ICP
• 1st reaction: resorption of CS fluid

• 2nd reaction: vasoconstriction
If ICP continue growing
Cerebral Perfussion Pressure:

Cerebral ischemia Inflamatory reaction aedema
ICP arterial pressure
Cerebral Perfussion Pressure
3.3 Head Injury evaluation
After the patient with craniofacial trauma has been properly stabilized, attention should be
paid to head injury trauma and a general evaluation of the neurological state of the patient
should be performed.
The goal is to properly classify the patients under one of these three groups:
1. L
ow risk: Minor signs and local and general symptoms such as headache, dizziness or
scalp lacerations.
2. M
oderate risk: Signs as vomiting, alcohol or / and drugs intoxication, posttraumatic
amnesia, or signs of a basilar or depressed cranial vault fracture.

3. High risk: Most serious initial symptoms such as decreased level of consciousness, fo-
cal neurologic signs or penetrating injuries.
To classify the patients a detailed clinical exploration, Glasgow scale evaluation, X-ray ex-
amination, CT scan studies and monitoring will help not only in classify the patient but to
assist us to treat it properly and give a certain predictability about the outcome.
3.3.1 Physical exploration
3.3.1.1 Neurological exam. Glasgow Scale.
Actually, the basic neurological exam is based on the patient response to eyes, verbal and
motor stimuli. In 1974 Teasdale and Jennet, identified the clinical signs that predicted
outcome of a patient with a head injury. They designed what is actually known as the
Glasgow Coma Scale.
They defined coma as the status in which the patient could not obey commands, to ut-
ter words and to open the eyes. Depend on the responses for eye, verbal and motor
stimuli a score is given and the total sum gives a certain score that will range from the
minimum 3 to the maximum 15, being the patient who scored 3 fully comatose, to 15
fully awake and conscious.
Glasgow Coma Scale

1 2 3 4 5 6
Opens eyes in Opens eyes
Does not Opens eyes
Eyes response to in response N / A N / A
open eyes spontaneously
painful stimuli to voice
Utters Oriented,
Makes no Incomprehensible Confused,
Verbal inappropriate converses N / A
sounds sounds disoriented
words normally
Abnormal
Flexion / Localizes
Makes no Extension to flexion to Obeys
Motor Withdrawal to painful
movements painful stimuli painful Commands
painful stimuli stimuli
stimuli
Table 1.- The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum
are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).
For practical purposes, it has been generally accepted that
1. Mild Traumatic Brain Injury (TBI):
Glasgow Coma Scale of 13-15.

Patients awake, with certain loss of consciousness less than 5 minutes, headaches and
possibly amnesic.
Some neurological symptom may be present.
2. Moderate TBI:
Glasgow Coma Scale from 9 to 12.

Patients have an impaired consciousness, are confused or somnolent but usually able to
follow simple commands.
Neurological focal deficits present. Approximately 10% deteriorates and lapse into coma.
3. Severe TBI:
Glasgow Coma Scale: 8 or less.
However, distinction between patients from mild to moderate trauma brain injury is the
most difficult part of the diagnosis, as has been reported that neurobehavioral deficits in
patients with mild head injury (GCS 13-15) and an intracranial lesion on initial CT scan
were similar to those patients classified as moderate head injury (GCS 9-12).
3.3.1.2 Pupil examination.
Examination of the pupils is not only a very useful complement to the Glasgow Coma
Scale, but a mandatory evaluation. The pupil size and its response to light stimuli is one
of the first physical examinations for every patient who had suffered a Head Injury.
Assisted by a bright light or much better an ophthalmoscope, the light response and the
subsequent papillary size should be checked. The result of this examination will provide
valuable signs for a diagnosis.
Mild dilatation of the pupil and fixed response to papillary light examination is a clear
sign of Temporal lobe herniation. This herniation causes a compression or distortion of the
oculomotor nerve, affecting the parasympathetic axons that transmit the signal for papillary
constriction resulting in mild papillary dilation. As the herniation is more severe, the oculo-
motor nerve becomes more severely distorted and full midriasis is accompanied by ptosis
and paresis of the medial rectus and the other extraocular muscles innervated by that nerve.
Paradoxic pupilary dilation is the reaction to the swinging flashlight test indicating an
optic nerve injury. In these cases the response to the light is dilation rather than constriction.
Bilaterally small pupils used to have a limited reaction to the light examination test.
Usually it makes reference to the use of certain drugs as opiates but could also corre-
spond to methabolic encephalopaties or pontine lesions.

Mydriatic pupil usually unilateral and not accompanied by ocular muscle paresis is a
sign of direct trauma to the globe.
Bilateral dilated and fixed pupils could be the sign of inadequate cerebral vascular
perfusion caused by hypotension secondary to blood loss that impairs the cerebral blood
flow. At the initial stages, if the blood flow is adequately restored, the papillary response
could return to normal.
3.3.1.3 Eye movement.
To determine certain cerebral damage or local orbital fractures involving the extra-ocular
muscles, movement of both eyes should be recorded. If the patient is sufficiently awake
and conscious the ocular motor system within the brain stem could be easily explored
and muscles entrapment due to orbital fractures could also be determined.
When the patient is depressed and the voluntary eyes movements lost, the oculoce-
phalic or oculovestibular responses should be checked. The oculovestibular response
could be easily tested with cold water dropped in a clear external auditory canal as it
cause a fast-phase nystagmus of the eye (usually an ipsilateral deviation).
3.3.1.4 Motor function.
Beside the neurological, pupils and eyes movement exams, a gross test of the move-
ments and strength of each extremity should also be done. As many of head injury
patients had fractures associated and also may be not very cooperative or very re-
sponsive, this exam is not very reliable when assessing a head injury status.
3.4 Diagnosis of Head injury and Cranial Hypertension
Once the patient has been stabilized a proper diagnose should be established. In the most
severe cases the patient should be sedated and intubated previously to the realization of
the diagnostic procedures.
3.4.1 Computed tomography.
CT scanning is the elective procedure to evaluate and diagnose a close or open head injury;
however in underdeveloped areas it is not usually available. The sooner a CT scan is obtained
the sooner the most reliable data about the brain status will be obtained. New CT scans should
be obtained in those cases with changes in its clinical evolution or its neurological status.
On a CT scan, each of the main lesions could be diagnosed ought to their difference ap-
pearance in density (low or high, diffuse or focal). The simple brain contusion, edema, and
hematomas will have their particular appearance on a CT scan.

3.4.1.1 Brain contusion result in intermixed areas of edema and hemorrhages and
they are characterized as non homogeneous areas of low density besides areas of high
density (salt and pepper appearance), their distribution depending on the relationship
between edema and hemorrhages.
3.4.1.2 Edema is seen on a CT as an area of low density associated with an image of

distortion, displacement or compression of the adjacent ventricles. Edema may present
as focal, multifocal or diffuse. Though the diffuse edema is more difficult to appreciate at
the CT scans (as there are no normal areas to compare with), the images of compression
on both ventricles could give a sign about what is happening.
3.4.1.3 Hematomas. Blood collections had a variety of images depending not only in
its location but in their evolution. So, acute hematomas use to be hyperdense, subacute
isodense and / or of mixed density, and chronic hypodense as compared with normal
brain tissue. Epidural hematomas could be differentiate by their shape (lenticular or
biconvex) because the close attachment of the dura to the inner table of the skull. Sub-
dural hematomas use to be more diffuse lesions and because their distribution over the
brain substance, have a concave image. Subarachnoid hematomas are not very com-
mon but when located in the posterior fossa could result in an acute obstructive hydro-
cephalus. Intracerebral hematomas could be seen as high-density lesions surround-
ing by zones of low density due to edema. As the majority of this hematomas have a
traumatic origin they use to be located in the frontal and anterior temporal lobes.
3.4.1.4 Ischemic lesions appear as low density areas compared with the adjacent brain
tissue. Normally the infarction may be seen after the first 24 hrs and is quite clear by 7
days.
3.4.2 Ventriculography. When CT scans are not available, the ventriculography have three
main advantages: Could be obtained more easily than the CT scan, gives information about
the supratentorial brain shift and from the intracranial pressure.
3.4.3 Angiography is another diagnostic procedure that could be done in absence of a

CT scan when vascular injuries are suspected. It also could give extra information in those
cases in which the neurological status of the patient is not correlative with the CT findings.
3.5 Medical therapy
The advances in medical therapy, emergency services and Intensive care units have repre-
sented a great improvement in both the treatment and the outcome of severely injured
patients. Though there are a great variety of available drugs, it could be summarize in 5. The
goal of the treatment is to reduce the ICP, the brain edema, and improve or avoid the ce-
rebral anoxia and ischemia. The main drugs for so are:

3.5.1 Anticonvulsants. Though their use is controversial it seems that they have their
role, as a variable percentage of patients develop post-traumatic epilepsy.
3.5.2 Manitol. It is the most commonly used drug to reduce intracranial pressure at the
intensive unit cares as well as in the operating theatre. It could be initially used as a bolus
of 1 to 2 g / Kgm.
3.5.3 Furosemide. Its use is associated with Manitol to reduce the intracranial hyperten-
sion. The diuresis can be enhanced by the combination of these drugs. A dose of 0.3 to
0.5 mg / Kg of Furosemide is adequate.
3.5.4 Barbiturates. Their role in the treatment is to protect the brain from the effects
of anoxia and ischemia and reduce the intracranial pressure. As hypotension is associated
to the use of barbiturates, the cerebral perfusion pressure should be constantly checked to
avoid undesirable effects.
3.5.5 Steroids. Though they are clearly useful in reducing edema, their use in traumatic
head injured patients is controversial as they may also have a deleterious effect on the
metabolism.
3.6 Surgical therapy
Though neurosurgical procedures are not the common practice of Plastic and General Sur-
geons, certain guidelines as to when or why a head injury patient is eligible for surgery
should be pointed out.
3.6.1 Conservative procedures. Conservative treatment makes reference to medical

therapy, observation and ICP monitoring. It seems, beside the result on the CT scan, that
ICP could be use as a frontier for conservative or surgical therapy. Patients who had sus-
tained brain contusion but could follow verbal orders at admission, or patients with ICP
lower than 20 mm Hg, will not require ICP monitoring and simple observation will be
enough with a highly favourable outcome. Acute hematomas causing less than 5 mm Hg
shift of the midline, in an alert patient with a normal neurological examination, is also a
candidate to conservative approach and, especially in these cases, careful observation.
3.6.2 Surgical treatment. Brain contusions in patients with ICP higher than 30 mm Hg or
mass lesions (acute hematomas) which deviates the midline 5 or more mms Hg, are can-
didates to surgery, especially in those patients with temporal lobe hematomas rather than
those with frontal or parietal ones. Temporal lobe hematomas have much greater risk of
developing tentorial herniation. In patients with unexplained rise of the ICP or deterioration
of their neurological status, new CT scans are mandatory and should be considered candi-
dates for surgery if they still deteriorate.

Once is decided that the patient is candidate for surgery, the sooner the surgery is carried
on and the mass evacuated, the better the prognosis and the outcome. Of course, previ-
ously to surgery, medical therapy to reduce the ICP and enhance the oxygenation of the
brain should be administered (Manitol and hyperventilation specifically).
3.6.2.1 Depressed skull fractures. As a guideline it could be considered that a de-

pressed skull fracture in which the outer table is below the level of the inner table of the
non fractured area of the skull, is candidate for surgery. It also should be taken into con-
sideration other signs and symptoms to move the patient into the operating room.
3.6.2.2 Epidural hematomas. Its main cause use to be tearing of the middle menin-
geal vessels as the temporal region is the most commonly affected. Venous epidural he-
matomas tend to be smaller, have a good outcome and managed non surgically while
arterial hematomas tend to be more severe and increase the intracranial pressure. It treat-
ment is addressed to relieve this pressure as soon as possible by a localized craniotomy.
3.6.2.3 Subdural hematomas. These types of hematomas are mainly due to bleeding
from a lacerated brain tissue or rupture of the cortical vessels. They are most commonly
placed at the frontal lobes and anterior temporal lobes. Depending on the evolution and
deterioration of the patient, a rapid approach for an emergency small temporal cranioto-
my could be performed to quickly decompress the brain or just as the initial treatment
for a most extensive frontotemporal craniotomy to explore the area searching for the
bleeding vessels.
3.6.2.4 Intracerebral hematomas. As contusions are mainly located in the frontal

lobes or anterior temporal lobes, these are the areas where hematomas are generally
found. Currently, the initial lesion is that of a contusion with a “salt and pepper” image on
the CT scan that evolves during the next days to a true hematoma (otherwise called
Delayed Traumatic Intracerebral Hematomas). While minor cases that are awake, alert
and able to follow verbal commands could be treated conservatively, for comatose pa-
tients with significant midline shift, surgical treatment is the choice. Between those situa-
tions, the decision about a surgical or conservative treatment is much more difficult es-
pecially when debridement of the left lobes is required, as the speech as are located in
these lobules.
3.6.2.5 Posterior fossa hematomas. These types of hematomas are much less
commonly found than the others. When present, the brain could suffer irreversible dam-
age and the patient deteriorates rapidly. An aggressive and rapid surgical approach is
indicated.
3.6.2.6 Venous sinus injuries. These represent a real major problem as the bleeding
could be fatal for the patient. An emergency craniotomy is required to try to stop the
bleeding. While ligatures of the anterior third of the superior sinus is well tolerated, liga-

tures of the middle third have unpredictable effects and ligatures of the posterior third is
most likely to produce massive venous infarction of the brain. It seems that the best op-
tion is local pressure together with hemostatic agents.

Chapter 4
Local Evaluation and management of craniofacial trauma
Traditional management of facial fractures in the form of conservative treatments, close
reduction and delayed surgery has evolved to an early “one stage” surgery. But some of the
old principles as prolonged intermaxillary fixation (6 weeks are actually enough) and wire
fixation are still not only useful but of first need especially in undeveloped areas. Though
this management has change, diagnosis of fractures on the craniofacial skeleton is based
in two classical points:
Local Physical exploration beside the knowledge of the mechanism of the injury will led
to suspect about the fracture, its level, its type and associated damages. The way in which
the trauma has happened and details about the direction of the stroke, speed, energy and
situation of the head of the patient provides very useful information about what could be
expected.
X-Ray films, when available and well done, will lead us to confirm the proper diagnosis
(and some times find associated fractures). As X-Ray films of excellent quality may be dif-
ficult to obtain and CT scans are the most of the times not available, an accurate history and
physical examination will be the basis for a proper diagnosis. In complex craniofacial frac-
tures it is also desirable to have the recent dental history, dental models and recent face
pictures (see fig. 122). All this together could help us not only to know what we have to
achieve but which were the conditions before the trauma.
4.1 Physical exploration
As X-Ray films will confirm the diagnosis of a fracture, the fracture itself could and should
be suspected by a careful local exploration. Palpation and mobility of fragments, local
numbness or anesthesia, occlusal alterations, functionality of mobile bones as the man-
dible, and functionality of mobile organs as the eyes and the visual acuity itself, will ad-
dress to a proper diagnosis. Complete and careful exploration will be possible as long as
the patient could be cooperative or not. Of course some of the exploration exercises
should be done with the patient completely awake and others with the patient complete-
ly under anesthesia. Exploration of a conscious patient will differ substantially from the
exploration of a completely sedated or comatose one. So proceed systematically. In a
conscious patient, independently of the previous complete neurological exam, the explo-
ration routine should include:

• Bleeding or leakages. Careful exploration of bleeding or leakages especially from nose
or ears should be done at the first stages, as rhinorrea or othorrea may indicate the pres-
ence of a basal skull fracture.
• Neurological exploration: search for numbness, hyposthesia or anaesthesia in the

nose, forehead, maxillary areas, and chin. Explore the different movements and expres-
sions of the face (lids, brows, mouth, etc). If the facial nerve has been damaged, the
early the repair the better the prognosis.
• Ocular evaluation. A brief history of the pre-injury vision is very important, as it is de-
terminant to asses the ocular motility (function of the extraocular muscles) and possible
points of muscles locking, visual acuity, pupillary reflexes, possible eye globe lacerations,
and presence of diplopia. Exophtalmoses or dystopia may significate severe fracture of
the zygomatico-orbital complex, and combination of ophthalmoplegia, proptosis and up-
per lid ptosis may significate fracture of the superior orbital fissure. It should be taken
into account that the presence of a ruptured globe, retrobulbar or optic nerve hematoma
or a detached retina, may delay definitive facial fracture treatment.
• Mandible and Dental occlusion. Mobility of the mandible in rest position, while open-
ing and when fully open, asymmetries with open or close mouth, open or cross bite, and
limitation in its movement should be assessed. Ecchimosis, “steps”, impairment and pain,
are suspicious of fractures. Temporomandibular Joint (TMJ) pain associated with maloc-
clusion may indicate a fracture on the mandible or their condyles while trismus is more
commonly associated with fractures of the zygomatic arch. Comparison between the ac-
tual occlusion with the previous should be made, as the patient could have a pre-existing
malocclusion. Search for loose tooth or fractured dental prostheses or orthodontic devices.
• Palpation and Inspection, done symmetrically with both hands at the same time on
opposite areas is the best clinical method to assess all bony prominences looking for
asymmetries, crepitances and pain.
For comatose patients, exploration follows a different way as they are unable to follow ver-
bal commands. Furthermore, the induced or not medical relaxation could lead to errors
when performing the neurological exploration.
In a comatose patient or an anesthetised one, neurologic sensitive exploration is the

most of the times impossible to perform, as well as a proper visual acuity test. The assis-
tance of an ophthalmologist will help when exploring and diagnosing internal injuries of the
eye. So said, for these types of patients, comatose or conscious, but already anesthetized
patients, the exploration at the theatre, should also include:
• Exploration of ducts, as the lacrimal and stenon, if their section is suspected by an

avulsion or a direct incisional injury.

• Surgical exploration of wounds. Careful exploration of every laceration and open
wound, as non radiolucency foreign bodies may be present and miss in the X-Ray exam.
• Eye globe mobilization with forceps at the conjunctive level to check for locking of
normal movements.
• Passive mobilization of the jaw searching for locking, abnormal movements or loose
fragments.
4.2 X-Ray exploration
Depending on the technology available, simple X-Ray films or CT scans, will suffice to con-
firm the suspected fractures and diagnose new ones. CT-scans provide for the best images
and can precisely outline and diagnose fracture patterns of the craniofacial skeleton. 3D CT
scan, could also be very helpful, though they are rarely used in those instances. As it is quite
unusual to have a Computer tomography scanner in undeveloped areas, the most of the
times one should relay on conventional radiographies, beside the clinical exam.
ven when a Ct-scan is available the best X-ray examination, which will provide an extremely
E
useful information in a single shot, are the Waters Reverse or / and Water. This film will pro-
vide information about the orbital rims, maxillary and frontal sinuses, angles, ramus and condy-
lar processes of the mandible, malar bone, zygomatic arches, frontal bones and nose, thus
giving an excellent starting point for further detailed explorations on the craniofacial skeleton.
Fig. 1.- CT-scan showing 90º displaced fracture of the left condyle

Fig. 2.- Frontal X-Ray could also show the bilateral fractured and displaced condyles.
Fig. 3.- Waters position. (Selected readings, ref. 1).

Fig. 4.- Waters Reverse position. (Selected readings, ref. 1).
Fig. 5.- Antero-posterior position. (Selected readings, ref. 1).

Fig. 6.- Mayer view for unilateral TMj, external auditory canal, and petrous process exploration. (Selected readings. ref. 1).
Fig. 7.- Submento vertex position. (Selected readings, ref. 1).
4.3 General management
Once the patient has been stabilized, its general and local conditions should be assessed
in order to decide if he will be treated immediately or not. Three options are considered:
Immediate intervention, early delayed or late delayed.
4.3.1 Immediate Intervention. Is considered when the surgical treatment could be done
during the first 4-6 hrs after injury. At this stage local edema is not fully established, so the
skin incisions, the approaches to the fractured bones, the fragment mobilization, reduction
and internal fixation will be much easier than in later stages. Local swelling represents also
a challenge when searching for symmetry between the healthy side and the injured one.
So said, the best moment for treating facial fractures are the immediate hours after trauma.

4.3.2 Early delayed. Delays in transferring the patient to the hospital, in properly stabilis-
ing the patient, in finding the specialist, failing with the initial cares and diagnosis, could lead
to loose valuable time and local swelling develops in such degree that makes the surgery,
open reduction and internal fixation, an impossible and risky task with a poor prognosis. In
such conditions is much better to delay the surgery until general and local conditions im-
prove. It means that the patient should be given steroids and kept in such position (half-
seated) that the edema will resolve or much improved after some 3 to 6 days. At that stage,
the tissues use to be soft enough to be undermined and the fragments loose enough to
be mobilised and reduced. Of course certain swelling and edema are still present and he-
matomas, though still not organised, also makes the surgery more difficult than in the early
stages, but as has been said, after 3 to 6 days and under better local or general conditions,
the surgery could still be carried on with a good prognosis.
4.3.3 Late delayed. In some instances, the patients are in so poor or bad general condi-
tions that there is no way to operate them during the first hours or days. In such conditions,
the hematomas become organized, the edema resolve but scarring tissue starts appearing
everywhere, fibrosis develops, small bone fragments disappear or loose their volume due
to resorption and the fractured bones (displaced or not) become fixed. In those conditions,
open (or close) reduction is just impossible. Late delayed treatment is now the treatment
of the different sequels. In those instances, bone remodelling, osteothomies, refracture of
the displaced fragments, filling dead spaces or whatever could be needed, should then be
considered. Of course this is the worst option and the results are not always as good as
could be in the early stages.
Management of Cranio-facial trauma
Immediate Early delayed Late delayed

intervention • 3-6 days post injury • Until general
• First 4-6 hrs after the • After steroids conditions improve
injury treatment • The worst option
• The best option when • Swelling improved • Surgery of sequellas
possible or disapeared
• Depending of general • Patient stabilized
condition
• Depending on local
swelling

Chapter 5
Management of wounds and open fractures
The effect of high speed traumas frequently result in combined severe injuries of soft tis-
sues associated with bone fractures. This combination of fractures with open wounds
and / or tissue loss represents a great challenge for the surgeon, as it requires skill and ex-
perience in managing bone as well as soft tissue injuries, their different ways of healing and
the timing of their combined repair, knowledge of local flaps and experience to coordinate
the whole reconstruction as a functional and aesthetic unit.
5.1 Local management; Principles
As has been mentioned, immediate intervention is the best form of treating facial fractures.
The principles for a complete approach to facial fractures are:
1. Early one-stage repair.

2. Exposure of all fracture fragments (open reduction).
3. Precise anatomic reduction and fixation (Rigid always preferable).
4. Immediate bone grafting (if needed)
5. Definitive soft tissue repair.
5.2 Whole management of the facial injury
After general stabilization and local exploration, diagnosis of every injured part of the face
should be done and once this is completed, the next step is a methodical planning of what
has to be done, the order in which every part should be repair and how. A guide for se-
quentially treat craniofacial lesions is:
1. Great vessels. Compression or ligation is obviously the first step in case of an injury
to a great vessel as the carotid artery, jugular vein, maxillary artery and so on.
2. Surgical debridement and exploration for foreign bodies. As the facial tissues are
highly vascularised, debridement is rarely needed and if it is the case it should be very
conservative as the most of the tissue will survive even in the worst conditions.
3. Close or Open reduction and internal fixation of fractures. Always start from the
stable and non fractured bones to the fractured ones in comminute fractures. Bone or
cartilage harvest and grafting if necessary.

4. Repair of Ducts, as the stenon or lachrymal. Though they are rarely injured, espe-
cially the lachrymal, when it happens they should be repair with a 6-0 or 7-0 mono-
filament with a catheter inside the duct that will be let in place during three weeks.
Failure in diagnose or repair will lead to cysts of salivary fistulas.
5. Nerve repair. Neurorraphies of transacted nerves, with special remark for the Facial
nerve should be done at the same stage at the end of the surgery, that´s to say, after
all the bone fractures had been reduced and fixed. As always in nerve repair, it should
be done without tension and if there is a gap, nerve grafting should be considered.
6. Miorraphies of sectioned muscles, especially when avulsions could lead to unde-

sired adhesions between one or several muscles that will result in undesired, non
functional or anaesthetic movements in the face. So, in the presence of muscle avul-
sions, great care should be taken in suturing each group or each muscle. Simple cuts
or minor muscles avulsions will need no suture.
7. Cutaneous repair. Though cutaneous repair could be planned before starting the
surgery, it represents the last step. Soft tissue defects must be perfectly defined in
order to choose the best way for its repair. The most of the times, soft tissue defects
could be repaired by surgical debridation and direct suture (see fig. 13). Not very
often, repair of soft tissues, especially skin, will require more than direct suture, and
then grafts (very rarely) or flaps should be considered. Even the option of secondary
healing over healthy subcutaneous tissues may be an excellent option (see fig. 16).
Fig. 8.- Partial avulsion of the left check with laceration of the sali-
vary duct. A catheter is used to check its integrity and direction.

Fig. 9.- Stenon duct repair. (Selected readings, ref. 1)
Fig. 10.- A) The patient before the surgical exploration and treatment. B) The same patient, 15 months after. No cyst or
fistula appears after the duct was repair.

Fig. 11.- A) Patient with palsy of the frontal branch of the
facial nerve, already treated and sutured elsewhere.
B) Trans-op view of the sectioned frontal branch and the
comminute fracture of the zygomatic arch. (Selected
readings, ref. 5).
Fig. 12.- A) Zygomatic arch has been anatomically reduced

and repaired while the frontal branch is still retracted with a
clamp. B) The same patient, 9 months after, eyebrow is nor-
mally functioning and zygomatic profile maintained. (Select-
ed readings, ref. 5).

Fig. 13.- Surgical debridation and direct suture after the fractures of the nose and maxilla has been treated .(Selected read-
ings, ref. 5).
In some special cases, as partial or complete avulsion of the scalp together with the perios-
teum, multiple trephines reaching the diploe must be done (the trephines must be seen
bleeding) then changes of dressing at least two to three times a day with wet gauzes will
allow the buds of granulating tissue to emerge from the diploe and gradually cover the full
extension of the defect. This defect could then be covered with split thickness grafts.
Fig. 14.- Complete avulsion of the scalp including the left ear. Multiple cranial vault monocortical trephines have been
performed to allow granulation tissue to growth. After a good and thick layer of granulation tissue has been obtained, skin
grafts are required. (Selected readings, ref. 5).

There are situations I which the loss of soft tissue could be repaired at the same time only
by using local flaps. The immediate cover will allow better bone healing, better functional
recovering and better cosmetic result, as secondary procedures to restore the normal anat-
omy tends to be much more difficult.
Fig. 15.- Loss of 2 / 3rds of the lip by a dog bite and immediate reconstruction with a cheek flap. (Sel. read. reference 5)
Fig. 16.- Secondary healing in a lip would allow time for the physiologic contraction of the wound takes place thus re-
ducing the area. In such way instead of a flap with multiple scars on the face, only a minor revision is needed. (Selected
readings, ref. 5).

Chapter 6
Approaches to the craniofacial skeleton
Open reduction techniques means that the different areas of the craniofacial skeleton could
be reach through the skin and the different layers of soft tissues in a safety way. As has been
mentioned, the same injuries could be used as approaches as old scars could be also of use.
Many approaches had been described by not all are safe enough and not all are aestheti-
cally accepted. Generally, the incisions should be created over the wrinkles or lines of minimal
tension, properly dissecting the underlying structures only to reach the safest anatomical layer,
the subperiosteal plane. Depending on the area to be reached there are many possibilities.
6.1 Coronal approach
The coronal approach is an excellent way to gain access to all the upper third bones of the
craniofacial skeleton with a minimum visible scar. The incision in the scalp runs from one
pre-auricular area to the opposite and it exposes completely all the forehead, parietals,
temporal areas, the nasal root and superior half of the orbits. The incision use to bleed and
some care should be taken to control it with forceps. Dissection could be done supra peri-
ostically or subgaleal until the traumatized area is reached, then it should continued sub-
periostically. In the same way, if orbits need to be treated, 1 or 2 cm above the orbital rims,
undermining should change from subgaleal to subperiosteal.
Fig. 17.- The Coronal approach: a) Forehead bones exposed supraperiostically. b) 2 cms above the orbital rims the dissec-
tion plane changes from supraperiostically to subperiostic, c) The orbital rims are exposed as well as the supraorbital neu-
rovascular bundles, d) Coronal incision, e) the pink line mark the incision over the temporalis galea if the zygomatic arch
wants to be exposed. (Selected readings, ref. 2).

Though the undermining and rising of the frontal flap is quite easy and secure, two are the
points where facial nerves could be damaged.
• First: when undermining the lower forehead or the superior part of the orbits, care should
be taken with the supraorbital nerves and vessels. Sometimes they travel in a channel on
the medial superior orbital rim and could be clearly dissected and let attached to the coronal
flap, but sometimes it traverses through a tunnel in the orbital rim and then the both walls
of that tunnel should be cut with a small chisel in order to free the neurovascular bundle.
Fig. 18.- Coronal approach: All the fractures at the orbit, zygoma and temporal area have been exposed. Notice the su-
praorbital nerve preserved by dissection (arrows). In other circumstances it should be freed from its channel. Wire fixa-
tion provides a good stabilization in this area.
• Second difficult point is to avoid damage to the frontal branch of the facial nerve; if the
zygomatic arches need to be undermined and exposed, the temporalis fascia should
then be incised from the helix root to the frontozygomatic suture, and the dissection
should then proceed downward until the bony ridge of the zygomatic arch is reach. Pro-
ceeding sub aponeurotically the frontal branch of the facial nerve is preserved and there
is no risk of damaging it as the nerve runs included in the flap. (see fig. 19)
Fig. 19.- A) Dotted arrows indi-

cates the proper way of under-
mining the temporal region to
keep the frontal branch of the fa-
cial nerve save from the dissect-
ing instruments. Dissection
from the subgaleal space (1),
should traverse from the outer
layer of the temporal fascia (2)
through the internal fat tempo-
ral fat pad AND THROUGH the
inner layer of the temporal fascia
(3), reach the inner part of the
zygomatic arch (5) and, subperi-
ostically, proceed downwards.
This is the way to safely reach
the zygomatic arch, TMJ and
middle facial bones. (Selected
readings, ref. 9).

Fig. 20.- The Coronal approach: A) Common wrongly description of the superficial temporalis fascia being divide in two
layers and each one descending directly to each of the sides of the zygomatic arch opposite to what is described in fig 19.
C) The complex and important close relation of the TMJ with the facial nerve and temporal vessels. D) Exposition of fracture
and highly displaced condyle through the approach above mentioned. (Sel. Read. References C) 7 and D) 8)

Fig. 21.- A) and B) The Coronal approach: The flap has
been raised and bleeding controlled by a plastic colon
clamps exposing the forehead. The lateral orbital wall and
zygomatic archs.
6.2 Orbital approaches
Orbits are a frequently injured area where many facial bones meet (Zygoma, sphenoid,
frontal, ethmoid, lacrimal, palatine and maxilla). Depending on the types of fractures, the
anatomic areas involved and if they are isolated or associated with some other fractures, a
variety of approaches could be used. Though some of them are highly practical, give a wide
exposure and could hardly been evident in the postoperative period, there are others that
are not aesthetically nor functional acceptable.
Fig. 22.- a) Supraciliary incision. b) “W” me-

dian paracanthal. c) External canthal incision.
d) Upper infraorbital. e) Median nasal.
f) Frontoethmoidal g) Infraorbital. h) Trans-
conjunctival. i) Subciliary incision. j) Latheral
canthal. (Sel. read. reference 2)

Of all these approaches, there are some that give a wide exposure, ease of dissection and
highly aesthetic result while there are others which do not fit these characteristics. Between
those, our preferred incisions are:
• Subcilliary incision.
• “W” median paracanthal incision.
• Lateral canthal incision.
• Coronal approach.
As incisions to be avoided because their very noticeable scar and possible post-operative
distortions are:
• Supracilliary incision.
• Fronto-ethmoidal or lateral paranasal incisions.
• Transconjunctival
• Infraorbital or superior infraorbital incisions
• Lateral canthal.
6.2.1 Subciliary incision
The incision is done 1 mm under the eyelashes line, it runs from the lacrimal point to
the lateral cantus and could be (should be) extended 10-15 mm further on the eyelid
lateral wrinkles. The incision should include the skin, orbicularis muscle and subcutane-
ous tissue. The orbital septum should be exposed and, without entering or rupturing it,
the dissection should proceed to the orbital rim. Once there, the periosteum should be
incised and dissection could then be carried on subperiostically. Is highly advisable to
close both eyelids together with a simple stitch of 6 or 5-0 silk in order to protect the
cornea and handle the lids up and down at will, without clinching them repeatedly with
forceps.
Fig. 23.- A stitch is first sutured to close both eyelids, then dissection could be performed over the septum to reach the
orbital rim. (from...)

Fig. 24.- The periosteum is incised and levators are used to follow the dissection subperiostically to expose the fractures.
6.2.2 External canthal incision.
This approach is highly useful to explore, reduce and fixate fractures of the zygoma at the fron-
tozygomatic suture, or if extended medially over the superior eyelid, to explore and treat orbital
roof and lateral wall fractures. The incision could be placed just below the eyebrow or following
the lateral wrinkle of the superior eyelid. It should traverse the skin with the orbicularis muscle
and proceed directly to the periosteum. Care should be taken with the lachrymal gland.
Fig. 25.- The lateral canthal approach is a useful

approach for maxillary suspensions or reduction
and fixation of a displaced zygoma with wire as
well as with plates and screws. (Selected read-
ings, ref. 2).

6.2.3 Medial conjunctival approach.
The transconjunctival medial approach, though being a delicate and difficult one, could be
used as a single approach or combined with the “W” skin medial canthal incision, and is
essential to perform the medial canthopexie when the coronal approach has not been
done. On the conjunctiva, the medial canthal ligament should first be located with a for-
ceps, and then a curved incision could be made directly to the periosteum to expose the
rear part of the medial canthal ligament (it should be remember that the medial canthal
ligament has three insertions points, the anterior, superior and posterior to the lachrymal
sac). The cornea should be especially protected when this approach is used, otherwise
could be easily injured.
Fig. 26.- Medial transconjunctival approach: From A to C,

the medial canthal ligament is identified with the forceps.
The conjunctiva crease behind the ligament is then pulled
and incised to proceed directly to expose the bony surface
in the posterior aspect of the ligament.
6.3 Intraoral approaches
Intraoral are the basic approaches for lower and midface fracture exposure as they give
access to a wide area of the facial skeleton. There are various possibilities depending
on the area to be treated; however some of them are more versatile and useful than
others.

As could be seen in fig. 27 the possible intraoral incisions are:
Fig. 27.- Intraoral incisions:

a) Superior vestibular incision.
b) and c) Lateral vestibular incision.
d) and e) inferior vestibular incision.
f) Dentogingival incision.
g) Vestibular retromolar incision.
(Selected readings, ref. 2).
However, the most of the already mentioned incisions are rarely used. The most com-
monly used incisions are the superior vestibular and inferior vestibular, as they are the only
ones which give an adequate and wide exposition.
Fig. 28.- Superior vestibular approach. All the lower max-

illa and zygomatic bones could be exposed. (Selected read-
ings, ref. 6).

Fig. 29.- Inferior-anterior vestibular approach. It could be limited from pre-molar to pre-molar or extended from the third
molar to the opposite. It gives an excellent exposure of the chin and body of the mandible.
Fig. 30.- Inferior-lateral vestibular approach. The fracture could be easily reduced and fixed if necessary with the special
devices for drilling and engaging the screws. If only wire is at hand, the extraoral angular approach is the choice.
Those vestibular incisions from molar to molar, are very commonly used approaches as
the subperiosteal plane is easily reached and the subperiosteal undermining easy and
secure to perform, give a wide exposure of the mandible (the inferior), and the maxilla
and zygoma (the superior), use to heal well and the scars are no noticeable and good. In
both cases, care should be taken to incise the mucosa at least 5 to 7 mms outside from
the sulcus in order to let a strip of tissue where sutures could be firmly anchored. After
the initial incision, subperiosteal dissection is easily performed to expose the maxilla or
the mandible. In both cases too, care should be taken with the respective nerves that
arise from both the infraorbital foramen and the mental foramen. Both nerves should be
surrounded to respect their integrity to preserve innervations to their respective cutane-
ous areas, nose and upper lips for the infraorbital nerve and lower lip and chin for the
inferior alveolar nerve.

6.4 Extraoral approaches
Perimandibular incisions are referred to those made through the skin to reach and expose
certain areas of the mandible. They are rarely used as intermaxillary fixation and transcuta-
neous rigid fixation needs no external approaches and the most of the fractures concerning
the condyles will heal properly without manipulation.
Fig. 31.- Extraoral approaches: a) preauricular with

a temporal extension, b) auricular incision, c) An-
gular incision (Risdon), and d) retromandibular
incision. (Selected readings, ref. 2)
However of those incisions above mentioned, the preauricular and the angular incisions are
the most commonly used.
6.4.1 Pre-auricular temporal approach
This is a highly difficult and demanding approach, but is the only way to achieve a direct
exposure of the Temporo Mandibular Joint (TMJ) (see figs. 20 and 32). As the whole TMJ,
and especially the neck of the condyle where the most of the fractures are localized, is a
wide area, the incision should start at the inferior point in front of the tragus and run up to
the temporal area where it should be curved directly to the hairline.
As have been previously explained, the incision should traverse both layers of the tempo-
ral fascia to avoid the frontal branch of the facial nerve (see figs. 19 and 20), but instead
of continuing subperiostically as for the zygomatic arch exposure, from the subperiostic
plane the incision should proceed supraperiostically to reach the external surface of the
TMJ. Then, over the ligaments and without entering the joint, the undermining should
reach and isolate subperiostically (again) the neck of the condyle, where the most of the
fractures are localized.

Fig. 32.- Two types of pre auricular-temporal incisions for TMJ or condyle surgery. A) The first is following the auricular
landmarks and then extended to the temporal, and B) the second runs from the ear lobe to the tragus and then directly to
the temporal region.
6.4.2 Angular incision
Though rarely used, this incision could be extremely useful in certain fractures of the man-
dibular angle, especially the unstable ones and when lacking the appropriate devices for
rigid internal fixation.
The incision would leave a visible scar, but gives a rapid and easy approach to the area, and
if only one wire point is needed for stabilization, the incision will not be very large. Once the
skin has been incised, the subcutaneous tissue and the platysma muscle are traversed to
reach directly the periostium. If the incision is extended forward below to the body of the
mandible there is the risk of Injury to the marginal mandibular branch of the facial nerve as
in crosses the border of the mandibular body.

Chapter 7
Principles of bone healing
The most important factor for a bone to heal is stability, of course bone to bone contact
and good local conditions play an important role, but without stability, the bone under-
gone a process of resorption, that will finish with loss of mass, strength and volume.
The bones of the face (composed by membranous bone), heal by the process called
fibrous union exclusively. On the fracture site a callus consisting partly of cartilage is first
formed, and it becomes stable four weeks later. Despite there is evidence of bony
union, the fracture site remains radiographically translucent. It does not mean that frac-
ture consolidation has not been achieved; it only means that deposits of minerals in the
fractured site of a membranous bone are such that radiolucency persists.
However, if there is not an appropriate contact between the fractured surfaces the heal-
ing process would fail. That is why open reduction techniques with anatomical reposi-
tioning of the fragments and rigid fixation, would lead to a better healing of the bones.
It should be noticed that midface bones acts as a support system to the upper dentition
while protecting the eye globes and the rhinopharinx, while the mandible gives support
to the lower dentition as great load bearer. So, morphology is close related to function
as well as aesthetics, and so, proper healing of the bones are the key and the link be-
tween the preservation of the face structure and function.
In summary, good bone healing requires:
• Perfect reduction of the fragments to its anatomic position

• Rigid fixation of the fragments
• Get good soft tissue cover
• Allow enough time for the bone to heal.

Fig. 33.- Onlay bone grafts on the orbits and a cantilever graft over the nasal dorsum. Plates
and screws provide rigid and stable fixation on a well vascularized environment to allow the
best healing conditions.
Not infrequently, trauma, specially again in high speed injuries, use to let some areas
with a completely destroyed bone, or the bone fragmented in so many pieces that they
are not longer suitable for sustain rigid or even wire stabilization. In those circumstances
bone grafts should be employed to fill those spaces, maintain the natural axis of stress
distribution along the face and finally avoid the dead spaces which will be associated
with secondary deformities.

Chapter 8
Principles for Bone grafting
One of the concepts that have changed in the last two decades for these types of severe
traumatism is one stage surgery. In many of these high speed traumas, some facial
bones are so badly comminute that they virtually disappear and ceased to exist as a
functional structure or they are just so small that they could not afford the use of any
method of fixation. In these circumstances the introduction of primary bone grafting has
reduce dramatically soft tissue scarring contraction and shrinking with the associated
secondary deformities.
8.1 Principles of graft survival
Resorption of bone and displaced small fragments which could not afford any type of fixa-
tion could result in gaps and dead spaces between fractured bones. Secondary deformities
and functional impairment could then be expected. In those circumstances primary bone
grafting, as well as bone grafts for secondary procedures, are indicated. Bone grafts are
employed to fill dead spaces and gaps as well as for contouring the facial skeleton in sec-
ondary reconstruction.
These bone grafts are used to provide a matrix of osteogenic cells (osteoblasts, osteoclasts and
osteocytes mixed with myeloid and fat cells in a fibroblastic stroma). Graft survival involves neo-
vascularization in an angiogenesis phase based on chemotoxic factors promoting the prolifera-
tion and ingrowth of capillaries with an effect of bone resorption. Bone resorption induces the
chemotactic factors to act to activate the osteoclasts precursors and, finally, the osteoinduction.
In terms of revascularization the difference between the two types of bone grafts (cancel-
lous or endochondral bone and cortical or membranous one) is important too, as cancel-
lous grafts may revascularize very early (within hours) when compared with the cortical
graft which will require peripheral osteoclastic resorption and vascular infiltration. So said,
cancellous bone grafts could be completely revascularized within 2 weeks, while the corti-
cal bone graft could take 2 months to be completely revascularized.
For a bone graft survival to success some conditions are required:
• Well vascularized recipient site.

• Rigid immobilization.
• Accurate apposition on the recipient site.

8.2 Types of bone grafts
Grafts could be classified by its embryological-histological characteristics, by its anatomic

origin or their actual physical properties. Membranous bone is that which does not have
cartilaginous precursors, while endochondral bone has in origin cartilaginous precursors.
Though they are not “bone”, special mention should be made in this chapter to cartilage
grafts, as they are occasionally used to add volume, mass or just support to certain bony
areas of the face.
Another type of bone graft that should be considered is a loose fragment of bone resulting
from the same trauma.
8.2.1 Membranous bone grafts. The classical example is the calvarial bone graft, usu-
ally the split calvarial bone. This type of graft is primarily cortical, rigid and strong enough to
afford the use of miniplates and screws on it and also to be use as a plate itself for buttress
reconstruction.
8.2.2 Endochondral bone grafts. To that category belong the two other classical bone
grafts, the rib and the iliac crest. Though they lack the rigidity and strength of the calvarial
bone graft, they are flexible and can be easily bent, furthermore by their characteristics, they
are extremely useful when mass and volume is required.
8.3 Choosing a graft type
The election of a donor area for harvesting a determined type of graft is mainly based on
the characteristics of the recipient area.
Despite their physical differences already mentioned, various studies had demonstrated
that bone grafts of membranous origin maintain their volume and mass to a greater extent
than those of endochondral origin. This is an important argument for choosing one graft or
another, especially when the contour has to be reconstructed.
Finally, the indication for using one type or another depends on the physical properties of
each graft and the mechanical factors required by the recipient area. The three classical
bone grafts are calvarial bone, rib and iliac crest.
8.3.1 Calvarial bone graft
It is the most commonly used bone graft in craniofacial surgery. It could be used as full
thickness or split thickness. Harvesting Split thickness grafts require certain skill, experi-
ence and availability of powered instruments like burrs. Splitting off separately the outer

table is not an easy procedure even in skilled hands and has a moderate risk of inner table
perforation with dura penetration (an incidence of 14.5% has been reported), cerebral-
spinal fluid leakage, bleeding and even infection. Full thickness graft harvesting means
a formal craniotomy, with all their implications. A split thickness graft is rigid enough to be
able of sustaining fixation with wire or plates and screws, though is not very thick. The full
thickness one is thick enough to add mass and volume to rigidity.
Fig. 34.- Bone grafts can be harvested in situ as partial or full thickness grafts. When larger pieces are needed, the bone can
be harvested as a full thickness bicortical graft, returning the inner table to its original place to use only the outer table for
grafting. (Selected readings, ref. 3).
The technique for harvesting split cranial bone grafts includes an incision on the
scalp and delimitation of the graft with a burr until the diploe is reached (starts bleeding).
After the inner table has been reached but no burred, the outer tabled could then be split-
ted off with an oscillating saw or a chisel.
Their advantages are:
• Proximity of the donor area to the recipient site.

• Membranous origin (better long term prognosis in terms of mass retaining).
• Rigid enough to sustain plates and screws.
• Hard enough to maintain the shape and contour in place.
• Minor or no donor site morbidity.

Fig. 35.- Harvesting split thickness grafts is best done marking
the grafts with a burr and proceed deep to the diploe. The
chisel is then used to completely remove the graft. If larger
grafts are needed, the best and safety option is a complete cra-
niotomy and then split the bone in two halves.
As disadvantages could be marked:
• D ifficult to obtain. Risk of intracranial damage.

• D ifficult to contour.
• N
ot suitable for big areas.
8.3.2 Rib graft. Is a very suitable bone graft, and could also be used as full thickness or
split. Its harvesting also requires special skill as there is the risk of perforating the pleura and
produce a pneumothorax.
After an incision following the profiles of the selected rib (usually the sixth or seventh) is
done, the different planes are traversed to reach the outer surface of the rib (periostium or
perichondrium). The easiest way to harvest the rib is to proceed directly to the periostium
over the external surface of the rib, it should be cut longitudinally until the cartilage union
is reached. With a periostium elevator the periostium is undermined and raised freeing
completely the superior and inferior margin. After those superior and inferior edges are
free, the undermining of the inner surface should proceed very carefully with an elevator of
blunt borders. There are special instruments for harvesting the ribs, though it could be har-
vest with the single help of a periosteal elevator. Once the complete subperiosteal under-
mining of the rib is done, it is much easier to start detaching the extreme at its junction with
the cartilage. At this level, protecting the internal or pleural surface with an elevator or what-
ever flat, curved and blunt instrument you have, the cartilage could be cut very carefully
with a surgical blade. With one extreme free the rib could then be raised and the other
extreme cut much more easily. Their advantages as grafts are:

• Extensive donor area
• E xcellent capacity to be incorporated (especially the split rib).
• E xcellent capability to be contoured
• M
inor donor site morbidity
Between their disadvantages, are:
• E ndochondral origin.
• N ot hard enough to sustain plates and screws, especially under tension.
• N
ot very easy to harvest. Risk of pneumothorax.
Fig. 36.- Comminute defect in the superior right orbital rim secondary to severe punctual trauma with a metal tube.
B) Reconstruction of the rim with a rib graft.
8.3.3 Illiac bone grafts. Illiac crest is another of the most commonly used autogenous bone
graft. It provides a good source of cancellous as well as cortical bone. That cortical is much
easier contoured than the cranial bone while providing more mass and volume at the same time.
Similarly to the others it could be harvested as full thickness or split thickness. Harvesting that
type of graft is easy and fast. A direct incision over the iliac crest is first done, the bone is almost
immediately reached, and undermining continued subperiostically in each side. Of course a
powered saw is far better than a chisel or a gigli saw to do the osteotomies. The donor area
uses to bleed quite profusely and drainages are mandatory during some days as well as local
compression. The main problems with that type of graft are always related to the donor area.
Its advantages are:
• G ood rate of cortical and cancellous bone in the same graft.

• E asy to reshape and contour.
• A
vailable as a wide graft in a wide donor area.
Between their disadvantages are:
• S ignificant blood loss at the donor area

• P ain and hyperesthesia around the incision for a long term.
ndochondral origin with the possible loss of mass.
• E

Fig. 37.- A) Exposure of the anterior iliac crest. B) Iliac crest
graft. The graft already removed has now to be shaped to
the desired form.
8.3.4 Cartilage grafts. Cartilage grafts are mainly used for adding volume over bony
surfaces, remodelling profiles, adds support structures or reconstruct certain frameworks
as nasal nostrils and / or ear. Donor sources depend more on the shape and volume
needed rather than its origin or type. Common sites are: Conchae of the ear, nasal sep-
tum and ribs. Cartilage is a highly flexible material that depends on the perichondrium
to be nourished but also for maintaining its shape. Loosing or removing part of that peri-
chondrium could provoke distortion of the graft. Sometimes the graft needs to be re-
shape and this could be done not only by tailoring but for reshaping the perichondrium.
If the graft cartilage is needed to be curved to one side the perichondrium should to be
partially removed, or even excise, on the opposite side. After that is done, the cartilage
will start twisting gradually until the superficial tension between the two surfaces be-
come neutral. The most important factor for a cartilage graft to survive is a good vascu-
larized environment. Cartilage resorption is rarely seen in autografts, while was very
common in allografts.
Their main advantages are:
• E xcellent for tailoring and contouring. Even, if well selected, the original shape in origin
needs not remodelling at all, and could perfectly fit the affected area.
• P ractically no resorption.
• E xcellent donor sites with minimum or none morbidity.
• E
xcellent for adding mass and volume without stress.
Between their disadvantages are:
• N ot able to sustain any stress and unable to afford rigid fixation under stress
• N ot interaction with bone nor primary bone healing as it is not bone.
• P ossible late distortions on the recipient area if the graft has not been perfectly tailored
and managed, specially regarding to the periostium in both opposite surfaces.
• D
ifficult to obtain if there is no skill or experience in septoplasty or rib removal.

Fig. 38.- A) Ear cartilage, by backward approach. Almost the full conchae could be harvested without creating distortions.
B) A good example for a conchae cartilage graft is the orbital floor repair after trauma. C) Cartilage graft taken from the rib
for nose reconstruction. From one piece of rib, the outer parts will become curved by themselves and used for alar recon-
struction, while the septum is repair by the central remaining part of the rib.
8.3.5 Loose fractured fragments. Though this is not a procedure by itself, some-
times, pieces of fragmented bone from places where they are not strictly necessary (as
the maxillary sinus wall or pieces of cortical bone from the mandible) could be used as
grafts.
Fig. 39.- Fragments of the anterior maxillary sinus wall are used to reconstruct the orbital floor. Contrary to cartilage
grafts, is far better to fix the bone graft on the area to be used in order to diminish the risk of resorption.

Chapter 9
Techniques and elements for bone fixation
As has been mentioned, immobilization is the first requirement for a bone to heal. This
immobilization could be achieved by fixation in two ways; Wire fixation or rigid fixation.
Wire fixation is not as rigid as it should be and micromotion between the fragments is
present, micromotion which could lead to a fibrous union with the associated risk of re-
sorption. Rigid fixation with plates and screws eliminates that micromotion and allows
better primary bone healing as well as better revascularization of bone grafts.
Rigid fixation of the fractured bones with miniplates and screws is actually considered the
best way to achieve total stability though they are rarely available in undeveloped areas. The
technique will be revised but great emphasis will be given to those procedures employing
the old procedures of suspensions and wire fixation as they will be the current techniques
to be employed in non developed regions.
9.1 Rigid fixation
9.1.1 Types of metal plates. From the first trials in rigid fixation, different materials have
been used for plates and screws. Beginning with stainless steel through vitalium, tantanli-
um and Titanium, to the most modern and biodegradable materials. Two of these types
will be revised.
9.1.1.1 Stainless steel. The first plates used for rigid fixation were made of stainless
steel. Though it was a considerable advance from the wire as a fixation method they pres-
ent serious problems. Their main disadvantages are:
• Corrosion of the plates that could lead to a foreign body reaction, local necrosis and
implant failure.
• Extreme rigidity, that makes them almost impossible to bend, and when bended, sur-
face crevices may appear increasing the risk of corrosion.
• Highly reflective to CT scans.
• They are very bulky and noticeable under the skin, especially in certain parts of the
face.
On the other hand the steel has been used for what is known as the compressive dy-
namic plates that are still a good option for fractures on the body of the mandible.

9.1.1.2 Titanium plates. The most of the miniplates systems in use for craniomaxillo-
facial surgery are made of Titanium. Their advantages are:
• It is a highly pliable material that allows precise contouring of the plate to the bony surface.
• It could be bent with little rebound and without increased the risk of corrosion.
• Is rigid enough to resist external forces and maintain the bones in the desired position.
• It is not very reflective to CT scans.
Fig. 40.- Extensive use of Titanium miniplates (Se-

lected readings, ref. 3).
Fig. 41.- A) Steel plates could be used in the absence of the more appropriate plates. Of course beside the rigid fixation their
main disadvantages are their rigidity and thickness that makes them extremely difficult to contour and fit. The thick screws
are also difficult to fit in the thin facial bones. However, the mandible could afford much better these types of plates.

Fig. 42.- On the opposite, the lesser and thinner titanium plates allow a perfect contour of the plates to the curves of the
bony surfaces, and could easily fit the different shapes and be unnoticed even under the skin.
9.1.2 Principles of rigid fixation
Rigid fixation makes reference to a procedure in which plates and screws are used to ana-
tomically reduce and solidly fix the fragments. This process is:
1. Open reduction via the same skin injuries from the trauma or aesthetic new incisions as
has been mentioned.
2. Always start from the most external fractures adjacent to healthy and stable bones to the
central ones. If the occlusion has been modified by fractures, consider first to establish
a definitive or temporal intermaxillary fixation.
3. Clear exposure of the bony area around the line of fracture.
4. Bend the plate to the precise contour of the bony surface at each side of the line of fracture.
5. Drill the holes first in one side, engage the screws and finish with the opposite screws.
Of course, screws including two cortical are more reliable and could afford more stress
and tension than those who only reach the external table, so bicortical placement of
the screw is preferable to unicortical placement. The depth of the bone could, and
should, be measured with a depth gauge to know the length of the screw which better
fits the thickness of the bone. Is better, in terms of stability, to be longer than shorter
with the screw.

Fig. 43.- Procedure for a proper drill and engagement of screws. A) Check the proper diameter of the drill for a given screw,
and drill the hole perpendicularly to the bony surface as deep as needed. B) A threaded guide is used to easily and prop-
erly engage the screw. C) Check the length required for the screw and engaged it through the miniplate. It should be
tightened enough to hold firmly the plate against the bone, but with great as if it is too thigh it could break the bone and
become loose. (Selected readings, ref. 2).
9.1.2.1 Simple plates. For single plates the initial procedure is as mentioned before.
Once the bent plate is at place, a mark is done over one of the holes of the plate, a hole
is drill and a screw is engaged in one side. Pressing and holding the not drilled bone frag-
ment against the other, a drill is done over this bone and the screw engaged in place. The
plate through the line of fracture with one screw in each side gives two-dimension stabil-
ity but does not prevent rotation, so 1 more screw should be placed in each side for a
minimum total of 2 per side.
9.1.2.2 Dynamic compression plates. A method for increased the bony surface con-
tact between two fragments could be achieved by the use of compression. Compression
plates are designed specially for compressing the fragments one against the other once
the screws are in place. In fact they are only used for the mandibular body. They are
designed with a variable number of oval holes along one side of the plate axis, with the
same holes distribution opposite in the other side. The narrow portion of the hole is
outward. To achieve compression, the hole is drilled through the narrow portion of the
plate hole into the bone. The screw is then engaged into the bone, and as the screw is
tightened, the screw head is forced into the wider portion of the plate hole medially, and
this result in compression of the bone ends.

Fig. 44.- Use of dynamic compression plate.
After the plate fits perfectly to the bony sur-
face, the first two screws beside the line of
fracture are engaged to achieve axial com-
pression, while the other two prevent rota-
tion. (Selected readings, ref. 3).
Fig. 45.- Dynamic compression plates a) Horizontal and b) eccentric. (Selected readings, ref. 2).
9.1.2.3 Lag screws. If the dynamic compression plates achieve axial compression, the
way to get vertical compression of the fragments is by means of lag screws. The Lag
screw technique differs significantly from that of engaging screws in a single plate. The
first and essential step is maintaining the two bone fragments perfectly reduced in con-
tact (is a good help to keep them firmly hold with bone clamps). Secondly, a hole with a
proper diameter drill involving the two pieces is performed perpendicular to the line of
fracture (if not some displacement will result when tighten the screws). After that, the
fragments could be let loose again and on the proximal fragment the hole is over drilled

to permit the screw to be introduced without the help of the screwdriver. Then again,
fragments should be reduced one against the other and the screw engaged until the two
fragments are firmly attached to each other.
Fig. 46.- Scheme of how a lag screw should be planned and engaged. A) Detail of the different width of the proximal and
distal holes, the former over drilled and the last drill to the appropriate diameter. B) As the screw threads, engage the distal
bone and, C) at the end, the distal bone is compressed against the proximal. (Selected readings, ref. 11).
Fig. 47.- Effect of reduction and compression between the bone fragments while engaging the lag screw in place. (Selected
readings, ref. 2).
9.1.2.4 Three-dimensional Plating. Three dimensional plating system has been

developed on the premise that geometrically closed quadrangular plates fixing the
bone fragments with the adequate screws could achieve even more stability than
simple plates while employing shorter plates and fewer screws. The plates are thin
enough to be very easy to contour to fit the irregular profiles of the facial bones. It rep-
resents a step forward.

Fig. 48.- Different types of plates on the Cranio-facial skeleton.
9.1.2.5 Absorbable plates. Actually there are available plates of absorbable material.
They are mainly used to stabilize cranial vault osteothomies in small children who un-
dergo craniofacial surgery.
9.2 Wire fixation
Though rigid fixation is the best method for treating facial fractures, these equipments of
multiple plates of multiple forms with a great variety of screws in different sizes and diam-
eters are rarely available in undeveloped areas. The same is for the powered devices for
drilling and burr; they are very expensive and rarely disposable. In these conditions the
treatment of craniofacial fractures should relay on much more less sophisticated methods
of fixation, which could provide appropriate stability to the fractured bones exclusively with
the employment of wire, IMF (Inter Maxillary fixation) and even cranial suspensions.
Despite what has been previously mentioned, the fact is that many single facial fractures
could be properly treated with the only use of wire fixation. Of course the lack of rigidity
should be compensate with a more accurate reduction of the fragments and a perfect plan-
ning of where to drill the holes to compensate the different vectors of force for each wire
ligature while compensating the different vectors of force from the attached muscles.

Fig. 49.- A) Sagital fracture at the angle of the mandible
exposed by direct approach. B) Reduction and fixation by
wire. Though perfectly reduce and fixed, intermaxillary fixa-
tion is mandatory when wire fixation has been used.
It is important to remember that wire fixation, especially at the mandible is mainly used to
maintain unstable displaced fragments reduced and attached one to the other and that
Intermaxillary fixation should be maintained during the next 4 to 6 weeks.
In the cases of completely displaced fractures of the zygoma, at least a perfect reduction
and three stable points of fixation are required to prevent rotation.
Fig. 50.- A) Wire ligatures to fix a rib graft over the zygoma, and B) Single wire ligature at the fractured suture site on the
frontal process of the zygoma. Though both ends fits perfectly and are properly reduced, three ligatures at different points
are needed to get long term stabilization.

Wire fixation though technically less advanced and less sophisticated, is a time consum-
ing procedure that requires skill and patience. There are some requirements and tips
and it would depend on the structures involved and the extension of the fractures that
wire fixation will relay only in some ligatures, in intermaxillary fixation or even in cranio-
facial suspensions.
Requirements for open reduction and wire fixation (ORWiFi) are:
1. A drill (much better a powered than a manual drill) with reels of 0.5mm,1 mm or
1mm ½ at maximum, as 2 mms could be good for the body mandible but is too wide
for some bone fragments in the maxilla and orbit.
2. Wires of different size. Ideally it should be considered 0.15 wires for dental wiring, 0.3
wires for interfragment wiring at maxillary and / or orbital level and 0.5 for mandible
wiring. The greater the diameter, the more the difficulty in bending it adequately and
the more the risk of breaking the bone fragments while they are pulled together.
3. Open reduction via the same skin injuries from the trauma or aesthetic new incisions
as has been already mentioned.
4. Always start from the most external fractures adjacent to healthy and stable bones to
the central ones. If the occlusion has been modified by fractures, consider first to
establish a definitive or temporal intermaxillary fixation.
5. Clear exposure of the bony area around the line of fracture.
6. Consider that generally, three are the minimum required points to be used as anchor-
age for wire fixation between a bony displaced fragment and their neighbouring
bones. The drills should be done in the thickest part but especially in those areas that
could better prevent rotation of the fragments.
7. Wires should be used taking into account the thickness of the bone to be fixed. Is
much easier to start introducing the wire from the outer surface to the inner and then
proceed in the opposite bone, from the inner to the outer. Sometime a bent wire
with a loop in its tip should be used as a guide to pass the wire from the inner surface
to the outer one.
8. The wire ligature should then be twisted with a rude needle holder or a Kocher for-
ceps until the fragments are pulled together. It is very important to tight it properly as
if it is let too loose no fixation is achieved, and if it has been thigtened too much it
will become broken or will break the bone. If multiple ligatures are needed is much
better not to thighten the ligatures completely until all of them have been placed and
then proceed systematically to tighten them one by one, checking possible rotations
or misalignments.
9. After all the ligatures had been properly twisted, 3 to 5 mm should be respected and
the rest cut away. These extremes should be tilted and introduced into one of the
drilled holes in order to protect soft tissues to be damaged with the sharp ends.

9.3 Intermaxillary fixation
A proper occlusion is the first requirement to achieve long term stability when treating frac-
tures involving the maxillae and / or the mandible.
The first step before start reducing and fixing fractures affecting the dental arcades is to
check the previous occlusion. It could be very frustrated and time consuming trying to ob-
tain a proper occlusion on a patient with previous dental alterations. Once the previous
dental relationship has been established, a stable dental occlusion should be obtained by
closing together the superior and inferior dental arcades as they were previously to the
trauma, immobilizing them by an intermaxillary fixation.
Depending on the type of fractures and the fixation system used, rigid or wire, intermaxillary
fixation (IMF) could be used during the surgery as a guide to reduce and fixate the frag-
ments with miniplates (or wire), or be maintained during 4-6 weeks to allow the bone
fragments to heal. When wire fixation has been used or in those cases in which no open
reduction has been performed and the only treatment is the intermaxillary fixation itself, it
should remain up to 6 weeks, exception made for condyle fractures, in which the time is
reduced to 3 weeks (see forward).
Fig. 51.- Intermaxillary fixation IMF, with Winter bars and orthodontics rubber bands. The bands do not need to be placed
under great tension, they only need to maintain the proper occlusal relationship.

There are several possibilities to perform an IMF and however it will depend on the mate-
rial available. The proper material for an IMF is: adequate wire (0.15 or 0.2 mm diameter),
orthodontic rubber bands and dental arch bars. Though the orthodontic bands could be
substituted by “elastic rings” cut off from a finger of a surgical glove and the bars avoided
by other techniques, the better and specific is the material the better, the easier and more
comfortable will be the IMF.
IMF has two separate parts:
• Elements on both dental arcades as support structures for the intermaxillary material of
fixation (dental bars, eyelets or wire buttons...).
• Specific material to maintain the lower and upper arcades pulled together (rubber bands,
orthodontic elastic bands or wires).
9.3.1 Dental support methods
As proper occlusion is the key stone of the treatment, the wire or bands that pull the
mandible to the maxillae should be anchored over the dental arcades. In order to provide
the support structures over the dental arcades some methods have been described.
9.3.1.1 Arch bars IMF method. Arch bars are made of malleable but somewhat flexi-
ble steel. They usually have hooklike projections for anchoring the wires or rubber bands
that will close the jaws.
Fig. 52.- Examples of two straights bars contoured to fit each one of the dental arcades. This is the firs thing to be done.
It is EXTREMELLY IMPORTANT to model the bar exactly to fit the contour of the dental
arches. As these bars are flexible they will exert some sort of force over the teeth if they
not fit exactly the shape of the dental arcades. The effect of inadequately contoured bars

will be as that of an orthodontic device and could mobilize the teeth. Even more, if these
forces are added to those of the too tight wires over the neck of the teeth, extrusion may
be the result.
Fig. 53.- Different types of bars in their front and profile views. From A to C all relay in hooks to anchor the intermaxillary
rubbers or wires, while the fourth add some pieces of tube for passing wires in a longitudinally way. (Selected readings, ref. 2).
So said, the procedure should start by contouring the bars to each of the dental arcades.
After that, what we feel more comfortable and less time consuming is start passing the wire
ligatures around the neck of the available teeth of one of the dental arcades leaving them
open. When all the ligatures are in place, the previously contoured bar is placed and the wires
twisted to its end “feeling” the tension until the bar is secure but without breaking the wire.
Fig. 54.- Process of contouring the

bars and wiring them to the dental
arcade. (Selected readings, ref. 1).

There are some tips for placing teeth ligatures:
• Keep an instrument (a single small “mosquito” p.e.) pulling down the wire on the inner
surface of the tooth, to avoid it from slipping upward.
• At least six ligatures in each of the dental arcades should be placed.
• If available, is much better to place the ligatures on the canines, premolars and molars
than on the incisors, as their roots and attachments are stronger.
• Tilt the ligatures in clockwise direction. Doing so you will always know how to proceed
if you have to remove them.
• Always check the stability of the bar and the sharp ends of the ligatures to avoid mu-
cosa lacerations.
In certain circumstances, as in edentulous patients or when only are few available teeth,
the bars should then be secured by supplementary fixation. This fixation could be ac-
complished by passing one or several wires trough the piriform aperture or anterior nasal
spine in the case of the maxillae, or by circumferential wires around the body in the
mandible (Fig 55).
Fig. 55.- When teeth are missing and the bars could not be properly fixed, supplementary fixation could be obtained by
passing wires through the underlying bones, A to B) The bar could be secured by passing wires through holes on the piri-
form aperture, the anterior nasal spine or , even, the zygomas. Small incisions over these areas are enough to get free space
for drilling the needed holes. C to D) for the lower bar, circumferential wires may be used to firmly secure it with no need
for holes to be drilled. (Selected readings, ref. 1).

Fig. 56.- Method for interosseous wire fixation and
internal wire suspension of dentures in edentu-
lous patients. Note that two of the forward lower
teeth have been remove to facilitate feeding. (Se-
When an edentulous patient presents associated unstable fractures of the maxilla (as
the Lefort II use to be) the own´s patient denture, modified or not, could be secure to
the craniofacial skeleton by wire suspension. As shown in (fig 56). These ligatures could
be attached directly to the skeleton by drilling holes as previously mentioned.
Once the bars (or denture) are secured in place, the IMF could be accomplished by two
ways, intermaxillary wires or rubber bands as it will be discussed later in this chapter.
9.3.1.2 Dental wiring. The Gilmer technique.
In certain areas, undeveloped regions or small not specialised hospitals, even the bars
are not disposable so we have to relay solely on wire. It means that a solid structure act-
ing as a bar where the rubbers or wires could be anchored and maintained for weeks,
should be obtained.
The Gilmer technique (described in 1887) consist of passing wires around the neck of
all the available teeth twisting them until they are completely tight leaving the extreme
free with a length of 2 to 3 cm. After these ligatures had been completed, the lower and
upper dental arcades are brought into occlusion and the free wires twisted again be-
tween them to effectively finish the IMF. The wires are cut short and however, the ends
turned in against the teeth to avoid mucosa lacerations.

Fig. 57.- Gilmer method for IMF. The
wires passed through the neck of avail-
able teeth are twisted and the upper wires
twisted again between the upper and
lower arcades. (Selected readings, ref. 1).
However is advisable to twist the wire in one direction, more currently clockwise, to fa-
cilitate the removal of the ligatures.
The disadvantage of this method is that the mouth con not been opened for inspection,
or whatever other reason, without removing the neck wires and the whole system.
9.3.1.3 Dental wiring. The Ivy technique.
Popularized by Ivy in 1922, and as well as in the Gilmer technique, this method relays
only on wire. The wire should be take in its middle portion with forceps and twisted twice
to make a loop. Then both ends are passed through the interdental space from the outer
side to the lingual one, the one end of the wire is passed from the inner surface to the
outer around the proximal tooth, while the other end is passed around the posterior tooth
and then passed through the loop to join the anterior end. Both ends are then twisted
together until the whole wire is tight enough around the teeth. This procedure is repeat-
ed again and again until sufficient numbers of eyelets are established. Both arcades are
then brought into occlusion by intermaxillary ligatures or rubber bands. (see fig. 58).
This method has the great advantage that, if needed, the mouth can be opened without
the need to remove the dental support wires.

Fig. 58.- Ivy technique for IMF. A loop is previously done, the wires passed through an interdental space and then around
the anterior and posterior tooth to be passed through the loop and joined and twisted. Then intermaxillary ligatures with
wire or rubber bands could be used to bring the dental arcades into occlusion. (Selected readings, ref. 1).
9.3.1.4 Dental wiring. The Kazanjian button.
In certain occasions what is need is not a complete arch in each of the dental arcades
but scarcely two or four points for anchoring the intermaxillary ligatures or rubber bands.
In these cases is extremely useful what is call the Kazanjian button.
This method is useful in providing isolated points of anchoring. Two wires are passed
around the neck of two teeth (one beside the other), and then twisted together. With the
end of these four wires a solid button is made. (see fig. 59).
Fig. 59.- The Kazanjian button.


The different techniques to provide the elements to support IMF have been review. The
second part of the IMF is the specific material to maintain the lower and upper arcades
pulled together. There are several different options.
9.3.2 Intermaxillary fixation elements.
As has been said IMF could be done with wire or elastic bands. Depending on the desired
effect, one of them could be used independently or combined.
9.3.2.1 Elastic bands: Could be use immediately after the fractures had been reduced
and fixed and the bars secured. The elastic traction would allow the segments (espe-
cially when closed reduction has been done) to be brought together progressively (or
when IMF is the previous step for rigid fixation). Another advantage is that in case of
vomits could be easily removed. The negative point is that elastic forces exert some type
of continuous traction over the teeth that could result in displacement or even extrusion,
if they exert too much tension.
9.3.2.2 Wire: Is more reliable than rubber bands and do not exert “orthodontic” forces
over the teeth, but lacks the continuous and progressive force of traction. We use it when
the fracture is completely stable or to replace the elastic bands when the effect of traction
had succeed.
9.3.3 Interdental fixation.
When the fracture is limited to the alveolar process and the teeth are not completely loose
or extruded, both the bone and the involved teeth could be treated by reduction and fixa-
tion with an arch bar fixed to the other teeth and securing the involved ones. Depending
on the extent of the fracture, lingual splints or even intermaxillary fixation could be neces-
sary to reinforce the interdental fixation (see forward; dental management in fractures).

Chapter 10
General approach to Facial Fractures
On chapter 4, general management of the injured face at all levels has been presented. In
this chapter, the principles, general evaluation and management of the different types of
facial fractures will be exposed.
Open Reduction and Internal fixation (rigid or not) is in the most of the cases, espe-
cially in the midface, the best option to be considered as it gives proper stability and thus
better bone healing and more reliability in long term evolution.
With disregard to the methods available on the spot, the basis for an open reduction is to
get the more precise and anatomic reduction (even employing wires or bone grafts) previ-
ous to the internal fixation (Rigid or not).
As has been mentioned, midface bones acts as a support system to the upper dentition
while protecting the eye globes and the rhinopharinx, while the mandible gives support to
the lower dentition as great load bearer. Thus, they provide the shape and proportions of
the face, as well as the function.
The structure of the face is best regarded as a building with their main pillars (fig. 60), verti-
cal and horizontal, giving the main proportions and supporting the rest of the bones as if
they were the walls. It means that this main system of pillars and buttresses sustain the rest
of the bones and finally, is the responsible for the proportions of the face. Is thus, this main
system, which should be first repaired maintaining the previous relationship and dimensions.
Fig. 60.- Heavy lines indicates the buttress support system, Vertical
and horizontal, of the face, that must be maintained after proper re-
duction of the fractures. (Selected readings, ref. 12).

However despite the type of osteosynthesis, the first goal when reducing and stabilizing bone
fractures of the face, is maintaining or restoring the main buttress support system of the facial
skeleton. If this system could be maintained, proportions of the face will be restored.
The guidelines for a proper open reduction and fixation (rigid or not) are:
1. All the fractures must be exposed clearly by the best approach in order to have a precise
idea about the fracture itself, the structures involved, the fragments (viable for use or not)
and the needing of bone grafts.
2. When occlusion has been affected, intermaxillary fixation must be done first, carrying
maxillary and mandible segments to its previous relationship.
3. Start reducing and fixing (temporarily or not) all the fractured pieces concentrically, it means
from the stable and non fractured bones (maxillary segments already fixed by IMF could
be considered as “stable or non fractured bones” if they are anatomically reduced) to next
fractured segment. Just consider that you are “completing” a puzzle from the free borders.
4. Consider the use of bone grafts when bone is lost over the main buttress or pillars of the
face (horizontal or vertical).
5. When every piece of bone fits the proper position, proceed to fix them with plates (or
wire if you do not have plates). At least 2 screws must be in each side of the fracture line
to give stability, unless the fragment is fixed on more than one side.
6. Check the osteosynthesis and relative position before proceed to another bone fragment,
until all fragments had been brought together in its original position.
Fig. 61.- Proper way of stabilization for multiple displaced fractured bones, from the peripheral healthy solid structures to
the central area of the fracture. A) Initial fractures and displaced segments. B) First IMF is done to secure the lower maxilla.
C) Zygomatic bones are fixed and reduced. D) Small displaced fractures close related to the recently fixed segments are
then reduce and fixed. E) Once the periphery is stabilized, the central displaced fragments are then reduced and stabilized.

Chapter 11
Frontal sinus fractures
Frontal sinuses are two asymmetric compartments separated or not by a septum in the
midline, located in the frontal bone just in the upper a medial part of the orbits. Both have
an anterior wall (lower frontal bone) and a posterior wall (anterior cranial fossae) with a floor
(supraorbital rim). Both sinus drains into the nasal cavity through the nasofrontal ducts.
Fractures may occur as a result of direct trauma or associated with middle third traumatisms
(Lefort III), nasoethmoidal fractures or even isolated cranial vault fractures. The fracture could
involve the outer table or both, the outer and inner table, involving or not the nasofrontal duct.
L ate complications of frontal sinus fractures improperly treated include, acute and chronic
sinusitis, mucocele, mucopyocele, osteomyelitis, meningitis and brain abscess.
Fig. 62.- a) Right comminute frontal sinus fracture. b) Bilateral comminute frontal sinus fracture.
Two are the main goals for treatment of frontal sinus fractures:
• Recreate the normal contour of the forehead.

• Recreate a safe sinus.
Through a coronal incision a stable and anatomic reduction, employing bone grafts if nec-
essary, should be achieved. If doubts exists about the integrity of the posterior wall or the
nasofrontal duct, a wide frontal craniotomy should be done in order to completely expose
the fractures on the posterior wall, remove all the mucosa remnants, obliterate the naso-

frontal duct and reconstruct it. If fractures are comminuted and the posterior wall and / or
nasofrontal duct have been affected, is much better to proceed to the cranialization of the
sinus. This procedure includes complete resection of the posterior wall, complete oblitera-
tion of the nasofrontal ducts and careful and meticulous removal of all the sinus mucosa
and, finally, reconstruction of the anterior wall.
The space created by the removal of the posterior wall will be occupied by the frontal lobes.
This procedure may require a frontal craniotomy but in experienced hands is a very safe
technique.
a b
c d
Fig. 63.- a) Scheme of the cranialization procedure. b) Bilateral frontal sinus fracture. c) Frontal craniotomy and fragments
have been temporarily removed and the posterior sinus wall with the whole mucosa completely resected. d) Outer table is
repaired.

Chapter 12
Fractures of the Orbit
As the orbits occupied a central position in the face and are surrounded by the main but-
tresses, they are very easily involved in traumas and suffer a variety of fractures by direct or
indirect impacts.
Orbital fractures may be part of nasoethmoidal, zygomatic and maxillary fractures or may
be presented alone, without any fracture of the rim or the neighbour bones. This type of
fracture is produced by a blunt trauma over the eye that projects the energy of the impact
over the thin walls breaking them. The most of the times is the orbital floor which is broken
first, and is known as Blowout fracture. The reason because the floor is the most com-
monly fractured wall is because its fragility. The thin bone in that area is also traversed by a
channel or groove where the infraorbital nerve lies, increasing thus its fragility. The fact of
that nerve running in a channel in this wall makes that any fracture involving the orbital floor
gives some sort of paresthesia or anesthesia in the cheek.
Fig. 64.- A) Mechanism of blowout fracture (Selected readings, ref. 1), and
B) Fat entrapment in the fractured floor.
Blowout fractures or simple fractures involving the orbital floor, gives certain specific and
typical signs and symptoms.
• Diplopia. As result of the fact that fat and muscles are trapped and even displaced
into the maxillary sinus, the position of the globe changes slightly and an extraocular
muscle imbalance occurs. Usually the soft tissues affected by the fracture may include
the inferior rectus muscle, the inferior oblique muscle, the suspensory ligament of
Lockwood, periorbita and periorbital fat. All this impairment usually, not always, results
in diplopia. Motor nerve injury of these two inferior muscles could also be the cause

of diplopia. The inferior division of the third cranial nerve runs a short distance into the
orbit and are rarely affected. Other causes of diplopia may be direct injury to the
muscles, injury to the third, fourth or six cranial nerves, hemorraghes or disruption of
the origin of the muscles.
• Eye mobility. The entrapment of the muscles into the lines of fracture, especially, the
inferior oblique and inferior rectus, uses to fix or severely impair the normal movement
of the affected globe. Though rarely happen, entrapment of the superior rectus muscle
could also happen after fractures involving the orbital roof (see fig. 66) Hematomas and
swelling use to be the cause of certain limitation, but true entrapment is only due to the
entrapped muscles.
• Skin anesthesia or numbness. These signs indicate damage to the orbital floor affect-
ing the channel where the infraorbital nerve runs. Section of the nerve is rarely seen, but
its entrapment will result in local anesthesia and numbness of its territory, the upper
cheek, ipsilateral nose and ipsilateral upper lip.
Fig. 65.- A) Blowout fracture of the left orbital floor; no swelling and no apparent distortion. B) When the child tries to fol-
low the fingertip the muscle entrapment of the left inferior muscle does not allow upward movement of the globe.

Fig. 66.- A) Fracture of the left orbital roof. B) As patient is asked to look downward, the eye movement is limited by the
entrapment of the superior rectus muscle at the fracture site.
Medial canthal ligament disruption is a possibility in fractures of the naso-ethmoidal com-

plex involving the orbit. Great care must be taken to explore this situation and to solve it, as
if it remains untreated, a lateral displacement of the eye will be produced with distortion of
the eyes and face. Though is rare in this types of injuries, section of the lacrimal system
must be taken in consideration and explored.
However the goals of the treatment is to restore the previous anatomic shape, the pre-existing
orbital volume (in order to avoid enophthalmus), reconstruct the lost or damaged structures
as the canthal ligament or lacrimal duct and restore the orbital content to its original position.
The surgical approach to the orbit usually involves a subcilliary incision. A skin muscle flap
is raised until the orbital rim is reached, then continue subperiostically to expose the differ-
ent fragments of the rim itself or the floor. Subperiosteal removal of the lateral canthal liga-
ment enlarges the access to the lateral orbit. However, the intact margin of the orbit serves
as a guide for proper reduction and osteosynthesis of the fragments. Grafts must be em-
ployed if there are gaps in the orbital walls and medial canthopexy or reduction and osteo-
synthesis of the fragment including de medial canthus ligament, must be done.
Fig. 67.- a) Cartilage graft from the concha via posterior ap-
proach B) Ear cartilage graft covering the orbital fractured
floor.

If the superior orbital rim is affected a classic eyelid incision is the best way to reach the
injured area. If the fracture is great and comminute, coronal incision must be considered.
Minor and temporary complications associated to orbital fractures are, diplopia, scleral show
and ectropion. Time, massage and eyelid exercises usually solve these problems. Of course
complications associated with unsuccessful surgeries or untreated fractures, includes, en-
ophthalmus, diplopia, canthal ligament displacement, eye entrapment, severe ectropion,
lacrimal obstruction and even dystopia.

Chapter 13
Fractures of the Zygoma
Zygomas, as the nose, are frequently involved and injured in craniofacial traumas. As a
prominence itself, has a very important role in the aesthetics of the face, as part of the orbit
(lateral and inferior walls), play also an important role maintaining the eye in its proper
position, and the attachment of the powerful masseter muscle makes it prone to disloca-
tion when fractured.
Fractures of the zygoma are generally characterised by local swelling, periorbital ecchymosis
and numbness in the infraorbital nerve territory (ipsilateral anterior cheek and nose, upper
lip and teeth) .In backward displaced fractures, the opening of the mouth could be se-
verely impaired because the zygoma impactation effectively blocks the anterior movement
of the coronoid process or simply by pain in the fractured area around the TMJ and coro-
noid. The zygoma displacement and luxation may be quite evident in the first hours, but
later, after some hours local swelling will surely enhance the exploration. Palpation with the
fingertip at the inferior orbital rim, especially without too much edema, denotes the fracture
as a gap or a bony step.
Fig. 68.- Infraorbital nerve channel in the orbital floor.

Depending on the displacement various types of deformities could be found and because
being part of the orbit, ophthalmologic exploration must be done (diplopia, entrapment
and enophthalmus) as mentioned above.
Fig. 69.- Typical signs of fractured zygoma with external rotation displacement.
X-ray exploration, especially with the Waters or Waters reverse view, usually gives enough
and reliable information about direct and indirect signs of fractures involving the zygoma.
Air-fluid levels at the maxillary sinus and steps in the orbital rim should be explored as they
are the most commonly seen signs indicating the fractures.
Indications for surgery include aesthetic and functional restoration of the orbit and orbital
contents, and may be approached by a variety of incisions from the most commonly used,
the subciliary approach, to small lateral brow incisions to reach the frontal apophisis and
temporal or buccal sulcus incisions to reach the zygomaticomaxillary junction (see chapter
of craniofacial approaches).
Close reduction of the zygoma could be considered by intraoral or by temporal approach

with a blunt instrument as could be seen below, but even when close reduction could be
appropriate, it is only a matter of time that some relapse appear with the typical secondary
deformities as enophtalmos and lack of projection.

Fig. 70.- A) Temporal approach for close reduction of the zygoma. B) Close reduction of the by Intraoral approach. (Se-
Its reduction and fixation follows the general lines already mentioned. After all the fracture
lines have been exposed and soft tissue undermined, reduction of the zygoma must be
done by a gentle pull. In those cases in which the zygoma has been completely fractured
and displaced, a good strategy is to start fixing its frontal process to the frontal bone with a
wire not completely thigh and then proceed to reduce the other fractures until the bone
completely fits in its place. Only then could the bone be fixed, definitively.
Fractures of the zygoma, however, are better treated by rigid fixation. If only wire is at hand,
at least three osteosynthesis must be done at the inferior orbital rim, the zygomaticofrontal
suture and the zygomaticomaxillary buttress, if not, the pulling of the strong masseter
muscle from the mandible would displace the zygoma downward after some weeks, and
late enophthalmus and diplopia may appear.
Fig. 71.- A) Wire osteosynthesis at the inferior zygomatico-orbital rim. B) Wire osteosynthesis at the Frontal suture.

Zygomatic arch must be always explored in the presence of zygoma fractures. It only re-
quires open reduction and fixation if it is severely comminuted, it is so displaced that no
closed reduction could achieve its reposition or (rarely) blocks the forward movement of
the coronoid process. Then, preauricular and temporal approach is used to expose, reduce
and fix the arch.

Chapter 14
Fractures of the Nose
The nose is composed by the nasal bones, the frontal apophisis of the maxillae, the septal
cartilage and its extension to the perpendicular plate of the ethmoid and vomer, plus the
triangular and alar cartilages. Its prominent and central position in the face makes the nose
an easy subject for trauma, and the thin bones, prone to be fractured. It is the most fre-
quent facial fracture.
14.1 Exploration and diagnosis
After a fracture, nasal hemorrhages and deformities are evident from the very first mo-
ment, later, swelling will make deformity less evident, and minor deviations could then be
missed and become apparent after the edema resolves. If the fracture could not be
treated during the first hours, a delay of 5 to 7 days is preferable to allow the swelling to
disappear, the diagnosis will be more accurate and the fragments more accurately re-
duced. Generally, the greater the swelling and ecchymosis, the more severe is the fracture.
Palpation, especially in the first hours, will denote crepitances and displacements, but
some fractures are impacted and self retained and do not respond to palpation. X-ray
exploration may not reveal a fracture as the thin bones will be difficult to see over the
other facial bones. Intraoperative palpation will give more information as the patient under
local or general anesthesia will be easier to explore. Compression on the tip will reveal a
septal fracture if the tip rotates downward and backward. If the middle vault could easily
be compressed will also means septal middle vault collapse with middle septal fracture.
Though the presence of important edema, pressing under anesthesia on the upper vault
could then reveal crepitances, gaps or steps.
14.2 Surgical management
14.2.1 Open reduction. Open reduction is referred not to the classical incision for an
open rhinoplasty but to use the injuries as approaches to reduce and fix anatomically the
different elements.
Careful attention must be paid when repairing all the inner layers, in order to avoid circular
scars or internal bridles that would result in an unsatisfactory functional and / or aesthetic
outcome. However, if careful and meticulous reduction and reconstruction has been carried
out, the final result uses to be excellent.

Fig. 72.- A) Open wounds involving the nose. Wound should be revised in order to proceed to reconstruct it layer by layer
from inward to outward. Care should be taken about circular scars which could greatly compromise nasal function.
Fig. 73.- A) Open fracture of the bones, cartilages a nasal mucosa of the nose. B) Right after com-
plete reconstruction of all the layers, shape and function has been preserved.
Fig. 74.- A) Open fracture and almost complete avulsion of the nose (see fig. 72 B). Not only anatomic reduction and 3D
reconstruction should be made. A very conservative and meticulous surgery will ensure survival of even almost completely
avulsed noses.

Septal management in open wounds includes realignation and fixation (with reabsorbable
stitches or even cantilever cartilage grafts), careful suture of the mucosa (considerer z-
plasties in “U” shaped lacerations) and even local flaps to avoid open communications
between one side and the other through the septum.
Fig. 75.- A) Open fracture revised 15 days post-trauma. B) Final result after a precise layer by layer anatomic repair.
14.2.2 Closed reduction. Though closed reduction could be performed without

anesthesia and only using the digits, it would be a painful management that rarely is
successful as the patient could not hold enough. Greenstick fractures in young stoic
adults with non fractured septum could be essay to be treated in this way. Normally
general anesthesia is the best choice as internal bleeding and the upper airway could
be easily controlled. Reduction could be done with blunt, thin, plane instruments as
the handle of a surgical knife without blade. The instrument is placed beneath the
nasal fracture and gentle manipulation, upward and outward, will suffice to restore the
nasal bones to their anatomical position. Transnasal wires and external compression
devices are rarely needed. Intranasal packaging should then be done with Vaseline
gauze (to avoid pain when removed) and retired after 5 days. The nose is covered
with paper drapes and an external cast splint is maintained during 10 days. The sep-
tum should also be checked, reduced and maintained in place by a symmetrical nasal
packaging. After that, an external nasal splint is applied to immobilize the fractured
bones during 10 to 14 days.

Fig. 76.- A) Lateral displacement of the nose. B) After close reduction.
14.2.3 Septum fractures management. As nasal septum greatly determines the

alignment of nasal bones is the first structure to be checked and reduced if necessary.
Superior displacements should first corrected and then proceed to the lower taken care
to align the septum over the premaxillary groove (some times sutures will be needed to
maintain that position). Once the septum has been properly aligned, intranasal packag-
ing should be done bilaterally and simultaneously in order to equilibrate the pressure
over the septum from on side and the other. Packaging should be maintained for at least
5 days.
14.2.4 Total nasal collapse. Occasionally the nasal bones and cartilages are completely
destroyed and collapse without any possibility of being reconstructed or being able to
maintain the shape and function. Normally these complicated fractures are associated to
naso-ethmoid-orbital fractures. In these situations cartilages and bones grafts should be use
to reconstruct missed segments and provide support to those comminuted.

Chapter 15
Fractures of the Naso-Ethmoidal-Orbital complex
The intricate anatomy of bones at the naso-ethmoidal-orbital complex, make proper recon-
struction very difficult and complicate. Even more, as they are very thin, when injured by
even a moderate trauma, used to result in a comminute form which makes interfragment
fixation extremely difficult. The presence of the lacrimal system and the medial canthus,
make the matter much more complicate to treat.
This complex contributes to the medial orbital walls as well as the support to the nasal
pyramid. Due to its close relation with the frontal sinus and the anterior cranial fosse up to
25 to 50 % of this fractures have dural leak, leaks that in approximately 95 % will seal alone
within 2 weeks. Despite their position, the lacrimal system as well as the medial cantus are
rarely sectioned. Damage of these structures are usually the cause of a mild or severe post-
traumatic telecanthus.
A fractured Naso-Ethmoidal-Orbital complex (NEOC) may be presented in a wide variety

of forms, from a simple linear fracture, to the more complicate comminute fractures that
detached the lateral medial canthus, to the more complex of all fractures, the complete
fracture and dislocation of the whole NEOC. It means four fractures in a time, fracture of
the frontal processes of the maxilla at the glabella, the inferior orbital rim, medial orbital wall
and nasal bones. This “central fragment”, when fully fractured and free is very unstable
making its management difficult and the prognosis poor, specially when only wire is at hand
for osteosynthesis.
Fig 77.- A) Complete comminute open fracture of naso-ethmoid-orbital complex associated with multiple craniofacial
fractures. B) Anatomic reduction and rigid fixation of the NEOC plus Transnasal canthopexy. (See 125).

In absence of CT-scan, X-ray films as Waters projection combined with a meticulous palpa-
tion, gives the keys for the diagnosis. As they are frequently accompanied by fractures at
the maxillae, dental occlusion should be checked.
Local incisions and coronal approach are the common practice for open reduction and in-
ternal fixation. However, and especially in these cases, rigid fixation is the first choice (and
the unique) if acceptable long term result are expected.
Before proceeding to repair medial canthus avulsions, the lacrimal system must be
checked. If that system has not been sectioned or lacerated, monocanalicular intubation
has proved to be quite effective. The silicone tube must be sutured to the surrounding tis-
sue in the eyelid and must be threaded into the proximal canaliculus to the lacrimal sac (3
to 4 cms). If the lacrimal system seems to be severely damaged a DacrioCistoRhinostomy
with a polyethilen tube may be indicated, suturing the proximal end in position close to the
lacrimal lake and the distal end inside the nose cavity through the fracture or a burr-hole.
But in general lines, Dacriocistorhinostomy could reasonable be done 4 to 6 months after
trauma surgery.
Fig. 78.- Dacriocystorhinosthomy with a polyethylene tube (Selected readings, ref. 1).
Management of canthal ligaments dislocation is the key point in the treatment of NAOC
fractures. When performing open reduction and internal fixation of the fragments, detach-
ing the canthal tendon from bone fragments during dissection, increases the likelihood of
telecanthus. So meticulous bony reduction, with overcorrection of the intercanthal distance
and the use of bone grafts, provides the basis for the best long term results. In conse-
quence the medial transnasal canthopexie is the Key point to get stable and accept-
able aesthetic results.

Fig. 79.- A & B) Reduction and fixation of the bone fragment with the medial canthal ligament still attached to it. C) Single
unilateral canthopexie when medial canthal ligament is avulsed or attached to a very small piece of bone no viable for os-
teosynthesis. (Selected readings, ref. 2).
Fig. 80.- Procedure for bilateral medial transnasal canthopexy. (Selected readings, ref. 2).

The procedure for a canthopexie starts with:
A. Two laces of 2 / 10 steel wire are passed through the thickness of the ligament.
B. D rills are done, if necessary, at the anatomical place where the tendon must be at-
tached.
C. F rom the opposite side a third steel lace is passed through the nasal septum (with
the help of Reverdin needle) to embrace the two previously laces on the canthal liga-
ment.
D. T his last steel lace is pull together with the laces from the ligament through the nasal
fosse to bring them to the opposite side. The wire is then progressively tightened
until the desire position has been reached (overcorrection is always desirable).
E. S uture on the healthy side is done through the healthy ligament. If local fractures or
fissures on the healthy side is suspected or the hole drilled is too wide, a small graft
could be use to retain the steel lace in place.
F. In case of bilateral canthopexie due to complete or bilateral comminute fracture of the
NEOC, wires are passed transnasally from one side to the other and tightened over
bone grafts in order to maintain tension and not slip away through the hole to the
nose.
The skin in the called “naso-orbital soft-tissue valley” usually becomes swollen and edema-
tous due to the trauma and the surgical manipulation. Local hematomas still complicate
more the events and post-op scarring will result in thickening the whole area, and so, de-
spite a perfect reduction with a successful canthopexy, the final appearance could not be
completely satisfactory. In these situations, bilateral external soft padded bolsters are placed
over the lateral aspect of the nose just over the medial cantus and adapted to the underly-
ing skin and fixed with an extra transnasal wire. It should be used only when really needed
as the risk of necrotizing pressures against the skin could be the cause of ulcers and scarry
tissue which will have to be posteriorly revised (see fig.81).
Fig. 81.- Despite the acceptable result in a very severe comminute facial frac-
ture, Lefort I, III and complex naso-ethmoid-orbital complex fracture and a
succesfull medial canthopexy, lack of support to lower eyelids and specially,
skin necrosis due to excessive pressure of the bolsters in the medial cantho-
pexy, are clearly visible.

Finally, despite adequate reduction of the NAOC if the thin bones of the nose have been
completely fractured and comminute and cannot be reconstructed, the skeletal support of
the nasal dorsum will collapse. In this situation a cantilever nasal dorsal bone graft must be
tailored and fixed in the same surgery.
Late complications after treatment of NEOC fractures are recurrent telecanthus, epicanthal
folds (fig 81), epiphora and dacryocystitis.
Fig. 82.- A) Severe fracture of the Naso-Ethmoid Orbital complex associated to a Lefort I and Lefort II. Observe the
elongation of the orbits due to the lower displacement of the whole maxilla. B) Waters view after ORIF and wire fixation
with an IMF as support. The orbits had recover their original shape after the complete fractures has been reduced and
stabilized. C) and D) facial proportions are restored and stable after 4 years.

Chapter 16
Fractures of Maxilla
Maxillas are the main bones of the face and particularly important in maintaining the shape
and structure by a system of “pillars” or buttresses (see chapter 10, fig 60). There are three of
this “pillars” in each Maxilla that must be preserved or reconstructed when treating a craniofa-
cial fracture. One is the medial Pillar or nasomaxillary buttress, other is the lateral “pillar” or
zygomaticomaxillary buttress and the third is the posterior “pillar” or pterigomaxillary buttress.
Naso maxillaryry
Zygomatico maxillary
Pterigomaxilary
Fig. 83.- The three maxillary buttresses. (Selected readings, ref. 12).
16.1 Classification of the main maxillary fractures
There are three basic types of fracture patterns usually seen in maxillary traumas and these
are those described by the French Surgeon Rene LeFort. He made dissection of cadavers
of imprisoned man that (after a natural death) were hit in the face or simulated a low
speed facial traumatism by other mechanisms. He found that three types of fracture pat-
terns were reproduced in the craniofacial skeleton with much more frequency than others:

16.1.1 Lefort I type is a monoblock fracture in which the line of fracture is just above the
apices of the teeth, including the alveolar process, the vault of the palate and the pterygoid
processes in a single block.
16.1.2 LeFort II type has a pyramidal shape and comprises both maxillas with the line of
fracture extending from the pterigomaxillary junction up within the zygomaticomaxillary
suture, the inner medial part of the orbit up to the radix of the nose along with the naso-
orbital ethmoidal complex.
16.1.3 LeFort III type is a true facial disjunction from the cranium at the level of the cra-
nial base.
16.1.4 Segmental fractures of the maxilla are not a very common type of fracture and
generally are found as part of other major fractures. The more frequent presentation is the
alveolar fracture though isolated forms of portions of the maxilla including teeth could also
be found.
Fig. 84.- A) LeFort I. B) LeFort II. C) LeFort III. (Selected readings, ref. 2).
16.2 Exploration and clinical findings
These fractures where described from low energy impacts at low speed. Actually, as the
more common origin of fractures are from traffic accidents, great energy impacts are the
main origin of craniofacial injuries, and it means that these pure types of Lefort descriptions
are rarely seen in the isolated form. These fractures are usually associated to a variety of
segmental fractures involving other areas of the facial skeleton.

16.2.1 X-ray exploration use to give enough and highly reliable information for an ac-
curate diagnosis. Though CT scan is quite more clear and precise, especially when search-
ing for fractures at the temporal bone, optic channel or frontal sinus, X-ray films like Waters
and Lateral views are usually enough to diagnose the most of the fractures involving the
maxillas (see 4.2). In these films, the presence of bilateral air-fluid levels is highly sugges-
tive of this type of fracture. CT-scans are always a helpful exploration, and mandatory when
ear leakage, facial palsy or lesion to the optic nerve is suspected. Physical examination,
beside the X-Ray exploration, use to be conclusive.
16.2.2 Initial observation and inspection gives a “primary report” about what could be
expected. It is not uncommon that while the face is not severely injured, edema, nasal
hemorrhages, oral bleeding, scleral ecchymosis, and subcutaneous hematomas are pres-
ent and suggestive of multiple facial fractures. Impaired occlusion, especially if associated
to an anterior open bite is another common finding (previous patients pictures would be a
great help). The aspect of the face could also give information about the type of fracture.
Wide faces with augmented intercanthal distances and anterior open bites are suggestive
of an impacted Lefort III fracture, the so called “Dish faces”. Long and narrow faces with or
without open bites (horse-like appearance) are typical of Lefort II fractures (see fig. 85).
Abnormally increased intercanthal distance and flattening of the nasal bones are highly sug-
gestive of fractures at the naso-ethmoid-orbital complex.
Fig. 85.- A) Wide and flat face secondary to Lefort III fracture, note the telecanthus, flattening of the nose and, not visible,
an anterior open bite. B) Moderate horse-like aspect of a Lefort II, no telecanthus, anterior open bite and elongated face
due to the downward displacement of the naso-maxillary complex.

Open anterior bite is a common founding in Lefort II and III because the impactation of the
upper maxilla over the cranial base. It makes the mandible to contact prematurely with the
maxillae at the molar level and consecutively the forward part (incisives and canines) could
not reach their opposites in the maxilla resulting in an anterior open bite.
Fig. 86.- A) Anterior open bite due to severe comminute facial fracture, Lefort I, posterior impacted Lefort III and complex
naso-ethmoid-orbital complex fracture and mandibular fracture. B) Lateral X-ray showing how posterior impactation
blocks prematurely the mandible. C) After ORIF, the facial proportions had been restored and stable 1 year later. Lower
eyelid retraction and right naso-orbital skin scar from a pressure ulcer due to a bolster will need revision.

16.2.3 Mobilization of the maxillas by grasping the anterior portion of the maxilla with
the fingers between the thumb and the index finger is an important part of the examination
in fractures as the Lefort type. Normally, by pressing forward or downward the maxilla, some
degree of movement could be noticed, from a slight instability to the complete and free
movement of the maxilla. This gentle movement of the bones may be seen under the facial
skin, giving thus an approximate idea about the type of fracture (Lefort I, II or III). However,
this test is not fully reliable as fractures can be impacted and then no movement is noticed.
16.2.4 Palpation should be done gently and simultaneously on both sides to compare
one with the other, by doing so, gaps, steps and crepitances could be noticed. Again this
exploration is not entirely reliable as edema could mask the findings. Intraoral palpation is
an important part of the exam as fractured fragments, loose teeth or foreign bodies could
be detected in time.
16.2.5 Rhinorrhea or otorrhea. Leakage of cerebrospinal fluid from the ear (otorrhea)
or nose (rhinorrhea) as well as from the pharynx is a clear indication of fractures involving
the cranial base at the temporal bone, cribiform plate or anterior cranial base.
16.3 Treatment of maxillary fractures
Treatment of maxillary fractures, especially the extensive and comminute affecting the
naso-ethmoid complex are considered a life-threatening injuries as the airway could be
compromise and the bleeding be so profuse.
16.3.1 Emergency treatment
16.3.1.1The airway could be severely compromised in a great variety of forms. Loose

teeth, fractured bone segments, soft tissue lacerations, tongue avulsions, foreign bodies and
local edema are only some of the possible causes. Management includes removal of for-
eign bodies, larynx mask and endotracheal intubation or even a coniotomy or tracheotomy.
16.3.1.2 Hemorrhages are always severe in this type of fractures. Local arteries may be
lacerated by the same injuries or displaced bone fragments and bleeding could be so
severe that the patient could even become exsanguinating. As emergency treatments to
control bleeding are local compressive dressings, clamping and ligature of the involved
vessels and nasal tamponades. Normally bleeding will stop by itself during the first 30 to
60 minutes and will appear again when the fractured bones are manipulated for reduc-
tion. Once the fractures had been properly reduced to their anatomic position, bleeding
will stop again. For extensive bleeding from the nasal or nasopharinx area the best option
is to proceed to pack the nasal cavity (see fig. 87), this type of naso-pharinx pack could
be gently remove in two or three days. Finally, for a very profuse and out of control bleed-
ing the last, a rarely and risky option (we never have seen one) is the ligature of the ex-
ternal carotid.

Fig. 87.- Packing of the nasopharinx. A) A rubber catheter is introduced by the nasal cavity and partially retired from the
mouth, to this extreme a thick suture attached to a gauze pack (posterior) is tied, the catheter is then pulled from the nos-
tril until the posterior nasal pack is in place. B) The suture from the posterior pack is leaving hanging through the nostril.
The nasal cavity is then packed with horizontal Vaseline gauze, and when fully packed an anterior nasal roll of gauze is tied
with the suture from the posterior pack. (Selected readings, ref. 1).
16.3.2 Treatment of maxillary fractures
Treatment of the different fractures Lefort I to III, follows the general and basic principles of
chapter 10. Open Reduction and Internal Rigid, or wire, Fixation (ORIF) is the rule.
Airway management should be our first concern. A detailed plan for treatment, espe-
cially for the complex maxillary fractures should start planning with the anaesthesiologist
the need of a tracheotomy (rarely necessary), nasal intubation (preferable, especially with
an intact nose) or oral intubation posterior to the molars (to allow IMF). For complex com-
minute maxillary and mandibular fractures tracheotomy is preferred.
Incisions for open reduction are described in chapter 6, and will be detailed later for each
of the fractures, but not hesitation should be in using as much incisions as necessary to get
the more anatomic reposition and the more stable fixation.
Reduction of these fractures could be done by digital manipulation or with gentle traction
using elastic bands from dental arches. When severe impactation is present (very often) the
use of special forceps will be of great help as they could press and fix the maxillas in a
anatomical way facilitating the precision of the movements to disengage the impacted
bone (see below).

Fixation. On the basis of open reduction and perfect anatomic reposition, wire fixation
could also proportionate enough long term stability, though rigid fixation is generally not
always disposable in undeveloped areas. Simple segmental maxillary fractures, Lefort I and
Lefort III, if not comminute, use to respond well enough to wire fixation. Comminute or
Lefort II fractures are highly unstable and need more accurate repositioning and more
points of fixation always accompanied by Inter Maxillary Fixation (IMF).
Fig. 88.- A) Rowe´s disimpaction forceps, B) Hayton-Williams disimpaction forceps. (Converse. Reconstructive Plastic Sur-
gery. Snd Edition, vol 2, pg. 705). (Selected readings, ref. 1).
Bone grafts (especially rib grafts, see Chpt. 8) should be used if bone is missing or extra
support for small fragments are needed. Bone grafts are well tolerated and survive well
retaining their mass in the orbits, nasal dorsum and zygomas, but present a high rate of
resorption beside the open maxillary sinuses, where they easily become infected. On the
other hand, and despite the risk of resorption all gaps in the main buttress system should
be reconstructed with solidly fixed bone grafts.

Fig. 89.- A) The left zygomatico-maxillary buttress has been completely destroyed by an impact. B) Some examples of bones
grafts use to stabilize the fracture. Note how the bone grafts are placed in a vertical position following the vectors on the
buttresses.
Craniofacial suspension is the method to stabilise the entire fractured complex by wire
ligatures attached to the first solid structure immediately above. In the absence of rigid fixa-
tion, extended comminute fractures or edentulous mandibles and maxillas could benefit from
craniofacial wire suspensions. This procedure has been mostly abandoned since rigid fixation
is available, but as this manual is especially addressed to the practice of surgeons in undevel-
oped regions, it should be taken into consideration. Wire suspension uses to be made bilater-
ally a symmetrically, though this is not a rule and the most important is to find a solid struc-
ture. The zygomas, infraorbital ridges and the zygomatic process of the frontal bone are the
more commonly used areas as support structures. Skin incisions as subciliary, and external
canthal incisions (6.2.1, 6.2.2) are use to reach the solid bones and drill and pass the wires.
F rom these attachments, long laces of steel wire are passed through the soft tissues to the
maxillary arcade and tightened around the dental arches. When tightening the different
steel laces, great care must be taken not to leave them loose nor too tight, as an exces-
sively compressive suspension could result in partial resorption of the middle third and
height loss in that area.
Fig. 90.- Different types of craniofacial suspensions to hold lower un-

stable fractures of the maxilla a) Frontoglabella screw. b) Zygomatic
process of the Frontal bone. c) Nasal spine. d) Maxillo-nasal process.
e) Circumferential zygomatic. f) infraorbital rim suspension. (Select-
ed readings, ref. 2).

Fig. 91.- Method for craniofacial suspension at the zygoma process of the frontal bone. (Selected readings, ref. 2).
16.3.2.1 Alveolar Fractures are usually non displaced and when so, they easily re-
spond to digital reduction. The easiest and reliable method to treat these types of frac-
tures is by stabilizing the fragment to the adjacent teeth by ligation of an arch bar in their
proper anatomic and occlusal relationship. Depending on the stability an intermaxillary
fixation could be applied. If the fragment could not be adequately reduced, an intermax-
illary fixation with rubber bands will effectively reduce the fragment in some days, as the
mandible will push the segment in place. Once the fragment is in position 4 weeks of
IMF will be enough to get appropriate consolidation.
Fig. 92.- Fracture dislocation of a large seg-

ment of alveolar bone and palate. Reduction
accomplished by intermaxillary fixation with
elastic bands. (Selected readings, ref. 1B).

16.3.2.2 Lefort I fracture. As mentioned, Lefort I involve the lower part of the maxilla
above the level of the apices of teeth. Treatment follows the lines already explained
about rigid and wire fixation (see chapter 9). Initially the original dental occlusion should
be re-established. Open reduction is done by an intraoral superior vestibular incision (see
6.3) In case of very high Lefort I fractures a subciliary incision approach could also be very
helpful for placing wires or plates (see 6.2.1). All the lower part of the maxilla could be
safely undermined, and only the infraorbital nerve should be respected. When rigid fixa-
tion has been used, post operative IMF could be obviated though is always advisable to
leave the arches in place during the next 3-4 weeks.
16.3.2.3 Lefort II fractures, are highly unstables fractures involving the frontal process,
the nose, the lacrimal bones, orbital floor, zygomaticomaxillary suture, the maxilla and the
pterygomaxillary junction. Great attention should be paid to the medial cantus as failure
in doing so will result in a very poor aesthetic outcome. Impacted fractures are often the
cause of an anterior open bite. However, IMF should be first re-established. The incisions
to gain access are the classical molar to molar vestibular incision and subciliary incision.
Once again, rigid fixation is preferable to wire, and if wire is used IMF should be used for
at least 4 weeks.

Fig. 93.- A) Horse-like appearance of a patient with a Lefort II impacted fracture and the associated anterior open bite. B)
Lateral view, the chin is displaced downward and the face elongated despite the swollen aspect. C) X-ray showing Lefort I
fractured in two halves, Lefort II with a comminute fracture of the left zygoma and zygomatic arch. D) X-ray after open
reduction and rigid fixation of all the fragments combined with wire fixation too. Facial parameters of width and height
have been restored.
Fig. 94.- Same patient of fig. 93. Rigid fixation allows an extremely reliable stability even in complex combined fractures.

16.3.2.4 Lefort III fractures, though as a monoblock craniofacial disjunction, is a rela-
tively stable fracture, and it is the most of the times associated to many other small frac-
tures. When impacted an anterior open bite is frequently present. Detachment of one or
both medial canthal ligaments uses to be also associated. In those conditions the coronal
approach plus superior vestibular and (sometimes) subciliary incisions are the selected
incisions to reach all the involved lines of fractures. In absence of rigid fixation, with an
excellent and meticulous anatomic reduction and wire and IMF fixation, with a solid me-
dial canthopexy, a more than acceptable outcome could be reach (see chpt. 15). Early
complications are related to hemorrhages and airway obstructions already mentioned,
other complications as infection is less frequent, and blindness really rare but not some-
times present. Late complications of Lefort III fractures includes lacrimal system obstruc-
tion, infraorbital anesthesia, extraocular muscle imbalance, lower eyelid retraction, flat-
ness of the face, malunion of the multiple fragments, and rarely, non-union of fragments.
Fig. 95.- A) Lefort I, II and III, B) Meticulous anatomic reduction of all the involved fragments fixed mainly with wire and a
big steel plate plus IMF. Wire could also anatomically reduce and fix the fragments and sustain stable results.
Fig. 96.- A) The same patient with a Lefort I, II and III, seen in fig. 95,4 years after. Though wire fixation of the multiple
fractures where used, facial proportions are maintained over the years.

Chapter 17
Fractures of Mandible
The mandible is one of the strongest bones in the body and the unique with a ginglymo-
arthrodial joints that allows two types of movement, rotational and translational. It gives
support to the lower dental arcade and forms the lower third of the face. Because of its
prominence is frequently subject to trauma, and because its semicircular shape, the man-
dibular arch, when hit, usually breaks at two or more places.
The mandible, though being a strong bone has some specific weak areas. That’s why there
are repeated patterns of fractures, as the weakest areas of the subcondylar region, angle
and parasymphysis, are the ones which break in first instance. Specific areas with no teeth
also represents a weak point, as when tooth are lost, the empty socket start to collapse and
the alveolar ridge resorbs and the mandible is weakened. One marked difference with the
rest of the other facial bones is dentition. Treatments will differ from a child fractured man-
dible with a mixed dentition to that in an elderly patient with an edentulous one. Another
important fact is the amount of strong and multidirectional muscles strongly attached to it
and their vectors of force and mobility.
Finally, it will depend on the anatomical area where the fracture is, that the treatment
will vary. For example, an intermaxillary fixation is maintained for 6 weeks for a fracture
at the mandibular body, while for a condylar neck fracture is maintained only for three
weeks.
However the goals in the treatment of mandibular fractures are functional as well as aesthetic:
• Adequate union of the fractured segments.

• Restoration of the previous occlusion
• Maintenance of facial symmetry and previous proportions
• Avoidance of secondary problems to our treatment.
Mandible fractures could be classified by different concepts. One is regarded to the pres-
ence of teeth related to the line of fracture, so as described by Kazanjiam and Converse
Class I fractures are these types in which teeth are present on both sides of a fracture line.
Class II are those with teeth in only one side of the fracture, and Class III, those fractures
with no teeth. Another type of classification falls by their consideration in Stable or Favor-
able, and unstable or unfavourable. That condition is referred to the favorable or unfavour-
able effect of the musculature on the fractured segments, causing spontaneous distraction
(unfavourable) or reduction (favourable).

However, the most of the mandibular fractures are considered open fractures as they use
to communicate with skin or mucosa or a tooth socket, so the most of them benefits from
antibiotic therapy.
17.1 Exploration
There are a great variety of X-Ray views for radiological exploration of the mandible as
the Fronto-occipital position (external frontal profile of body and ramus), Lateral (lower
profile of one side body an angle), Verticosubmental position (inferior profile of the body
and ramus), Oblique Lateral views (symphysis, angle and lower part of the ramus),
Oblique ant.-post. fronto-occipital and lateral transcranial views (condilar neck an con-
dole). Of course the best exploration is CT-scann, especially for Temporomandibular
joint (TMJ) traumas.
Fig. 97.- a) Oblique Lateral view (Selected readings, ref. 1).
Fig. 98.- Oblique anteroposterior fronto-Occipital view (Selected readings, ref. 1).

Though all this X-Ray views, the best is the Ortopantomography. This exploration is rarely
available, especially in undeveloped areas, but it will give very precise information about
any fissure or line of fracture, and furthermore it will also facilitate the diagnosis of even the
smallest dental root cysts that could interfere with a successful outcome.
Fig. 99.- Ortopantomography showing two plates at the right angle. The whole body, condyles and dentature with their
roots could be explored in that type of X-Ray exploration.
In all instances, mechanics of the injury and physical examination are important, but in the
case of mandibular fractures, when perhaps we miss the simple possibility of even the
simplest X-Ray exploration (as in undeveloped regions), are imperative. History about the
mechanism, direction and point of impact, will give valuable information about the areas
and types of fractures, and possible fractures associated with (impact in the frontal aspect
of the symphysis usually produces a bilateral condylar fracture i.e.). Clinically, submucusal
hematomas and ecchymosis, crepitances, steps on the dental arcade, malocclusion and
impaired function are the typical clinical signs indicating a fracture.
Fig 100.- Typical signs in a high-

ly traumatized mandibular frac-
ture associated with maxillary
trauma. Ecchymosis, wounds,
traumatic lack of dental pieces
and hematomas together with
crepitances, pain and functional
impairment is a classical pre-
sentation.

Fig. 101.- Occasionally, the most of the physical signs are absent but a slight or severe step together with func-
tional impairment is the only signs in a less dramatic appearance.
17.2 Stable (Favourables) Fractures
Once the fracture has been diagnosed, is extremely important to determine if the fracture,
or fractures, are stable or not. The term “stable” makes reference to the resulting forces of
the agonist and antagonist muscles pulling the fragments one against the other and so
reducing the fragments by themselves. On the opposite, an unstable fracture is referred to
those fractures in which the different segments of the mandible are pulled apart one from
the other by the natural action of antagonist muscles. So said, beside a clear idea of the
direction of the line of fracture, a precise knowledge of the anatomical disposition of the
muscles attached to the mandible is mandatory, as failure in doing so will result in a un-
desirable outcome when a close reduction is done and the treatment relays only in Inter-
maxillary fixation, which will be the case in most of underdeveloped areas.

Fig. 102.- A) and B) Two types of stable fractures. Upward and outward pulling of the Masseter muscle, tends to maintain
the bone fragments in contact despite the complete fracture as it oppose its pulling against the pulling of antagonist
muscles over the other fragment. No ORIF is needed and IMF will be enough. (Selected readings, ref. 3).
The treatment of single stable fractures could be as simple as an intermaxillary fixation for
six weeks, followed by a period of 3 weeks under soft diet, or open reduction and internal
fixation with wire or miniplates and screws (see 9.3 Intermaxillary fixations).
Favourable fractures are rarely displaced, if so, Open reduction and internal rigid fixation is
again the best method. However in certain situations (again in undeveloped areas) in the
presence of steps at occlusal plane due to displacement of the fragments, the best method
is that of intermaxillary fixation but using a separate piece of bar for the displaced fragment.
Then, gentle traction with elastic rubber bands will bring the fragment into position. By
managing the elastic bands we could reduce the fragment and continue with an intermax-
illary fixation until the bone heals properly.
17.3 Unstable (Unfavourable) Fractures
Unstable fractures are those in which the muscles pull the fractured segment out of contact
with the rest of the bone fragment (see figs. 103 and 105). While one or several muscles
pull the segment in one direction, the rest of the musculature pulls in the opposite with the
final effect of distraction, having the fragments pulled away one from the other.
This effect on the fragments means that unless the fracture is reduced and fixed, it will have
the tendency to relapse. Intermaxillary fixation is the previous step to get a proper occlusion

but the fragments should be properly reduced and fixed. In these cases open reduction is
what really guaranties anatomical reduction and long term stability. As in the rest of the
fractures, anatomical reduction means to bring the segments together by pulling them one
against the other to its previous anatomic position, manually or using a special bone clamps
that should be screwed to each of the segments to handle them and by a pinch movement
brought them together (Instrument rarely used and rarely available).
Fig. 103.- Unstable (unfavourable) Fractures: A) Pulling of the Myloyoid m. on the segmental fracture of the right man-
dibular body. B) Pulling of the Geniohyoid and Digastric muscles on the segmental fracture of the symphysis. (Selected
readings, ref. 3).
Fig. 104.- Unstable (unfavourable) Fractures: Pulling of the masseter muscle in cases of unstable fractures on the angle and
body of the mandible. Note that the vectors are pulling away one fragment from the other, creating thus a gap. (Selected
readings, ref. 3).

Fig. 105.- Unstable (unfavourable) fracture of the condyle. Pulling of the lateral Pterygoid muscle causes medial-forward
displacement of the condyle. (Selected readings, ref. 3).
Once the fragments of an unstable fracture have been reduced:
17.3.1 Rigid fixation. Open reduction and rigid fixation (ORIF), as has been mentioned,
is always preceded by restoration of the previous occlusion by Intermaxillary Fixation (IMF).
ORIF has many advantages such as the mouth will remain open for inspection, minimizes
the risk of airway complications (vomits), facilitates oral hygiene, allow the benefits of
movement of the TMJ and jaw, and permits the patient to feed with a variety of diets. On
the opposite, if a perfect occlusion has not been obtained and there are one or more inter-
ferences at the occlusal plane, the plates should be removed, the segments reduced again
until the proper occlusion is obtained and then, and only then, the plates and screws
placed again. When the manoeuvre has to be repeated, what will happen is that in one of
the segments the plates will be displaced from the former holes. If they are displaced
enough, new drills on solid bone should then be done, but if the new screws should be
placed in contact with the previous drilled holes, then the screws will not hold properly the
plate and then whole rigid fixation will be challenged.
Fig. 106.- Post-operative Ortopantomogra-

phy showing a wire ligature, used to reduce
the fragment, and rigid fixation with mini-
plates and screws on either side. On the left
side 4 out of 6 screws were monocortical as
teeth roots were too close. Intermaxillary
fixation and bars have been removed after
proper occlusion has been obtained.

17.3.2 Lag screw fixation. Is not uncommon that fractures in the mandible, especially
those in which a secondary fracture appears in the opposite side from that of the impact,
that a Sagital split fracture is produced. The fracture could be favourable or not but a great
surface of bone is or will be in contact. Though multiple ligatures could be used for that
type of fractures, once again, the best method is the one that provides rigidity. Though
plates and screws could be used, in cases of Sagital fractures the best method is that of the
“Lag screw technique (see 9.1.2.3).
Fig. 107.- A) Sagital fracture of the angle of the mandible exposed by direct
approach. B) Reduction and fixation by lag screws technique.
17.3.3 Rigid fixation plus dental arch bar stabilization. The fracture could be stabilized
with miniplates and screws, without removal of the arch bars or a temporal intermaxillary
fixation. Normally, if the anatomic reduction has been well performed and a proper occlu-
sion has been obtained rigid fixation will suffice, but occasionally, suspected alveolar frac-
tures, partial dental avulsions or just a conservative attitude, makes advisable to leave at least
the arch bars still attached to the dental arcades. It has the advantage that is something
wrong happens (screws or plates that become loose, local infection, displacement of the
fragments, or whatever happens) the removal of the plates and screws will not represent a

whole failure as long as we still have the arch bars in place to continue with an intermaxillary
fixation alone. On the opposite the arch bars difficult in some degree the intraoral brushing,
and can be the cause of dental distortion if the bar does not fit perfectly to the dental arcade.
17.3.4 Wire ligatures plus intermaxillary fixation. The fracture could otherwise be sta-
bilized with wire ligatures and Intermaxillary fixation (see 9.2). Open reduction to the ana-
tomic position could be stabilized the most of the times with wire ligatures, but as wire could
not give full stabilization and rigidity another system should be employed, that is why beside
fixation with wire, intermaxillary fixation is, in the most of the cases, mandatory. Beside the
use of IMF the wire ligatures should be positioned in such way that the drilled holes should
be placed one in front the other perpendicular to the line of fracture in such manner that
each time the wire is pulled and bended, the segments become reduced anatomically. If the
line of fracture makes angles more than one wire ligature may be used. Then is better to
bend and pull the wires simultaneously or switching from one to the other.
Fig 108.- A) Complete unstable fracture of the right mandibular angle. B) Open reduction fixation of the fragments with
one wire ligature and intermaxillary fixation for six weeks.
So said, is determinant to identify exactly the line of fracture in a mandible, its direction and
its location, in order to determine if a fracture is or not stable. When non stable fractures are
present great attention must be made to perfect anatomic reduction. Constant checking of
occlusion must be done while reducing the segments, failure in doing so may result in gaps
or dental interferences in others points or the dental arcades.
Generally, mandibular fractures could be treated by close reduction and Intermaxillary fixa-
tion (6 weeks for body and ramus fractures, and 3 weeks for condylar).

17.4 Condylar Fractures
Fractures of the condyles are relatively common as the condylar neck is not only the weak-
est part of the whole mandible but an area that use to suffer the indirect stress of an impact
in another mandibular point. (A direct hit on the chin is usually the cause of a bilateral neck
condylar fracture. A hit on the left mandibular area of the mandibular nerve use to provoke
a neck condylar fracture on the opposite side). The anatomic structure of the condyles is
what determines the clinical findings.
Fig. 109.- The insertion in their respective areas of the Pterygoid muscles, lateral and medial, together with the masseter
muscle will determine the different pulling on the fractured segments. (Selected readings, ref. 3).
As the thin condylar neck determines the common site of fracture, the attachments of the
lateral pterygoid muscle determines its medial-forward displacement. However this medial-
forward displacement could vary from a non displaced fracture, through a mild form, to 90º
displacements in which the same condyles interfere with the occlusion being the cause of
an open bite deformity.

17.4.1 Aggressive treatment. Open reduction is a very demanding surgery as has
been already exposed (see 6.4.1 Pre-auricular temporal approach), even for an experi-
enced surgeon. Narrow and complicate approach, undermining of tissues close to great
vessels and nerves, and bone manipulation makes this open approach prone to compli-
cations as bleeding, malocclusion, facial nerve injury or joint disorders. When the line of
fracture is low enough, it could be managed by a more safety intraoral approach (see
6.3 intraoral approaches) or a Risdon extraoral approach, but these approaches do not
allow a comfortable and secure condyle manipulation and reduction and the screws
used for are rarely available. Indications for open reduction and internal rigid fixation of
the fractured condyles are:
• Medial displacement of the condyle more than 90º.

• Displacement of the condyle into the cranial fossa.
• Lateral extracapsular displacement.
• Complete block of the mandible.
Fig. 110.- Different possibilities at the mandibular body where plates and screws could be safely placed. (Selected readings,
ref. 2).

Fig. 111.- Different possibilities of rigid fixation used for condylar fractures. (Selected readings, ref. 2).
17.4.2 Conservative treatment The great difficulties and potential complications make
conservative treatment even more desired than ORIF. Fortunately, the vast majority of con-
dycar fractures, though could be medially displaced, will react well to a conservative treat-
ment of IMF with rubber bands. During at least 2 to 3 weeks IMF is maintained under
control to change the direction of the rubber bands if necessary.
Whatever the treatment which has been performed, what is also of importance is the post-
operative physical therapy to improve the movement of the joint.
17.5 Dental management in maxillo-mandibular fractures
Teeth are commonly involved in fractures affecting the maxilla and especially the mandible
as they represent a weak point on the bone. Third molars, especially when impacted, adds
weakness to the angle zone increasing thus the likelihood of fractures at this site. The teeth
themselves could be injured, and depend on the type of injury and severity they could be
saved or not, extracted or preserved.
17.5.1 Teeth extraction. It has been a common practice the routine extraction of teeth
involved in the line of fracture in order to avoid dental complications. Actually is considered
that extraction of the teeth is justified only in those cases in which the teeth prevent the
proper reduction of the fracture, significant caries, root cysts or root fractures or extensive
periodontal damage and complete extrusion. However it seems that no special benefit is
obtained from that procedure, on the contrary, it is quite clear that when removing a tooth,
a closed fracture becomes in fact an open one. Much more the empty socket will cause the
alveolar ridge to collapse and resorbs adding a new weak point to the bone.

17.5.2 Teeth preservation. The current trend under favourable conditions is always to
preserve the teeth. Each tooth has a dual blood supply, the main from the apical vessels
and a secondary from the periodontal ligaments as perfusion. So even when partially ex-
truded it could be saved, especially if the treatment is accomplished in the first 30 minutes
and stable fixation is obtained with more possibilities to younger patients than in adults.
Exception made for the conditions previously mentioned in 17.7.1, teeth should always be
preserved in place. To be preserved, the teeth need to be fixed and stabilized without being
used as support for the dental bar wire ligatures.
17.5.3 Teeth reimplantation. In adults, a loose tooth is generally a lost tooth, on the
contrary, in children the expectations of a favourable outcome are much better. The goal is
to maintain the tooth well pressed against its socket for at least three to four weeks. This
could be accomplished by a conservative splint treatment by a dentist. Otherwise, when a
dentist is not available as uses to be in undeveloped areas, the method to get the desirable
vectors of strength in the adequate direction consists in placing arch bar perfectly suited to
avoid undesirable movements of the teeth. The bar should be secure in place, especially
on both sides to the affected tooth, which is then pushed in place by a gentle, soft and
continuous pressure with the fingertip as much as possible or until the level of the collat-
eral teeth is reached. In that moment one or two wire ligatures embracing the tooth and
around the bar are placed as shown in fig 113. After three or four days the tooth and liga-
tures should be controlled as they will become partially loose as could be the bar. After
three or four weeks (four always preferable if the patient or his family are not very coop-
erative), the ligatures could be removed leaving the arch bar in place until the outcome,
successful or not, is quite clear. Soft diet up to three weeks is then the key to secure suc-
cess. The outcome is not always successful, but it works well around the 70% of patients.
Fig.112.- Typical dislodging of the central incisive in a child.

Fig. 113.- Dental impactation stabilized with dental bars A) 1 wire ligature and B) 2 ligatures.
Fig. 114.- Successful tooth reimplatation after 4 weeks of stabilization.
17.6 The edentoulous mandible
Finally, the edentulous mandible presents its own challenges. Absence of teeth determines
a collapse of the alveolar ridge and dental sockets with the final result of bone resorption
and demineralization. Thus, despite the advantage of having no dental roots to be con-
cerned about, the bone of the edentulous mandible is thin and weak. This weakness
should be taken into consideration when rigid fixation with thick plates and screws are
used.
However the best treatment is again open reduction and internal fixation. Beside ORIF, the
mandible needs also stabilization to maintain the proper relationship with the maxilla. For
this reason, when the own patient dental prosthesis is available, it should be used, modified
or not, attached to the mandible and / or the maxilla with wire suspensions to the maxilla
or circumandibular wires for the mandible.

Fig. 115.- A) Lower denture attached by circumandibular wires to the body of the mandible. B) Whole denture fixed to the
mandible and maxilla to get reliable IMF. (Selected readings, ref. 2).
Fig. 116.- A to D: A Reverdin needle is passed transcutaneously through the oral floor to the lingual aspect of the mandible.
A wire is passed trough the needle and this is retired progressively always in contact with the bone until the cower border
is reached. Then it should be pulled to the vestibular sulcus. With the two extremes of the wire free, the circumandibular
ligature could be firmly attached to the denture. (Selected readings, ref. 2).

IMF has their own disadvantages, as poor intraoral hygiene, feeding and risk of vomits. It
could be managed or diminished by modifying the central anterior par of the denture open-
ing a space (see fig.117). In such way feeding and intraoral hygiene will be easier and the
risk of vomits diminished considerably.
Fig. 117.- The denture has been modified removing the incisor teeth. Note that in this case, the superior denture has been
secure by wire suspensions to the maxilla with two long screws. (Selected readings, ref. 3).
The mandible especially the edentulous could be perfectly reduced and fixed with dynamic
compression plates (see 9.1.2.2) or long multiple barrelled plates. Occasionally, and specially
in undeveloped regions the only material we have at hand is the best and the unique possibil-
ity, so, old methods using external devices or Kischner wires could be used only in the last
instances (see below), as they give limited stability and local problems as infection at the per-
cutaneous entrance of the wires or osteomielitys by infection and resorption of the fragments.
Fig. 118.- External pin fixation for stabilization of mandibular fracture.


Fig 119.- External fixation for comminute or segmental
fractures of the mandible could be obtained (after ade-
quate IMF) with K-wires. A) 2 crossed wires will be al-
ways preferable to a single one to avoid rotation (Selected
readings, ref. 2) B) Represents exactly what NOT to do: a
single wire passed extremelly closed to both mental fora-
men!!! (Selected readings, ref. 1).

Chapter 18
Facial fractures in children
The facial skeleton of a child varies greatly from that of an adult. The child craniofacial skel-
eton will differ greatly from that of 1 year old to that of a 17 y.o. patient. As a growing en-
tity, craniofacial bones change year after year as differentiation occurs with their pararell
effects on bone mineralization, bone resilience, dentition, paranasal sinus, and the func-
tional growth matrix.
Fig. 120.- Morphological changes in the craniofacial skeleton of children aged 1 year old, 3 years old and 7 years old.
Notice the changes from an almost solid round bone mass to the pneumatized pillared bone structure and the subse-
quent changes in dentition. All these changes will affect the pattern of fractures presentation from birth to adult age.
18.1 Characteristics of the craniofacial pediatric skeleton
18.1.1 Functional Growth matrix. The craniofacial pediatric skeleton is a continuous grow-
ing entity. The proper growth of these bones relays in a proper relationship between normal
soft tissues and normal bone. As soft tissues grows (especially the brain during the first two
years) the bones become expanded. Aggressions or injuries to facial soft tissues will result in
distortions or scars that will arrest the subsequent bone growth (excessive scars on the lip
and muscle will arrest forward development of the maxillae in operated cleft lip patients). In
the same way, injuries due to trauma (condylar fractures) or surgical aggressions (as cleft
bone grafting was in the past) seem to arrest the subsequent local bone growth. Much more,
in a rapid growing craniofacial skeleton, metal plating systems for rigid fixation could be over-
lapped and left behind (Titanium microplates and screws used to fix craniofacial osteotomies
in 12 to 18 months y.o. patients where found later as being part of the meninx). So said,
treatment of facial fractures could not so freely relay on rigid fixation as it is in adults. Open
reduction (with subsequent soft tissue and subperiosteal undermining) and rigid fixation

(drilling holes through the periosteum on growing bones) could signify an aggression to the
functional matrix and restriction of bony growth. While it is quite clear that condylar fractures
or severe nasal fractures will arrest local growth on these areas, large subperiosteal under-
mining of the fronto-orbital region after surgical treatment of craniosinostosys does not have
that effect. On the other hand, children seem to have a great potential for remodelling ap-
propriately mild forms of fractures, in fact is considered that many of them likely go unrecog-
nized. So said, it seems the best option to be us much conservative as possible when treating
facial fractures in children, and the younger is the patient the more conservative.
18.1.2 Bone mineralization. Mineralization of the craniofacial bones not only means
growth of bones but hardening. The bones of a 1 y.o. patient are a relative resilient mass that
could absorb better the effects of impacts on them. In the same way this elasticity makes the
response to impacts different from that of an adult, being the fracture patterns different from
small children to an adult. Of course as mineralization takes place the craniofacial skeleton
becomes less and less elastic and the brittleness increases enormously after the age of 2 or
3 years. That resilience has the effect that in children comminuted fractures are likely to be
less frequent than adults and the greenstick-type patterns have a higher incidence. All to-
gether makes fractures in children more difficult to happen but also to be diagnosed.
18.1.3 Paranasal sinuses. Another great difference is the paranasal sinuses development. In
the case of maxillary sinus it starts from birth to the age of 12-13 y.o. In the case of the frontal
sinuses they appear to initiate aeration from the age of 5 to the end of puberty. The develop-
ment of these cavities has the effect of change the craniofacial skeleton from an initial solid
mass to a pillared structure (see figs. 120 and 121). Once again, the craniofacial structure of a
child 4 y.o. is quite different from that of a child 11 y.o., a 17 y.o. boy and from that of an adult,
and these different structures have a different response to traumas and are traduced in different
fracture patterns. The LeFort classification for midface fractures in adults (see 16.1) is of little
use, if any, when describing patterns in children. In small children craniofacial fractures seems
to cross midline in an oblique pattern. In general, from birth to age 5, midface fractures tend to
occur in large greenstick blocks that use to extend to the frontal bone. From age 5 to 12, mixed
dentition and aeration of sinuses makes fractures tend toward adult fractures pattern.
Fig. 121.- Representation of paranasal sinuses development in A) at birth, B) at 5 years old and C) at 18 years
old. (Selected readings, ref. 1).

18.1.3 Dentition. As could be clearly seen in fig. 120, dentition from birth to adult age is
changing constantly. From a new born edentulous mandible full of buds, through a strong
mandible with full definitive dentition to the weakest demineralizated edentulous mandible
of an old patient. As the functional matrix could be mainly affected by subperiosteal under-
mining, the presence of buds and mixed dentition are determinant respecting the method
of fixation as they could highly interfere with rigid fixation. Mixed dentition represents a seri-
ous challenge as primary teeth and partially erupted secondary teeth do not provide a strong
and stable foundation on which to fix dental bars for intermaxillary fixation. Much more these
teeth are highly sensible to the traction of rubber bands and could easily been extruded. The
conic shape of the children teeth adds another complication for wiring the bar in place.
18.1.4 Diagnosis and Incidence
If in adults CT-scan is the best method to properly diagnose fractures, in children is almost
the unique exam that could be completely reliable. Children, especially after having sus-
tained a trauma, are highly uncooperative and difficult to explore and poorly communica-
tive. Family is sometimes the only source of information and not infrequently they are not
available or not completely reliable. Experience and sensible judgment capacity, beside the
CT-scan and physical examination is what will finally give the diagnostic.
However as child are more cooperative, simple X-rays films could be obtained, and espe-
cially ortopantomography is a very helpful exploration as it will give precise information
about the whole mixed dentition and buds.
About incidence it seems that craniofacial fractures are less frequent in children than in
adults. The elastic properties of the young craniofacial skeleton, small volume mass ex-
posed to trauma, the protected environment in which children live, but probably the non-
diagnosed fractures and the lack of data about large series of pediatric patients have much
more to say about this lower incidence.
18.1.5 Treatment of fractures. Conservative vs. aggressive management
As has been previously stated the unique characteristics of bone in children makes the
fully accepted Open Reduction and Rigid Fixation (ORIF) for fractures in adults not widely
accepted. However it is not the same to treat a 2 y.o. patient than a 14 y.o. As stated in
adults no tooth should be discarded beside or in the line of fracture and, especially in the
body of the mandible, no debridement and minimal, if any, manipulation should be done.
18.1.6 Conservative treatment. Conservative treatment of facial fractures makes refer-

ence to a close reduction and intermaxillary fixation. This type of immobilization (IMF) is
not free of difficulties and challenges in children (see 18.1.4). Fixation of a bar greatly
depends on the shape and size of each of the individual tooth that in mixed dentition
could greatly vary from one to another. Much more, their teeth hardly tolerate the tension

produced by ligatures to the bar and could be easily extruded if IMF is based on elastic
bands. So, before fixing a bar, time should be taken to carefully explore the more appro-
priate and solid teeth to place the ligatures for the bar (see 9.3), and if not precisely
needed, wire ligatures are always preferable to elastic band. When elastic bands are used,
close control of each tooth should be maintained to detect rotation and extrusion. An
even more conservative treatment is to be assisted by a dentist and use splints, bands or
glued brackets as support system for the IMF. On the other hand, the rapid heal proper-
ties, and much more less powerful musculature in small children, make that intermaxillary
fixation should not need to last as much as in adults (three or four weeks are enough to
the six of adults) and certain dental displacements are better tolerated and easier to cor-
rect with orthodontics.
Fig 122.- Bicondylar neck fracture treated by intermaxillary fixation during three
weeks and active physiotherapy. Result 3 months later.
18.1.7 Aggressive management. As aggressive management it is understood open re-

duction and rigid fixation (ORIF). In children with unstable fractures where small teeth or
mixed dentition does not allow sustaining an intermaxillary fixation, conservative manage-
ment is then non viable and open reduction and fixation is then the proper option. When
needed, to restore the previous occlusion a very conservative Intermaxillary fixation should
be done first (avoid tension over the individual tooth). Then, a very conservative and limited
subperiosteal undermining will be preferable to a wide one in order to respect the func-
tional growth matrix. However the use or mini or microplates result in much more under-
mining than when wire ligatures are employed. ORIF (or ORIWiF; open reduction and inter-
nal wire fixation). The election of the method for osteosynthesis then should go into
consideration, especially at the mandibular body, where plates and screws should be placed
depending not only on the line of fracture and the principles for reducing the fragments but
in the presence of multiple dental buds that could interfere with screws.

Fig. 123.- A) Parasymphyseal and body fracture in a child. B) Wire stabilization of the fracture at the alveolar ridge, open
reduction and rigid fixation on the free border of the mandible where full thickness screws could be placed on solid bone.
Once the line of fracture has been exposed, the plates should be placed in such position
that the dental buds will be completely avoided. So said the best method is to keep the drill
holes and screws far from the area where they are, the free mandibular border. Start reduc-
ing the fracture on that site has the potential risk of a rotational effect on the opposite
border (alveolar ridge) where a gap may appear leading to malocclusion (see fig 124). So,
prior to reduce and fixate the fracture at the free mandibular border, the fracture should be
reduced and gently fixed at dental level (interdental wire or arch bar fixation) or close to the
alveolar ridge (monocortical wire ligature or monocortical rigid miniplate). Only then, plates
and screws or wire ligatures could be employed at the free mandibular border with no risk
of producing gaps at the alveolar ridge.
Fig. 124.- A) Fixation on the free border of the mandible without securing the line of fracture at the alveolar ridge has the
risk of opening a gap that which will result in dental malocclusion. B) By wire, miniplates or dental arch, the alveolar ridge
should be secured before proceed to stabilize the free border. (Selected readings, ref. 1).
An important consideration is that of overgrowing. Small children grow rapidly (especially 1

to 4 y.o. children). Craniofacial bones grow by a continuous mechanism of bone apposi-
tion / resorption that will result in an inward position of the plates that become overgrown
by bone. As have been mentioned in craniofacial surgery, plates have been even found
included in the dura. The effect of overgrowing at the facial skeleton is not known though
it seems that no deleterious consequences appear. Anyway, removal of rigid plates and
screws seems advisable until more data are available.

For Lefort or maxillary fractures in children the general rules are the same as for adults, with
great concern about the maxillary dental buds. The principles are the same and plates or
wire should be use as much as needed to stabilize the different fragments. Bone grafts
should also be used if needed but in a much more conservative way than in adults, espe-
cially around the alveolar area.
Fig. 125.- A) and B) Frontal an lateral view of a child with a severe Lefort III impacted fracture with comminute fracture of
the naso-ethmoid orbital complex. Note the increased width at the intercanthal distance and the collapse at naso-frontal
area. C) Pre trauma picture of the child is useful to check the previous facial proportions (very especially in children).
Fig. 126.- A) 10 months later, facial proportions and appearance has been restored and maintained. Reduction and fixation
has been performed following the same principles as for adult patients but in a more conservative way.

18.2 Summary for facial fractures in children
The already mentioned factors of growing bone, aeration of paranasal sinuses, bone miner-
alization and dental buds, combined with the fact that the most of fractures in children fol-
lows a “green stick” pattern, makes conservative treatment the general election for almost
all fractures. But besides all this difficulties, children has a great advantage over adults; small
occlusal discrepancies could be better tolerated than adults as they could be much more
easily corrected by the self remodelling properties or orthodontics treatments. Beside this,
the muscles are not so powerful, so displaced unstable fractures are less likely to happen.
Guidelines for general management of pediatric facial fractures:
1. Maintain a high index of suspicion for maxillofacial injury in the pediatric patient, espe-
cially when multiple traumas exist.
2. In addition to careful physical examination, utilize CT scanning on a routine basis, even
for apparently trivial injuries.
3. Give consideration to observation only for minimally displaced fractures.
4. Respect the functional matrix and employ the least invasive surgical approach that will
access the fracture and allow stable reduction.
5. Employ methods of fixation that adequately stabilize the facial skeleton without rigidly
immobilizing long segments.
6. If rigid internal fixation is necessary, in the form of conventional plate and screw fixation,
give consideration to interval removing.
7. Microplates appear to provide enough stability so that their use can be advocated when-
ever possible.
8. Avoid the use of alloplastic materials.
9. Use bone grafts sparingly, except in instances in which inlay reconstruction is necessary
and onlay reconstruction required to maintain soft-tissue support.
10. Be aware of the pediatric dentition and avoid iatrogenic injury to evolving is teeth and
tooth buds.
(From : S.P. Barlett,, MD, and J.B. DeLoizer III MD. Clin Plast Surg 19:245, 1992)

Chapter 19
Summary
The evolution of techniques for diagnosis, exploration, surgical access to the fractured
bones and rigid internal fixation has improved the aesthetic and functional results after in-
juries and fractures of the craniofacial skeleton.
However in undeveloped areas, certain technological devices are not at hand and diagno-
sis and treatment as well as a favourable outcome will relay on what we have at hands
(sometimes nearly nothing!!!!!) but the leading points for a successful treatment remain
the same:
• Stabilization of the patient.

• Careful and methodical exploration.
• Meticulous surgical planning of each step and their order.
• Earlier and combined treatment of injuries and fractures.
• Consider Open reduction and stable fixation (rigid when possible) or close reduction.
• Keep a close control of the patient, especially if Intermaxillary fixation has been used.
Fig. 127.- Extremely severe form of Lefort I, II and complete comminute fracture of the naso-ethmoidal orbital complex
associated with avulsion of the maxilla, the nose and multiple fractures of the mandible.

Fig. 128.- Despite the anatomic reduction and rigid fixation, extensive use of bone grafts, meticulous soft tissue man-
agement and dental treatments, this type of patients will mostly need minor revisions get an acceptable aesthetic
and / or functional outcome. The patient is shown A) 6 months after the emergency surgery, B) 18 months later, and
C) 6 years later.
Even in the best hands with the most advanced instruments and devices, craniofacial
trauma, especially the in the more severe cases, could have complicated outcome. So on
craniofacial fracture surgery does not finish in emergency treatment but continue with the
treatment of the sequellas..., but this will be the item of a new book.

Selected readings
1. Converse. Reconstructive Plastic Surgery. 2nd Ed. Vol. 2. Chp 24. WB
Saunders Company.
2. Chirurgie des traumatismes faciaux. Monteil JP, Esnault O et Lahbadi M.

Encycl Med Chir, Editions Scientifiques et Medicales Elsevier SAS Paris.
Techniques Chirurgicales- Chirurgie Plastique 45-505, 1998, 26p)
3. Advances in Craniomaxillofacial fracture management. Clinics in Plastic

Surg. Vol. 19. nº 1, January 1992.
4. Surgery of the jaws. In MCarthy JG (ed): Plastic Surgery, Vol. 2 MCarthy

JG, Kawamoto HR, Grayson BH et al. Philadelphia, WB Saunders 1990, pg
1221.
5. Wound healing, grafts and basic cutaneous flaps. Musolas A., Quinodoz
P. Cirujanos Plástikos Mundi. 2007.
6. Rhinoplasty. Ortiz-Monasterio F. WB Saunders Company. 1994.
7. Zide Surgical anathomy around the orbit. Lipincott. ISBN 0-7817-5081-4.
8. Temporomandibular Joint. JE Norman and P Bramley. Wolf Medical Pub-

lications Limited, 1990.
9. The extended subperiosteal face lift: a definitive soft tissue remodel-

ling for facial rejuvenation. Ramirez, O., Maillard GF, Musolas A.: Plastic
Reconstructive Sur.. 88: 227, 1991.
10. Surgery of the jaws. In MCarthy JG (ed): Plastic Surgery, Vol. 2. MCarthy
JG, Kawamoto HR, Grayson BH et al. Philadelphia, WB Saunders 1990,
pg 122.
11. NiederdellmanH: Rigid internal fixation by means of lag screws. In

Krüger E, Schilli W (eds): Oral and Maxillofacial Traumatology, vol 1. Chi-
cago, Quintessence Publishers, 1982, p 377.
12. Complex Craniofacial problems. Churchill Livingstone 1992. Craniofacial

Trauma. JM Serletti, PN Manson, Chp. 18: 373.
13. Principles of Neurosurgery. Setti S. Renganchary, MD, Robert H. Wilkins,

MD. Chapter 16. Closed Head Injury, Raj K. Narayan. Mosby-Year book 1994.

Chapter 1. Introduction ........................ 7 6.4 Extraoral approaches ............................46
Chapter 2. Inital evaluation ............... 9 Chapter 7. Principles of bone

healing ............................................................49
2.1 Cervical spine injuries ............................. 9
2.2 Airway compromise ................................ 9 Chapter 8. Principles for
2.3 Hemorraghe ............................................... 9 Bone grafting .............................................51
2.4 Open or closed head injury ...............10
2.5 Thoracic, Abdominal 8.1 Principles of graft survival ...................51
and Orthopaedic injuries .....................10 8.2 Types of bone grafts .............................52
8.3 Choosing a graft type ...........................52
Chapter 3. Head Injury ........................11
Chapter 9. Techniques and
3.1 Classification of Head Injury ..............11 elements for bone fixation ..............59
3.2 P
hysiopathology of
the traumatic Brain Injury ....................12 9.1 Rigid fixation ............................................59
3.3 Head Injury evaluation .........................14
9.2 Wire fixation .............................................65
3.4 D
iagnosis of Head injury
9.3 Intermaxillary fixation ............................68
and Cranial Hypertension ...................17
3.5 Medical therapy ......................................18
Chapter 10. General approach
3.6 Surgical therapy ......................................19
to Facial Fractures ................................77
Chapter 4. Local Evaluation
and management of craniofacial Chapter 11. Frontal sinus
trauma..............................................................23 fractures ........................................................79
4.1 Physical exploration ...............................23

Chapter 12. Fractures
4.2 X-Ray exploration ...................................25 of the Orbit ..................................................81
4.3 General management ..........................28
Chapter 5. Management of wounds of the Zygoma ...........................................85
and open fractures ................................31
5.1 Local management; Principles ..........31 of the Nose ..................................................89
5.2 Whole management
of the facial injury ..................................31 14.1 Exploration and diagnosis..................89
14.2 Surgical management..........................89
Chapter 6. Approaches to the
craniofacial skeleton ...........................37 Chapter 15. Fractures of the Naso-
Ethmoidal-Orbital complex .............93
6.1 Coronal approach ..................................37
6.2 Orbital approaches ................................40 Chapter 16. Fractures
6.3 Intraoral approaches .............................43 of Maxilla ......................................................99

16.1 Classification of the main 17.5 D
ental management in
maxillary fractures ...............................99 maxillo-mandibular fractures.......... 122
16.2 Exploration and clinical findings....100 17.6 The edentoulous mandible............. 124
16.3 Treatment of maxillary fractures....103
Chapter 18. Facial fractures in
Chapter 17. Fractures children........................................................ 129
of Mandible .............................................. 111
18.1 Characteristics of the craniofacial
17.1 Exploration............................................. 112 pediatric skeleton............................... 129
17.2 Stable (Favourables) Fractures...... 114 18.2 Summary for facial fractures
17.3 U
nstable (Unfavourable) in children............................................. 135
Fractures................................................. 115
17.4 Condylar Fractures.............................. 120 Chapter 19. Summary........................ 137

Craniofacial Trauma

Craniofacial Trauma: Health Sciencies Cooperation Monographies

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Craniofacial Trauma Dr.

Dr. Alberto Musolas

Craniofacial.indd 1 22/01/10 13:22

Edited by Alberto Musolas

Publication of this book has been possible thanks to the

This book is published with the aim of cooperation in mind,

Its sale is expressively not permitted.

Craniofacial.indd 2 22/01/10 13:22

Craniofacial.indd 3 22/01/10 13:22

Dr. Alberto Musolas

Craniofacial.indd 4 22/01/10 13:22

4. Local evaluation and management of Craniofacial trauma

5. Management of wounds and open fractures

6. Approaches to the craniofacial skeleton

7. Principles of bone healing

8. Principles of Bone grafting in facial fractures

9. Techniques and elements for bone fixation

10. General approach to Facial Fractures

11. Frontal sinus fractures

12. Fractures of the orbit

13. Fractures of the Zygoma

14. Fractures of the Nose

15. Fractures of the Naso-Orbital-Ethmoidal complex

16. Fractures of Maxilla

17. Fractures of Mandible

18. Facial fractures in Children

Craniofacial.indd 5 22/01/10 13:22

Craniofacial.indd 7 22/01/10 13:22

Management of Cranio-facial trauma begins with a coordinated and

2.1 Cervical spine injuries

2.2 Airway compromise

Craniofacial.indd 9 22/01/10 13:22

2.4 Open or closed head injury

2.5 Thoracic, Abdominal and Orthopaedic injuries

Craniofacial.indd 10 22/01/10 13:22

3.1 Classification of Head Injury

Head injury could be classified in different ways:

The American Association of Neurology describes three mechanisms of cranial trauma:

• Impact of an object to the cranium (penetrating or not).

Craniofacial.indd 11 22/01/10 13:22

After a cranial traumatism some lesions, isolated or associated, could result.

3.2 Physiopathology of the traumatic Brain Injury

The cranium has three main components:

• Brain tissues (aprox. 85%).

Craniofacial.indd 12 22/01/10 13:22

• If PaO2 is over 120mm Hg, the CBF decrease.

Regarding to the PaCO2:

Craniofacial.indd 13 22/01/10 13:22

Primary lession ICP

• 1st reaction: resorption of CS fluid

If ICP continue growing

Cerebral Perfussion Pressure:

ICP arterial pressure

Cerebral Perfussion Pressure

3.3 Head Injury evaluation

Craniofacial.indd 14 22/01/10 13:22

3.3.1 Physical exploration

3.3.1.1 Neurological exam. Glasgow Scale.

Glasgow Coma Scale

For practical purposes, it has been generally accepted that

1. Mild Traumatic Brain Injury (TBI):

Glasgow Coma Scale of 13-15.

• Brain tissues (aprox. 85%).

3.4.1.2 Edema is seen on a CT as an area of low density associated with an image of

3.6.2.1 Depressed skull fractures. As a guideline it could be considered that a de-

3.6.2.4 Intracerebral hematomas. As contusions are mainly located in the frontal

• Neurological exploration: search for numbness, hyposthesia or anaesthesia in the

• Exploration of ducts, as the lacrimal and stenon, if their section is suspected by an

6. Miorraphies of sectioned muscles, especially when avulsions could lead to unde-