Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2018; 63:(1 Suppl): S35–S47

doi: 10.1111/adj.12589

Current and evolving trends in the management of facial

fractures
N Vujcich, D Gebauer
Oral& Maxillofacial Surgeon, Royal Perth Hospital, Perth, Western Australia, Australia.

ABSTRACT
The oral and maxillofacial region has a complex regional anatomy including hard and soft tissues. Trauma in this region
may affect the airway, cause potentially life threatening bleeding and head injuries. The senses of olfaction, sight and
hearing can also be disrupted as well as a profound psychological impact following disfigurement. This oral and maxillo-
facial trauma update provides information on demographics, incidence, pathophysiology, diagnosis, fracture patterns
and management of facial trauma. It also discusses the role of new advancements in the management of facial trauma.
Keywords: Le Fort, mandible, maxilla, maxillofacial, naso-ethmoidal complex, occlusion, orbit, trauma, zygoma.
Abbreviations and acronyms: CAD = Computer assisted design; CAM = Computer assisted manufacture; CT = Computerised tomogra-
phy; IMF = Intermaxillary fixation; MCT = Medial canthal tendon; MRI = Magnetic resonance imaging; NOE = Naso orbital eth-
moidal complex; ORIF = Open reduction, internal fixation; RPH = Royal Perth Hospital.
Accepted for publication October 2017.

important nonverbal form of communication. Psycho-

INTRODUCTION
Maxillofacial trauma is classified into injuries involv-
ing the lower, middle and upper thirds of the face. It
includes the soft and hard tissues of the face and oral
cavity.
Oral & Maxillofacial surgeons have played a major
role in the evolution of facial trauma management,
and are currently at the forefront of management and
advances in these treatments. The majority of Aus-
tralian oral and maxillofacial surgeons treat facial
fractures as part of their practice.1
Maxillofacial injuries occupy a spectrum of com-
plexity. At one end are minor dentoalveolar injuries
managed as an outpatient. Dental Traumatology has
been fully presented in the 2016 Australian Dental
Journal Supplement and will not be discussed further
in this paper.2 At the other end are multisystem, life
threatening injuries requiring tertiary hospital admis-
sion, multidisciplinary treatment and complex recon-
structive procedures. Central to managing these facial
injuries is a strong dental education.
Facial trauma may be life-threatening as a result of
airway obstruction or haemorrhage. Longer term
functional complications may arise including injury to
vital sensory structures responsible for vision, olfac-
tion, hearing and taste. Motor nerve and soft tissue
injuries with scarring may impair facial expression, an
© 2018 Australian Dental Association
logical distress is common in those patients who suffer
cosmetic deformity. Non anatomical repairs of under-
lying facial bones and associated soft tissues may also
result in changes to occlusion and speech. Reconstruc-
tion of the oral cavity without consideration for den-
tal rehabilitation will complicate the prosthetic
outcomes following healing.
Reconstructive goals in managing maxillofacial
trauma include returning the patient to as close to
their pre-injury status as soon as possible, and an
early return to function. In cases of severe trauma,
multiple surgical procedures may be may be required
to achieve this goal.
DEMOGRAPHICS
Facial trauma is a frequent presentation in emergency
departments, with the aetiology and fracture pattern
influenced by the geographic region studied.
In the adult group, facial fractures are usually the
consequence of behavioural risk-taking. The majority
are the result of interpersonal violence and motor-
vehicle accidents, and less so falls, sports, and work-
place injuries. In the paediatric and geriatric groups,
lower levels of co-ordination together with cognitive
deficits are a greater cause of trauma than the beha-
vioural issues seen in the adult group.
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N Vujcich and D Gebauer

Royal Perth Hospital (RPH) is the major tertiary

trauma hospital in Western Australia and includes the Residence of paents
State’s Trauma Unit (excluding paediatrics). The average 18 (6%)
19 (6%)
age of a patient treated for facial fractures in RPH dur-
ing 2012 was 28 years, with a male dominance (87%).3
Certain subgroups were over-represented, with 6% of Perth Metropolitan

all operative patients being prison inmates (0.1% of 141 (47%) Rural Western Australia

nations population3), and 30% of all operative facial 124 (41%)

Non Western Australian

fracture patients being of Aboriginal descent3 (3% of Inmate

Western Australia’s population) (Figs 1 and 2).4

O’Meara found that 53% of facial fractures were
involved with recent alcohol use.5 Other illicit drugs
were also frequently, with 47% testing positive, and Fig. 2 Residence of patients.
cannabis the most common drug involved.6
Paediatric (<18) and geriatric (>65) populations are
less likely to sustain facial injuries or require surgery Percentage of operave facial fractures
in the event of such trauma. Paediatric fracture inci- by age , RPH3
dence increases with age, with 10% of fractures
50
occurring in those under five, and increasing to 50% 45
in the 15–18 year old group of paediatric patients.7 40
35
Facial fractures occurring in older patients are usu- 30
ally associated with other significant injuries, greater 25
severity and death.8 The risk to benefit ratio in older 20
15
patients influences operative decision making, often 10
resulting in a lower operative rate (Fig. 3). 5
0
<20 20s 30s 40s 50s >60

FRACTURE PATTERN AND INCIDENCE Fig. 3 Percentage of operative facial fractures by age, RPH3

Facial trauma classification is divided into vertical

facial thirds. The upper third includes the frontal
bone, the mid third includes the maxilla, zygomas,
orbits, nose and naso-orbital ethmoidal complex
whilst the lower third includes the mandible (Fig. 4).
Lee reviewed data from more than 2500 patients
treated by Oral & Maxillofacial surgeons in New
Zealand over 10 years.8 He found the incidence of
facial third fractures with the lower third was 33.1%,
middle third 63.5% and upper third fractures 3.3%
(Fig. 5).5 The proportion of operative cases of all
facial fractures is shown in Figure 6.3
Lee noted 53% of fracture patients required surgery
whilst 47% did not illustrating differences between
fracture incidence and operative cases.8
TRAUMA MANAGEMENT
The initial management of facial trauma follows life
support principles, as outlined by Early Management
of Severe Trauma of the Royal Australasian College
of Surgeons.9
In the primary survey life threatening injuries are
diagnosed and stabilized. Once the patient is
stabilized, the secondary survey diagnoses other
injuries.
Maxillofacial trauma not associated with airway
obstruction or major bleeding is treated after the
patient is stabilized, as part of the secondary survey.
The goals in managing facial trauma are

Sex Aboriginal
40
(13%)

90
Male (30%) Yes
262 Female 212 No
(87%) (70%)

Fig. 1 Three hundred and two facial fracture patients operated on by the OMS team Royal Perth Hospital in 2015.2
S36 © 2018 Australian Dental Association
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Facial fractures

I II III
Fig. 4 Vertical facial thirds of the face.

LOWER THIRD FRACTURES

Percentage of consulted facial fractures
by individual bones Mandible
35
30
The mandible is one of the most common of all facial
25 fractures, and has the highest surgical intervention
20 rate of all facial bones.
15 Classification is based on the anatomical location of
10 the fracture. The most common sites are of the
5 mandibular condyle, angle and parasymphysis whilst
0 the body, coronoid and ramus are least frequent.10
Frontal Zygoma Orbit Maxilla Nose NOE Mandible
Bone Mandibular fractures can result in malocclusion,
inferior alveolar nerve paraesthesia, and ankylosis.
Fig. 5 Percentage of consulted facial fractures by individual bones.8
Infection and osteomyelitis may occur in patients who
have a delayed presentation.
A Tasmanian study recently found that 68% of diag-
Percentage of operave facial fractures
nosed mandibular fractures require treatment.11 Early
by individual bones operative time (within days) is preferred as many are
70
open fractures and painful due to mobility. Mandibular
60
condyle fractures may be best left until oedema has
50
40
resolved (several days), to simplify surgical access.
30
Historical treatments involved wiring fracture seg-
Royal Perth
20 ments and inter maxillary fixation or ‘wiring of the
10 jaws’ (IMF) into occlusion. IMF is maintained for 4–
0 6 weeks and impairs feeding. It increases the risk of
Frontal Zygoma Orbit Nose Maxilla NOE Mandible
Bone
ankylosis and the potential need for tracheostomy.
Closed reduction with IMF is still used in some
Fig. 6 Percentage of operative facial fractures by individual bones.3 cases, alone or combined with plating techniques. The
use of arch bars with interarch elastics rather than
• Restoring anatomy and eliminating deformity wires guides the occlusion for 4–6 weeks. It does not
• Restoring occlusion and masticatory abilities prevent mandibular movement (Figs 7a–c and 8).
• Restoring function including nasal airflow and ocu- Current treatments involve repositioning and secur-
lar function ing fracture segments with metal plates and screws
• Minimising morbidity and are termed open reduction and internal fixation
• Early return to function (ORIF).
Formal dental training provides the treating surgeon Small strategically placed load-sharing plates are
superior diagnostic abilities, improves surgical outcomes used to counter mandibular muscular forces, and dis-
and enhances the post-operative management of facial tribute the force between the plate and mandible. This
trauma patients. Understanding occlusion is particularly technique, developed in the 1970s, is based on theoreti-
important with respect to mandibular trauma, mid- cal tension bands, and resisting displacement when the
facial fractures, and pan-facial fracture sequencing. mandible is loaded. These smaller plates provide semi
rigid fixation, allowing a small degree of movement.
© 2018 Australian Dental Association S37

N Vujcich and D Gebauer
(a) (b)
Fig. 7 (a, b, and c) An axial and reconstructed CT scan of a badly comminuted mandible, wired into rigid IMF (left lateral view) for closed reduction
using a custom occlusal splint. This fracture was not amenable to open plating.
Fig. 8 An example of surgical archbars with interarch elastics.
Larger load bearing plates can provide absolute
rigid fixation of fractures. They require greater surgi-
cal access and may be better suited to more commin-
uted fractures.
The preference of plating technique depends on the
surgeons training and both techniques can provide
ideal outcomes (Fig. 9).
There is some conjecture in the literature around
the management of mandibular condyle, edentulous
and paediatric fractures.
Mandibular condyle fractures often present with
posterior (unilateral fractures) or anterior (bilateral
fractures) open bites. Historically, closed approaches
with arch bars were used due to difficulty accessing
the condyle for plating. Many authors now advocate
open approaches, directly viewing the mandibular
fracture of the condyle through a transfacial
approach, and reduction and fixation with miniplates.
The benefits include immediate return to function,
and anatomical reduction (not achieved with IMF)
providing a reliable means of securing the occlusion.
This comes with the risks of facial nerve injury, sialo-
coeles, and a facial incision (Fig. 10).
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(c)
Endoscopic techniques using mini-cameras have
arisen to view and fix the mandibular condyle without
significant facial incisions. This technique minimises
the risk of facial nerve injury, but is technique-sensi-
tive (Figs 11a and 11b).
Plating materials originally included stainless steel
which was superseded due to corrosion and difficulty
of adaption difficulty. Current systems utilize titanium,
which has better biocompatibility, handling and
strength and is often left permanently in situ. It is non-
ferrous, and does not interfere with MRI protocols.
Drawbacks of metallic fixation includes the possible
need for removal due to loosening or exposure, con-
cealment of underlying fractures on imaging, possible
interference with growth and the query of stress
shielding of bone, with local osteopaenia after fixa-
tion. For these reasons, research into resorbable plat-
ing systems has arisen (Fig. 12).
Resorbable systems are fabricated from polymers,
the properties of which influence the strength and
resorption rate. These systems are generally not fit for
load bearing scenarios. They maintain peak strength
for around 3 months, before gradual hydrolysis over
1–2 years. Although promising, their handling proper-
ties, the presence of foreign body reactions and overall
bulkiness, has precluded widespread support.
MIDDLE THIRD FRACTURES
The middle third of the face consists of many articu-
lated bones, the most commonly fractured being the
maxillae, zygomatic, nasal bones and orbital complex.
Because of their proximity to the oral cavity, nasal
cavity, orbit, and floor of the anterior cranial fossa,
reconstruction is complicated due to limited access
and complex local anatomy.
Treatment goals are to correct the relevant occlusal,
mid-facial, nasal and orbital anatomy whilst monitor-
ing the base of skull for brain injury.
© 2018 Australian Dental Association

(a)
Fig. 9 (a and b) A badly displaced comminuted mandible (with previous fracture and unremovable hardware) repaired with a load bearing rigid plate.
(a)
(b)
Fig. 10 Example of mandibular condyle fractures (a) having undergone
open reduction and (b) internal fixation. These plates are examples of
load sharing techniques. Whilst very strong, they do not provide absolute
rigidity like the larger load bearing plates.
MAXILLA
Proposed at the start of the 1900s, the Le Fort classifi-
cation (I–III) is still the most commonly used in
describing maxillary fractures
The Le Fort I is a horizontal fracture above the
tooth bearing portion of the maxilla. The Le Fort II is
a pyramidal like fracture pattern involving the central
mid-face, and the Le Fort III is craniofacial dysjunc-
tion, with the face detached from skull base. These
fractures may not follow cleanly defined lines, and
can vary between sides. The pathognomonic
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Facial fractures
(b)
radiological sign on CT scan, is fracture of the ptery-
goid plates (Fig. 13).
A higher amount of energy absorption is
required to create a Le Fort fracture than other
facial fractures, with over 80% of these fractures
attributed to motor vehicle accidents.12 Le Fort
fractures have a higher association with other inju-
ries, including cervical spine and head injuries.
Patients may present with a flattened and mobile
midface, anterior open bite malocclusion, and
infraorbital nerve paraesthesia. Significant issues
include profound epistaxis and cerebrospinal fluid
rhinorrhea.
The maxilla may also present as fracture of an iso-
lated maxillary antrum, or in conjunction with a
zygoma or naso-maxillary fracture.
Historical treatment involved wiring either direct
open interosseous wiring of the fragments, or closed
circumosseous wiring, suspending the maxilla from
upper intact facial bones. These techniques had limita-
tions including facial shortening.
Miniplate fixation in the maxilla evolved in the
1980s to provide rigid fixation, immediate function,
and more predictable outcomes. Combination of open
(ORIF) and closed (archbars) approaches are usually
used in Le Fort fractures (Fig. 14).
Maxillary fractures can be complicated by an addi-
tional split palate, which can cause transverse width
issues. Treatment of such fractures utilizes orthog-
nathic principles. Following impressions, the ideal
occlusion is re-established by sectioning stone models
into an ideal occlusion, and an occlusal splint is made.
This is wired to the maxilla during reduction to cor-
rect the transverse width at the time of ORIF. It is
kept in situ for 4–6 weeks post operatively (Figs 15
and 16).
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N Vujcich and D Gebauer

(a) (b)

Fig. 11 (a) An endoscope being placed through a transoral incision to view a condyle fracture. (b) The screwdriver is then placed through a buccal (fa-
cial) stab to fixate the plates which were positioned via an incision inside the mouth.

(a) (b)

Fig. 12 (a and b) Plate exposure in the mandible 10 years after ORIF.

I II III
Fig. 13 ORIF Le Fort I, ORIF Le Fort II and ORIF Le Fort III illustrations of the three levels of the Le Fort midfacial facture patterns.

(a) (b) (c)

Fig. 14 (a) Le Fort I level fracture on 3D CT, (b) coronal views with fractured pterygoid plates, and (c) the repair with open reduction and archbars.

S40 © 2018 Australian Dental Association

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Facial fractures

(a) (b)

Fig. 15 (a) 3D reconstruction CT scan of a split palate, also (b) seen on the axial CT scan views.

(a) ZYGOMA
The zygomatic bone is the most vulnerable and thus
frequently fractured mid-facial bone, due to its promi-
nence in the face. It has 4 effective junctions with the
skull; at the zygomatic arch, the zygomatico-frontal
suture, the orbital rim and finally, at the zygomatico-
maxillary buttress. It is these 4 regions that the treat-
ing surgeon must assess to determine the need for
intervention.
The depressed zygomatic complex causes a relative
flattening on the injured side and therefore facial
asymmetry. This may not be immediately evident due
to facial swelling. Aside from these cosmetic conse-
quences, if the zygomatic arch is severely depressed, it
can restrict mouth opening. This is due to interference
of the coronoid process on the mandible. Finally, the
zygomatic bone makes up the lateral orbital wall and
its injury can influence globe position and mobility.
The 3 dimensional nature of the fractured zygoma
makes them challenging to orientate in theatre. They
are typically repaired either very soon after injury (be-
fore swelling), or in a delayed setting (after swelling).
Surgical options include a lift reduction or ORIF.
Isolated zygomatic arch fractures and non-comminu-
(b) ted zygomatic body fractures may be amenable to
temporal elevation. Sir Harold Gillies was a New
Zealand surgeon who first described the procedure for
repositioning a zygomatic bone using an instrument
via a small incision in the temporal hairline with no
fixation (Figs 17 and 18).
If the zygomatic complex is not stable after eleva-
tion, comminuted or unstable, or part of a pan-facial
injury, it requires fixation. A fracture may receive fix-
ation at one, multiple or all junctions of the zygoma.
Fig. 16 (a) The patient's trauma model (bottom model) is sectioned and
Miniplates and screws used in the midface are smaller
waxed into an ideal arch form and occlusion (top model), (b) with a than for mandibular trauma (Fig. 19).
splint made and wired into the patient.

© 2018 Australian Dental Association S41


N Vujcich and D Gebauer
(a)
Fig. 17 (a) A fractured left zygomatic arch on axial CT. (b) A CT scan 2 years later after the original Gillies lift, after another assault.
(a) (b)
Fig. 18 (a and b) A comminuted right zygomatic fracture with displacement at the arch, infraorbital rim, oral buttress and latral orbital wall.
(c) Post op CT scans shown in comparison.
ORBIT
The orbit is a four-walled pyramid, with a floor, roof,
medial and lateral walls. The incidence of these walls
fracturing and their management is influenced by the
patient age.
In the adult group, the orbital floor is the most fre-
quently fractured wall, due to its thin nature
(<0.5 mm). It is followed by the medial wall whilst
roof fractures are rare.
Orbital wall fractures may result in cosmetic and
functional deformity. The cosmetic issues include
changes in the globe position leading to hypoglobus
(lower eye) or enophthalmus (sunken eye). The func-
tional issues involve entrapment of the extraocular
muscles or adjacent tissues, limiting eye movement
and leading to diplopia (double vision).
Surgical access to the orbital walls is usually made
around or within the eyelids. The orbital roof is usu-
ally accessed via a brow incision or intracranially via
a coronal flap and craniotomy performed neurosurgi-
cally.
Due to the thin nature of orbital walls, reduction
and fixation is not feasible. After releasing tissues
from the fracture defect, the wall is instead replaced
with autogenous grafts (calvarium), xenografts
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(b)
(c)
(resorbable collagen) or alloplasts (polyethylene, tita-
nium mesh). Such materials are anatomically fash-
ioned to the wall and secured to the orbital rims
(Figs 20 and 21).
Timing to repair fractured orbits typically follows a
period of observation (1–2 weeks) before any opera-
tive decisions are made.
Three-dimensional imaging has revolutionised orbi-
tal trauma management over the last 10–20 years.
After computed tomography (CT) was introduced in
the early 1980s, continued advances have included the
introduction of intraoperative CT or cone beam imag-
ing, enabling the surgeon to identify their reconstruc-
tion in theatre at the time. This minimises the risk of
poorly positioned reconstructions and complications
including blindness.
CT can also be applied intraoperatively with real
time navigation, permitting image guided surgery. The
intraoperative position of the surgeon’s instruments
can be displayed on the CT and is useful in commin-
uted fractures or pan-facial trauma, assisting anatomi-
cal reduction.
From preoperative CT, computer assisted design
(CAD) and computer assisted manufacture (CAM) of
models and plates have also evolved. Many larger ter-
tiary hospitals now have bioengineering departments
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Facial fractures

(a) (b) (c)

Fig. 19 (a) Coronal and (b) Sagittal (c) CT of right orbital floor blowout repaired with titanium mesh.

(a) (b)

Fig. 20 (a and b) Axial CT of right medial wall and orbital floor repaired with titanium mesh.

(a) (b) (c)

Fig. 21 (a) Coronal CT of right medial wall and floor fracture. (b) 3D orbital model from CT “mirrored” from normal left side. (c) Pre bent titanium
mesh placed over the ‘fractured’ model to confirm anatomy before surgery.

capable of printing three dimensional stereolitho-
graphic biomodels from the CT. These may be used for
• Surgical planning, including assessing complexity
and access
• Creating a mirrored model of the non-fractured
side, enabling one to bend up a plate on the normal
side and apply to the fractured side
• Creating a custom titanium plate to fit the defect
exactly
Such technology has also been utilized in orthog-
nathic surgery and is becoming routine throughout
Australia. The main difficulty in trauma is the time it
may require to fabricate such plates and models in
urgent cases (Fig. 22).

© 2018 Australian Dental Association S43


N Vujcich and D Gebauer
Fig. 22 An example of bilateral NOE fractures.
CENTRAL COMPONENT
Naso orbital ethmoidal complex (NOE)
This central component consists of the maxillary, nasal,
frontal, lacrimal, and ethmoid bones. NOE fractures
are not the same as external nasal bone fractures, which
usually require a much simpler closed reduction.
One complex aspect of NOE fractures is whether
the medial canthal tendon (MCT), a ligament which
supports the eyelids, is displaced. Displacement of
the MCT leads to telecanthus, a lateralising of the
medial aspect of the eyes, resulting in a broad nasal
bridge.
(a) (b)
Fig. 23 (a) 3D CT reconstruction (b) coronal and (c) axial views of an anterior table frontal sinus fracture.
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Surgical correction of NOE fractures depends on
bony displacement, and whether the MCT has been
displaced. Measurements of the intercanthal distance
will vary with age, sex and race. If the MCT has led
to telecanthus, one must determine if repositioning
the bones will correct the issue, or whether explo-
ration, identification and securing of the MCT is
required. This requires a significantly more compli-
cated procedure, usually requiring a coronal flap
(Fig. 23).
UPPER THIRD TRAUMA
Frontal bone
Frontal bone trauma is infrequent due to the signifi-
cant strength of this bone. Further, the ‘forehead’ is
often protected by helmets in sporting and motor acci-
dents, and is less likely to be targeted in assaults.
Trauma to this site typically involves the frontal
sinus, with fracture classifications based on involve-
ment of the two walls of the frontal sinus that are the
anterior and posterior tables (Figs 24 and 25).
Decisions to operate are influenced by the presence
of a cosmetic defect (i.e. depressed bone) or obstruc-
tion of the drainage apparatus (nasofrontal duct).
Involvement of the anterior cranial fossa and dural
tears may require a joint approach with neurosurgery.
Unless a laceration has led to an open fracture, sur-
gery is usually delayed from 1 to 2 weeks to permit
swelling to subside to accurately assess the cosmetic
defect.
A coronal flap is folded over the brow to provide
the necessary access and fractured segments are
anatomically fixed using microplates or if markedly
comminuted, mesh may be used.
Trauma and improper reconstruction of the frontal
sinus may lead to sinusitis, mucopyocoeles, meningitis
and brain abscesses.
(c)
© 2018 Australian Dental Association

Fig. 24 A coronal flap raised to repair the frontal fracture as in Fig. 18.
Note the face is on the upper aspect of the figure (hidden under the
scalp), with the occiput on the bottom aspect of the figure.
Raising a coronal flap itself has complications
including scarring, facial nerve injury, temporal
depression and paraesthesia of the frontal region.
This has led to an endoscopic approach to repair
anterior table fractures. This is done in a similar
fashion to cosmetic brow lifts and is suited to large
fragment anterior table fractures, not involving the
posterior table nor the nasofrontal duct. Incisions
are placed in the hairline, and subperiosteal dissec-
tion identifies the fracture using the endoscopic
(a) (b)
(c)
Fig. 25 (a) Panfacial trauma (b) in this case a split palate first (using custom splint, (c) usually begins with managing occlusion (d) before plating and
reconstruction of the bones.
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Facial fractures
camera. The fracture may be reduced and not
require fixation, or mesh can be placed over the
defect. It is secured using screws via separate tran-
scutaneous stabs over the fracture.
PANFACIAL FRACTURES
Panfacial fractures denote simultaneous fractures of
each level of the facial thirds. Such fractures imply a
high velocity and force, and are more likely to be
associated with injuries of the head and spine
(Fig. 26).
Often without reliable landmarks to begin recon-
struction, pan-facial trauma requires a logical and
ordered approach to achieve an ideal outcome. This
process is referred to as sequencing.
The sequence of ‘bottom to top and outside in’ is a
well-established approach. Restoring the mandible
and occlusion first (‘bottom’), ensures the vertical
height of the face is corrected. The occlusion is there-
fore the basis for reconstructing the entire face. The
maxilla is then wired into occlusion but not fixed.
The zygomatic complex (‘outside’) is then repaired
ensuring the width of the face is corrected, before cor-
recting the central component (NOE, ‘in’), and finally
plating the maxilla.
Similar to an orthognathic surgical case, these
patients are observed during their recovery with the
use of intermaxillary elastics to achieve the operative
occlusion.
(d)
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N Vujcich and D Gebauer

(a) (b)

Fig. 26 (a) A bucket handle edentulous fracture, with the anterior mandible “pulled” down due to the pull of the suprahyoid musculature. (b) After tran-
scervical plating.

A pan-facial trauma commences with managing the submandibular approach with a rigid reconstruction
occlusion and split palate first, before plating and plate tends to be the preferred management option
reconstruction of the midface and frontal bones. (Fig. 27).

PAEDIATRIC PATIENTS MIDFACE

Paediatric fractures are discussed elsewhere in this
supplement.13,14
GERIATRIC PATIENT
Mandible
The edentulous fracture is difficult to manage as it is
associated with old age and often smoking, both risk
factors for treatment failure. Elderly patients have
decreased osteogenesis and limited blood supply.
Atrophic edentulous mandibles have little room to place
fixation, due to anatomical relationship to the mental
foramen and denture bearing areas limiting plate loca-
tions. Historically, circumosseous wiring or wiring of
a splint to the mandible was used to assist reduc-
tion, without lifting the periosteum in an open tech-
nique. Open reduction and internal fixation via a
Atrophy in the edentulous maxilla, may make plating
impractical due to very thin, often comminuted bone,
which does not retain screws. Closed reduction may
be appropriate in this case. Historically, wiring the
patient into a bimaxillary or Gunning splint was used.
In isolated mid-facial trauma, securing the maxilla to
the undamaged mandible could maintain the correct
anteroposterior position of the maxilla. If both jaws
were fractured and the mandible not amenable to
rigid fixation, the bimaxillary splint could be fixed to
an external (skull) frame to maintain horizontal and
vertical positions of the jaws for 6–8 weeks. Plating
provides immediate function and is preferred, but
plates must be kept away from the denture-bearing
surfaces to avoid future impingements.
An atrophic mid-facial fracture patient may have
cleats added to his upper denture that is then ‘screwed’
on to the maxilla, and then wired into intermaxillary

(a) (b) (c)

Fig. 27 (a and b) An edentulous midfacial facture patient where wiring of his occlusion is not possible. Limited plating of the right zygoma, floor of orbit
and the left molar buttress. (c) Cleats are added to his upper denture which is then “screwed” to the maxilla enabling intermaxilliary fixation and correct
positioning of the maxilla. The maxilla is then conventionally opened and plated.

S46 © 2018 Australian Dental Association


fixation. This technique enables the correct AP position
of the maxilla to be established. The maxilla is then
conventionally opened and plated.
CONCLUSION
Facial trauma remains a major source of injury in all
parts of the world. Its management involves many dis-
ciplines in the hospital setting, but knowledge of
occlusion, the masticatory apparatus and anatomy
that is part of the dental curriculum is important for
the best outcomes. Oral & Maxillofacial surgeons are
typically involved in the management of this trauma,
and many of the patients will subsequently require
further dental treatment following reduction of frac-
tures. Hence, an understanding of the management of
facial trauma and its sequelae is important for the
general dental practitioner.
ACKNOWLEDGEMENT
Thanks are given to the Royal Perth Hospital Medical
Illustrations team for their kind assistance in prepar-
ing diagrams for this article.
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Address for correspondence:
Nathan Vujcich
Royal Perth Hospital
197 Wellington St
Perth
WA 6000
Australia
Email: nathan_vujcich@hotmail.com
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