Facial fractures

Facial fractures involve the bones of the craniomaxillofacial skeleton and frequently occur following falls, accidents or interpersonal violence. The facial skeleton serves many important functions within a small space, such as protection of the brain and eyes, structural support for the upper airway, providing a stable platform for which chewing occurs and gives definition and structure to the face. The face is also important in one’s identity. Facial fractures may cause significant functional and aesthetic morbidity if left untreated.

Anatomy of the facial skeleton

The facial skeleton comprises of thin and flat membranous bones (e.g. the skull, upper and mid face) as well as thick, strong cortical bone (the lower jaw). The geometry of the facial bones is complex and a good appreciation of the anatomy in three dimensions is required for optimal reduction of the fracture fragments.

How does it manifest?

The clinical presentation of facial fractures is varied and depends on the affected part. In general, facial fractures present with pain, swelling, bruising, contour deformities and/or open facial wounds. 

Fractures of the upper face may manifest as persistent fluid leak through the nose or ears and/or broadening of the distance between the eyes. Fractures of the midface may present with double vision, restriction in eye movement, a sunken eye, nasal obstruction, and pain when chewing. Fractures of the lower face may present with misalignment of the jaws and teeth, difficulty with opening or closing the jaw fully, as well as deviation of the chin.

Why do facial fractures require special attention?

Facial fractures involve many functional units within a small anatomical space. Accurate reduction of the displaced bone fragments and fixation with implants are required for functional restoration. For example, fractures of the jaw(s) where even a 1 mm misalignment exists may result in improper bite and be functionally significant. Furthermore, the face has an important aesthetic, psychological and social function and fracture fixation surgery needs to be performed through incisions that are easily concealed for optimal postoperative outcome. This ensures expedient functional recovery and social reintegration.

treatment

Facial fracture surgery utilizes well-concealed incisions that still permit adequate fracture site exposure, accurate bony fragment reduction and stabilization. The ideal timing for facial fracture surgery is within 2 weeks of the injury if the medical condition permits. Optimal results are attained by careful preoperative planning and precise intraoperative execution by experienced plastic surgeons. Private hospitals give individuals the best access to specialist-level care and operating facilities where required.

A CT scan of the face is required prior to surgery to ascertain the geometry and complexity of the facial fractures. Furthermore, fractures of the jaws may sometimes require dental X-rays to assess the alignment of the jaws and teeth.

Facial fracture fixation surgery is usually performed under a short general anesthesia and may require an overnight hospital stay. Fractures of the upper face are often accessed through incisions in the scalp behind the hairline for optimal scar concealment. Fractures of the midface are exposed through incisions on the inner side of the eyelids and/or the inside of the upper gum. Fractures of the lower face may be approached through skin incisions behind the lower jaw or inside the mouth depending on the fracture characteristics. Wound irrigation and removal of infected foreign bodies are performed and the fractures are exposed. The fractures are reduced to their original position and fixed in place with implants. In adults, titanium implants are often used and these may be permanently left in individuals without long-term side effects. In children, resorbable implants are sometimes used. These implants gradually dissolve over 12 to 18 months hence permitting normal bone growth. Fractures involving the jaws and/or realignment of the teeth may require the use of special braces (arch bars) that help to realign the teeth. These braces are temporary and are removed after a few weeks.

Facial fracture fixation is a delicate art as there are many critical structures within the face. Gentle and meticulous technique is required to ensure precise fracture reduction and avoidance of injury to adjacent critical structures. Wound closure is also performed carefully to deliver a scar that is inconspicuous when healed.

Stitches are removed on the 7th postoperative day. Scar management will be commenced one week postoperative and continued for one to two months for optimal scar outcome. Fractures involving the jaws may temporarily require special diet consisting of finely-blended food to minimize chewing until the fracture is healed.

Facial Fractures Surgery in Singapore: Causes, Types, Treatment & What You Must Know