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| IMC Wiki | Comminuted fractures

Comminuted fractures

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Definition

Central midface fractures include fractures of the Le Fort I and II planes, as well as midface comminuted fractures and fractures of the nasal bone
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Examinations

Clinical examinations

Inspection

Symptoms:
  • Bilateral periocular hematoma
  • Subconjunctival hemorrhage
  • Extraoral and intraoral swelling
  • Open bite
  • Elongated middle face
Palpation
  • Infraorbital step formation
  • Nasal root
  • Zygomatic buttress
  • Abnormal mobility of the middle face
Function tests
  • Sensibilität V 2
  • Ocular motility
  • Diplopia
  • Facial nerve
  • Olfactory nerve
  • Mouth opening
  • Mandibular protrusion/laterotrusion
  • Glucose test because of CSF leakage

Radiographic examinations

Basic examinations
  • Paranasal sinuses
  • OPG
  • Lateral skull
  • Preferably side-view teleradiograph, CT
Further examinations

3 dimensional reconstruction, if useful #pic# , #pic#

Indications for therapy

  • Profuse bleeding from mouth and nose
  • Dislocated fracture
  • Functional deficits
  • Facial deformity
  • CSF leakage

Conservative therapy

Craniofacial suspension and intermaxillary fixation, only as an emergency measure in the presence of profuse bleeding if definitive management is precluded because of systemic problems, together with Belloque-tamponade.

Surgical treatment

Intraoral access

Two 2.0 (or 1.5) miniplates at the infraorbital border, if indicated bilaterally at the anterior and posterior buttresses for stabilization following repositioning. Simpler if combined with intermaxillary fixation.
1.5 miniplates or 1.0 microplates are suitable to fixate multiple small fragments.
If indicated, reconstruction of the facial maxillary sinus using PDS film to prevent a soft-tissue prolapse into the maxillary sinus

Extraoral access

Additionally in cases of substantial dorsal displacement of the nasal bone, using either coronal or paranasal incision

Additional measures

  • Pain therapy
  • Gastric probing, if indicated
  • Antibiotic therapy, if required

Risk factors

  • Soft-tissue defect
  • Degree of fracture dislocation
  • Number of fractures (multiple fractures, splinter fractures)
  • Contaminated wound
  • Impaired blood supply to the fragments and the covering soft-tissue structures
  • Pretraumatic occlusal interference
  • Tooth fractures
  • Tooth in fracture line
  • Presence of infection
  • Additional maxillofacial trauma
  • Delay until fracture management
  • History of keloid or hypertrophic scar formation

Complications

  • Infection of the maxillary sinus
  • Occlusal deficits
  • Loss of pulp vitality
  • Pseudarthrosis
  • Skeletal deformity
  • Tooth loss
  • Oroantral fistula
  • CSF fistula
  • Anosmia
  • Enophthalmia