The causes of facial traumas are in order of frequency accidents of the road (The traumatology road thanks to prevention and information fortunately appears to be decreasing), sports injuries (eg football, rugby, tennis, etc.), accidental falls , beatings, gunshot wounds to the face etc., sports injuries (eg rugby, tennis, soccer etc.), domestic and non-domestic falls, beatings. Traumatic lesions of the facial mass can be isolated or associated with lesions of the neurocranium and / or other districts. If involved different sectors of the organism as internal organs, skeletal structures in the various body districts, or if the patient is in a coma state, maxillofacial surgical treatment should be postponed. All the anatomical sectors can be involved: bones of the cranial vault, orbit, nose, cheekbone, upper jaw and mandible. These fractures may present themselves as isolated or combined up to the more complex picture of “facial fracture”.
Interested anatomical sectors:
Orbital floor fractures
Orbital floor fractures are related to the bone disruption of the orbital floor alone. The etiology of these fractures recognizes a traumatic agent limited to the region of the ocular globe. In fact, a trauma that is directly exercised on the ocular globe transmits its energy, through it, to the walls of the orbital cavity; among these, the most fragile is the floor of the orbit, which with relative frequency can fracture and allow the herniation of the orbitary contents in the maxillary sinus. Diplopia (double vision) and anesthesia of the anterior region of the cheek and upper lip are present, the objective ones are the enophthalmos (the receding eye: the enophthalmos is a consequence of the prolapse of the orbitary contents in the maxillary sinus). The treatment of the orbital floor fractures is exclusively surgical and must be performed within fifteen days of the trauma.
Fractures of the malar bone
They are consequent to localized traumas and of relative intensity, as for example can occur in sports activities, aggressions. In the case of more intense trauma, malar fractures are associated with major traumatic injuries, such as fractures of the maxilla or cranial fractures. Diagnosing a malarial fracture is not always easy due to the soft tissue edema of the periorbital region that frequently accompanies such lesions can prevent a precise objective examination. Diplopia, often present in fractures of the malar, may not be manifested immediately after the trauma. Variable as intensity is subclassal hemorrhage. Edema and bruising are present and mainly affect the region. It is also possible to observe an enophthalmos, following the prolapse in the maxillary sinus of the orbital content; in this case the two ocular globes are no longer on the interpupillary axis. For these reasons in the suspicion of a fracture of the malar, an accurate radiographic assessment must always be performed. Surgery should be performed within the first two weeks of the trauma and to prevent the consolidation of the bone fragments and especially the fibrosis of the extrinsic muscles of the eye
Fractures of the upper jaw
Fractures of the upper jaw are less frequent than those of the jaw and the malar. The fractures of the upper jaw are obtained only by traumas of particular intensity and which are mainly exercised in the anteroposterior sense. In practice, the traumatic energy transmitted from the maxilla is depleted in the fracture rut with safeguard of the cranial regions.
Types of fractures
The LeFort I fracture occurs when the traumatic impact is exerted below the anterior nasal spine; in this case the fracture line runs horizontally from the anterior nasal spine to the inferior edge of the pyriform opening, and ends at the maxillary tuberosity.
The Le Fort II fracture occurs due to more violent trauma impacts in a direction exerted in anteroposterior and top to bottom directions. In this case the fracture line starts from the fronto-nasal suture and goes down to finish posteriorly in correspondence of the maxillary tuberosity.
The Le Fort III fracture, or craniofacial disjunction, occurs for even more violent impacts, exercised in an anteroposterior and top down directions. Also in this fracture the bone interruption line starts from the fronto-nasal suture, but it extends horizontally inside the orbital cavity along the papyrus lamina of the ethmoid, the inferior orbital fissure, the great sphenoid wing, the frontal suture, the Temporozygomatic suture and ends at the highest part of the maxillary tuberosity. Intermascular disjunction: The fracture gap in this case follows a midline that starts from the anterior nasal spine along the intermaxillary line to reach the posterior nasal spine.
Consists of a monolateral Le Fort I fracture
It is characterized by a horizontal line extending from one premolar region to the other associated with a fracture of the interincisive region.
Extends from one canine region to another
Fracture of Basserau
it is a fracture that extends from one side incisor to the other. In consideration of the local and general conditions it is not always possible to interrogate a patient who has reported a fracture of the upper jaw and therefore the diagnosis will have to be oriented mainly by the objective examination and by radiographic examinations.The most constant symptom in the fractures of the maxilla is the so-called traumatic open bite. This definition refers to the loss of normal dental occlusion, obviously extended to the district affected by the fracture: Pain is a constant symptom Epistaxis or nasal bleeding is an almost constant symptom but is of importance only in high fractures. Nasal liquorrea may be present if an ethmoidal fracture is associated with the fracture of the upper jaw. The elongation and flattening of the face with depression of the nasal pyramid and the zygomatic regions, together with the deformation of the orbital region, are characteristic of the Le Fort II and III fractures. Edema and subcutaneous ecchymoses, sometimes extremely intense, can affect the upper and lower palpebral region and the entire facial region. The submucosal endoral ecchymoses occur rapidly inversely proportional to the severity of the fracture. Diplopia is mainly found in Le Fort II fractures due to the involvement of the orbital floor
Fractures of the jaw
Fractures of the jaw can be classified according to the site. In order, the locations involved are those of the condyle, of the body, of the angle, of the parasitic region; the branches where mandibular fractures are less frequently found are the branch and the coronoid apophysis. The mandibular condyle region is the weakest in the entire jaw and in particular the point of greatest weakness is the condyle neck. This responds to the purpose of defending the average cranial fossa from the traumatic energy that would be transmitted to it by the mandibular condyle. The first element that is observed is the patient’s attitude to keep the mouth half-open, leaving the saliva free to escape from the oral rhyme (sialorrhea). This is determined both by the patient’s desire to avoid any movement of swallowing, which would awaken pain, or by a real increase in salivary secretion by stimulation of the salivary glands. Edema and bruising or, in severe cases, more serious wounds and gingival lacerations are easily detectable at the site of the traumatic impact. The presence of cutaneous or intraoral bleeding can be particularly important if the patient is not able to eliminate the blood material from the oral cavity with the risk of inhalation in the tracheobronchial tree. A characteristic element in the vast majority of cases of mandibular fracture is the variation of the dental occlusion, but it should always be remembered that it can be found in the presence of a patient carrying a dental malocclusion preceding the trauma. Subsequently, the stability of all the dental elements present is evaluated. Occlusal alteration detectable after a mandibular fracture can also be indicative of the fracture site. For a bicondylar fracture, it will be common to observe an open anterior bite by going up the two mandibular branches. In the case of fractures of the angle, of the body or of the symphyseal region, it will be possible to find the loss of the dental articulation starting from the fracture site. For a fracture of a mandibular condyle, a contralateral traumatic open bite and a homolateral cross-bite to the lesion will be present. For a bicondylar fracture, it will be common to observe an open anterior bite by going up the two mandibular branches. In the case of fractures of the angle, of the body or of the symphyseal region, it will be possible to find the loss of the dental articulation starting from the fracture site. However, the diagnosis of certainty to identify both the site and the number of fractures and the subdivision of the fracturing abutments is entrusted to radiological examination. The treatment of mandibular fractures, as always, involves reduction and restraint.
Fractures of the condyle of the jaw
The fractures of the mandibular condyles very heavily affect the homeostasis of the stomatognathic system, altering the physiological relationship between the condyle and the articular fossa. This type of fracture can be intracapsular or extracapsular. In intercapsulated fractures there is a greater risk of ankylosis of the temporomandibular joint. Instead of extracapsular fractures, the functional and structural mandibular alterations related to the displacement of a large skeletal fragment are more evident. The contraction of the external pterygoid muscle in these cases causes a medial and anterior dislocation of the fractured condyle. If the stump does not interfere with mandibular normomotility, clinical pictures can be objectivable due to structural, occlusal and functional alterations, determined by the monochondyl or bicondylar nature of the fracture. In the case of bicondylar fractures, the displacement of the articular heads may result in a reduction in the posterior vertical height of the mandibular branches. This deficit is objectively occlusal with an open anterior bite, while the decrease in sagittal dimension results in a mandibular retrusion. The treatment of condylar fractures is, unlike the other fractures of the jaw, usually conservative. Summing up, in the case of polytrauma, the expertise of several specialists is needed: Orthopedist, Surgeon General, Ophthalmologist, Neurosurgeon, Reanimator, Pediatrician, Otorhinolaryngologist. Outcomes of trauma: The outcomes of inadequately treated traumas make necessary surgical interventions for the correction of the soft tissue or bone sites alterations that may involve bone grafts taken from the patient or of synthesis. Otherwise fractures of the face should be considered urgency and treated within 7-14 days. The role of the team with the skills of more specialists is always important in order to guarantee a rapid morphological and functional recovery.
Outcomes of trauma
The outcomes of inadequately treated traumas make necessary surgical interventions for the correction of the soft tissue or bone sites alterations that may involve bone grafts taken from the patient or of synthesis. Otherwise fractures of the face should be considered urgency and treated within 7-14 days. The role of the team with the skills of more specialists is always important in order to guarantee a rapid morphological and functional recovery.