ZYGOMATIC AND NASAL BONES DAMAGES IN PEACETIME AND IN EXTREME CONDITIONS: CONDITIONS, FREQUENCY, CLINIC COURSE, DIAGNOSIS AND TREATMENT. TEMPORARY IMMOBILIZATION WHEN FACIAL BONES OF THE SKULL ARE DAMAGED: REQUIREMENTS, TYPES, ADVANTAGES AND DISADVANTAGES. PERMANENT (MEDICAL) IMMOBILIZATION OF THE JAWS WITH DENTAL TIRES.

FACIAL FRACTURES

Facial fractures occur for a variety of reasons related to sports participation: contact between players (eg, a head, fist, elbow); contact with equipment (eg, balls, pucks, handlebars); or contact with the environment, obstacles, or a playing surface (eg, wrestling mat, gymnastic equipment, goalposts, trees). Direct body contact accounts for the majority of sports-related injuries, and the most commonly associated soft tissue injuries were found in the head and neck region.

Although most sports-related facial injuries are minor, the potential for serious damage exists. A physician examining these injuries must rapidly assess the patient in a consistent and methodical manner, allowing for prompt diagnosis and appropriate treatment, while considering the physical demands of the sport, as well as the athlete’s return to play.

Facial fractures may be associated with head and cervical spine injuries. A review by Boden et al of catastrophic injuries associated with high school and college baseball demonstrated 1.95 direct catastrophic injuries annually, including severe head injuries, cervical injuries, and associated facial fractures.

Fractures of the facial bones require a significant amount of force. The physician must take into account the mechanism of the injury as well as the physical examination findings when assessing the patient.

Forces that are required to produce a fracture of the facial bones are as follows:

• Nasal fracture – 30 g
• Zygoma fractures – 50 g
• Mandibular (angle) fractures – 70 g
• Frontal region fractures – 80 g
• Maxillary (midline) fractures – 100 g
• Mandibular (midline) fractures – 100 g
• Supraorbital rim fractures – 200 g

Epidemiology

Frequency

United States

In 1977, Schulz noted that athletic injuries account for 11% of all facial fractures and that facial injuries occur in 2% of all athletes. More recently, Reehal noted that facial fractures accounted for 4-18% of all sports injuries. A review by Romeo of facial fractures sustained by athletes during sports participatiooted that sporting activities account for 3-29% of facial injuries and 10-42% of all facial fractures. Tanaka and colleagues showed that 10.4% of all maxillofacial fractures are related to sports.

In another report, Laskin stated that 250,000 individuals, many of whom were children, experience facial trauma while engaged in athletic activities.^[8] The review by Hwang et al demonstrated that athletes aged 11-20 years were the population that accounted for most (40.3%) sports-related facial bone fractures.^[1] Additionally, it is estimated more than 100,000 sport-related injuries could be prevented by wearing appropriate head and face protection.^[8]

Retrospective analysis demonstrated a significant male predominance (13.75:1) among athletes who sustained sports-related facial bone fractures.^[1] The sports most commonly associated with facial fractures were soccer (38.1%), baseball (16.1%), basketball (12.7%), martial arts (6.4%), and skiing/snowboarding (4.7%).^[1]

Nearly 75% of facial fractures occur in the mandible, zygoma, and nose.^[9] Sports participation is the most common cause of mandibular fractures (31.5%), followed closely by motor vehicle accidents (27.2%). A study of facial fractures sustained during recreational baseball and softball demonstrated that the zygoma or zygomatic arch was the most common fracture subtype, followed by temporoparietal skull fractures and orbital blow-out fractures.^[10] A number of studies in the medical literature, however, indicate that the nasal bones are the most commonly fractured bones in the face, but because many of these patients do not seek medical treatment or the injuries are managed in the outpatient setting, the statistics may not reflect this trend.^[2] It is likely that the nasal bones are more commonly fractured because of the lesser degree of force that is required to fracture the bone.^[11]

Fractures of the orbit occur more commonly in young adult and adolescent males: the mean age for adult males is 32 years; the mean age for children, 12.5 years, and the majority of orbital fractures occur in boys. In addition to sports-related injuries, injuries sustained in motor vehicle collisions, assaults, and occupational injuries account for the majority of orbital fractures.

Functional Anatomy

Frontal sinus: Both the anterior and posterior wall may be damaged. Because the posterior wall is adjacent to the dura mater, damage in this region could result in central nervous system (CNS) complications such as a cerebrospinal fluid (CSF) leak or meningitis.

Orbital: The bony orbit (see image below) is composed of 7 bones of varying thickness. The frontal bone forms the supraorbital rim and orbital roof. The medial surface consists of the ethmoid, whereas the greater wing of the sphenoid and the zygoma create the lateral margin. Inferiorly, the floor and infraorbital rim are formed by the zygoma and maxilla. This portion is very thin; therefore, it is the most common site of fracture within the orbit. Fracture of the orbital floor, also known as a blow-out fracture, can result in entrapment of the inferior rectus muscle, limiting upward gaze.

The bony walls of the orbit.

The most common fracture to the orbital rim involves the orbital zygomatic region; this fracture, which typically results from a high-impact blow to the lateral orbit, often results in a fracture to the orbital floor as well.^[12]

Nasal: The nose is the most prominent feature of the facial structures and is the most commonly fractured of all facial bones.^[5] The upper third of the nose is supported by the paired nasal bones and the frontal process of the maxilla, whereas the lower two thirds of the nose are maintained by cartilaginous structures.^[11] A more serious injury, a nasoorbitoethmoid fracture, occurs with trauma to the bridge of the nose. This injury involves extension into the frontal and maxillary bones and can result in disruption of the cribriform plate with concomitant CSF rhinorrhea.

Zygomatic/zygomaticomaxillary complex: The zygoma, like the nasal bones, is a prominent facial bone and, therefore, is prone to injury. Commonly, a breakage in this area involves a central depression with fractures at both ends. The central fragment may impinge upon the temporalis muscles, resulting in trismus. Because of its thickness, isolated fractures of the zygoma are rare, often involving extension into the thinner bones of the orbit or maxilla, otherwise known as zygomaticomaxillary (ie, tetrapod or tripod fractures).

Maxillary (Le Fort): Rene Le Fort first described fractures of the maxillary region in the 1900s (see image below). Classification of maxillary fractures is based on the most superior level of the fracture site.

Le Fort fractures.

Le Fort I injuries involve a transverse fracture of the maxilla above the level of the root apices and through or below the level of the nose.

Le Fort II injuries traverse the nose, infraorbital rim, and orbital floor and then proceed laterally through the lateral buttress and posteriorly through the pterygomaxillary buttress.

Le Fort III injuries, also known as craniofacial dysjunction, result from motor vehicle or motorcycle accidents and are the result of the mid face being separated from the cranial base.

Mandibular: Fractures of the mandible (see image below) can involve the symphysis, body, angle, ramus, condyle, and subcondyle regions. Fractures of the mandibular body, condyle, and angle occur with nearly equal frequency, followed by fractures of the ramus and coronoid process.^[5] Generally, motor vehicle accidents result in fractures of the condylar and symphysis regions because the force is directed against the chin, whereas injuries from boxing are more likely to be located in the mandibular angle, as the result of a right-handed punch. Over 50% of mandible fractures are multiple; the presence of one mandibular fracture mandates evaluation for additional fractures, perhaps contralateral to the affected side.

 

Mandibular fractures.

Sport-Specific Biomechanics

In general, facial fractures in athletic activities result from direct trauma over a small surface area. Sports that present a higher risk are those that involve small objects that are propelled at high velocity, such as baseball, softball, hockey, lacrosse, jai alai, and racquetball. Athletes who participate in sports with high levels of physical contact and collision are at risk as well; these sports include football, basketball, rugby, hockey, martial arts, and boxing.

Many of these sports have safety measures to limit the incidence of facial injuries, and attention should be paid to the rules of use. Racquetball players should always play with goggles to limit orbital blow-out injuries. In hockey, face guards with helmets are required in lower levels of play but not at the professional level. High school football players should all have mouthpieces fitted for them, and mouthpieces should be worn in place before every play.

An athlete’s vision should be checked as part of a preparticipation physical examination yearly. Visual risk factors include a corrected visual acuity of 20/40 or less or spectacle correction greater than 6 diopters (D). These athletes need an ophthalmologist’s evaluation before competing in sports.

A one-eyed athlete is defined as one with a visual acuity in one eye of 20/200 or less. These athletes may be able to participate with proper protection, and an ophthalmologist’s evaluation is essential.

History

Injuries to the head and neck frequently involve the airway or major vessels. The initial assessment, therefore, should begin with airway, breathing, and circulation (ABCs).

First, protect the airway by removing any foreign bodies and by placing the patient in a sitting position or on the side to facilitate expectoration of blood. If severe maxillofacial trauma is present, the athlete is at risk for airway obstruction because of a lack of tongue support from the mandibular structures. Consider placing an oral airway or, if necessary, performing endotracheal intubation. Second, assess the athlete for breathing and circulation. Lastly, evaluate the cervical spine. In the literature, cervical spine injuries have been shown to be present in 1-4% of patients with facial fractures. Because of the force necessary to fracture the facial bones, one should consider the cervical spine is fractured until proven otherwise, and cervical spine immobilization should be maintained.

Following initial stabilization of the ABCs, the examiner should proceed with the history and physical examination. The patient should be questioned regarding the mechanism of the injury, the presence of numbness or pain over any parts of the face, and visual disturbances. Specific questions regarding specific fractures of the face include the following:

• Frontal sinus fractures
• This injury results from a severe blow to the frontal or supraorbital region, which can result in fracture of the anterior and/or posterior wall.
• The patient may report numbness in the distribution of the supraorbital nerve.
• Orbital fractures
• Blow-out fractures generally occur with blunt trauma to the orbit with an object larger in diameter than the orbital entrance (eg, baseball, fist).
• A blow-in fracture results when a fracture fragment is displaced into the orbit, resulting in decreased orbital volume and impingement on orbital soft tissues, such as from high-velocity trauma (eg, falls from a height, severe blows to the orbit with a weapon).
• Patients may report diplopia.
• Nasal fractures: With the exception of nasoorbitoethmoid fractures, nasal fractures are typically diagnosed based upon the history and physical examination findings. Often a history of a blow to the nose and epistaxis is present.
• Zygomatic/zygomaticomaxillary complex fractures
• The athlete may report a forceful blow to the cheek with a bat or an elbow.
• Fractures of the zygomaticomaxillary complex may result in trismus or numbness in the distribution of the infraorbital nerve.
• Maxillary (Le Fort) fractures (see image below)

  Le Fort fractures.

• Le Fort I is a transverse fracture of the maxilla just above the teeth.
• Le Fort II is a pyramid fracture of the maxilla, the apex of which is above the bridge of the nose and which extends laterally and inferiorly through the infraorbital rims.
• Le Fort III is a complete craniofacial disruption and involves fractures of the zygoma, infraorbital rims, and maxilla. This injury requires a significant causative force and, therefore, is relatively uncommon in athletes; however, it may be observed with an injury from a hockey puck, baseball pitch, or baseball bat. Athletes with this injury may report diplopia, malocclusion, or numbness.

  Mandibular fractures (see image below): The patient may report malocclusion and jaw pain or numbness.

 

Mandibular fractures.

Physical

The physical examination should be performed in a methodic, sequential manner. One approach organizes the examination from inside out and bottom up and involves inspection, palpation, and sensory and motor testing.

Examine the oral pharynx for lacerations, tooth fragments, or other foreign bodies. Look closely at the dentition to assess for tooth avulsion or tooth mobility, which can indicate underlying skeletal fractures. Then, carefully evaluate each region of the face, including the mandibular, maxillary, zygomal, nasal, orbital, and frontal bones.

Any areas of obvious trauma, such as a laceration, swelling, depression, or ecchymosis, should be examined more closely. Evaluate the mandible for trismus and mobility. The mid face should be assessed for stability and depression of the bones.

After inspection and palpation, test the motor and sensory function of the facial nerves and muscles. Hypoesthesia in the region of the infraorbital or supraorbital nerve may suggest an orbital fracture, whereas decreased sensation of the chin may result from inferior alveolar nerve compression from a mandibular fracture. Trismus, spasm of the muscles of the jaw, which results in the inability to open and close the mouth, can be secondary to mandibular or zygomatic fractures.

Any fluid from the nose should be inspected for possible CSF rhinorrhea, indicating disruption of the anterior cranial base. Lastly, examine the eyes, including the pupils, extraocular movements, visual acuity, and, if clinically indicated, intraocular pressure and corneal fluorescein. Findings for specific fractures include the following:

• Frontal sinus fractures
• Look for a visible or palpable depression in the region of the frontal sinus.
• A fracture of the posterior wall implies fracture of the dura and may be manifested by CNS depression, CSF rhinorrhea, or visible brain matter.
• Orbital fractures: Patients with orbital fractures may present with ecchymosis and edema of the eyelids, subconjunctival hemorrhage, diplopia with limitation in upgaze or downgaze, enophthalmos, infraorbital nerve anesthesia, or emphysema of the orbits/eyelids.
• One of the significant clinical features of a fracture to the orbital floor is entrapment of the inferior rectus muscle, resulting in impaired upward gaze on the affected side. Entrapment of the inferior orbital nerve may result from a fracture of the orbital floor and is manifested by decreased sensation to the cheek, upper lip, and upper gingival region on the affected side.
• Entrapment of these structures may be more commonly encountered in children, whose bones may be more flexible and demonstrate a linear pattern that snaps back to create a “trap-door” fracture; in adults, the floor of the orbit is thinner and more likely to shatter completely. Other features commonly encountered with fractures of the orbit include enophthalmos, in which the eye appears to recede into the orbit, and orbital dystopia, in which the eye on the affected side appears lower in the horizontal plane relative to the unaffected side.^[12]
• Nasal fractures
• Evidence of a nasal fracture includes epistaxis, swelling, tenderness, deformity, crepitus, nasal airway obstruction, and periorbital ecchymosis.
• Always evaluate for septal deviation or septal hematoma. A bulging, bluish, tender septal mass requires evacuation. Failure to do so can result in necrosis of the nasal septum. Widening of the intercanthal distance suggests the possibility of a nasoorbitoethmoid fracture.
• Zygomatic/zygomaticomaxillary complex fractures
• Impingement of the temporalis muscle may result in trismus, although this is only occasionally observed.
• Depression of the inferior orbital rim, paresthesia in the distribution of the infraorbital nerve, or diplopia suggests extension into the orbit or maxilla.
• Maxillary (Le Fort) fractures: Physical examination findings include facial distortion in the form of an elongated face, a mobile maxilla, or mid-face instability and malocclusion.
• Mandibular fractures
• In a report, Schwab et al looked at physical examination characteristics that predicted a mandibular fracture. The tongue blade test assesses the ability of patients to grasp a tongue depressor in between the teeth and patients’ ability to hold the blade against mild resistance by the examiner on each hemimandible.^[13]
• Inability to hold the tongue depressor had a negative predictive value of 96%, whereas malocclusion had an NPV of 87%; facial asymmetry, 76%; and trismus, 75%.

Laboratory Studies

Consider ordering preoperative laboratory studies, such as a complete blood cell (CBC) count, prothrombin time/active partial thromboplastin time (PT/aPTT), and blood type and crossmatch, for the consulting surgeon.

Imaging Studies

Generally, computed tomography (CT) scanning is the study of choice when evaluating facial fractures.

• Frontal sinus fractures: Plain posteroanterior, lateral, and Waters radiographic projections demonstrate the fracture, whereas a CT scan with a thin 2-mm cut through the sinuses demonstrates the anatomy, the integrity of the posterior wall, and any pneumocephali that are pathognomonic for a posterior wall fracture.
• Orbital fractures:
  
  Facial CT

  scanning in the axial and coronal planes with thin cuts through the orbits is the study of choice. Herniation of the orbital contents into the maxillary sinus, observed as clouding of the maxillary sinuses on plain radiographs, suggests an orbital floor fracture.

• Nasal fractures: Radiographs are not usually necessary to diagnose this injury. However, plaiasal radiographs that consist of a lateral view that cones down on the nose and a Waters view can confirm the diagnosis. If a nasoorbitoethmoid fracture is suspected, facial CT scanning confirms the diagnosis.
• Zygomatic/zygomaticomaxillary fractures: If a fracture is suspected, a facial CT scan with coronal and axial cuts elucidates the injury. A plain Waters view may be used as a scout radiograph.
• Maxillary (Le Fort) fractures: These fractures are very difficult to assess with plain radiography. If the clinical examination findings are equivocal, then a plain Waters image may provide additional information; otherwise, facial CT scanning with coronal and axial cuts is the criterion standard. Radiographically, Le Fort I fracture is the only one of the 3 Le Fort fractures to involve the nasal fossa; Le Fort II fracture is the only one of the 3 Le Fort fractures to involve the inferior orbital rim; and Le Fort III fracture is the only one of the 3 Le Fort fractures to involve the zygomatic arch.^[5]
• Mandibular fractures: The study of choice is panoramic radiography. If this study is not available, then a mandibular series consisting of a right and left lateral oblique, posteroanterior, and Towne view may be obtained. Fractures of the condyle may require coronal plane CT scanning.

Other Tests

• CSF rhinorrhea
• Two methods exist to determine if CSF is present iasal or ear secretions. The first involves placing a drop of the nasal fluid onto filter paper or a bed sheet. The CSF migrates farther than blood, forming a target shape with blood in the center and blood-tinged CSF on the outer ring.
• An additional way to delineate CSF is by checking the glucose content of the nasal fluid as compared to the patient’s serum. CSF generally contains 60% of the glucose of serum, and nasal mucus contains none. Keep in mind that neither of these tests is sensitive or specific.
• Foreign-body aspiration: Chest radiography may assist in detecting aspiration of a foreign body.
• Spinal injuries: A C-spine series detects any bony injuries to the cervical spine.

Procedures

• Nasal packing
• If the mid face is stable, the nares can be treated with drops of a vasoconstrictor (eg, Afrin) and packed with gauze.
• If the mid face is unstable, this method does not work. Instead, insert a Foley catheter into the nares and inflate the balloon with air. Gently pull the balloon back to close off the posterior choanae. Then, pack the nasal chamber with gauze.
• Lateral canthotomy: Lateral canthotomy can help relieve intraocular pressure if the physical examination reveals a proptotic and tense globe, which is suggestive of a retrobulbar hematoma. Using local anesthetic, an incision is made on the lateral canthus between the upper and lower eyelid to the orbital bone.
• Temporomandibular joint reduction: The mandible dislocates forward and superiorly. Reduction is performed by placing gauze-covered thumbs on the third molars of the mandible with the fingers curled under the symphysis of the mandible. Then, downward pressure is exerted on the molars, with slight upward pressure on the symphysis to lever the condyles downward. A relaxant (eg, diazepam) may be useful if the muscle spasms. If the injury is trauma related, obtain a radiograph to rule out the presence of a fracture.

Acute Phase

Medical Issues/Complications

• Frontal fracture: Repair of the anterior wall may be delayed, but posterior wall fractures require immediate neurosurgical evaluation. The decision regarding whether prophylaxis with antibiotics is needed should be left to the consulting surgeon.
• Orbital fracture: The initial treatment is generally supportive, including head elevation, ice, and analgesics. The indications for surgical repair are controversial and may include diplopia that persists 2 weeks after the injury, large fractures, and enophthalmos. Orbital fractures that result in inferior rectus muscle entrapment, inferior orbital nerve entrapment, enophthalmus, or orbital dystopia may result in both cosmetic and functional impairment and should be referred to a specialist (ie, ophthalmologist, oral-maxillofacial surgeon, or plastic surgeon) within 24 hours to insure prompt resolution.^[12]
• Nasal fracture: An angulated nasal fracture can be reduced by exerting firm, quick pressure with the thumbs toward the midline or by inserting a soft probe in the nares to elevate the depressed or deviated septum into anatomic position.^[6] Ongoing management of these injuries consists of control of epistaxis and supportive care with analgesics. Operative repair is best performed early, within 1-2 hours following the injury, or in 10-14 days following the injury once the swelling and edema has receded. Any open wounds require antibiotics.
• Zygomatic/zygomaticomaxillary fracture: Open reduction and internal fixation to restore the normal contour is the standard of care.
• Maxillary (Le Fort) fracture: Open reduction with internal fixation is the standard. If CSF rhinorrhea is present, a neurosurgeon should be consulted. Prophylactic antibiotics are warranted if the fracture extends through the tooth-bearing region or through the nasal or sinus mucosa.
• Mandibular fracture: Most cases require admission with fixation. These fractures often require antibiotics because of their location in the tooth-bearing region. Penicillin or clindamycin are acceptable choices.

Consultations

Once a fracture has been identified, an appropriate surgeon or specialist (ie, plastic surgeon; ophthalmologist; ear, nose, and throat specialist; oral-maxillofacial surgeon; or neurosurgeon) provides the definitive care.

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained injuries.

Ibuprofen (Motrin, Ibuprin)

 

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Acetaminophen (Feverall, Tylenol, Aspirin Free Anacin)

 

DOC for pain in patients with a documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.

Acetaminophen and hydrocodone (Lortab, Norcet, Vicodin, Lorcet HD)

 

Drug combination indicated for moderate to severe pain.

Aspirin and oxycodone (Percodan, Roxiprin, Codoxy)

 

Drug combination indicated for the relief of moderate to severe pain.

Ketorolac (Toradol)

 

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.

Morphine (Duramorph, Astramorph, MS Contin)

 

DOC for analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Various IV doses are used; commonly titrated until desired effect is obtained.

Antiemetics

Class Summary

Antiemetics are useful in the treatment of symptomatic nausea.

Promethazine (Phenergan, Anergan, Prorex, Phenazine)

 

Anti-dopaminergic agent that is effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system.

Ondansetron (Zofran)

 

Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally. Prevents nausea and vomiting associated with emetogenic cancer chemotherapy (eg, high-dose cisplatin) and complete body radiotherapy.

Return to Play

Evidence-based research to recommend return to play for athletes who have sustained facial fractures is lacking. Studies have demonstrated that bone healing begins with an inflammatory reaction hematoma stage for up to 5 days following the fracture, followed by callus formation stage 4-40 days following the fracture, and the remodeling stage occurring 25-50 days after the fracture. Based on this healing schedule, it has been recommended that the athlete not participate in activity for the first 20 days following the fracture, light activity days 21-30, noncontact drills days 31-40, and lastly, full-contact training and game play after day 41. The exception to this rule is combat sports in which return to activity is recommended no sooner than 3 months following the fracture.^{[5, 14]}

In fractures that involve or approximate the eye, visual acuity is the most important factor in return to play. Any unexplained loss of acuity needs a complete workup. The aforementioned 20/40 criteria to play still apply (see Sport-Specific Biomechanics). Any athlete returning to competition without complete bone healing needs adequate protection, such as a full face shield, modified batting helmets, extended hockey eye visors, or larger football face masks.

Athletes need to regain their confidence in returning to play. An athlete who has physically recovered may not be mentally recovered from the trauma of the injury and, thus, is at risk of further injury. This is often observed in baseball players hit in the face by a pitch or hit ball. Psychologic recovery from facial fractures can be assessed in controlled practice situations. A consultation with a sports psychologist may be necessary if difficulties linger.

Return-to-play recommendations are not affected after orofacial fractures.^[15] In a report by Laskin, the author observed that more than 100,000 sport-related injuries could be prevented annually by wearing appropriate head and face protection.

Prevention

Adherence to the rules and guidelines established by the specific sports governing body is most important. Almost all eye injuries are preventable, but other fractures can and do occur in sports with high levels of physical contact. Visual acuity, protective gear, and adherence to the rules of the sport are the best ways to limit the risk of facial fractures.

Zygomatic Complex Facial Fractures

History

Attempts to treat facial fractures were recorded in the 25-30 centuries BC. The Smith Papyrus is likely the first document in which treatment of several types of zygomatic fractures are described.

In 1751, du Verney described the anatomy, type of fractures observed, and approach to reduction in two cases. Recognizing the importance of reduction for proper healing, du Verney took advantage of the mechanical forces of the masseter and temporalis muscles on the zygoma in his approach to closed reduction techniques.

In 1906, Lothrop was the first to describe an antrostomy reaching the fractured zygoma through a Highmore antrum below the inferior turbinate.^[1] This allowed for rotation of the fractured zygoma upward and outward for a proper reduction. This transantral approach is known today as the Caldwell-Luc approach. This method avoids external incisions, with access to the maxillary sinus for drainage and for debridement of pulverized bone and mucosal debris.

In 1909, Keen categorized zygomatic fractures as those of the arch, the body, or the sutural disjunction.^[2] He was the first to describe an intraoral approach to the zygomatic arch via a gingivobuccal sulcus incision.

In 1927, Gillies was the first to create an incision made behind the hairline and over the temporal muscle to reach the malar bone.^[3] Gillies further described the use of a small, thin elevator that is slid under the depressed bone enabling the surgeon to use the leverage of the elevator to reduce the fracture. The Gillies method remains in use today to elevate the arch. See the image below.

Gillies approach to reduction.

Adams recognized the need for greater stabilization in more comminuted fractures and was one of the first to write of internal wire fixation. This technique, described by Adams in 1942, remained the mainstay treatment at many institutions for years. A study performed by Dingman and Natvig demonstrated that many zygoma fractures treated with a closed reduction technique and then later re-examined were more severe than they had appeared clinically or by roentgenographic evaluation.^[4] It appeared that although the fracture was reduced at one point, the bone became displaced again because of extrinsic forces. Therefore, they concluded that most displaced fractures of the zygoma should be treated by open reduction and direct wire fixation.

Other advocates of internal wire-pin fixation were Brown, Fryer, and McDowell.^[5] In their publication in 1951, they described the use of Kirschner wires, either alone or in combination with direct wiring, for the purpose of stabilizing middle-third facial fractures.

Osteosynthesis became a reality for facial fractures in the 1970s. The Swiss AO group and Association for the Study of Internal Fixation developed miniplate fixation. The success of miniplates was supported further by Michelet et al and others, who continued to develop techniques for reduction and fixation of facial fractures using miniplates.^[6] For unstable, displaced fractures of the zygoma, miniplates were found to efficiently stabilize the bones with minimal complications. The complications noted were attributed to surgical technique rather than the plating system.

One can appreciate readily that the treatment of facial fractures has progressed. This article discusses the most current methods of diagnosis and treatment of zygoma fractures.

Anatomy

The integrity of the zygoma is critical in maintaining normal facial width and prominence of the cheek. The zygomatic bone is a major contributor to the orbit. From a frontal view, the zygoma can be seen to articulate with 3 bones: medially by the maxilla, superiorly by the frontal bone, and posteriorly by the greater wing of the sphenoid bone within the orbit. From a lateral view, one clearly can see the temporal process of the zygoma join the zygomatic process of the temporal bone to form the zygomatic arch. Attached to the zygoma anteriorly are the zygomaticus minor and major muscles, as well as part of the orbicularis oculi muscle. Laterally, the masseter muscle from below attaches to the zygomatic arch and produces displacing forces on the zygoma. See the image below.

 

Anatomic depiction of the masseter muscle as it relates to the zygomaticomaxillary complex and mandible.

Sicher and DeBrul were the first to depict facial anatomy in terms of structural pillars or buttresses.^[7] This concept allows consideration of an approach for reduction of midface fractures and, ultimately, the production of a stable reconstruction. Manson et al have elucidated this concept further by emphasizing the idea that the mid face is made of sinuses that are supported fully and fortified by vertical and horizontal buttresses of bone.^[8]

Three principal buttresses need to be considered in midface fractures. The medial or nasomaxillary buttress reaches from the anterior maxillary alveolus to the frontal cranial attachment. The second is the pterygomaxillary or posterior buttress, which connects the maxilla posteriorly to the sphenoid bone. The third is the lateral or zygomaticomaxillary buttress. This important buttress connects the lateral maxillary alveolus to the zygomatic process of the temporal bone. These buttresses help give the zygoma an intrinsic strength such that blows to the cheek usually result in fractures of the zygomatic complex at the suture lines, rarely of the zygomatic bone.

Fracture lines usually run through the infraorbital rim, involve the posterolateral orbit, and extend to the inferior orbital fissure. The fracture line then continues to the zygomatic sphenoid suture area and on to the frontozygomatic suture line. All zygomatic complex fractures involve the orbit, making visual complications a frequent occurrence.

Another important landmark with respect to zygomatic fractures is the sphenozygomatic junction (especially laterally displaced fractures). The alignment of the zygoma with the greater wing of the sphenoid in the lateral orbit is critical for determining adequate reduction of zygomatic fractures. Reducing the 3 points that make up the buttresses also helps ensure proper alignment of the zygoma and proper reduction of other facial fractures present. This graduated approach helps preserve facial height and width.

Lastly, the branches of the fifth and seventh cranial nerves lie within the bounds of the mid face. Particularly, the temporal and zygomatic branches of the seventh nerve and the zygomaticotemporal and zygomaticofacial branches of the fifth nerve must be identified carefully upon surgical dissection of the area to prevent complications of paresis and paresthesias, respectively.

Classification

In 1961, Knight and North described a classification system of zygoma fractures, hoping to better determine the prognosis and treatment of these injuries.^[9]

Group I encompassed fractures with no significant displacement. While fracture lines may be evident on imaging, their recommendation was observation and soft diets. Group II fractures include isolated arch fractures. Fracture is indicated when trismus or aesthetic deformities are present.

Unrotated body fractures, medially rotated body fractures, laterally rotated body fractures, and complex fractures (defined as the presence of additional fracture lines across the main fragment) belong to groups III, IV, V, and VI, respectively. Knight and North defined these groups by their stability after reduction. They found that 100% of group II and group V fractures were stable after a Gillies reduction, and no fixation was required. However, 100% of group IV, 40% of group III, and 70% of group VI were unstable after reduction and required some form of fixation.^[9]

A study by Pozatek et al concurred with the findings of Knight and North except for group V fractures.^[10] This group was found to be unstable in 60% of cases. Dingman and Natvig studied patients who were treated by closed methods of zygomatic elevation.^[4] In a significant number of patients, they found concomitant fractures along other suture lines and within the orbit after exposing the site through a brow or lower lid incision. They postulated that these fractures were overlooked because of the edema and hematomas present at the time of evaluation and reduction. A significant number of patients suffered from displacement of the zygoma after reduction without fixation. This displacement recurrence may occur because of masseteric displacing forces.

Lund found that all group III fractures were stable after reduction, disagreeing with the findings of Knight and North.^[11] It now seems apparent that displaced fractures require open reduction and fixation.

Manson and colleagues have proposed a more modern classification system in which CT scan is used to assess and classify zygomatic fractures.^[8] CT provides information about facial structures, including both bone segmentation and displacement, allowing for complete repair of the fractures. This system divides fractures into low-energy, medium-energy, and high-energy injuries.

Low-energy zygoma fractures result in minimal or no displacement. These types of fractures often are seen at the zygomaticofrontal suture, and inherent stability usually obviates reduction.

Middle-energy zygoma fractures result in fractures of all buttresses, mild-to-moderate displacement, and comminution. Often, an eyelid and intraoral exposure is necessary for adequate reduction and fixation.

High-energy zygoma fractures frequently occur with Le Fort or panfacial fractures. The zygomatic fractures often extend through the glenoid fossa and permit extensive posterior dislocation of the arch and malar eminence. A coronal exposure, in addition to the oral and eyelid incisions, usually is necessary to properly reposition the malar eminence.

Biomechanics

While 2-point fixation of zygomatic fractures may be used commonly, it often leaves an axis of rotation for the zygoma following an adequate reduction. Forces such as the masseter muscle often displace the zygoma postoperatively. Thus, making the diagnosis and then choosing the correct approach to establish 3-point fixation and ultimate stability is essential for obtaining a successful outcome. Since biomechanical properties are of primary importance underlying the treatment of zygoma fractures, a brief discussion is warranted.

Primary bone healing allows quicker and stronger healing of a fracture than callous healing. A study by Lin et al reported that rigidly fixated bone grafts maintain their position and volume better than mobile grafts.^[12] Furthermore, rigid fixation helps the bone heal by primary processes rather than by fibroelastic processes. In terms of postoperative stability of a reduced zygoma fracture, 3-point fixation is undoubtedly best. However, at times, 2-point stabilization is perfectly adequate.

Some biomechanical models predict downward, backward, and medial rotation of the zygoma with 2-point alignment. Furthermore, the superiority of miniplates over interfragmentary wiring is observed only when fewer points of fixation are used. In this study, the authors found that one miniplate could be used as effectively as 3 points of wire fixation. However, only 5 kg of force were used in the study (normal sustained forces of up to 50 kg are seen in vivo).

In a study by Rinehart et al, mechanical loads that better approximate the actual sustained forces observed physiologically were used.^[13] Deforming forces of this magnitude require at least 2 miniplates (with 1 miniplate stronger than 3 points of wire fixation and slightly weaker than 3 plates).

In a retrospective study by Rohrich et al, rigid miniplate fixation achieved consistently better malar and global symmetry than did interosseous wires.^[14] Furthermore, fewer complications occurred, including infraorbital nerve sensory abnormalities. Long-term experimental studies demonstrate that miniplates maintain the osseous volume of bone grafts and prevent nonunion at bone graft contact points better than wires. Rigid fixation with plates and screws is the best form of bony fixation; it restores 3-dimensional stability and allows for the least amount of motion between ends of fragments, the main cause of bone resorption and instability.

Presently, several types of microplating systems are available to choose from when rigid fixation is needed for stabilization. A study by Gosain et al directly compared titanium plates with biodegradable plate and screws and cyanoacrylate glue fixation systems.^[15] Titanium miniplates were the strongest in distraction and compression across a central gap.

However, in many situations, resorbable plates and screws are believed to be adequate. Such situations may include the presence of primarily compressive forces of relapse and sturdy bone fragments that can be fixed in direct contact, since forces of relapse are absorbed by bone fragments and not the fixation system. Resorbable plates and screw fixation systems can be used when standard titanium midface and microplate systems are believed to be adequate. Resorbable plates fixed with cyanoacrylate glue may be used if forces of relapse are primarily compressive and titanium midface or microplate and screw fixation systems are believed to be adequate.

Preoperative Assessment

Although isolated zygomatic complex (ZMC) fractures occur, fractures of this nature are usually associated with other facial skeletal and soft-tissue injury.

Initially, assessment of a zygomatic fracture in an emergent setting should be directed at prevention of life-threatening complications including major bleeding, airway compromise, aspiration, and identification of other fractures. Cervical spine injury should always be considered if the injury is the result of a high velocity event or if the patient has altered mental status. Intracranial, thoracic, extremity, and pelvic injuries require proper evaluation and management.

Once other more pressing injuries have been dealt with and the patient is stable, a thorough preoperative assessment of facial skeletal architecture can be performed. Symptoms include paresthesias in the distribution of the maxillary branch of the trigeminal nerve, trismus, diplopia, and flattening of the zygoma.

Signs classically include subconjunctival and periorbital hemorrhage and hypesthesias in the distribution of the maxillary branch of the trigeminal nerve. Flattening of the malar eminence, lateral canthal dystopia, and reduction in mandibular movement may be present. Ipsilateral epistaxis and buccal sulcus hematomas may occur. Reduced extraocular muscle function, diplopia, and enophthalmos can occur secondary to orbital floor fractures, resulting in entrapment of orbital contents.

A thorough ophthalmologic examination is required to evaluate and document ocular status. If a ruptured globe, retinal detachment, or traumatic optic neuropathy exists, treatment of these supersedes repair of a ZMC fracture.

Since mandibular fractures are most often associated with ZMC fractures, tooth roots can be injured, necessitating a thorough intraoral examination.

Imaging

Noncontrast computed tomography (CT scan) with three-dimensional reconstruction is most commonly used to confirm the presence of a fracture and optimize pre-surgical planning. Ultrasonography has been used and found to identify lateral orbital wall fractures with high sensitivity and specificity. Combining this modality with CT allows for excellent visualization of fractures, leading to maximal perioperative planning and repair.

Management and Surgical Repair

Isolated zygomatic arch fractures

Optimal repair of isolated zygomatic arch fractures is within 72 hours of the injury. Within this time frame, the arch is easily reduced without the need for internal fixation or external splints.

Arch fractures resulting in decreased mandibular motility can be dealt with via a Gillies temporal approach or supraorbital approach described by Dingman and Natvig in 1964.^[4] The temporal approach allows for surgical reduction of a depressed zygomatic arch while leaving a well-camouflaged scar within the hairline. Dissection exposes the deep temporalis fascia followed by creation of a plane between the fascia and temporalis muscle. The lateral eyebrow incision of the supraorbital approach allows for additional access to the frontozygomatic suture line. A supraperiosteal dissection plane allows for access to the arch. Both approaches provide safe and direct access to the zygomatic arch, since the seventh cranial nerve lies above the dissection planes.

An instrument such a Rowe zygomatic elevator or Kelly clamp is placed beneath the arch. Once the instrument is properly positioned, the arch is elevated in a superolateral vector taking care to not use surrounding facial bones as a fulcrum. Proper placement of the instrument can be confirmed with palpation by the surgeon’s free hand placed within the intraoral, posterior buccal sulcus. A cracking sound is heard when the convexity of the arch is restored with full reduction. The surgeon should be cognizant of the normal flattening of the middle of the arch. A persistent protuberance will occur if care is not takeot to avoid fracture overcorrection. The wounds are closed, and the patient is advised to avoid direct contact to the area for several weeks.

A less popular buccal sulcus approach can used. Masseter muscle bleeding may occur along with ocular insult if the instrument is placed too high.

Studies by Kobienia et al of intraoperative portable fluoroscopy have demonstrated improved results with the use of a temporal or supraorbital approach for arch fractures.^[16] Fluoroscopy allows for visualization of the arch and confirmation of fracture reduction, reducing the need for postoperative CT scanning in patients with isolated zygomatic arch fractures.

ZYGOMATIC COMPLEX FRACTURES

ZMC fractures are usually repaired with open reduction and internal fixation within 3-4 weeks following injury. Plating systems are used to fixate the zygomaticomaxillary buttresses, zygomaticofrontal suture, and zygomatic arch. Osteotomies are indicated for fractures older than 1 month with onlay bone grafting for fractures present for 4 months or longer.

Various approaches to ZMC fractures have been well described in the literature. These include coronal,^[17] eyebrow, upper eyelid, transconjunctival and infraciliary lower eyelid, and maxillary vestibular approaches. The approach to the ZMC is dictated by the degree of injury and need for exposure for open reduction and internal fixation.

Recently, a navigation-guided approach to open reduction was reported by several authors to have a high success rate.^{[18, 19]}

In most instances, 2 areas of internal fixation are necessary to provide rigidity and satisfactory malar contour and eminence. The frontozygomatic suture and maxillary buttresses are the usual fixation points, with plating of the inferior orbital rim when reconstruction of the orbital floor is necessary.

Many materials, both autogenous and allogenic, are used for plating. Description of these materials is beyond the scope of this article. Typically, miniplating systems are used for fixation. When fixating the frontozygomatic suture, the plates should be placed posterior to the orbital rim to avoid prominence and easy palpation by the patient. The author has used an AlloDerm overlay to reduce visibility and palpability of orbital rim fixation devices.

Complications

Infraorbital nerve dysesthesia

Fractures of the zygomatic complex frequently result in sensory disturbances in the infraorbital nerve distribution. These symptoms include dysesthesia of the skin of the nose, cheek, lower eyelid, upper lip, gingiva, and teeth of the affected side. These arise because fractures generally occur in the vicinity of the infraorbital foramen and canal. This incidence can range from 50-94% with long-term dysfunction of 20-50%, depending on the technique of sensory measurement.

Several authors have noted significant improvement in sensory function after open reduction and internal fixation with plates versus a closed reduction technique.^{[20, 21, 22, 23]} This does not make infraorbital nerve dysfunction after a nondisplaced zygoma fracture a sole indication for exploration and decompression, since sensory function returns in most patients.

Trismus

Trismus is also a common finding (45%), particularly after a fracture involving the zygomatic arch. It results from impingement upon the coronoid process of the mandible by a depressed zygomatic arch. This may indicate a need for elevation of the depressed arch, accurate reduction, and fixation. If new bone has formed in the space below the zygomatic arch and restricts the movement of the mandible, an intraoral approach for coronoidectomy may be required to permit mandibular movement.

Diplopia

Diplopia may occur after zygoma fractures for numerous reasons. These include, but are not limited to, hematoma, muscle injury, motor nerve injury to the extraocular muscles, entrapment of extraocular muscles, or damage to the fine connective tissue system described by Koornneef.^[24] In Ellis et al’s series of 2067 zygomatico-orbital fractures (1985), diplopia was noted in approximately 12% of patients.^[25] Diplopia that occurs after zygoma fractures not associated with significant orbital floor fractures and entrapment is usually transitory and is probably associated with hematomas. Barclay reported an 8.4% incidence of diplopia; 60% were transitory.^[26]

A symptomatic diplopia associated with a positive forced duction test and CT evidence of entrapped muscle or soft tissue with no improvement over 1-2 weeks may be an indication for surgery. When diplopia is associated with enophthalmos, an improvement in vision can be predicted after correction of the enophthalmos. Diplopia associated with zygomatico-orbital fractures may persist longer, and young patients may recover more slowly than adults.

Enophthalmos

A study of over 1000 patients by Zingg et al (1992) demonstrated a 3-4% incidence of acute enophthalmos. The eye is supported by intramuscular cone fat, a network of intraorbital ligaments, and the bony orbit. The displacement of orbital contents into an enlarged bony orbit with subsequent change to a more spherical orbital soft-tissue shape is thought to be the principal underlying mechanism behind the development of enophthalmos.

The most common causes of enophthalmos include the failure to properly reduce displaced zygoma fractures and malunited zygoma fractures. Blowout fractures of the orbit, especially those of the medial wall and those of floor fractures behind the axis of the globe, and high-velocity comminuted fractures involving combinations of lateral wall, posterior floor, and medial wall fractures are other causes of enophthalmos. Other theories of possible causes of enophthalmos include fat atrophy, soft-tissue contracture, and fibrosis.

Before surgical correction of enophthalmos, examine the patient to assess visual function, extraocular eye movement, and the sensory function of the infraorbital nerve. Both thin coronal and axial slices on CT scans are helpful in determining the extent of orbital damage.

Infection

While an infrequent occurrence, infection is a problem that threatens all postoperative patients. A study by Zachariades et al of 223 patients treated with rigid internal fixation of facial bone fractures reported that interosseous wiring resulted in a greater rate of infection when compared to bone plates.^[27] While 4.5% of patients suffered from both late and early infection, only 0.8% of infections were located in the mid face. Sinusitis has been found to be the most common type of infection seen in postoperative patients; preseptal cellulitis and dacryocystitis also can occur.

Complications with plates and/or screws

Since microplate development in the late 1980s, wire fixation techniques have been used less in zygoma fractures. However, no matter how well these plates and screws work, occasions exist in which their removal is required. The usual cause is a palpable plate, although a pain syndrome may occur. More rarely, infections may occur. Very rarely, screws can fracture into bone and create problems for removal.

These problems may be limited by a broad availability of drill sizes for use in thin or dense bone. In a review of 55 patients who had internal fixation devices removed after many types of craniomaxillofacial surgery, including trauma, Orringer et al found palpable plates and screws to be the most common reason (35%), followed closely by pain, infection, or loosening of the fixation device (approximately 25%).^[28] The authors’ experience with complications of fixation of zygoma fractures is limited mainly to palpable plates and screws at the frontozygomatic suture and infraorbital rim.

Summary

Zygomatic complex (ZMC) fractures remain the most common facial fracture behind nasal fractures. Advances in imaging, surgical technique, and materials for fixation have allowed for improved functional and aesthetic outcomes.

ZYGOMATIC ARCH FRACTURES

Background

The zygomaticomaxillary complex (ZMC) is a functional and aesthetic unit of the facial skeleton. This complex serves as a bony barrier, separating the orbital constituents from the maxillary sinus and temporal fossa.

The zygoma has 4 bony attachments to the skull, and ZMC fractures are sometimes known as tetrapod fractures. Trauma to the ZMC can result in multiple fractures (ie, tetrapod), but solitary bony disruption may occur, as with isolated zygomatic arch fracture. This article focuses on the zygomatic arch fracture.

History of the Procedure

In 1751, Dupuytren detailed an intraoral and external technique to reduce a medial displaced zygomatic arch. Also described was an approach to the zygomatic arch by way of a plane between the temporalis muscle and deep temporalis fascia.

In 1844, Stroymeyer described the percutaneous traction technique that is still used for repair of zygomatic arch fractures.

In 1927, Gillies was first to mask incisions within the temporal hairline.

Epidemiology

Frequency

The zygoma is the second most commonly fractured facial bone, eclipsed iumber only by nasal fractures. The vast majority of zygomatic fractures occur in men in their third decade of life.

In 1994, Covington et al reviewed 259 patients with zygoma fractures and found that ZMC fractures occurred in 78.8% of patients, isolated orbital rim fractures occurred in 10.8% of patients, and isolated arch fractures occurred in 10.4% of patients.^[1] Of the isolated arch fractures, 59.3% were displaced or comminuted.

Etiology

Zygoma fractures usually result from high-impact trauma. Leading causes of fractures include assault, motor vehicle or motorcycle accidents, sports injuries, and falls.

Presentation

Arch fractures may result in trismus, flattening of the midface, asymmetry of the malar regions, or a reduction in oral aperture.

Indications

Surgical exploration and fracture repair are indicated with a displaced or comminuted fracture, trismus, or significant aesthetic deformity.

Although rarely indicated, emergent surgical repair and decompression are necessary when exophthalmos or signs and symptoms of an orbital apex syndrome are present.

Relevant Anatomy

The zygomatic arch is a principal constituent of the midfacial skeleton, bound by the zygomaticotemporal suture line posteriorly and the malar eminence anteriorly.^{[2, 3]}

The arch, in essence, is a rim of bony armor surrounding the temporalis muscle and the coronoid process of the mandible and is the origin of the masseter muscle.

The zygomatic arch is part of the facial subunit known as the zygomaticomaxillary complex (ZMC). The ZMC has 4 bony fusion sites with the skull.

See the image below.

Anatomic depiction of the masseter muscle as it relates to the zygomaticomaxillary complex and mandible.

Contraindications

Surgical correction is contraindicated in patients who are medically unstable or unable to tolerate anesthesia.

NASAL AND SEPTAL FRACTURES

Background

Nasal fractures are the most common types of facial fractures; however, they are often unrecognized and untreated at the time of injury. Its central position and anterior projection on the face predisposes the nose to traumatic injury. Studies have shown that most nasal fractures involve the septum, which can be an obstacle to successful reduction.

Fractures can be classified as open or closed, depending on the integrity of the mucosa. Prompt identification and management of the injury in the early postinjury period is imperative to avoid the potential complications of nasal and septal fractures. Confirming that septal hematoma is not present is crucial to avoid further compressive damage to native tissue and dangerous infectious complications. Longer-term follow-up allows the surgeon to assess for both early and late sequelae of injuries to the nasal complex. Surgical intervention may be appropriate in the early postfracture period or much later, after the fracture has healed.

An oblique view of nasal fractures is depicted below.

Oblique view.

Epidemiology

Frequency

Nasal fractures are the third most common types of fractures, behind fractures of the clavicle and wrist. Nasal fractures are often cited as the most common type of facial fracture, accounting for approximately half of all facial fractures in several studies. Zygomatic (22%), blowout (12%), mandibular bone (8%), and maxillary bone (9%) fractures follow in frequency.

Etiology

Most commonly, nasal bone fractures are sustained in fights (34%), accidents (28%), and sports (23%). A 2009 study of 236 patients with facial fractures incurred while playing sports determined that fractures of the nasal bone were most common.^[1]

With increasing use of air bags in automobiles, a shift in the mechanism of injury and the type of nasal fractures has occurred; therefore, the incidence of septal injury iasal fractures, without concurrent nasal bone fracture, has increased.

In children, nasal fractures are most commonly due to falls. The possibility of child abuse should be considered in every child presenting with a nasal fracture.

Pathophysiology

The direction of force to the nose during injury determines the pattern of the fracture.

• Frontal force causes damage ranging from simple fracture of the nasal bones to flattening of the entire nose.
• Lateral force may depress only one nasal bone; however, with sufficient force, both bones may be displaced. Lateral force can cause severe septal displacement, which can twist or buckle the nose. Septal fragments may interlock, creating further difficulty in reduction.
• Superior-directed force (from below) rarely occurs. It may cause severe septal fractures and dislocation of the quadrangular cartilage.

Presentation

Clinical findings in patients with a history of trauma to the nose or face may include the following^[2] :

• Epistaxis, which is common iasal fractures due to mucosal disruption
• Change iasal appearance
• Nasal airway obstruction
• Infraorbital ecchymosis

Indications

Indications for repair of nasal fractures include abnormal nasal function, abnormal appearance, and presence of early postinjury complications. Several methods of reduction and repair can be performed to achieve good cosmetic and functional results.

• Closed reduction may be performed under local anesthesia or local anesthesia with mild sedation. Indications include the following^[3] :
• Simple fracture of nasal bones
• Simple fracture of nasal-septal complex
• Open reduction requires deeper sedation or a general anesthetic. Indications include the following:
• Extensive fracture-dislocation of nasal bones and septum
• Fracture dislocation of caudal septum
• Open septal fractures
• Persistent deformity after closed reduction
• Relative indications, eg, septal hematoma, inadequate bony reduction due to septal deformity, cartilaginous deformities, displaced nasal spine, and recent intranasal surgery

Relevant Anatomy

• Nasal skin has an abundant blood supply and tends to be thinner over the rhinion and thicker over the nasion. Nasal skin thickness varies among individuals.
• The nasal pyramid is composed of 2 nasal bones and the frontal process of the maxilla. The thickness of the bones decreases toward the tip of the nose; as a result, most fractures occur in the lower half.
• Upper lateral cartilages form the middle nasal vault. Upper lateral cartilages are attached to the nasal bones superiorly, the quadrangular cartilage of the septum medially, and the lower lateral cartilages (ie, tip cartilages) inferiorly.
• The images below depict the oblique and lateral view of the nasal anatomy.

Oblique view.

  Lateral view.

  Sesamoid cartilages are less important and lie in the fat pad between lower lateral cartilages and the piriform aperture.

  The nasal septum (as seen in the image below) has a cartilaginous and bony component that is lined with mucoperichondrium and mucoperiosteum, from which the cartilage and bone receive their blood supply. Interruption of the opposition of perichondrium to cartilage (as with septal hematoma) may interrupt the blood supply and lead to resorption of septal cartilage and possibly subsequent saddle-nose deformity.

 

Nasal septum.

Contraindications

Some fractures do not need correction, providing the patient is satisfied with the appearance and function of the nose. In more severe injuries, one must entertain the option of deferring a nasal procedure until the patient has become stabilized.

Imaging Studies

• The use of radiography is controversial. Old fractures, vascular markings, and suture lines can lead to false-positive results. A Water’s view can be used to evaluate the bony septum, dorsal pyramid, and lateral nasal walls. However, studies have shown that radiographs are not helpful in the diagnosis or management of nasal fractures.^[4]
• CT is more useful to assess for other associated injuries, as well as extent of nasal injury. Septal fractures may be more obviously depicted on these films. Because the nose occupies such a prominent and accessible position, careful examination is possible and may obviate any need for radiographic study.
• Photographs are useful and necessary for documentation and for comparison with preinjury photos. Photographs should include the standard angles used in facial analysis: frontal, left and right lateral, left and right oblique, base view, and often a bird’s eye or partial base view. A smiling lateral view can also be helpful to evaluate depressor septae nasalis function. While 35-mm film and cameras still allow a superior resolution, digital photography is quickly becoming more prevalent.

Medical Therapy

Elevation of the head and use of cold compresses in the periorbital and nasal region can be helpful while waiting for edema to subside. Even in the presence of significant edema, a nasal deformity often may be obvious. In a patient with no apparent abnormality at the initial visit, reassessment of the nose after the edema subsides may reveal findings necessitating repair. Surgical intervention may then be undertaken.

Surgical Therapy

No clear recommendation exists regarding the type of surgical approach or the timing of surgery in patients with nasal fractures. Standard therapy instructs the surgeon to perform closed or open reduction between 3 and 7 days, and up to 2 weeks, depending on which source is consulted. The potential for optimal results lies in the reduction of the fracture within the first several hours following the injury before significant edema has appeared. If this window has passed, subsequent reassessment of the injury is advisable, with correction planned between 4-7 days following the injury.

Studies have shown that as the significance of the nasal deviation increases, successful reduction of the nasal fracture becomes more difficult. Recent literature indicates a significant dissatisfaction with closed reduction results, suggesting that open approaches may reduce the need for future revision procedures. Clearly, each fracture and patient must be individually assessed, and proper clinical judgment must be applied to achieve overall patient satisfaction. A further delayed approach can be taken if the fracture is first identified after significant bony healing has occurred. Waiting at least 3-6 months to perform surgery allows fractures to stabilize and wounds to heal.

Most surgeons agree that closed reduction is often an imperfect solution to restore the nose to its preinjury condition. However, note that the satisfaction of the surgeon and the satisfaction of the patient are generally discordant.^[5] That is, patient satisfaction after closed reduction is significantly higher than that of the surgeon. If the patient is made aware of this issue, a decision can be made as to whether to defer surgery or to proceed with an attempt at reduction; the procedure results in improvement, but the results are not perfect.

Preoperative Details

Nasofrontal and ethmoid fractures must be ruled out because these may require other types of surgical intervention. Injury to the nasofrontal duct, cribriform plate, or medial canthal ligaments must be recognized.

Dorsal nasal reconstruction with rib graft or calvarial bone grafts is necessary in patients with severe nasal injuries, significant saddle-nose deformity, loss of dorsal projection, and shortened nasal length; the reconstruction must be discussed with the patient.

Intraoperative Details

• An approach to closed reduction
• Anesthetize the nose first by using a topical anesthetic (eg, cocaine, Pontocaine), followed by injections of lidocaine (1:100,000 epinephrine) at the base of the anterior septum and along the nasal dorsum, lateral and medial to the nasal pyramid.
• Using Boies, Ballenger, Sayer, or another appropriate elevator, elevate the depressed fragment by using force opposite to that which caused the injury (usually pulling anterolaterally).
• Reduction of the nasal bones may also affect the correction of existing acute septal deformity; if this reduction does not occur, Asch forceps or other appropriate instrumentation can be used to manipulate the septum.
• Reduce all injuries before repairing lacerations.
• Stabilize the fracture. An external nasal splint may be sufficient, but silastic splints or intranasal packing may also be needed.
• An approach to open reduction
• Using traditional septoplasty and rhinoplasty techniques, approach, assess, and reduce the septum and nasal structures through appropriate incisions when necessary.
• Pack and splint as in closed reduction.

Postoperative Details

• Splints and packs may be left in place for 7-10 days wheecessary.
• Typically, simple closed or open reduction requires no packing.
• Patients with packs should continue taking antibiotics to avoid toxic shock.
• The use of cold compresses for 1-2 days reduces edema and discomfort.

Follow-up

• Treat nasal crusting, remove splints and packing, and carefully reassess the cosmetic result as routine postoperative care.
• Assess airway patency.
• Assess the need for further intervention (eg, septorhinoplasty).

Complications

Complications from nasal fractures include cosmetic deformity and airway obstruction. Problems arising from nasal fracture complications may be mitigated by adequately recognizing and treating the injury at the time it occurs.

• Hematoma (may require drainage to avoid septal necrosis and superinfection that exacerbates septal deterioration)
• Unremitting epistaxis
• CSF rhinorrhea

Delayed complications

• Airway obstruction
• Scar contracture
• Nasal deformity
• Saddle-nose deformity (due to injury or ischemic necrosis of nasal septum secondary to hematoma formation, followed by loss of dorsal nasal support)
• Septal perforation

Outcome and Prognosis

The treatment of nasal and septal fractures must be instituted only after a thorough evaluation and an accurate assessment of the severity of injury. Patients should expect to have an excellent recovery of nasal respiration as well as cosmetic restoration, but they should be warned that injuries to the nose alter the anatomy permanently. Therefore, one should hope for, but not expect, a complete return to the prior state.

Future and Controversies

The future of the management of nasal and septal fractures involves a better assessment of diagnostic and reparative techniques. At present, clinical judgment guides the physician in the selection of radiographs; whether any radiographs are of practical benefit in the management of nasal fractures is controversial. Although recent studies seem to indicate less of a need for revision after using open approaches to nasal fractures, further studies involving multiple surgeons and larger patient populations are still needed. The role of antibiotic prophylactic treatment is unclear. Resolving these issues may help to reduce cosmetic and functional complications of nasal and septal fractures.

NASAL FRACTURE

Background

Nasal fractures seen in participants of athletic activities occur as a result of direct blows in contact sports and as a result of falls. The nasal bones are the most commonly fractured bony structures of the maxillofacial complex.

See the images below.

Lateral radiographic view of a displaced nasal bone fracture in a patient who sustained this injury because of a punch to the face during a hockey game.

Lateral radiographic view of a nasal bone fracture in an elderly patient who fell forward on her face as a result of syncope. Marked comminution is present.

The nasal bone’s protruding position coupled with its relative lack of support predisposes it to fracture. Prompt appropriate treatment prevents functional and cosmetic changes. Because of the nose’s central location and proximity to important structures, the clinician should carefully search for other facial injuries in the presence of facial fractures.

For excellent patient education resources, visit eMedicineHealth’s First Aid and Injuries Center. Also, see eMedicineHealth’s patient education articles, Facial Fracture and Broken Nose.

Epidemiology

Frequency

United States

Nasal fractures occur nearly twice as often in males as in females. Athletic injuries and interpersonal altercations account for the greatest proportion of causes. Less common causes include falls and motor vehicle accidents.^{[7, 8]}

In a retrospective study, Erdmann et al investigated the medical records of 437 patients with 929 facial fractures.^[3] These authors noted that the most common etiology of facial trauma was assault (36%), followed by motor vehicle collision (MVC, 32%), falls (18%), sports (11%), occupations (3%), and gunshot wounds (2%). Of the facial fractures sustained, the most common fracture type was nasal bone fracture.^[3]

International

In a retrospective study of Brazilian children aged 5-17 years, Cavalcanti and Melo found that facial injuries were most frequent in males (78.1%; 3-fold more common than in females) aged 13-17 years (60.9%), and the most common causes of these injuries were falls (37.9%) and traffic accidents (21.1%).^[1] Of the facial injuries, nasal fractures were also most common (51.3%), followed by the zygomatic-orbital complex (25.4%).

In another retrospective study, Hwang et al reviewed and analyzed the medical records of 236 patients with facial bone fractures from various sports who were treated at one hospital between 1996 and 2007.^[9] The investigators noted the age group with the highest frequency of such injuries was 11-20 years (40.3%), with a significant male predominance across all age groups (13.75:1). There were 128 isolated nasal fractures, with soccer accounting for 39% of these; baseball, 18%; basketball, 12.5%; martial arts, 5%; and skiing or snowboarding, 5%.

Functional Anatomy

The lay term nose consists of bone and cartilage. The nasal septum, a commonly injured structure, consists of the vomer, the perpendicular plate of the ethmoid, and the quadrangular cartilage. Paired protrusions from the frontal bones and the ascending processes of the maxilla complete the bony component. The upper lateral and lower lateral cartilages, as well as the cartilaginous septum, compose the nonbony portion.

The blood supply occurs via branches of the ophthalmic artery, the ethmoidal and dorsal arteries, the facial artery, the nasopalatine, the sphenopalatine, and the greater palatine arteries. Sensation results from many small nerve branches; the external surface superiorly receives sensation from the supratrochlear and infratrochlear nerves, and the inferior portion receives sensation from branches of the infraorbital and anterior ethmoidal nerves. Internally, sensation is supplied by branches of the anterior ethmoidal ganglion and the sphenopalatine ganglion.

Sport-Specific Biomechanics

Any force directed to the mid face, either frontally or laterally, can disrupt the nasal anatomy, causing bony or cartilaginous injury. Frontally directed forces must be greater thaormal to cause bony injury because the upper and lower lateral cartilages absorb a great deal of impact.

Children are more likely to sustain cartilaginous injury for a variety of reasons. This is mainly because children have a greater proportion of cartilage to bone, and the cartilage provides increased protection from fracture. Children’s bones are also more elastic than adults’ bones. This explains the increased incidence of greenstick fractures in children (fracture without displacement).

History

Any history of a fall or force directed toward the mid face should alert the clinician of a possible nasal fracture.

The clinician should obtain details of the injury, including the mechanism and location of injury as well as the direction of force. These details allow estimation of its severity.

Physical

In cases of nasal fracture, there is evidence of trauma to the mid face. Often, deformity of the nose provides the greatest clue. Other signs include swelling, skin laceration, ecchymosis, epistaxis (bleeding from within the nose), and cerebrospinal fluid (CSF) rhinorrhea. Epistaxis implies mucosal disruption; this should increase the clinician’s suspicion for a nasal fracture, including possible nasal septum fracture.

Internal examination

• Acute edema may hide deformities; however, a careful search for intranasal injury must take place.
• Adequate lighting must be available, and the patient should be placed in a comfortable, slightly reclined position. Bleeding can be controlled with topical cotton pledgets soaked in vasoconstrictors, such as 0.25% phenylephrine (Neo-Synephrine [Bayer HealthCare, Morristown, NJ] is also available as a spray) or 4% cocaine, which also provides anesthesia. Retained blood clots should be removed with suctioning or swabbing.
• The clinician should search for any deformity or septal hematoma; however, septal deviation does not automatically determine fracture. An estimated 33-50% of the populatioormally has a septal defect.

Manipulation: A cotton-tipped swab should be placed in each naris up to the septum to check for deformity and mobility.

Laboratory Studies

In cases with a significant amount of bleeding or where a patient may require operative intervention, the following blood tests should be obtained:

• Complete blood cell (CBC) count – To check baseline level of hemoglobin and platelet count
• Coagulation studies (prothrombin time [PT] / activated partial thromboplastin time [aPTT])
• Blood typing and cross-matching for packed red blood cells – In the event transfusion should be required

Imaging Studies

• Nearly 50% of nasal fractures are likely to be missed on plain film nasal radiographs. A high incidence of false-positive studies secondary to the complex anatomy of the developmental suture lines exists. Cartilaginous injury is not detected by radiographs; therefore, it is not considered routine to order nasal radiographs only when an isolated nasal fracture is suspected.
• Facial x-ray series: If suspicion for other facial injury exists, then a complete facial radiographic series should be obtained.
• Computed tomography (CT) scanning provides the best information regarding the extent of bony injury iasal and facial fractures, particularly digital volume tomography (DVT).^[12] Again, cartilaginous injury is likely to be missed.

Procedures

Closed reduction

• Closed reduction of nasal fractures, including nasal septal fractures, should be performed by an otolaryngologist, plastic surgeon, or maxillofacial surgeon.
• The repair technique requires specialized instruments and involves a reversal of forces that caused the injury.
• An attempt at closed reduction of an obvious nasal deformity may be made in the acute setting by medical personnel who are trained in this procedure, in which only a gloved hand is used.

Acute Phase

Medical Issues/Complications

High-force midfacial injuries may involve structures other than the nose itself.

• Septal hematoma
• This is a common and serious complication of nasal trauma. Septal hematomas are collections of blood in the subperichondrial space. This places pressure on the underlying cartilage, resulting in irreversible necrosis of the septum. The patient also becomes predisposed to infection. A saddle deformity may develop from loss of tissue.
• Drainage procedure: Septal hematomas must be drained immediately upon their being found. Cotton pledgets soaked in 4% cocaine are used for topical anesthesia. A scalpel incision must be made to allow drainage. A small Penrose-type drain is placed to prevent reaccumulation. Finally, nasal packing is placed. The patient should be started on oral antibiotics with anti-staphylococcal coverage.
• Blowout fractures
• Orbital wall and orbital floor blowout fractures may occur.
• Any abnormality of ocular anatomy or function should alert the clinician of the possibility of these injuries.
• A common finding is extraocular muscle dysfunction, commonly characterized by the inability to look up on the affected side, suggesting entrapment of a nerve or muscle.
• The presenting complaint may be diplopia.
• Nasolacrimal duct injury
• The nasolacrimal complex lies in close proximity to the nasal bones.
• High-force midfacial injuries or those resulting in comminuted fractures require a consultation with an ophthalmologist.
• Infection: Although rare, infections resulting from nasal fractures can cause serious complications. For this reason, patients should be placed on antibiotics with coverage for staphylococcal pathogens.
• Fracture of the cribriform plate
• This type of injury may predispose to leakage of CSF, allowing rare but extremely serious complications such as meningitis, encephalitis, or brain abscess to follow.
• Drainage of clear rhinorrhea immediately after trauma to the mid face and up to several days later should alert the clinician to the possibility of this associated fracture of the cribriform plate.

Surgical Intervention

High-force nasal trauma resulting in deformity from displaced fractures or dislocations or from comminuted fractures may require open reduction and/or fixation by a surgeon.

Consultations

If specialists were not consulted for the initial patient visit, appropriate referral to an otolaryngologist, maxillofacial surgeon, or plastic surgeon for outpatient management is warranted.

Other Treatment

In the acute phase, the patient should apply ice to the nose and elevate the head to aid in reduction of any swelling present. Nasal decongestants are prescribed to help reduce swelling and mucosal congestion.

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications and infections.

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Amoxicillin and clavulanate (Augmentin)

 

Drug combination that treats bacteria resistant to beta-lactam antibiotics.

Penicillin VK (Pfizerpen)

 

Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

Clindamycin (Cleocin)

 

Lincosamide for treatment of serious skin and soft-tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking the dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. DOC in penicillin-allergic patients.

Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)

 

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.

Decongestants

Class Summary

Decongestants reduce mucosal edema.

Phenylephrine nasal (Neo-Synephrine)

 

Applied directly to nasal mucous membranes where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.

Analgesics

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort and promote pulmonary toilet.

Acetaminophen (Tylenol, Feverall, aspirin-free Anacin)

 

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. Effective in relieving mild to moderate acute pain; however, it has no peripheral anti-inflammatory effects. May be preferred in elderly patients because of fewer GI and renal side effects.

Hydrocodone/acetaminophen

 

Drug combination indicated for moderate to severe pain.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary

NSAIDs have analgesic and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions. Treatment of pain tends to be patient specific.

Ibuprofen (Advil, Excedrin IB, Ibuprin, Motrin)

 

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Anesthetics

Class Summary

Anesthetic agents are used to produce local anesthesia.

Cocaine

 

Decreases membrane permeability to sodium ions, which, in turn, inhibits depolarization and blocks conduction of nerve impulses.

Use the lowest dose necessary to produce anesthesia. The 4% solution is available as a 4-mL unit-dose vial (total of 16 mg of cocaine) or 10-mL multidose vial (total of 40 mg cocaine).

Return to Play

Uncomplicated nondisplaced fractures should not prevent a patient who participates in noncontact sports from returning to play in 2 weeks. In healthy adults, fracture healing occurs in approximately 3 weeks. Athletes involved in contact sports should have adequate head and face protection for several weeks when returning to play.

Prevention

Nasal fractures in sports can be prevented with the use of helmets that have adequate face protection.

Prognosis

Most nondisplaced nasal fractures heal without cosmetic or functional deformity. Both open and closed reduction techniques produce a high rate of refractory cosmetic deformity, manifested by septal deviations. Many patients eventually require nasal-septal rhinoplasty.

Temporary and Permanent Splinting
The term splint indicates the act of fastening or confining, supporting, or bracing a displaced or movable part. In dentistry, splinting designates tying together or uniting two or more teeth in order to gain occlusal stability.There are numerous of splint design constructed with different splint material and aim at different purposes. In order to correctly and maximally delivering the therapeutic benefit of an occlusal splint, a cliniciaot only must understand the nature of the mechanism of splint therapy but also must be accurated in diagnosing the source of the problem. Several factors must be taken into account upon construction of the splint is to the determine whether the splint is temporary or permanent, extent of tooth coverage, the present state of occlusal harmonies in the patient and the oral habits of the patient. Splint may serve as palliative treatment, or relieving symptom appliance, or it serves as to permanently enhance the functional aspect of patient dentition. Success in splint therapy lies heavily on his or her ability to make an accurate diagnosis concerning the etiology of the patient’s functional disturbance.
Glossary of Periodontics term defines a splint as “any apparatus, appliance, or device employed to prevent motion or displacement of fractured or movable parts. A dental splint is an appliance designed to immobilize and stabilize loose teeth. Splint were classified as temporary, provisional, or permanent on the basis of duration and purpose. Temporary splints are those which are used less than 6 months during periodontal treatment and may or may not lead to other types of splinting. Provisional splints may be used from several months to years for diagnostic purposes, and usually lead to a more permanent types of stabilization. Permanent splint is a type of splint which is worn indefinitely and could be fixed or removable.
Morton Amsterdam and Lewis Fox in 1959 outlined the principles and technics of splinting. They defined that the term provisional splinting as the phase of restorative therapy utilizing a biomechanical combination of tooth dressing coverages and stabilization of teeth on an immediate and temporary basis. The rationales given for the procedures are to protect the investing structures of the teeth, to protect the pulp, to control of forces and stress, to establish physiologic occlusion, to be used as an evaluating procedure as revealed by functional requirement of the case, to serve as purpose of anchorage and stabilization of the cases requiring minor tooth movement, to treat periodontal cases which required both restorative and periodontal therapy to be executed simultaneously or required immobilization or to maintain periodontal result, and finally to establish the prognosis of a questionable teeth as it affects the final treatment plan. Requirement for the splints consists of color stability, esthetics, protective to pulp and occlusal forces, ease of fabrication and maintenance, safe, and capable of removal and insertion.
Simring in 1952 described the theory and practice of splinting in detail. He emphasized the importance of direction of forces and the movement of teeth under occlusal loads, thus rationalized the need for splinting as the safety procedure to employ when a tooth must withstand a forces beyond its individual physiologic limits. Since occlusal forces are multidirectional, he noted that an ideal splint would have to ruot only mesiodistally but also buccolingually. In this case, splinting was carried around the arch. He also described the edentulous distance and the splinting effect. When three or more missing posterior teeth are replaced, the splinting effect must be increased by including at least three abutments when opposed by the natural dentition or a stationary bridge. Restoration replacing three or more missing posterior teeth and employing only two abutments may be considered when the opposing denture is a tissue borned removable appliance due to the resulting low occlusal force. Simring stressed that splinting is indicated where the traumatic effects of occlusion are intense and the stimulating physiologic action of the occlusal forces needs to be improved. Wherever splinting is indicated, thorough occlusal equilibration and adjustment must be indicated first. Finally, the most effective splinting is attainable only with cast crown soldered together.
Jens Waerhaug evaluate the justification for the splinting in periodontal therapy as a protective mechanism in the case of occlusal trauma. Clinical trials have shown the splints can do no harm. However, they may indicate that splinting may speed up destruction of bone rather than retard it. Fixed splints caused interference with oral hygiene. He outlined the adverse consequence for splinting as they represents unnecessary expense for patients, both fixed and removable splints may cause damage if not properly made, they are substituted for real periodontal treatment which is necessary to save teeth, and destruction of periodontium continues undisturbed by the splints.
Lemmerman in 1976 reviewed the rationale for splinting. He described the use of splinting as to device as to reduced the mobility or stabilized an existing mobility. He described the concept of reversible mobility, a type of mobility in the normal periodontium and will be able to reverse to normal following therapy. He compared this type to irreversible mobility, which were the type observed in a reduced periodontium and can only be reduced but never be completely eradicated. He suggest the possible rationales for splinting are a)to prevent mobility or drifting, b)the use in post acute trauma to enhance stabilization, c)prevention of drifting iormal dentition during occlusal therapy, or to d)provide functional comfort by preventing mobility in disease dentition. Thus Lemmerman are referred to the importance of the clinician to identify whether the drifting of teeth is a result of primary occlusal trauma (injury resulting from excessive occlusal forces applied to a tooth or teeth with normal support), and secondary occlusal trauma (Injury resulting from normal occlusal forces applied to a tooth or teeth with inadequate support).
In the case of primary occlusal trauma, the periodontium is intact and not reduced, thus the drifting of the teeth is due to an excessive, continuous force resulting from an occlusal disharmony. Elimination of this interference will provide permanent relief from drifting and sometimes completely reverse if diagnosed early. Splinting plays a very minor role, if any, in the case of primary occlusal trauma. Ferenez in 1991 reported that there is little rationale for splinting teeth manifesting primary occlusal trauma.
In the case of secondary occlusal trauma, the periodontium is reduced and the teeth lost a lot of support. The need for splinting thus is more obvious as to achieve stabilization. Splinting during or after periodontal treatment is often aimed to achieve reduction of mobility to improved comfort and function. Moreover, in the case which required periodontal surgery, splinting is used to eliminate movements in the healing area since micromovement of the surgical site may inhibit repair to take place in the healing area. Ferenez in 1991 also divided the splint into its duration of use: short term splint, provisional splints, and long term splint.
Occlusal forces applied to a splints are shared by all teeth within the splint even if the force is applied to only one section of the splint. The rigidity of the splint acts as lever, so that the forces applied to some teeth in the splint may be much greater than before splinting. This phenomena is utmost important in the case of unstable occlusion because the inclusion of a mobile tooth in a splint does not completely relieve the tooth of the burden of occlusal forces, nor does it guarantee against injury from excessive occlusal forces. One tooth within the splint with occlusal disharmonies may cause damage to periodontium of the other teeth in the splint, thus the occlusioeeded to be stabilized prior to splinting. According to Caranza, two major indications for periodontal splinting are a)to immobilize excessively mobile teeth so that the patient can chew more comfortably and b)to stabilize teeth exhibiting increasing mobility. He further defined three procedures for provisional stabilization which are a) the reinforced resin splint for use in the posterior teeth, the acid etch resin splint for use in anterior teeth, and the resin bonded metal splint. As with any other appliance in the mouth, oral hygiene must be emphasized and must be taken into account in the design and construction of the splint.
Ramjford classified splint as temporary, diagnostic or provisional, or permanent. Temporary are used to reduce unfavorable occlusal forces for a limited time. This type of splinting can be seen in post acute trauma, in supportive measure in treatment of advanced periodontal disease, and for anchorage in orthodontic therapy. The diagnostic or provisional splint is used in borderline cases in which the final result of the periodontal treatment cannot be predicted with certainty at the time of initial treatment planing. Permanent splints are constructed to provide stability for teeth undergoing progressive tipping or for teeth that have lost so much of their periodontal support that they cannot carry out normal function if they are left as single units. All splints should enhance the stabilityy and function of the dentition. Temporary splints could be fixed, external types such as in the use of annealed stainless steel ligature wire (.010or .012 in.), single or double, bonded to the teeth facially, lingually, or even incisally. The splint of wire combined with acrylic is very effective. Other temporary fixed external type included orthodontic bands welded together (too cumbersome, poor esthetics), cast splints of gold or chrome nickel alloy cemented to the teeth and the facial and lingual parts tied together with ligatuer wire. The most popular temporary splint is the one made with acid etch, self polymerizing resin, and composite material. The acrylic can be reinforced with the orthodontic grid material or cast metal framework. Denture teeth can be used to substitute for the tooth or teeth missing and thus further increase the supporting periodontium. Long term benefits from splints is illlusory, since the teeth revert to its initial mobility when splint is removed.
Another type of temporary splint are the fixed internal type of which the teeth must be prepared with the interproximal box preparation with mark retention, then the teeth are held together with metal wires with acrylic reinforced. This type of appliance can be worn for up to 2 or 3 years.
Another type of temporary splint are the removable splint wich included the cast metal splint of Elbrecht, the acrylic Hawley or other types of orthodontic appliance, the bite guards or night guards. This type of splint is less stabilized than the fixed type, but provided better oral hygiene and convenience in construction.
In the case of diagnostic splint, a temporary external splints for teeth that have a reasonable good periodontal prognosis is recommended. The preferred technique is the acid etch technique.
The permanent splints included the fixed, semirigid, or removable splint with the use of anchorage internally or externally to the teeth. Fixed permanent splints is most recommended with utmost attention given to oral hygiene. Principles in its construction included elimination of all sources of gingival irritation, good access to oral hygiene, excellent retention in all abutment preparation, and adequate thickness or bulk of the splint and good solder joints. The use of semi regid or precision attachment connection can beused. Pin ledge type of abutment should be used for fixed splint whenever possible. The removable permanent splint included the use of telescoping crown and precision attachment to constructed a cast metal splints, clasped supported partial denture.
Glickman et al. (1961) evaluated the effects of splinting teeth in hyperocclusion using five Rhesus monkeys. The forces which applied to 1 tooth in a splint were transmitted to all teeth within the splint. The direction of the initial force was maintained and comparable areas of the splinted periodontium were affected. The bifurcation and bifurcation areas were most susceptible to excessive force. Forces applied to non-splinted teeth were not transmitted to adjacent teeth and force sufficient to cause necrosis did not cause pocketing.
Nyman et al. (1975) studied 20 patients who had originally exhibited severe periodontal breakdown and extensive tooth loss. Extensive fixed bridgework was placed following periodontal therapy and the patients monitored for 2 to 6 years. No further bone loss was observed between the insertion of the fixed bridgework and the final examination. The authors reported no increase in PDL width of the abutments or changes in mobility.
In summary, regardless whichever type of splint to be use, the rigidness, the oral hygiene, and stabilization of occlusion are the critical factors in the splint design. Common dysfunctional problem in splinting and oral rehabilitation are tipped abutment teeth which required uprighting with orthodontic appliance. It is also important that the splint be properly articulated in lateral excursion, allowing lateral movements with undue pressure on the splint. In the case of deep overbite, sufficient overjet must be provided so that lateral excursion are unrestricted. In patient with deep overbite and a markedly curved arch in the anterior region, maxillary incisors must be maintained for abutment, even if these teeth have extensive loss of support and appear very loose.
Disadvantage of splinting included gingival irritation, difficult oral hygiene access, interference of the splint to normal interproximal wear and mesial drift, crown become loose or fractured, interference with phonetics. With these disadvantage in mind, splinting should only be done when occlusal stability and adequate masticatory function desired. It should never be used to substitute occlusal adjustment therapy. Prognosis of the splinting teeth (tooth) relies greatly on oral hygiene achieved in the area.
Ramjford further describes the biomechanics of the splint. The reduction mobility is achieved by decreasing the occlusal forces to the mobile tooth through occlusal equilibration prior to splinting, and increasing the periodontal resistance with the inclusion of other teeth into the splint. Splinting allow better force distribution, directing the force to be distributed over the entire splinting area thus better periodontal support,and as a result of conditioned reflex activity, masticatory function is directed toward the area that most convenient and efficient for function. Lateral force or tipping forces should be avoided as much as possible. Functional contact should be in a straight line between the abutment of the splint in order to avoid tipping forces when biting forcefully. Mesial or distal force can be better distributed when two single rooted teeth are splint together. Intrusive forces are very well tolerated since their impact is spread over a maximal number of principal periodontal fibers. In order to achieve favorable a stabilization in the faciolingual and mesiodistal direction, a splint has to connect posterior and anterior segments or to engage teeth in the opposite side of the arch for support. Such a distribution of abutment produces the tripod effects: a tipping force acts as a well toleated intrusive force on one or more abutment. Fixed splint provided much greater stability than the removable appliances, and thus is recommended in splinting teeth with minimum residual support.
In summary, splint offered numerous therapeutic advantages ranging from increase periodontal resistances to occlusal relationship correction. Regardless of the type of splint design, material, and method of fabrication, it must provide good access to oral hygiene, rigid fixation, and also elimination of occlusal trauma by providing force distribution and resistance to occlusal overload.

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References

1. Carranza F, Newman, Textbook. Clinical Periodontology. CV. Mosby 1996.

2. Amsterdam, M., Fox, L. Provisional splinting-principles and practice. Dent Clin. N. Am., 1959.

3. Simring. Splinting-theory and practice. J. Am Dent. A. 1952

4. Waerhaug. Justification for splinting in perio therapy. J. Prosth. Dent. 1969.

5. Simring M. Poste. F. Harzard and shortcomings of splinting. NY State Dent. J. 1964.

6. Nyman S., Ericsson. The capacity of reduced periodontal tissue to support fixed bridgework. J. Clin. Perio. 1982.

7. Glickman I, Stein S, Smulow J. The effect of increased functional forces upon the periodontium of splinted and non-splinted teeth. J Periodontol 1961;32:290 300.

8. Kegal W, Selipsky H, Phillips C. The effect of splinting on tooth mobility. 1. During initial therapy. J Clin Periodontol 1979;6:45-58.

9. Lemmerman K. Rationale for stabilization. J Periodontol 1976 47:405411.

10. Nyman S, Lindhe I, Lunddgren D, The role of occlusion for the stabilily uf fixed bridges in patients with reduced periodontol support. J Clin Periodontol 2:53, 1975.

11. Nyman S, Lindhe J, Lundgren D. The role of occlusion for the stability of fixed bridges in patients with reduced periodontal support. J Clin Periodontol 1975;2:53 66.

12. Pollack R, Ponte P. Treatment of type II and type IV periodontal cases without crown and bridge splinting. Int J Periodontics Restorative Dent 1981;1(2):27 49.

13. Ramfjord, S. Textbook, Occlusion.

14. Rateitschak K. The therapeutic effect of local treatment on periodontal disease assessed upon evaluation of different diagnostic criteria. 1. Changes in tooth mobility. Pertodontol 1963;

15. Saravanamuttu R. Post-orthodontic splinting of periodontally-involved teeth. Br J Ortho 1990;17:29-32.