Reconstruction after craniofacial trauma

L. K. Lam, C. M. Ho, P. W. Yuen and William I. Wei

Abstract

Management of craniofacial trauma has became a sophisticated branch of reconstructive surgeryin the last 20 years. New operative techniques and advanced technologies have evolved to allowmuch better treatment results to be achieved. The general principles of diagnosis and managementof craniofacial trauma are discussed. The approach to individual fractures is also highlighted.

Keywords: Craniofacial; Facial; Trauma; Fractures

Introduction

The earliest descriptions of facial fractures and theirtreatment could be found in the ancient Egyptians'literature in the 16th century B.C. and also inHippocrates' writings in the 4th century B.C.1 In thefollowing 2,000 years, slow but definite progresseswere made in the management of facial fractures. Thetwo World Wars produced a large number of casual-ties and spurred the development of new plasticsurgery operative techniques. The introduction of an-tibiotics, availability of safe blood transfusion, andadvances in the administration of general anaesthesiahave all contributed to the improved results in thecare of patient who suffered from severe and com-plex facial trauma.

In the last two decades or so, management ofcraniofacial fractures has evolved from a largely con-servative approach that include delayed repair andlimited exposure of fracture fragments to an early,aggressive approach of fixing the fractures via wideexposures of the fragments.

Modern management of craniofacialtrauma

Early, primary and definitive treatments are the pre-ferred strategies. The goals are anatomical reduction,

Department of Surgery, The University of Hong Kong, Queen Mary Hos-pital, Pokfulam, Hong KongL. K. Lam, FRCSE, FRACSC. M. Ho, FRCSE, FRACSP. W. Yuen, FRCSEWilliam I. Wei, FRCSE, FACSCorrespondence to: Dr L. K. Lam

fixation of the fracture fragments and restoration ofthe pretraumatic occlusion and facial contour. Atpresent, the management principles include preciseanatomic diagnosis, direct and adequate fracture ex-posure, rigid internal fixation, primary bone grafting,and periosteal and soft-tissue suspension.2

The techniques in craniofacial surgery were pio-neered by Paul Tessier of Paris in l960s. Thisundoubtedly opened up a new chapter in plastic sur-gery texts. Much of Tessier's work was originally onthe treatment of congenital craniofacial deformities.3

However, the principles could well be applied totraumatic injuries. Incisions are designed to exposethe whole craniofacial skeleton, including the mandi-ble, subperiosteally. The fractured fragments arereduced to anatomical position or the osteotomizedsegments are repositioned in the desired manner.Sporadic reports of internal fixation of fractured facialskeleton appeared in the literature as early as the1940s.4 This, however, has only became a populartechnique starting from the mid-1970s.5, 6 Major ad-vances have been achieved in the hardware designsand the metallurgy of different systems by differentmanufacturers. The plating systems can be classifiedas compression or non-compression. Today, mostsystems use titanium because of its biological inert-ness. Low profile plates are available. More recently,the microplating systems are gaining popularity foruse in children and in regions like the infraorbitalrim.

Modern radiological modalities especially com-puted tomography (CT) scanning of the craniofacialskeleton is mandatory in the exact fracture diagnosesin complex and extensive injuries.7 This eliminatesdiagnostic guessing in such difficult situations andallows better preoperative planning. Three dimen-sional reformatting of CT images allows visualizationof the fractures and deformities resulted.8

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Clinical approach to craniofacial traumapatients

(A) Initial evaluation

In managing patients with severe facial trauma, theprinciples of general resuscitation apply. Control ofthe airway is of the first priority. In extensive midfacialand mandibular fractures, oedema of the pharynxcan compromise the upper airway. Aspiration ofblood, broken teeth, dentoalveolar segment or den-ture can cause suffocation or more distal respiratoryobstruction. Intubation or tracheostomy should beconsidered in severe mid- or lower facial fractures,especially if there is significant bleeding due to softtissue lacerations or fracture base of skull.

External sources of bleeding should be stopped byappropriate methods. Bandaging is usually adequatealthough bleeding from scalp may be devastating,and clipping or su turing immediately may be requiredfor more effective haemostasis. Bleeding from the na-sal and oral passage may be exsanguinating. Inextensive midfacial and concomitant skull base frac-tures, bleeding is often extremely difficult to arresteven with packing. Although tracheostomy wouldallow a more effective nasal/oral packing, the mor-tality rate under these circumstances is high. Exclusionof other associated injuries is essential. In one majorseries of hospitalized facial fracture patients, 19 %had a life-threatening injury.9

(B) Clinical fracture diagnosis

In history taking, attention should be given to themode of injury, particularly the magnitude and direc-tion of the impact. Besides, any known or suspectedhistory of previous facial fractures should be noted.In large urban centres, motor vehicle accidents andinterpersonal violence are the two major causes ofinjuries.10 During physical examination, the site ofsoft tissue swelling, bruises and local tendernessshould be noted. The initial deformities may bemasked by the soft tissue swelling and tenderness.Any limitation in extraocular muscle movements and/or diplopia should be noted. Telecanthus is a featureof severe nasoethmoidal fracture. Consultation to theophthalmologist should be a routine in any fractureinvolving the orbit.

Trismus is a feature of zygomatic arch fracturewhether it is isolated or part of a 'tripod fracture'.Malocclusion occur in displaced fractures of themaxilla or mandible. Any missing teeth ordentoalveolar segment should be recorded. Chest X-ray should be taken if aspiration is suspected. Stepsand/or tenderness along the mandible reveal under-lying fractures. Tenderness of the palate occurs inLeFort fracture. Concomitant tenderness and crepitus

of the nasal bridge implies the pyramidal or LeForttype II fracture. Numbness or paraesthesia of theinfraorbital nerve distribution can occur in orbitalfloor or zygomatic fracture, and numbness of the lowerlip can occur in mandibular body fractures.

(C) Radiological examination

After the initial history taking and clinical examina-tion, radiological examinations are required to eitherconfirm or exclude the presence of facial fractures.Some of the fractures such as those involve theethmoids or mandibular condyle are more confidentlyrevealed by X-rays. In addition, undisplaced stablefractures or impacted fractures could also be missedclinically. More over, X-ray documentation is impor-tant for medicolegal reasons.

The Waters view is a posteroanterior projection ofthe facial skeleton with the patient in the prone posi-tion and the neck extended. This allows the orbits,zygomas, and maxillary sinuses to be projected againstthe relatively homogeneous area of the posterior skull.Fractures of the orbital rims, lateral maxillary wallsand zygomatic arches are usually demonstrated. Thesubmentovertex view is in the patient supine positions,with the head elevated and the neck arched. The beamprojects an axial representation of the skull with thezygomatic arches outlined.

The orthopantomogram (OPG) of the mandible isthe single best plain film for examination of the wholemandible. It reveals the orientation of the fracturelines and their relationships with the teeth. However,it requires the patient to sit up and stay still which isnot always possible in trauma patients. Towne's viewof the mandible is an anteroposterior view with the x-ray beam tilted 30 degrees downwards. This projectsthe ascending rami and subcondylar areas.

CT scanning has important advantages over theplain films in diagnostic evaluation of the more com-plex facial fractures. It offers excellent delineation ofthe bony anatomy and pathology and provides gooddemonstration of soft tissues. Today, CT scanningshould be considered as a standard modality of in-vestigation of orbital, nasoethmoidal, frontal sinusand maxillary fracture as well as condylar fracture ofthe mandible.

Magnetic resonance imaging (MRI) is not routinelyused in the investigation of facial fractures as its de-lineation of bony structures is poor. It may, however,have a role in the investigation of suspected disc injuryof the temporomandibular joint and soft tissue en-trapment in orbital fractures.

CD) Treatment of facial fractures

After appropriate investigations to confirm the pat-tern of fracture, a treatment plan can be formulated.

nimal,

They are either the 'pure forms' where only the orbitalwails (usually the floor or medial wall) are fractured,or the 'impure forms' that are in fact part of the moreextensive fractures involving the orbital rim. The term'blowout fracture' has been used for the 'pure forms'to imply the hydraulic hypothesis.10 Signs of 'blowoutfracture' include dipiopta, enophthalmos, dvstopia ofglobe, pseudoptosis, infra-orbital, nerve numbness andthose of injuries of the globe. The Waters view mayshow the 'tear drop' sign or sometimes the displacedfracture fragment Fluid level in the maxillary sinusmay also occur. Coronal CT is excellent in revealingthe site and size of the fracture as well as soft tissueentrapment. Surgery is. indicated in entrapment andin. cases of sizable fracture with soil tissue displace-ment to prevent enophthalmos. The orbital floor canbe assessed via the subciliary or the transconjunctivalapproaches,11 After reduction of herniated soft tis-sues reconstruction of the orbital floor can be donewith either autogenous tissues or alloplastic materi-als. Split calvarium or rib, cartilage, antral wall oriliac bone can be used. Silastic or Telflon sheet, Marlexor vitallium mesh, absorbabie sheet like gelfilm orvicyl mesh have all been tried with variable results.12

maxi l lary bu t t ress and the lateral ha l f of theinfraorbital r im. Isolated arch fracture is the result ofloca l i zed impac t . The body f r a c t u r e s can beundisplaced or depressed and rotated. Comminutedfractures occur in high energy impact and often asso-ciated with other complex midface or orbital injuries.Subconjunctival haemorrhage, steps deformity alongthe orbital rim, infraorbital nerve numbness andtrismus may be present. The Waters view is the singlemost useful plain film in diagnosing the fracture. Thesubmentovertex view reveal depressed arch fractureas well as posterior displacement of the zygomaticbody. CT scan show up more accurately the displace-ment at different sites and the degree of orbital floordestruction. For undisplaced zygomatic fractures,conservative treatment is justified but the patient isadvised to have soft diet and malar protection forfour to six weeks. Intermittent examination for dis-placement is required.12 Most displaced zygomaticfractures should be managed by open reduction andinternal fixation preferably with the miniplating sys-t e m . l 3 In general the more unstable or comminutedones require more than one point of plating and atleast one plate is placed across the frontozygomaticjunction.14

(3) Nasal and nasoethmoidal fractures

Laterally displaced fractured nasal pyramid can berepositioned by the closed method followed by nasalpacking and some form of external splintage such asa plaster cast. Rigid internal fixation has been advo-cated in case of nasofrontal separation.15 In a series of

. l. (a)(Left) Coronal CT scan of face showing markedly displaced fractured left zygoma and disrupted orbital floor.• ' ;(b)(Right) Postoperative CT scan showing repositioned zygoma and repaired orbital floor with a rib graft.

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107 patients treated by the closed method, 50% hadsome degree of nasal obstruction and 70% had obvi-ous nasal deviation.16 Fractures of the nasoethmoidalcomplex are result of direct blow to the upper nasalbridge and is the weakest part of the facial skeletonbecause of its fragile bony framework. The wholecomplex either telescoped backwards or extensivelyshattered, Associated orbital, maxillary or cranialfractures are common. Clinically, there is markedlyswelling, flattened nasal bridge and possiblytelecanthus. Anosmia and cerebrospinal fluid (CSF)rhinorrhea should also be looked for, Principles ofsurgical repair include correction of epicanthal folds,restoration of bony contour, and re-establishment ofcontinuity of the lacrimal system and medialcanthoplasty.17 Reduction of the comminuted frag-ments and fixation with miniplates or microplates isthe preferred method of treatment.

(4) Frontal sinus fractures

They can be missed by palpation because of theoverlying soft tissue swelling. Other signs includetenderness and depression, supraorbital nervenumbness, CSF rhinorrhoea and subconjunctivalecchymosis. The Waters view and lateral skull filmmay reveal the fracture and fluid level in the sinus.CT is particularly useful in showing the posteriortable fractures as well as excluding intracranial com-plications. Only undisplaced linear fractures of theanterior table are managed conservatively. Surgery isindicated in depressed comminuted fractures of theanterior table, nasofrontal duct injury and commi-nuted posterior table fractures.18 Combined efforts ofthe neurosurgeon and plastic surgeon are often re-quired. The anterior wall fracture fragments arecarefully reduced and stabilized with miniplates orpreferably microplates. In cases with evidence of

Based on experimental works on cadavers, Le Fortgrouped the maxillary fracture lines into three types:I (transverse), II (pyramidal) and III (craniofacial dis-junction).19 With the more common high-velocityinjuries nowadays, combinations of more than onetype of fracture are usually seen. Clinically, them i d f a c e is swollen, f l a t t ened or elongated,Malocclusion is a rule. CSF leakage should be checkedfor in Le Fort II or III types of fractures. Mobility ofthe maxilla is demonstrated by grasping and gentlymoving the upper dental arch while the skull is sta-bilized. Concomitant skull base fractures should benoted and globe injuries be excluded. The Watersview is diagnostic but CT scan is much more in-formative in terms of delineating the exact fracturelines and soft tissue injuries. The principles of opera-tive treatment include wide exposure of the fractures,reduction of the fracture fragments, and establish-ment of the pretraumatic occlusion which may requirethe use of prefabricated splints and rigid fixation atthe structural struts.20 Mandibular fractures, if presentconcomitantly, should be reduced and rigidly fixed.before the manipulation of the maxillary fragments.

(6) Mandibular fractures

Mandibular fractures are classified as closed or open,displaced or non-displaced, complete or incomplete,linear or comminuted. Fractures in the body (tooth-bearing region) are often open or compound becauseof tearing of the gingiva or the periodontal ligaments.Anatomically, the fracture can be classified as den to-alveolar, condylar, subcondylar, coronoid, ramus,

Fig, 2. (a)(Left) Operative photo showing depressed comminuted fracture of the anterior wall of frontal sinus.(b)(Right) After fixation with titanium miniplates and screws.

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angle, body, parasymphyseal or symphyseal. Anotheruseful categorization is to divide them into unilateral,bilateral, multiple or comminuted types.

Diagnosis is made with history, physical examina-tion and appropriate radiology. Symptoms includepain especially during jaw moving, change in occlu-sion, paraesthesia in the distribution of the inferioralveolar nerve, Iingual nerve and long buccal nerve.Signs include tenderness, steps along the mandible,tears in the gingiva, trismus, swelling, ecchymosis,haematoma and malocclusion. An orthopantomogramand Town.es view are good, for screening purposeswhile other options, as mentioned above, are requiredfor certain cases. In cases where the fractures areundisplaced, without mobility across the fracturedfragments, unchanged occlusion and minimal symp-toms, conservative treatment with analgesics andblenderized diet for four to six weeks can be tried.The patients should be examined weekly for any un-favourable signs. Other f ractures often treatedconservatively are intracapsular condylar fracturesand high subcondylar f ractures . Resting byintermaxillary fixation for two to four weeks followedby active jaw exercise is often preferred.2 1

Intermaxillary fixation is the conventional method ofimmobilizing the fractured mandible. Use of directinterdental wiring or with arch bars are commonlyemployed. In unstable or severely displaced fractures,opened reduction and f ixat ion is required.Interosseous wiring has been used for decades. Al-though effective and cheap, it often does not provideadequate stability to dispense intermaxillary fixation.On the other hand, the use of metal bone plates pro-vides much more rigid fixation to allow omission ofintermaxillary fixation in most cases. Two major sys-tems are in use — the compression plates22 and thesemirigid miniplates.23 Both systems produce goodclinical results provided correct methods of applica-

tion are complied with. External fixation is seldomindicated nowadays, but is still used in selected casesof gross infection, severely comminuted fractures withmajor tissue loss and very atrophic mandible. Certainfractures are diff icul t to treat, for example, theedentulous fracture and the children's fractures. Inthe former, the intermaxillary fixation period mayhave to extend to eight weeks or even longer, In thelatter, the mandibular body is packed with uneruptedteeth, and the condylar fractures may result in sig-nificant growth disturbance. (Fig. 3)

(E) Secondary surgery for craniofacial trauma

The need for secondary surgery in the management ofcraniofacial trauma is greatly diminished if appropriateprimary treatment is instituted. The following are someof the more commonly performed procedures;(a) soft tissues adjustment such as scar revisions,

ranging from simple excision and re-suturing tothe use of complex procedures like tissue expan-sion or free tissue transfer;

(b) osteotomy or re-fracturing for malunited fracturessuch as in cases of unreduced nose or markedlydepressed zygomatic fractures;

(c) correction of contour defects in cases of depressedfractures of the supraorbital region, the nose ordepressed uncorrected zygomatic fractures;

(d) correction of enophthalmos in cases of inad-equately treated orbital fractures. This involvesthe freeing of the periorbita from the orbit, repo-sitioning of the bony orbit by osteotomies ifrequired and reconstruction of the walls by bonegrafting;

(e) correction of malocclusion or temporomandibularjoint dysfunction in cases of condylar or difficultsubcondylar fractures where primary treatmentsare often less satisfactory;

Fig, 3. (a)(Left) Post-operative OPG of mandible showing anatomical reduction and fixation of left angle and rightparasymphyseal fractures.

(b)(Right) PA view of the mandible. Note that the last molar tooth was extracted to allow plating at the left angle.

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(f) surgery for dental restoration with the use ofosteointegrated implants.

Conclusion

Craniofacial trauma is common in daily clinical prac-tice. It requires a coordinated team approach inmanagement especially in complex cases. Exclusionof associated injuries is important. Early definitivetreatment of the facial fractures with wide exposureof the fractures, anatomical reduction and rigid fixa-tion are the favoured approach. Liberal use of bonegrafting in primary repair lessens the chance of itbeing done secondarily. Secondary procedures are atthe best able to produce suboptimal results.

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