Nasal Bone Fractures: Analysis of 1193 Cases with an Emphasis on Coincident Adjacent Fractures.

Importance: The nasal bone is one of the most commonly fractured bones of the midface. However, the frequency of coincident fractures of adjacent bones such as the frontal process of the maxillary bone, nasal septum, and medial or inferior orbital walls has not been fully evaluated. Objective: The purpose of this study was to investigate the incidence of fractures of adjacent structures in the setting of a nasal bone fracture. Second, we propose a new classification system of nasal bone fractures with involvement of adjacent bony structures. Design, Setting, and Participants: One thousand, one hundred ninety-three patients with midfacial fractures were retrospectively reviewed. The characteristics of fractures of the nasal bone and the incidence of coincident fractures of the frontal process of maxilla, bony nasal septum, medial, or inferior orbital walls were analyzed. Exposure: All patients included in the study presented with nasal trauma. Main Outcomes and Measures: The coincident fractures of adjacent midfacial structures were assessed, and a new classification of midfacial fractures based on computed tomography (CT) scan images was proposed. Results: Among the 1193 cases, bilateral fractures of the nasal bone were most common (69.24%), and coexistent fracture of the frontal process of the maxilla and bony nasal septum was 66.89% and 42.25%, respectively. Coincident fracture of the orbital walls was observed in 16.51% of cases. The major etiology of fracture for the younger and elderly groups was falls, compared with assault as the most common etiology in the adult group. A classification scheme was generated in which fractures of the nasal bone were divided into five types depending on coexisting fractures of adjacent structures. Conclusions and Relevance: External force applied to the nasal bone can also lead to coexistent fracture of adjacent bony structures including the frontal process of the maxilla, nasal septum, and orbital walls. The proposed classification of nasal fracture based on CT imaging helps to incorporate coincident disruption of adjacent structures.

Surgical treatment of unilateral zygomaticomaxillary complex fractures: A 7-year observational study assessing treatment outcome in 153 cases.

This study investigates treatment outcome in zygomaticomaxillary complex (ZMC) fracture repair. METHODS: The medical records and CT-images of patients that received treatment for a unilateral ZMC fracture in 2005-2011 were studied. ZMC fractures were categorised as incomplete (type A), tetrapod (type B) or comminuted (type C). The incidence of sequelae, wound infection and secondary surgical interventions was analysed per fracture category. RESULTS: A total of 153 patients were treated in the selected period. Persisting sensory disturbances in the area innervated by the infraorbital nerve were observed in 50 cases (37%), facial asymmetry in 19 cases (14%), enophthalmos in 10 cases (7%) and persisting diplopia in 9 cases (7%). Wound infection occurred in 6 cases (4%). Secondary surgical procedures of the ZMC, orbital floor, and/or extraocular muscles were performed in 14 cases (9%). C-type fractures were associated with more secondary corrections for ZMC malreduction (12%, p = 0.03), more secondary reconstructions of the orbital floor (10%, p < 0.01), and more functional corrections of diplopia by extraocular muscle correction (5%, p = 0.02). CONCLUSION: Treatment outcome in C-type ZMC fractures is less favourable than treatment outcome in A-type and B-type fractures. Intraoperative imaging, surgical navigation devices and 3D-planning software may improve treatment outcome in C-type ZMC fractures.

Incidence and patterns of maxillofacial trauma-a retrospective analysis of 3611 patients-an update.

BACKGROUND: Maxillofacial fractures occur in a significant proportion worldwide and can occur as an isolated injury or in combination with other severe injuries including cranial, spinal, and upper and lower body injuries requiring prompt diagnosis with possible emergency interventions. The epidemiology of facial fractures varies with regard to injury type, severity, and cause and depends on the population studied. Hence, understanding of these factors can aid in establishing clinical and research priorities for effective treatment and prevention of these injuries. MATERIALS AND METHODS: In this present retrospective study, we provide a comprehensive overview regarding cranio-maxillofacial trauma on 3611 patients to assist the clinician in assessment and management of this unique highly specialized area of traumatology. A preformed pro forma was used to analyze the medical records of patients treated for facial trauma in The Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Chennai. The distribution according to age, gender, etiology, type of injury, time interval between accident and treatment, loss of consciousness, facial bones involved, pattern of fracture lines, treatment offered, and postoperative complications were recorded and evaluated. RESULTS: We inferred male patients sustained more injuries mostly in the third decade of age. Road traffic accidents were the most common cause of injury. Mandible was the most commonly fractured bone in the facial skeleton. Soft tissue injuries occurred more in road traffic accidents and upper lip was the commonest site of injury. CONCLUSION: Our study provides insights into the epidemiology of facial injuries and associated factors and can be useful not only in developing prevention strategies but also for grading the existing legal regulations and also for framing a more effective treatment protocol.

Completion of nonreducible Le Fort fractures by Le Fort I osteotomy: sometimes an inevitable choice to avoid postoperative malocclusion.

The aim of this study was to prospectively evaluate the use of a simultaneous Le Fort I osteotomy for completion of nonreducible Le Fort fractures. We analyzed the clinical and radiological data of 44 patients with Le Fort fractures, 9 of whom presented with a nonreducible type. Seven patients with an incomplete Le Fort I fracture had a contralateral Le Fort I osteotomy, and 2 patients with an incomplete Le Fort III fracture had a true bilateral Le Fort I-type osteotomy. We recorded age and sex, mechanism of injury, level of Le Fort fracture, concomitant mandibular fractures, concomitant maxillomandibular fixation (MMF) and its duration, surgical approach, status of healing, and complications. Follow-ups were at 1 week and 1, 3, 6, and 12 months.All patients recovered their normal pretrauma occlusion without the need for postoperative elastic guidance, except for 1 patient who required light class III traction elastics for 3 weeks to achieve the correct occlusion. None of the patients presented with intraoperative or postoperative complications.The present study has demonstrated that completion of nonreducible Le Fort fractures by Le Fort I osteotomy results in a high rate of success.

Assessment of changing patterns of Le fort fracture lines using computed tomography scan: an observational study.

OBJECTIVES: To assess the changing mid-face fracture patterns using a computed tomography scan. METHODOLOGY: Fifty patients with mid-face trauma requiring open reduction and fixation were studied using 1.6 mm axial, sagittal, coronal and 3D images. Images were evaluated clinically, intra-operatively and finally were compared with standard Le Fort lines. Results. The male population dominated the female at a ratio of 11.5:1. The majority of the mid-face fractures were seen in the age group of 21-30 years. Road traffic accident (78%) was the major etiological factor followed by work-related accidents (12%) and assaults (10%). The CT scan analysis included categorizing the patients into three groups: (1) Fracture patterns resembling Le Fort lines (24%); (2) Fracture patterns partially resembling Le Fort lines (56%); and (3) Fracture patterns that do not resemble Le Fort lines (20%). CONCLUSION: With the change in the velocity of wounding object, there is a change in the mid-face fracture patterns. The majority of the cases present as a variant of classical Le Fort fractures. Computed tomography is a valuable diagnostic tool in assessing the fractures of the mid-face. 2D images are more sensitive than 3D images. However, both the images are required in delivery of an optimal treatment plan.

Zygomatic arch fracture: a new classification and treatment algorithm with epidemiologic analysis.

Determining the optimal method for zygoma fracture reduction is a common challenge. Numerous methods for treating zygomatic arch fractures have been suggested. However, a substantial gap exists between suggested treatment strategies and real-world practice. A general consensus of classification and treatment guidelines for zygomatic arch reduction has not yet been established. We reviewed our cases and propose a new classification of zygomatic arch fracture and a treatment algorithm for successful reduction based on the injury vectors.

Classification and characteristics of pterygoid process fracture associated with maxillary transverse fracture.

OBJECTIVE: This study aimed to classify pterygoid process fractures associated with maxillary transverse fractures. STUDY DESIGN: Pterygoid process fractures in 100 patients with maxillary transverse fractures were observed 2- and 3-dimensionally using image processing software. Fracture line course and height and sphenoid sinus involvement were recorded. RESULTS: Pterygoid process fractures were classified as follows: class I, vertical (simple separation between medial and lateral plates); or class II, transverse (3 subcategories according to location of fracture line: II-1, within pterygoid fossa; II-2, above pterygoid fossa, not extending to sphenoid sinus floor; II-3, above pterygoid fossa, involving sphenoid sinus floor). Class I fracture was observed on 5 sides (2.7%); II-1, on 125 (66.5%); II-2, on 36 (19.1%); and II-3, on 22 (1.7%). CONCLUSIONS: Pterygoid process fractures were predominantly near the upper edge of the pterygoid fossa. Pneumatization of the pterygoid process is a risk in fractures involving the sphenoid sinus floor.

Le Fort II fractures are associated with death: a comparison of simple and complex midface fractures.

PURPOSE: To investigate whether complex midface fractures have a greater association with death and intracranial injury than simple midface fractures. MATERIALS AND METHODS: A retrospective chart review was performed for patients with blunt-mechanism midface fractures who had presented to an urban trauma center from 1998 to 2010. The survival and intracranial injury status was evaluated for patients with simple and complex midface fractures, including Le Fort, naso-orbitoethmoid, and/or zygomaticomaxillary fractures. Intracranial injury included hemorrhage and brainstem injury. Patients with upper face fractures were excluded to minimize confounding. Adjusted relative risk estimates were obtained using multivariate regression analysis. RESULTS: Of 3,291 patients with midface fractures, 213 (6.3%) died and 693 (21.3%) had an intracranial injury. The cumulative mortality reached 11.6% in patients with complex midface fractures and 5.1% in those with simple midface fractures (P < .001). Patients with complex midface fractures were 57% more likely to die (relative risk = 1.57; P < .005). Specifically, Le Fort II fractures independently conferred a 94% increased risk of death (relative risk = 1.94; P < .01), but Le Fort I and III fractures were not significantly associated with death. Among patients presenting without neurologic impairment, those with Le Fort II and III fractures remained 2.88-fold (P < .01) and 2.54-fold (P < .001) more likely to have an underlying intracranial injury, respectively. CONCLUSIONS: Le Fort II fractures are associated with increased mortality. Furthermore, Le Fort II and III fractures are associated with serious intracranial injury, even in the absence of alterations in consciousness. These patients should be monitored with heightened vigilance and followed up closely during hospitalization, regardless of the presenting clinical findings.

Pediatric maxillary fractures.

Pediatric craniofacial structures differ from those of adults in many ways. Because of these differences, management of pediatric craniofacial fractures is not the same as those in adults. The most important differences that have clinical relevance are the mechanical properties, craniofacial anatomy, healing capacity, and dental morphology. This article will review these key differences and the management of pediatric maxillary fractures. From the mechanical properties' perspective, pediatric bones are much more resilient than adult bones; as such, they undergo plastic deformation and ductile failure. From the gross anatomic perspective, the relative proportion of the cranial to facial structures is much larger for the pediatric patients and the sinuses are not yet developed. The differences related to dentition and dental development are more conical crowns, larger interdental spaces, and presence of permanent tooth buds in the pediatric population. The fracture pattern, as a result of all the above, does not follow the classic Le Fort types. The maxillomandibular fixation may require circum-mandibular wires, drop wires, or Ivy loops. Interfragmentary ligatures using absorbable sutures play a much greater role in these patients. The use of plates and screws should take into consideration the future development with respect to growth centers and the location of the permanent tooth buds. Pediatric maxillary fractures are not common, require different treatments, and enjoy better long-term outcomes.

A new approach to the treatment of nasal bone fracture: radiologic classification of nasal bone fractures and its clinical application.

PURPOSE: A radiologic examination is required in the treatment of nasal bone fracture to determine the fracture condition. Thus, there is an increasing need for radiologic classification of nasal bone fractures that can be applied to clinical practice. MATERIALS AND METHODS: Computed tomography was performed in 125 patients with nasal bone fractures to determine which axial view best showed the entire nasal view. The obtained axial view was then used as a reference for classification. The length from the top to the base of the nasal bone was divided into upper, middle, and lower levels, after which the fracture location was determined. If the fracture spanned the boundaries of these levels, it was classified as the total level. Subsequently, the fracture was subclassified based on the fracture direction and pattern and the concurrent fracture. RESULTS: Radiologic examination of patients with nasal bone fracture showed that nasal bone fracture was frequently found at the total, middle, upper, and lower levels, in that order. Nasal bone fractures at the upper level showed lower frequencies of complication and reoperation than the fractures at the other levels, whereas nasal bone fractures at the total level showed the highest frequencies of complication and reoperation. CONCLUSION: Radiologic classification can be useful for preoperative and postoperative evaluations of nasal bone fractures and can be helpful in understanding such fractures because it can efficiently predict the prognosis of a fracture.

Maxillary fragment stabilization after Le Fort I fracture with 1 screw pair per plate.

PURPOSE: The aim of the present study was to determine whether plates with only 1 screw pair can be used for Le Fort I fracture management. Good postoperative results motivated the direct application of mandible fixation principles to the fractured midface region without additional experimental research. However, the amount and distribution of the forces in the midface region is different from those on the mandible. MATERIALS AND METHODS: Testing was conducted on plastic anatomic models. The validity of the experimental model was tested before the fixation techniques were compared. Standard miniplates and miniscrews were used for fixation of the maxilla. The model surface strain analysis was conducted using the noncontact object grating method, which enabled the surface strain measurement without direct influence on the measured model. RESULTS: In 2 screw pair fixation, the outer screw pair has little effect on the local strain distribution, but it lowers the contact forces along the crack. One screw pair fixation is stable enough for fixation, but it has a greater strain peak at the crack edges. CONCLUSION: Our results showed that 1 screw pair per plate was enough for stable fixation, and 2 or more screw pairs should only be used when the bone fragment at the fracture site cannot sufficiently transmit forces along the crack.

Management of pediatric maxillary fractures.

BACKGROUND: Maxillary trauma in pediatric patients is a challenge to health care professionals. The successful treatment and extended care of pediatric maxillary fractures requires multiple considerations. METHODS: This review of the current literature investigates all components of management to provide optimal outcome. Specifically, pediatric management distinctions are discussed for both facial reconstruction and rehabilitation. The current etiology, incidence, classification of injury, and methods to diagnose and treat these patients is outlined. CONCLUSIONS: Pediatric maxillofacial fractures remain a challenging problem. The management of this patient population includes comprehensive knowledge of pediatric maxillofacial growth and development, available reduction techniques, biocompatible materials, and duration of the selected therapy.

Relationship between small-size medial orbital wall fracture and late enophthalmos.

According to the result of retrospective studies for patients who have not taken medical treatment, most patients experience late enophthalmos and perceive their facial asymmetry. Thus, correct diagnosis method and concrete operative indication were required for medial orbital wall fracture. Retrospective investigation on all patients with facial trauma, who had visited the emergency room between January 1, 2000 and December 31, 2006, was made. Height and longitudinal length of the defect were obtained, and computed tomographic scan of the defect area was obtained. The degree of enophthalmos was measured, and investigation on enophthalmos and presence of facial asymmetry perceived by the patients was made. When the defect area of medial orbital wall fracture was 0.55 cm, late enophthalmos of 1 mm occurred, and patients with late enophthalmos of 1 mm or more perceived their enophthalmos and facial asymmetry. In conclusion, medial orbital wall fracture whose defect area is 0.55 cm or more requires operation.

Facial fractures: beyond Le Fort.

This article presents a systematic approach for interpreting a craniofacial CT scan that is clinically useful to the reconstructive surgeon. By categorizing the fracture patterns and highlighting the variables that may affect fracture management, the radiologist can expand his interpretation of the fracture pattern into a clinically useful diagnosis that may affect fracture management.

A clinically applicable reporting system for the diagnosis of facial fractures.

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

Biomechanical evaluation of Le Fort I maxillary fracture plating techniques.

PURPOSE: This study used a biomechanical model to examine fundamental questions about rigid plate fixation treatment for maxillary Le Fort I fractures. Specifically, we sought to elucidate the principal strain patterns generated in miniplates and bite force transducers secondary to all masticatory forces, as well as the amount of permanent deformations incurred due to these loading forces. MATERIALS AND METHODS: Forty polyurethane synthetic maxillary and mandibular replicas were used to simulate the mandible and maxilla. Ten replicas were controls (group A). The other 30 were divided into 3 groups (10 each), according to the fixation techniques of 3, 2, and 1 miniplates each side (groups B-D), that were osteotomized in the Le Fort I fracture line on the maxilla. Different forces of masseter medial pterygoid, temporalis, and lateral pterygoid muscles were loaded onto the replicas to simulate different functional conditions (anterior incisor, premolar, and molar clenching). Rosette strain gauges were attached at predefined points on the plates and the bite force transducer to compare the stability and bite force of the different fixation methods for maxillary Le Fort I fractures. RESULTS: Statistically significant differences were found for the deformation of the plates among fixation techniques. The order of stability for each technique was: group B greater than group C greater than group D. In regard to bite force, no difference was found between those found with group A and group B (P > .05), whereas the bite forces of groups C and D were less than those of group A (P < .05). CONCLUSIONS: The fixation of 3 miniplates on each side provides sufficient stability and restores the bite force to the level of the intact maxilla. "The ideal fixation" with 2 miniplates on each side restores 90% of the bite force, and there were more deformations of the miniplates with the "ideal fixation" compared to those found with group B. Group D fixation produced the worst effects for the treatment of maxillary Le Fort I fractures with a weak bite force and insufficient stability.

Nueva clasificación de las fracturas de trazo unilateral del tercio medio facial / New classification of the facial middle third unilateral outline fractures

Las fracturas de trazo unilateral del tercio medio facial son las más frecuentes de las fracturas del macizo óseo-facial, en general. Dentro de estas, son las que afectan al maxilar superior y al malar las de mayor incidencia. Se producen como consecuencia de traumatismos severos, siendo la determinación de este tipo de fractura, por edad, sexo y agente causal importante para su manejo. Se pueden presentar en forma combinada con otro tipo de fractura facial. Tienen una mayor incidencia en el sexo masculino, afectando mayormente a individuos entre 20 y 40 años de edad. Los accidentes de tránsito y las agresiones por robo son las principales causas. El tercio medio del macizo óseo-facial está conformado por un complejo de huesos unidos unos a otros, dentro de los que tenemos principalmente a los maxilares superiores, huesos propios nasales, malares y temporales. Razón por la que se ha querido elaborar una clasificación, que incluya las estructuras óseas mencionadas, que a la vez sea comprensible y de fácil aplicación.

The facial middle third unilateral outline fractures are in general the most frequent fractures of the bony-face bulk, and the superior maxillary and malar having the larger incidence. They occur as a result of severe traumatism. Age, sex and causing agent are the most important factors to determine handling. In some cases they combine with other face fractures. There is more incidence in males, affecting individuals mainly 20 to 40 year-old. Traffic accidents and burglar aggressions are main causes. The facial middle third of the bony-face bulk is conformed by a complex of bones united, mainly the superior maxillary, nasal, malar and temporal bones. We elaborate a classification that includes all mentioned bony structures, comprehensible and for easy application.

[A revised scheme for LeFort classification of upper jaw fractures].

OBJECTIVE: To put forward a revised scheme on LeFort classification for the upper jaw fractures. METHODS: 193 consecutive cases with the primary diagnoses of upper jaw fractures were involved in this study, for each one of which water's and CT scan were available to decide the fracture site and pattern. Data were filed in term of classification items as LeFort I, II and III fracture, as well as sagittal fracture and alveolar fracture. Statistical analysis was done to validate the meliorating thought on and revised scheme on LeFort classification. RESULTS: It was validated that of 185 cases with upper jaw fractures only 30.81% which presented single-line fracture and 34.06% which presented multiple-line fracture were covered with LeFort classification. Additional 13.51% with single-line fracture and 21.61% with multiple-line fracture could be included when LeFort classification was extended with increase of items of sagittal fracture and alveolar fracture. Further results revealed that among total 344 sites or fracture lines included in 193 cases, 81.10% could be diagnosed fracture pattern of LeFort classification. Of 65 fracture sites presenting LeFort III type, 92.31% were concomitant with LeFort II type or LeFort I and II type, very few being alone. CONCLUSIONS: A revised classification was proposeded that upper jaw fractures could be classified into four types as follows: (1) high horizontal fracture (corresponding to LeFort II and III type), (2) low horizontal fracture (corresponding to LeFort I type), (3) sagittal fracture (including midline and para-midline fracture) and (4) alveolar fracture.

Fracturas sagitales de maxilar superior: presentación de un caso clínico / Sagittal fractures of the upper jaw: report of a clinical case

En el siguiente trabajo se enfatiza la importancia de un buen diagnóstico ante todo traumatismo del área maxilofacial, en busca de fracturas sagitales del maxilar superior, las cuales están asociadas en un 25 por ciento con los trazos tipo Le Fort. Se describe la modalidad correcta de diagnóstico y su tratamiento, presentando un caso clínico para ejemplificarlo (AU)