The anatomical structure of the midface is complex, with irregular bone morphology, many joints, sinus cavities, and thin bone walls, which makes it easy to be injured when subjected to external forces, and often results in complex multiple fractures. In clinical practice, any fracture involving two or more parts of the face, including the fracture of the middle part of the face, resulting in a change of the three-dimensional scaffold of the face, can be considered a comprehensive fracture. The extensive damage and loss of anatomical landmarks in a full fracture makes surgery difficult and is often associated with postoperative facial deformity and functional impairment.
Surgical anatomy
The maxillofacial skeletal structure consists of a number of horizontal and vertical pillars that are interlaced. The vertically oriented pillars include the nasomaxillary, zygomaticomaxillary and pterygomaxillary pillars. The condylar and mandibular ascending pillars represent another vertical pillar that maintains the posterior height of the face. The horizontal pillars of the face are also referred to as the anterior-posterior pillars, and they include the frontal, zygomatic, maxillary, and mandibular pillars. None of these pillars exist in isolation; they are interrelated for the facial skeleton to maintain its structural integrity. In these pillars, the bone is often thickened to neutralize the forces of chewing or impact. Correct repositioning of these pillars during fracture treatment makes it possible to properly reconstruct facial height, width, and facial prominence.
Some of the key maxillofacial landmarks that help restore the correct position of the facial bones are the upper and lower dental arches, the mandible, the zygomatic butterfly suture, and the zygomatic alveolar ridge. After a full facial fracture occurs, these important landmarks and anatomical structures can be used to accurately reset the fracture and reconstruct the facial pillars.
Causes of fracture
Motor vehicle traffic accidents, violence, sports accidents, industrial accidents and gunshot wounds, mostly caused by high-speed impact.
Fracture diagnosis
Full-face fracture injury is often more serious, after the vital signs are stabilized, in addition to careful examination to clarify the jaw and face injury, we should also pay attention to the situation of systemic injury, especially the cranio-cerebral injury situation, if there is suspicion of other organ injury, promptly ask the relevant department doctors to consult.
1. Medical history
Ask the patient or other witnesses to understand the nature, size and direction of the injuring force, whether there is a history of post-injury coma and post-injury treatment history, etc.
2.Clinical manifestations
(1) Severe facial deformity Due to the severity of the injury, involving multiple areas in the middle of the face, severe facial deformity may occur. Typical manifestations are widening of the face, smaller anterior protrusion, depression of the middle of the face, forming the so-called “disc-shaped face” deformity.
(2) Functional disorders are often manifested as severe occlusal disorders. It also often shows a widening of the maxillary and mandibular arch fracture. It is also often accompanied by gum tears, tooth fractures and tooth dislocations, making it difficult to restore the occlusion. There may also be dysfunction of the nose, eyes and other organs.
(3) Craniocerebral injury is often combined with obvious manifestations of craniocerebral injury. Such as coma, intracranial hematoma, cerebral contusion and cerebrospinal fluid nasal leakage.
3.Imaging examination
(1) Plain films are of little significance for the diagnosis of complex fractures in the general area.
(2) CT can assist the surgeon to formulate the surgical plan and determine the specific fracture repositioning sequence by observing different CT levels and 3D reconstruction images, the maxillofacial trauma surgeon can not only clarify the details of the fracture but also grasp the characteristics of the fracture as a whole.
Fracture Treatment
Surgery is the preferred treatment for full-face fractures. Because of the multiple bones of the face involved in a global fracture, there is a problem with the sequence of fracture repositioning. There are two classical clinical sequences for total fractures: “bottom to top, inside to outside” or “top to bottom, outside to inside”. However, neither treatment sequence can be suitable for all fracture situations and it is impossible to obtain the best surgical result in all cases. In general, treatment should follow the principle of the known leading to the unknown. The oral and maxillofacial trauma surgeon must be familiar with both treatment procedures and be able to apply relatively reliable landmarks to guide the repositioning with the aim of obtaining the best possible surgical outcome.
The deformities of the face are mostly caused by poor local anatomical repositioning, especially the fractures of the zygomatic complex p nasal orbital sieve and the orbit, which have a great impact on the face shape, and their precise repositioning is the key to facial rehabilitation and the key and difficult point in maxillofacial rehabilitation. In addition, soft tissue repositioning and strict layered alignment sutures are also necessary to ensure correct soft tissue repositioning. The treatment of such a serious maxillofacial trauma as a full facial fracture is a systematic project, which requires the collaboration of multidisciplinary physicians from maxillofacial surgery, ophthalmology, otorhinolaryngology, orthodontics, oral implantology and prosthodontics to achieve a relatively satisfactory treatment effect.
Post-operative precautions
It is recommended to apply antibiotics for 3-5 days after surgery. Antibiotics can be selected from penicillin and cephalosporin antibiotics. Postoperatively, we should also observe whether there is fluid accumulation in the operated area and whether there are signs of infection in the wound; we should also check whether there is cerebrospinal fluid leakage and vision; postoperatively, if the occlusal relationship is poor, elastic traction for 1-2 weeks; postoperatively, if there is restriction due to mouth opening, early mouth opening training is recommended to improve the degree of mouth opening; postoperative CT examination is recommended to clarify the fracture repositioning. Postoperative review should be done according to the doctor’s prescription in order to deal with surgical complications and arrange postoperative treatment in a timely manner.