The face is made from several different bones, many of which are fused together. There are two joints to the face on either side of the cheeks, called the temporomandibular joints. Facial fractures can be minor or severe, depending on their location and whether or not they are displaced. Open fractures are more serious than closed fractures because open areas of bone are prone to bone infections, which are difficult to treat.
Most facial fractures come from motor vehicle accidents, although sports injuries, falls, and assaults can result in facial fractures as well. Most facial fractures require medical attention with the exception of nondisplaced nasal bone fractures, which tend to heal on their own without any sort of medical intervention.
When a patient has sustained a facial fracture, especially when it has occurred as a result of a severe fall or motor vehicle accident, the likelihood of other injuries is high so that medical attention may not be focused on the facial fractures until other, more serious injuries can be tended to first.
Presentation of Facial Fractures
A facial fracture should be suspected anytime there has been trauma to the face associated with significant pain, facial swelling, bruising, malocclusion of the teeth, or things like double vision or other visual disturbance.
Each type of fracture of the face has its own particular set of symptoms and signs. For example, a nasal fracture will present with the following:
• Nasal swelling
• Tenderness to the touch of the nose
• Nasal deformity
• Nosebleed, which may be minor or profuse
• A severe deformity of the nasal bridge can mean a fracture of the ethmoid bones within the nose itself
• Clear nasal discharge if the cerebrospinal fluid is leaking
If the patient is suspected of having a broken jaw, also called a broken mandible, there can be these symptoms:
• Tenderness to touching the jaw bone
• Pain in the jaw
• Malocclusion, which means the teeth do not align correctly
• Bruising occurring at the base of the tongue
Midface fractures are also called maxillary fractures. Typical findings in a midface fracture include the following:
• Malocclusion of the teeth
• Visual disturbances
• Clear nasal drainage if the cerebrospinal fluid is leaking
• Bruising beneath the eyes
• Distortion of the facial features, such as a sunken cheek
• Difficulty breathing due to swelling which may require endotracheal intubation
Cheekbone or zygomatic fractures have these particular symptoms:
• Flattening or sunkenness of the cheeks
• Visual changes
• Numbness of the area below the eye
• Pain worse with movement of the jaw
• Blood in the eye on the affected side
Fractures of the eye sockets are called orbital fractures. Typical symptoms include the following:
• Numbness beneath the affected eye
• Sunken eye
• Double vision especially when looking upward
Temporomandibular Joint dislocation symptoms include the following:
• Deviation of the jaw to one side
• Tenderness over the TMJ on one or both sides
• Inability to close the mouth
Warning Signs that require medical attention
If you think you have a facial fracture, you should seek medical attention. Reasons why you might want to be seen rather acutely include having the following symptoms:
• Clear nasal discharge (which can mean cerebrospinal fluid drainage)
• Problems with breathing
• Severe bleeding from the nose
• Any type of loss of consciousness
• Double vision or blurred vision
• Loss of hearing or ringing in the ears
• Pain when you try to move the jaw
• Any type of malocclusion
• Asymmetrical facial features
• Open wounds with bone visible within the wound
Diagnosing facial fractures
Facial fractures may sometimes be able to be diagnosed by means of plain film x-rays. This is especially true of nasal fractures.
Other areas involving facial fractures are more difficult with the need for CT scan of the head/face or with an MRI of the head/face. There are special dental x-rays that can show the presence of a mandibular fracture or a maxillary fracture. This type of x-ray is not available at all facilities as they are usually used in the dental field. Remember that midface fractures from an automobile fractures are a sign of significant impact so that other injuries need to be looked for carefully. Often those with midface fractures have serious injuries elsewhere on the body.
Zygomatic or cheekbone fractures are easier to diagnose early on, before the swelling has taken hold. There are special views that can be done on x-ray that will show the zygomatic bone quite easily. CT scan of the face may be able to diagnose a zygomatic fracture as well. Orbital fractures can be diagnosed with plain film x-ray or CT scan. TMJ dislocations can also be diagnosed with x-ray.
The treatment of facial fractures depends somewhat on which part of the face is injured. In a nasal fracture, the doctor will control the bleeding if present and will drain any septal hematomas that may form on the nasal septum. Swelling is allowed to dissipate over a few days before surgical reduction of the nose is done in the operating room. Ethmoid fractures are a bit more serious than an ordinary nasal fracture and require hospitalization and monitoring for CSF drainage.
If a jaw fracture is closed, it can wait until an oral surgeon can repair the damage using surgery. If the mandibular fracture is open inside the mouth with bone exposed, it requires hospitalization and IV antibiotics before definitive surgery is done.
Midface fractures may require endotracheal intubation in order to maintain an airway because the amount of swelling can be so great that the airway is impeded. These fractures rarely heal spontaneously and require surgical repair using a plastic surgeon or maxillofacial surgeon. ENT doctors are also trained to repair maxillary fractures.
If the zygomatic arch of the cheekbone is fractured, the patient requires surgery so that there isn’t a permanent cosmetic defect on the affected side. Orbital fractures require surgical repair if there is entrapment of the inferior eye muscles into the maxillary sinus. If there is no entrapment, surgery may not be necessary. CT scans can help decide which fractures require surgery and which fractures may not. If the patient has TMJ dislocation, it can be manually realigned by the emergency room doctors. Sometimes a local anesthetic is given to relax the jaw prior to relocation of the TMJ.
Prognosis of Facial Fractures
The prognosis of facial fractures depends on the area of the face involved. Nondisplaced nasal fractures or those that are easily reducible during surgery often heal without sequelae, although persistent deformities can be present. Mandibular fractures usually heal well. People who have midface fractures tend to do more poorly because they often suffer from other serious injuries besides their facial fractures. Certain fractures of the maxilla can lead to blindness. Cheekbone fractures are not dangerous but the patient can be left with an unacceptable cosmetic result.
When there is a TMJ dislocation, the jaw should remain relatively closed after the relocation so that the jaw doesn’t dislocate again.
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