Maxillofacial reconstructive surgery can involve treatment of the bone and soft tissue structures of the face.
Bony structures: Mandible (lower jaw), Maxilla (upper jaw), Nose and internal nasal structures, Zygoma (cheek bones), Orbits and Orbital floor (bones about the eyes), Frontal bones and Frontal Sinuses (forehead).
Soft tissue structures: Skin, Eyelids, Lips, Tongue, Nose, Ears.
Maxillofacial surgery is considered reconstructive surgery when the treatment is necessary to restore function or alignment of structures in the head and neck. A good example of this is when surgery is required for facial fractures sustained as a result of a sports injury or a motor vehicle accident.
Reconstructive maxillofacial surgery is ideally performed within days of the primary accident, typically not to exceed 2 weeks from the date of injury. This has to do with the timeline of bone healing and difficulty of repair once the bones start to heal. In some cases, secondary surgery may need to be performed either months or even years after the primary surgery in order to try to improve, change or alter the results which have occurred as a result of normal scarring which occurs with the normal process of healing.
Orbital Bone Fractures
- The eyeball (orbital globe) is housed and protected within the bones of the face referred to as the Orbits. The orbits are made up of 8 individual and distinct --- hyperlink to image of orbital bones
- When a blunt traumatic injury to the orbital region occurs, it is common that one or multiple of these bones sustain a fracture. The most common injury is an orbital floor fracture commonly referred to as a “blowout” fracture.
- Common injuries resulting in orbital bone fractures:
o Sports related: baseball, tennis, etc in which one might get directly hit in the eye with a ball
o Traumatic injuries such as motor vehicle collision, work related, assault
- Swelling, bruising, and tenderness are all normal
- EMERGENT symptoms to report include difficulty moving your eye, nausea associated with upward gaze, vision changes such as blurry or double vision. These would necessitate immediate evaluation and may require surgery to prevent permanent injury.
- CT scan of the facial and orbital bones is required to confirm location and extent of fractures
- It is also recommended that a complete ophthalmology exam is performed to evaluate and rule out any injury to the globe itself
- Treatment of orbital fractures is dependent on location and severity of fracture
- Mild, nondisplaced fractures may heal over time with close observation
- Severe or displaced fractures require surgical repair to realign the bones and stabilize them in place with hardware.
- Orbital floor fractures specifically require an overnight hospital to closely observe for potential complications following surgery.
- Goals of orbital floor reconstructive surgery are to repair the fracture, protect the orbital globe, resolve any ocular nerve or muscle entrapment, preserve vision, and improve function and appearance
- The zygoma is commonly known as the cheek bone and lies between the orbital bone and the upper jaw (maxilla).
- It is commonly fractured by sustaining a direct hit from sports injuries or assault.
- Swelling, bruising, and tenderness.
- You may notice an indented appearance on the injured side.
- Additionally, you may have difficulty chewing or opening your mouth.
- A CT scan of the facial bones along with a complete physical exam is required to evaluate and diagnose the facial bone fractures accurately.
- If the diagnosis of a zygoma fracture is confirmed, surgery may be required. This may be done in a variety of ways depending on the complexity of the fracture and if there are other bones that were also broken at the time of injury.
- One option requires a simple incision behind the hairline and does not involve plates and screws to fixate the fracture.
- The alternative is to place incisions in hidden areas (ie- inside the mouth or lining of the eye) to provide access to the bone and allow for fixation.
- Goals of zygoma reconstructive surgery are to restore function and appearance while stabilizing any fractures.
Maxilla and Mandible Fractures
- The maxilla (upper jaw) and mandible (lower jaw) are the “teeth bearing” bones of the face.
- Fractures of these bones occur from either direct or indirect blunt force to the facial bones.
- Fracture of these facial bones may also be associated with fractures of the teeth or tooth roots within the region of the bony fracture sites. If this occurs, follow up with a dentist or oral surgeon will be advised.
- Maxilla and mandibular fractures can result in “mal-occlusion” of the teeth. When this occurs, the patient will feel that the teeth do not fit together. This occurs because the fracture site is contacting the teeth of the opposing jaw in a different way from before the injury.
- As with other facial fractures, a CT scan is indicated to assess exact location of the fractures and allow for surgical planning.
- Treatment of fractures of the maxilla and mandible are most commonly performed with surgical re-alignment of the fractured facial bones and fixating the fractures with micro plates and screws.
- It is often required that metal braces, referred to as “arch bars” or MMF for maxillomandibular fixation, be placed along the upper and lower teeth in addition to the placement of the micro plates and screws to optimize alignment of the teeth to their original position.
- The arch bars may remain in place for up to six weeks after surgery to provide additional support to the alignment of the bony fractures during the healing phase.
- If there are any broken teeth or tooth roots, these will likely need to be removed at the time of the surgery.
- The main goals of maxilla and mandible reconstructive surgery are to stabilize fractures and restore teeth occlusion, which will improve function and appearance of the jaw.
- One commonly known complication is the inability to perfectly align the teeth so that the bite feels “off”. This happens if even one tooth mismatches as little as a millimeter. In this case, dental consultation is recommended to assess need for tooth shaping or alternatives.
Frontal Bone and Frontal Sinus Fractures
- The bony support of the forehead is made up of the Frontal Bones.
- Within the frontal bones in the region above the nasal bridge lies the frontal sinuses.
- In cases where the forehead sustains blunt trauma the frontal sinuses are often fractured.
- Bruising and pain are common
- There may or may not be a bony deformity that is visible or palpable
- Frequently have no associated symptoms
- A complete CT evaluation of the involved region is required prior to treatment.
- The bony fractured segments are realigned and fixated with micro plates and screws.
- In some cases of high speed trauma, the bones may be broken into tiny pieces which are not able to be pieced back together. In certain circumstances, bone graft or titanium mesh will need to be used to bridge the gap and provide stability for the overlying tissue.
- Fractures of the frontal sinuses may cause long term issues which need to be addressed if the drainage system of the sinuses (nasal-frontal ducts) is damaged due to the trauma of the frontal bone fractures.
- Restore appearance and function, and prevent complications of frontal sinus fractures
- a CT scan is required with all frontal sinus fractures, whether surgery is performed or not, 6 months after the injury to ensure that the sinuses are draining normally. If there is any occlusion of the ducts, surgery may be required to restore normal outflow and function.
- Nasal bone fractures are the most common facial bone injury.
- Traumatic nasal bone injuries may or may not cause obvious deformities such as a crooked nose. More than that, they can result in difficulty breathing due to damage to the internal structure, the septum, causing it to deviate and make one of the nasal passages smaller than the other.
- Considered a surgical emergency, bleeding within the tissue lining the septum can result in a septal hematoma. If not treated in time, this can cause permanent damage to the septum itself and will require reconstructive surgery to restore both function and cosmetic appearance.
- Additionally, a perforated septum,
- Even if there is obvious deformity, a CT scan is usually required to correctly diagnose the extent of damage and determine if surgery is necessary
- Nondisplaced fractures that do not cause airway obstruction may be watched nonoperatively.
- Nasal bone fractures that are displaced or causing nasal airway obstruction require surgical repair. This may range from a simple reduction while awake to going to the operating room for more complex fractures or those that require intervention for septal damage.
- Even in cases where the nasal bones and/or nasal septum are aligned, straightened and reduced, there is always the possibility that due to normal healing and scar tissue, further surgery may be required in the future.
- Restore normal appearance and symmetry as best as possible and resolve nasal airway obstruction, improving air flow and breathing.
- In complex nasal and septal fractures, a saddle-nose deformity is a known potential complication, causing a collapse of the bony structure. In these cases, a bone graft, which may be taken from a variety of places including the ribcage, the iliac crest or hip bone, or cadaveric graft, to maintain the structural integrity of the nasal bones.