What is the treatment for fractures of the anterior nasal spine of the maxilla?

Treatment of Anterior Nasal Spine Fractures

For displaced anterior nasal spine fractures, perform open reduction and internal fixation via an intraoral or sublabial approach, as conservative management will not adequately address the displacement and associated functional symptoms. 1

Initial Diagnostic Assessment

• Obtain CT imaging with three-dimensional reconstruction to confirm the fracture and assess displacement of the anterior nasal spine, as this is the gold standard for characterizing midface injuries 2, 1
• Look specifically for pain aggravated by upper lip closure and tenderness over the nasolabial angle region, which are pathognomonic clinical features 1
• Assess for associated septal deviation, as the septum must be repositioned before addressing bony structures 2

Treatment Algorithm Based on Displacement

For Displaced Fractures (Primary Recommendation)

Surgical intervention is indicated when displacement is present:

• Perform open reduction and internal fixation through an intraoral or sublabial approach to directly visualize and stabilize the fracture 1
• Use permanent 5-0 nylon suture or PDS 4-0 suture driven through soft tissue including periosteum, or through small drill holes in the nasal spine or premaxillary ridge for repositioning 2
• This approach provides direct access to the anterior nasal spine without external scarring and allows precise anatomical reduction 1

For Minimally Displaced or Non-Displaced Fractures

• Conservative management may be considered only when displacement is minimal and no functional symptoms are present 1
• However, recognize that even slight deviations with residual cartilage tension may not be predictably corrected without surgical intervention 2

Critical Technical Considerations

Septal Management (Must Precede Bony Correction)

• Address any associated septal deviation first, as "as the septum goes, so goes the nose" 2
• For caudal septal deflection accompanying anterior nasal spine fractures, use suture fixation through the nasal spine or premaxillary ridge on the opposite side of deviation 2
• Consider the "contralateral subluxation locking" technique if the caudal septum is bowed, repositioning at least 1 cm width of septum to the contralateral side of the thinned nasal spine/maxillary crest 2

Surgical Approach Details

• Use the smallest manipulative force necessary to achieve reduction while preserving periosteal and mucosal attachments 3
• Avoid creating periosteal tunnels, as these destabilize the osseous framework 3
• The intraoral approach provides excellent access to the anterior nasal spine and maxillary structures without visible scarring 4, 5

Postoperative Management

• Resume regular diet within 2 weeks following uncomplicated open reduction and internal fixation 1
• Monitor for complete resolution of clinical symptoms, including pain with upper lip closure 1
• Assess for any residual nasal obstruction or deformity that may indicate inadequate septal correction 6

Common Pitfalls to Avoid

• Do not dismiss vague nasal discomfort following facial trauma, as this may be the only presenting symptom of anterior nasal spine fracture 1
• Never attempt closed reduction alone for displaced anterior nasal spine fractures, as this will not provide adequate stabilization 1
• Do not overlook associated septal injuries, which are responsible for postoperative nasal deformity and obstruction if left unaddressed 3, 6
• Recognize that anterior nasal spine fractures can be mistaken for simple nasal bone fractures, resulting in inappropriate treatment that jeopardizes outcomes 4

When to Consider Alternative Approaches

• Endoscopic endonasal open reduction may be considered for fractures involving the frontal process of the maxilla extending to the nasal spine region, providing excellent visualization and anatomical reduction 5
• For complex nasomaxillary fractures involving the anterior nasal spine, canine pillar, and anterior maxillary bone, open reduction and internal fixation via the intraoral approach with or without an added infraorbital approach provides good long-term outcomes 4