What are the different types of facial fractures and their treatments?

Types of Facial Fractures

Facial fractures are classified by anatomic location and include nasal bone fractures (most common), orbital floor fractures, zygomaticomaxillary complex fractures, maxillary sinus fractures, and mandibular fractures, with treatment ranging from observation to surgical repair depending on fracture pattern and functional impairment. 1

Classification by Anatomic Location

Upper Face Fractures

• Frontal bone and frontal sinus fractures occur from high-energy impacts and require CT imaging for evaluation 1
• These injuries may involve the anterior cranial fossa and require neurosurgical consultation 2

Midface Fractures

Nasal Fractures

• Nasal bone fractures are the most common facial fracture overall 1
• Motor vehicle collisions and recreational vehicle accidents frequently cause nasal bone injuries 1

Orbital Fractures

• Orbital floor fractures (blow-out fractures) are the second most common, often presenting with diplopia, enophthalmos, and extraocular muscle entrapment 1, 3
• Serious ocular injury occurs in up to 24% of blow-out fractures 4

Zygomaticomaxillary Complex (ZMC) Fractures

• Zygoma fractures are the second most common isolated facial fracture and typically involve multiple attachment points 3
• Penetrating trauma and assaults more commonly produce midface and zygomatic fractures 1
• Clinical presentation includes facial asymmetry, periorbital ecchymosis, and malocclusion 3, 5

Maxillary Fractures (LeFort Classification)

• LeFort fractures are transfacial fractures classified by involvement of pterygoid plates 6
• These represent complex strut fractures involving multiple facial buttresses 6
• Present with facial elongation, malocclusion, and midface instability 5

Lower Face Fractures

Mandibular Fractures

• Mandibular fractures are the most prevalent single fracture type and occur more frequently in males 1, 7
• Motor vehicle collisions commonly result in mandibular fractures 1
• Combat environments show mandible fractures as most common 1

Classification by Energy Pattern

Beyond anatomic location, fractures can be classified by comminution and displacement pattern 8:

• Low-energy fractures: Minimal comminution and displacement, subtle symptoms, simple treatment required 8
• Middle-energy fractures: Moderate comminution requiring standard surgical approaches and rigid fixation 8
• High-energy fractures: Severe comminution with dramatic instability and marked facial architecture changes, requiring multiple surgical approaches to visualize and fix the buttress system 8

Treatment Approach by Fracture Type

Immediate Surgical Repair (Emergency)

• Entrapped muscle with oculocardiac reflex (bradycardia/heart block) requires immediate surgery 4
• "White-eyed blow-out fracture" with muscle entrapment, particularly in children 4
• Globe subluxation into maxillary sinus 4

Early Surgical Repair (Within 2 Weeks)

• Symptomatic diplopia with positive forced ductions or CT-confirmed entrapment 4
• Large floor fractures with hypoglobus and progressive infraorbital hypoesthesia 4
• Early enophthalmos causing facial asymmetry 4
• Mandibular and maxillary fractures with malocclusion require reduction to restore normal dental occlusion 9

Delayed or Observation

• Minimal diplopia not affecting primary or downgaze can be observed 4
• Good ocular motility without significant enophthalmos may be managed conservatively 4
• Strabismus may resolve spontaneously; waiting 4-6 months is advised when no muscle entrapment exists 4

Imaging Recommendations

CT maxillofacial is the preferred initial imaging modality for suspected midface injuries, providing high-resolution delineation of osseous and soft-tissue structures 3

Critical Clinical Pitfalls

• Malocclusion is a direct indicator of midface and mandible injury and must be assessed in every facial trauma evaluation 5
• Up to 37% of patients have persistent diplopia postoperatively despite proper orbital fracture repair 4
• Associated cervical spine and intracranial injuries must be excluded before focusing on facial fractures 1
• The traumatic collapse of facial structures has a "cushion effect" that may shield the brain but can still transmit energy to the cervical spine 1