Surgical Anatomy. — The superior maxilla may be considered the shell which forms the wall of the antrum of Highmore, and from this shell we have projecting in various directions, processes of bone which articulate with the adjoining bones of the face and cranium. <Callout type="important" title="Important">The different regions into which these processes project and their several functions render the subject of fracture of this bone diverse.</Callout>
The ^lasal process extending upward, inward and backward, articulates with the nasal, lachrymal, frontal and ethmoid bones, and enters into the formation of the nasal cavity, the orbit, the anterior ethmoidal cells and the lachrymal canal. Fracture of this process is associated with fracture of the nasal bones and for surgical purposes is to be considered under fractures of the nose.
The alveolar process is thick and arched and is hollowed out into sockets corresponding in number, depth and width to the sixteen upper teeth. A portion of the alveolar arch is not uncommonly fractured in the extraction of teeth, but the injury is not, as a rule, of serious import provided the line of fracture is confined to this process.
The malar process is thick, composed of a heavy tissue, supports the malar bone and sustains most of the impaction when the malar is driven into the face. It is therefore best considered with fractures of the malar. <Callout type="risk" title="Risk">Severe direct violence can result in comminuted fractures involving the antrum.</Callout>
The palatal process forms the greater part of the roof of the mouth and in this position is rarely subject to injury. It is sometimes, however, fractured by falls on objects held in the mouth, and is not infrequently the site of suicidal gunshot injury.
Fracture of the body of the bone may occur from blows on the face especially in instances in which the malar is impacted into its substance. Fractures of the body involve the antrum of Highmore and are therefore compound connecting with the outer air through the nasal cavity. In comminuted fractures, especially gunshot injuries, the fragments may be driven into any adjoining cavity (orbit, nasal cavity, zygomatic fossa, temporal fossa, mouth) or they may be displaced into the antrum itself. We may have a vertical line of fracture separating the bones of the two sides, or a horizontal fracture disarticulating the maxilla from the frontal. Another form of horizontal fracture situated at a lower level, separates the alveolar and palatal processes from the rest of the bone. Such fractures are necessarily the result of severe direct violence, such as a fall from a height or a kick from a horse.
Symptoms. — Deformity is very variable and may be entirely masked by the swelling which is likely to be pronounced and follows the injury rapidly. The most common displacement consists in depression of the fragments, the face being 'driven in' to a greater or less extent, in the region of the injury. Hemorrhage from the nose or mouth is prone to occur, and emphysema is sometimes seen as a result of air having been forced into the tissues from either the oral or nasal cavities. Depression in the region of the antrum is most common. Mobility and crepitus are variable and their absence should not lead us to exclude fracture. Loss of alignment in the teeth and mobility of a section of the alveolar arch are usually present when the fracture involves this process. The symptoms in general will vary greatly according to the region of the bone involved and the associated injury of the soft part. We sometimes see cases in which the face is so severely crushed that it is no longer a question of which of the facial bones is fractured but, — have any escaped?
<Callout type="tip" title="Tip">Examine the nasal and oral cavities carefully when diagnosing maxilla fractures.</Callout>
Diagnosis. — The upper jaw is examined in a manner similar to the malar. The outline of the upper portion may be palpated through the face and its two sides compared. The lower portion of the bone and the teeth may be examined through the mouth, and the lateral wall of the nasal cavity inspected through the nostril. Mobility may rarely be elicited by making pressure on the face in various directions. Crepitus is likewise an uncommon symptom.
Treatment. — The treatment of fracture of the superior maxilla, like the symptoms, varies according to the region of the fracture. Fracture of the nasal process is treated similarly to fracture of the nasal bone, and is included under that heading. <Callout type="warning" title="Warning">Severe lacerated wounds associated with maxilla fractures can lead to significant blood loss.</Callout>
Fracture of the malar process is a condition very similar to so-called fracture of the malar, and is treated in a like manner. Fracture of the body of the bone frequently calls for some method of elevating the depressed fragment, and this may often be accomplished through the mouth, thus avoiding a scar of the face. Fracture of the superior maxilla is very commonly associated with severe lacerated wounds of the face, and when such is the case we have the wound to deal with in addition to the fracture itself. The vitality of the tissues is high on account of the free circulation, and accordingly it will seldom be necessary to remove fragments of bone or to trim away torn tissue unless manifestly devitalized. Lacerated wounds of the face should be freely washed with normal salt solution in order to remove infectious material which has been driven into the tissues, and wounds of the mucous membrane communicating with the fracture through the mouth should be frequently and freely irrigated in order to avoid subsequent infection. Fracture of the alveolar arch is to be treated according to the requirements of each individual case. When there is no tendency toward displacement of the fragments the chief indication is that of cleansing with a mild alkaline solution. If there is displacement of teeth and disturbed occlusion through loss of alignment it may become necessary to hold the fragments in position by wiring the teeth or by means of an aluminum dental splint as described in the treatment of 'Fracture of the Lower Jaw' (page 357). Separation of the two superior maxillae may also be immobilized in the same manner. Openings through the palatal process should, except in cases of simple fissure, be protected from the mouth during the process of healing by a hard rubber plate. In gunshot injuries, the area of fracture may be protected from contamination by food, and the nasal and oral cavities separated in this manner.
Operative Treatment. — Operative treatment is indicated in severe compound cases. It will be impossible, however, to lay down any hard and fast lines of procedure, since the needs of each and every individual case will vary, and the surgeon will find it necessary to meet the demands of the case in hand.
After-Treatment. — The chief indication of after-treatment will be to keep the parts clean, prevent infection and allow nature to unite the fragments. In the presence of infection we should see to it that the antrum is freely drained; this may be accomplished by the extraction of the first or second molar or by perforating the anterior wall of the antrum above the roots of these teeth. The antrum may also be entered and drained through the inferior or middle meatus; when the opening is made through the inferior meatus it may be necessary to previously remove the inferior turbinate. During the early part of the after-treatment the nose should be irrigated three to four times daily and the oral cavity should receive equally careful attention.
Prognosis. — Union usually takes place in from six weeks to two months. Prognosis as to life is good except in severe crushing injuries of the face in which shock is great, and associated injuries of the skull and brain probable. The prognosis as to deformity is frequently not good in fracture of the body of the bone. Fracture of the nasal process can usually be treated without subsequent deformity. Fracture of the malar process is not so favorable in this respect.
The presence of infection renders the prognosis worse but if proper treatment be established without delay and efficient drainage and lavage maintained the outcome should in most cases be good. In fracture of the alveolar process small sloughs of bone may require removal but this does not signify that the ultimate outcome will not be good.
<Callout type="gear" title="Gear">Hard rubber plates can be used to protect openings through the palatal process during healing.</Callout>
Key Takeaways
- The superior maxilla is a complex bone with multiple processes that articulate with other facial bones.
- Fractures of the nasal process are treated similarly to nasal fractures, while those of the malar process require similar treatment as malar fractures.
- Elevating depressed fragments through the mouth can avoid scarring on the face during treatment.
Practical Tips
- Carefully examine both the oral and nasal cavities when diagnosing maxilla fractures to ensure a comprehensive assessment.
- Use a mild alkaline solution for cleaning displaced teeth and maintaining occlusion in cases of alveolar arch fracture.
- Protect openings through the palatal process with hard rubber plates during healing to prevent infection.
Warnings & Risks
- Severe direct violence can result in comminuted fractures involving the antrum, which may lead to serious complications.
- Lacerated wounds associated with maxilla fractures can cause significant blood loss and require prompt treatment.
- Infection is a risk that must be carefully managed during after-treatment to ensure proper healing.
Modern Application
While the surgical techniques described in this chapter are historical, the principles of diagnosing and treating facial fractures remain relevant. Understanding these complex fractures can help in recognizing injuries and providing appropriate care, even if modern methods differ significantly in execution.
Frequently Asked Questions
Q: What are the common symptoms of a maxilla fracture?
Common symptoms include deformity, depression of fragments, hemorrhage from the nose or mouth, emphysema due to air being forced into tissues, and loss of alignment in teeth. Mobility and crepitus may also be present.
Q: How is a maxilla fracture treated?
Treatment varies based on the region involved but often includes elevating depressed fragments through the mouth or using dental splints to hold displaced teeth in place. Wounds are cleaned with salt solution, and irrigation of the nasal cavity may be necessary.
Q: What is the prognosis for maxilla fractures?
Union usually occurs within six weeks to two months. The prognosis varies depending on the region involved; fractures of the body of the bone often result in deformity, while those of the nasal and malar processes generally have a better outcome.