List of Abbreviations
BP – blood pressure
Maxilla – upper jaw
TMJ – Temporomandibular joint
MFR – maxillofacial region
TBI – traumatic brain injury
RTA – road traffic accident
PAP – perioperative antibiotic prophylaxis
SSI – surgical site infection
Terms and Definitions
Subcutaneous emphysema – accumulation of air or gas bubbles in the subcutaneous adipose tissue.
Bone crepitus – a crunching sensation upon palpation during movements at the fracture site.
Subcutaneous crepitus – a characteristic crunching sound caused by the movement of gas bubbles in the tissues.
«Step-off» sign – palpation finding of a displaced bone fragment edge.
Indirect load sign – sharp pain at the fracture site due to the displacement of fragments and irritation of the damaged periosteum when pressure is applied to a clearly intact area of the jaw.
Hypoesthesia – decreased sensitivity.
Malevich sign («Broken pot» sound) – a sign of a zygomatic bone or maxillary fracture; percussion of the teeth produces a dull, rattling sound resembling that of a cracked clay pot being tapped lightly.
Occlusion – contact between the dental arches or individual opposing groups of teeth.
Central occlusion – the intercuspation of the dental arches characterized by the maximum number of interdental contacts.
Bite – the pattern of closure of the dental arches in the central occlusion position.
Diplopia – a vision disorder consisting of double vision. Binocular diplopia occurs when viewing with both eyes, monocular when viewing with one eye.
Middle third of the facial skeleton – the zone bounded superiorly by a line passing through the upper margins of the orbits, and inferiorly by the line of dental occlusion. It includes the nasal bones, orbital walls, zygomatic bones and arches, and the maxillae proper.
Upper third of the facial skeleton – the zone including facial skeleton structures located above a line passing through the upper margins of the orbits. It includes the frontal bone, frontal and ethmoidal sinuses. The anterior cranial fossa and frontal lobes of the brain may be involved.
Hypophthalmos – a lower than normal position of the eyeball within the orbit.
Enophthalmos – a more posterior (deeper) than normal position of the eyeball within the orbit.
Exophthalmos – a more prominent (anterior) than normal position of the eyeball within the orbit.
Fragment reduction – a procedure aimed at repositioning and aligning bone fragments.
Osteosynthesis – surgical fixation of bone fragments.
Anisocoria – a condition characterized by unequal pupil sizes, and possible slight pupillary deformity.
Hemosinus – accumulation of blood in the paranasal sinuses.
Cerebrospinal fluid leak (CSF leak) – leakage of cerebrospinal fluid through a dural defect.
Nasal CSF leak – CSF leakage into the nasal cavity through a dural defect in the anterior cranial fossa.
Otorrhea (CSF) – leakage of cerebrospinal fluid through the external auditory meatus via a dural defect in the middle cranial fossa.
«Pocket handkerchief» sign – a clean handkerchief moistened with CSF remains soft after drying, whereas if moistened with nasal secretions, it becomes stiff («starch-like»).
«Double ring» sign – leaking blood forms a brown spot in the center of a gauze pad with a yellow halo of cerebrospinal fluid at the periphery.
«Raccoon eyes» sign – hemorrhage into the eyelid tissues.
Superior orbital fissure syndrome – ophthalmoplegia (paralysis of eye muscles), ptosis (drooping of the upper eyelid), loss of sensation in the upper eyelid and forehead skin, and pupil dilation and fixation.
Guérin's sign – pain along the fracture line upon upward pressure with the index finger on the pterygoid processes of the sphenoid bone.
Frankfurt horizontal (or orbitomeatal line) – the plane passing through the upper margins of the external acoustic meatus (porion) and the lowest point of the lower margin of the left orbit (orbitale).
External approach – a type of surgical access performed by sequentially dissecting the skin/conjunctival mucosa and deeper soft tissue layers to visualize the maxillary fragments.
Intraoral approach – a type of surgical access performed within the oral cavity by sequential dissection of the oral mucosa, periosteum, and sometimes deeper soft tissue layers to visualize the maxillary fragments.
Isolated maxillofacial injury – an injury involving a single lesion within the maxillofacial region.
Multiple maxillofacial injury – an injury involving multiple lesions within the maxillofacial region.
Multiple head injury – injury to multiple head compartments (maxillofacial, ENT, visual system, or brain) resulting from one or more wounding projectiles.
Polytrauma involving the maxillofacial region – simultaneous injury to the maxillofacial region and other anatomical body regions (head, neck, abdomen, pelvis, spine, limbs).
1. Brief information on the disease or condition
Maxilla (maxilla) – a paired bone of the facial skeleton.
Anatomical features of the maxilla
The maxilla consists of a body and 4 processes:
Frontal process
Zygomatic process
Alveolar process (containing dental alveoli)
Palatine process of the maxilla
Maxillary apertures and foramina:
Maxillary sinus ostium – a large opening on the nasal surface of the maxilla leading into the maxillary sinus.
Infraorbital foramen – located on the anterior surface of the maxilla, serving as the exit point of the infraorbital canal.
Alveolar foramina – several openings on the infratemporal surface of the maxilla, through which blood vessels pass to the upper large molars.
Canals of the maxilla:
Infraorbital canal – a canal that begins as a groove on the orbital surface of the maxilla, passes through it, and opens on the anterior surface, below the infraorbital margin, via the infraorbital foramen; the neurovascular bundle of the same name passes through the canal.
Nasolacrimal canal – formed by the frontal process of the maxilla, the lacrimal bone, and the inferior nasal concha, connecting the orbital cavity and the nasal cavity. The canal originates in the lower part of the medial wall of the orbit and opens into the inferior nasal meatus. Through this canal, lacrimal fluid drains into the nasal cavity, which is particularly noticeable when crying.
Incisive canal – an unpaired osseous canal formed by the fusion of the palatine processes of the right and left maxillae; a passageway for blood vessels and nerves.
Greater palatine canal – formed by the fusion of the maxilla and the perpendicular plate of the palatine bone. It connects the pterygopalatine fossa with the oral cavity; it opens in the posterior part of the hard palate via the greater palatine foramen, through which the neurovascular bundles of the same name pass.
Contributes to the formation of the walls of:
The orbit
The nasal cavity
The oral cavity
The infratemporal fossa
The pterygopalatine fossa
Le Fort fractures of the maxilla are complex fractures of the facial bones resulting from high-kinetic-energy trauma directed at the structures of the midface.
Fractures of the maxilla of all three types are typically accompanied by cerebral concussion (contusion) and a skull base fracture.
1.1 Definition of the disease or condition
Maxillary fracture – damage to the maxilla resulting in disruption of its integrity.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Mechanical (traumatic) maxillary fracture – damage to the maxilla resulting in a disruption of its integrity under a load exceeding the structural strength of the injured bone area [1].
A maxillary fracture can occur either as a result of a direct blow or due to compression of the facial skeleton.
A Le Fort I fracture usually occurs as a result of a horizontal force applied to the anterior part of the maxillary alveolar process and directed somewhat downward.
Le Fort II and III fractures are localized in the upper half of the midface; their location, pattern, and combinations depend not so much on the point of force application as on the direction of the force vector relative to the Frankfort horizontal plane.
A horizontal impact to the upper half of the midface usually leads to Le Fort II fractures.
An oblique impact directed downward causes complete separation of the facial skeleton from the neurocranium (Le Fort III) due to fractures in the frontonasal suture, lacrimal and ethmoid bones, and the orbital roof.
Maxillary fractures are frequently asymmetrical, can be unilateral, and are often combined with comminuted injuries of the nasoorbitoethmoidal complex and central regions of the maxilla.
The displacement of bone fragments largely depends on the direction of the traumatic force.
Pathological fracture of the maxilla – complete or partial disruption of bone integrity within an area of pathological remodeling (affected by a disease such as osteoporosis, tumor, osteomyelitis, etc.) [1].
1.3 Epidemiology of the Disease or Condition
Maxillary fractures account for 2 to 5% of all facial bone fractures [2].
Among all maxillary fractures, the inferior type (Le Fort I) occurs most frequently at 52–53%, Le Fort II accounts for 35–37%, and craniofacial separation (Le Fort III) is the least common at 13–15%.
The leading causes of maxillary fractures are road traffic accidents at 63%, falls from a height at 27%, and domestic trauma taking third place at 10% [2].
In the Russian Federation, maxillary fractures are most commonly observed during the summer season.
Multiple trauma in individuals with severe concomitant maxillofacial trauma occurs in more than 70% of patients and is distributed as follows: maxilla – 22.3%, orbit – 21.4%, nasal bones – 17.3%, zygomatic bone – 11.9%, mandible – 9.6%, and palatine bone. Dental injuries were observed in 5.8%, oral soft tissue wounds (tongue, gingiva, and lips) in 1.7%. Visual organ injuries (optic nerve trauma, eyeball avulsion, conjunctival trauma, and corneal/scleral injuries) and auditory organ injuries (tympanic membrane and auditory ossicles) were observed in 5.4% and 1.3%, respectively [1,2].
Maxillary trauma was accompanied by subarachnoid hemorrhage in 10% of cases.
Regarding gender differences, the ratio of maxillary fractures between men and women is characterized by a predominance in males, with reported ratios of 8:1 and 9:1 [1,2].
According to most authors, the highest number of maxillary fractures occurs in patients aged 20 to 30 years. Maxillary fractures occur in less than 1% of cases in children and elderly individuals.
Features of jaw fractures in children: they most commonly result from falls from a height, fights, swing accidents, motor vehicle accidents, play, etc.
1.4 Features of Coding the Disease or Condition
S02.4 – Fracture of zygomatic bone and maxilla
1.5 Classification of the disease or condition
Maxillary fractures are divided into two main groups: gunshot and non-gunshot.
1.5.1. Classification of gunshot fractures of the maxilla
Unlike non-gunshot maxillary fractures, gunshot fractures occur at the site of impact of the wounding projectile and may be comminuted, involving the facial bones.
Classifications of gunshot injuries to the maxilla were proposed by various authors: I. Vilga, 1919; McIndoe, 1941; Erich, 1942; Lukomsky I.G., 1943; Kurlyandsky V.Yu., 1944; Zbarzh Ya.M., 1965.
The most widely accepted classification of gunshot fractures of the maxilla is that by D.E. Tanfiliev (Table 1), proposed after summarizing and analyzing the experience of the Great Patriotic War.
Table 1
Classification of gunshot wounds of the maxilla
(Tanfiliev D.E., 1951)
By the nature of the injury | By fracture pattern | By location | By type of wounding projectile | |
|---|---|---|---|---|
1. Through-and-through 2. Blind 3. Tangential | A. Isolated a) with damage to the palatine process b) without damage to the palatine process B. Combined C. Single D. Multiple E. Penetrating into the oral and nasal cavities F. Non-penetrating into the oral and nasal cavities | 1. Linear 2. Comminuted 3. Punctate (perforated) 4. With displacement of fragments 4a. Without displacement of fragments 5. With bone defect (including avulsions) 5a. Without bone defect 6. Unilateral 6a. Bilateral 6b. Combined | 1. Within the dental arch 2. Outside the dental arch | 1. Gunshot 2. Comminuted |
1.5.2. Classification of non-gunshot fractures of the maxilla
Classification of non-gunshot fractures of the maxillary body
(Le Fort, 1901)
Le Fort I fracture (low-level fracture), also known as Guérin's fracture or dentoalveolar fracture, manifests as the separation of the alveolar process of the maxilla and the hard palate from the rest of the facial bones of the middle third.
The fracture line extends from the base of the pyriform aperture through the base of the alveolar process, the zygomaticoalveolar crest, and the maxillary tuberosity toward the pterygoid processes, resulting in the separation of the latter from the maxillary body, usually along with the hard palate. As a rule, the fracture is not accompanied by significant displacement. Disruption of the dental arches and mobility of the fragments are observed. Epistaxis may occur due to trauma to the mucous membrane of the maxillary sinus floor and nasal cavity.
Le Fort II fracture (mid-level fracture), or "suborbital" fracture, is known as the "pyramidal" fracture. This type of maxillary fracture produces a pyramidal-shaped bone fragment of the maxilla that can be displaced relative to the other bones of the middle third of the facial skeleton. The apex of the pyramid is located just below the frontonasal suture. The fracture line runs below the articulation of the nasal bones and the frontal processes of the maxilla with the nasal part of the frontal bone, then extends to the medial wall of the orbit (potentially involving the lacrimal bone), then to the floor of the orbit, and emerges at the infraorbital margin along the zygomaticomaxillary suture. The maxilla is detached together with the nasal bones and part of the orbit from the zygomatic bone and the cranial base. Epistaxis, bruising in the lower eyelid area ("panda sign"), facial edema, and malocclusion due to jaw displacement are observed.
Le Fort III fracture (high-level fracture), also known as "craniofacial disjunction" or "subbasal" fracture, results in the complete separation of the facial bones from the cranial base. Unlike Le Fort I and II fractures, the Le Fort III fracture also involves a fracture of the zygomatic bone. The fracture line runs below the articulation of the nasal bones and the frontal processes of the maxilla with the nasal part of the frontal bone, then extends to the medial wall of the orbit, then to the floor (formed by the orbital surfaces of the maxilla and zygomatic bone), passes through the lateral wall of the orbit, and emerges at its lateral margin in the region of the frontozygomatic suture.
The fracture line also passes through the nasal bridge and the orbit, but unlike the second type, the zygomatic bone is fractured off along with the maxilla, which is why all symptoms are more pronounced.
Comments: in clinical practice, maxillary fractures that correspond precisely to the types described by Le Fort are relatively rare. Combinations of several types of maxillary fractures on one or both sides are more common, for example: Le Fort I and II fractures of the maxilla on the right and Le Fort II and III fractures on the left.
Wassmund variants are close in their clinical course to Le Fort II and Le Fort III fractures; they differ in that the nasal bones remain immobile, since the fracture line runs from the upper margin of the pyriform aperture to the inferomedial angle of the orbit (the so-called "medial oblique line") and then follows the fracture lines of Le Fort II and Le Fort III maxillary fractures.
Wassmund I is a Le Fort II-type fracture, but without damage to the nasal bones. In a Wassmund I fracture, the line extends from the margin of the pyriform aperture through the base of the frontal process, the infraorbital margin, and further along the orbital floor toward the medial margin of the inferior orbital fissure
Wassmund II is a Le Fort III-type fracture, but without damage to the nasal bones. In a Wassmund II fracture, the Wassmund I-type fracture line is combined with a fracture at the zygomaticomaxillary articulation
Wassmund III – the fracture line begins as a Wassmund I type, then runs horizontally along the orbital floor, extending to its lateral margin.
Sagittal (unilateral) fractures occur when only one (right or left) maxilla is fractured. Externally, the fracture line runs in a typical location, and internally (medially) along the midline (the palatine suture connecting the two maxillae into a single maxilla).
Fractures of the maxillary processes:
alveolar (a portion of the process with several teeth is fractured), frontal (more frequently unilateral)
hard palate (occurs when falling onto a protruding object).
Fracture of the anterior wall of the maxillary sinus, which is comminuted.
Comminuted fractures of the central regions of the maxilla combined with fractures of the nasoorbitoethmoidal complex bones
1.5.3. Classification of maxillary fractures depending on their duration
1. Recent (up to 14 days post-injury),
2. Delayed (14 to 28 days post-injury)
3. Malunited (over 28 days post-injury).
If more than 28 days have passed since the moment of the fracture (the last movement of the fragments), such a fracture no longer belongs to this group of conditions and is coded according to ICD-10 as T90.2 – Sequelae of skull and facial bone fracture.
1.5.4. Classification of maxillary fractures depending on the fracture line pattern
1. Linear;
2. Comminuted
1.6 Clinical presentation of the disease or condition
Palpation of the skin may reveal crepitus – a sensation of "crunching" or "crackling" resulting from the infiltration of air from the airways into the subcutaneous tissue.
Mobility of the nasal bones is noted only when a maxillary fracture is combined with a fracture of the nasoorbitoethmoidal complex bones. In this case, an increase in the intercanthal distance is also typically observed.
"Floating palate" signs can be determined by palpation: the physician grasps the anterior group of teeth and the palate with the right hand and places the left hand on the cheeks externally. Gentle rocking movements are then performed forward, downward, and backward. In impacted fractures, the mobility of fragments cannot be determined in this manner. In such cases, the pterygoid processes of the sphenoid bone must be palpated. If a fracture of the maxillary body of one of the three types is present, the patient experiences pain.
The "step-off" sign (Le Fort II type) due to displacement of fragments in the region of the zygomaticomaxillary articulation. A step-off with sharp edges in the region of the zygomaticoalveolar crest can also be palpated in the oral cavity.
When a maxillary fracture is combined with damage to the zygomatic bones, "zygomatic syndrome" may manifest – decreased sensitivity in the innervation zone of the zygomaticofacial and zygomaticotemporal branches of the maxillary nerve, and reduced functional activity of individual mimic muscles.
Malocclusion may be observed due to the displacement of fragments, alteration in the mutual alignment of the upper and lower dental arches, and disruption of cusp-fossa contacts. An open bite fairly frequently develops because the entire maxilla drops inferiorly, rotating around its transverse axis.
Elongation or flattening of the middle third of the face is observed due to the displacement of the detached maxilla downward and backward.
Positive Malevich and Guérin signs are also noted.
Maxillary fractures are frequently combined with fractures of the nasal bones, the bones forming the orbital floor and frontal sinus, injuries to the visual organ and ENT organs, and traumatic brain injury. In these cases, the clinical presentation of the maxillary fracture will be supplemented by symptoms characteristic of the aforementioned conditions.
Maxillary fractures are characterized by rapidly developing soft tissue edema of the face, frequently combined with hemorrhage into the periorbital tissue ("panda sign").
Epistaxis is frequently noted in maxillary fractures, sometimes combined with nasal liquorrhea.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition:
anamnestic data (history of trauma, epistaxis, etc.);
complaint collection (edema, bruising, pain, epistaxis, decreased sensitivity of facial skin and teeth, facial disfigurement, unfamiliar bite, limited mouth opening, etc.);
physical examination (facial disfigurement, edema, bruising, malocclusion, pathological mobility and crepitus of bone fragments, subcutaneous emphysema, epistaxis, nasal breathing difficulty, hypesthesia of the facial skin and maxillary teeth, cracked pot sound on percussion, etc.);
instrumental examination (presence of fracture lines, dislocation of bone fragments according to radiographic data, alteration of eyeball position, etc.).
2.1 Complaints and Anamnesis
In patients with a maxillary fracture, to determine the indications for an initial visit (examination, consultation) by a neurologist (neurosurgeon), it is recommended to assess the patient's general condition, including consciousness (clear, confused, lethargic, unconscious), determine whether a loss of consciousness occurred and for how long, and check for memory disturbances (retrograde, episodic amnesia, etc.) [6].
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
When taking the medical history of patients with suspected maxillary fracture, it is recommended to clarify the mechanism of injury, paying special attention to the circumstances under which the injury was sustained. Record the date and time of the injury, exact address, or approximate location if the patient has difficulty remembering [1].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
When taking the medical history of patients with suspected maxillary fracture, it is recommended to determine whether there was dizziness, nausea, vomiting, headache, loss of consciousness, or memory loss to verify traumatic brain injury and timely schedule an initial appointment (examination, consultation) with a neurologist (neurosurgeon) [1,6,7,8].
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
If the medical history of patients with suspected maxillary fracture reveals circumstances involving illegal acts, or if the injury resulted from a road traffic accident, it is recommended to immediately notify law enforcement agencies in the established manner (Order of the Russian Ministry of Health No. 664n dated June 24, 2021 "On Approval of the Procedure for Medical Organizations to Inform Internal Affairs Organs in Cases Established by Paragraph 5 of Part 4 of Article 13 of the Federal Law 'On the Fundamentals of Protecting the Health of Citizens in the Russian Federation'" (Registered with the Russian Ministry of Justice on August 19, 2021, No. 64702) [1].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
2.2 Physical Examination
In all patients with suspected maxillary fracture, a physical examination is mandatory to clarify the diagnosis and determine treatment tactics [1,2,7]:
- visual examination for oral pathology, including the craniomaxillofacial region;
- palpation for oral pathology, including the craniomaxillofacial region;
- percussion for oral pathology, including the craniomaxillofacial region.
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
When examining a patient with a suspected maxillary fracture, it is recommended to determine the bite to identify changes in the relationship between the upper and lower dental arches, which is observed with fragment displacement [1].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
When examining a patient with a suspected maxillary fracture, it is recommended to assess facial sensitivity to detect compression of the trigeminal nerve branches by maxillary bone fragments [1].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: a decrease in skin sensitivity within the innervation zone of the infraorbital nerve (lower eyelid, infraorbital region, nasal bridge and upper lip, teeth on the affected side) is quite frequently observed.
When examining a patient with a suspected maxillary fracture, it is recommended to pay attention to the "panda eye" sign (periorbital hematoma) – hemorrhage into the eyelid soft tissues to verify the diagnosis and perform differential diagnostics [3].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: similar symptoms also occur in fractures of the skull base. The difference lies in the time of onset and extent. In maxillary fractures, the periorbital hematoma appears immediately after the injury and is widespread in nature, whereas in isolated skull base fractures, it appears no earlier than 12 hours (more often 24–48 hours) after the injury and does not extend beyond the orbicularis oculi muscle.
When examining a patient with a maxillary fracture and suspected skull base fracture, it is recommended to use the double-ring sign or handkerchief test to detect cerebrospinal fluid leakage [3].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: this sign is difficult to detect due to concomitant bleeding.
When examining a patient with a maxillary fracture, it is recommended to assess for enophthalmos, hypophthalmos, exophthalmos, oculomotor dysfunction, visual impairment including decreased visual acuity, and diplopia to detect orbital wall fractures and retrobulbar hematoma, and to rule out/confirm superior orbital fissure syndrome [6,9,14].
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
Palpation for oral pathology, including the craniomaxillofacial region, in patients with a maxillary fracture is recommended to be performed by grasping the alveolar process in the anterior region with the index finger and thumb of one hand and gently moving the maxilla in an anteroposterior direction to determine the mobility of bone fragments. The fingers of the other hand are placed simultaneously over the projected fracture sites in the nasal or infraorbital margin areas [1,11].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
2.3 Laboratory Diagnostics
Laboratory diagnostic tests are recommended for patients with maxillary fracture during the preparation and planning of surgical intervention to rule out contraindications to its performance [10].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
Laboratory diagnostic tests for ethanol (determination of blood ethanol concentration by gas chromatography or quantitative determination of urine ethanol by gas chromatography) are recommended for all patients with a maxillary fracture if acute alcohol intoxication is suspected, as well as in cases where the injury resulted from a traffic accident or occupational accident [1].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
2.4 Instrumental Diagnostics
All patients with a maxillary fracture at the diagnostic stage are recommended to undergo X-ray examination in at least 2 projections to determine the presence, localization, and nature of the fracture. When planning surgical treatment, computed tomography of the maxillofacial region is indicated to clarify the extent of damage [1,3].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
Comments: a patient with suspected maxillary fracture is recommended to undergo X-ray examination including: anteroposterior and lateral (on the affected side) projections of the skull, axial and semi-axial projections. The bony buttresses of the maxilla may superimpose on structures of other facial bones, making the diagnosis of fractures, especially without fragment displacement, rather difficult. Therefore, if necessary, cone-beam computed tomography or computed tomography of the facial skull (midface) is performed.
2.5 Other Procedures
All patients with a maxillary fracture at the diagnosis stage are recommended an initial consultation (examination) by a neurosurgeon or an initial consultation (examination) by a neurologist to rule out or confirm traumatic brain injury [1,6,18].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
If a patient with a maxillary fracture has signs of damage and/or pathological changes in ENT organs (hemosinus, etc.), an initial consultation (examination) by an otorhinolaryngologist is recommended to clarify the diagnosis and examination tactics [5,8].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
If a patient with a maxillary fracture has oculomotor disorders, enophthalmos, hypophthalmos, hyphaema, anisocoria, diplopia, changes in visual acuity, and other manifestations of visual organ damage at the diagnosis stage, an initial consultation (examination) by an ophthalmologist is recommended to clarify the diagnosis and examination tactics [18].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1. Conservative management
All patients with a maxillary fracture, in accordance with the modern concept of “Pain management” in surgery, are recommended to receive drug therapy aimed at stopping the pain response, in accordance with the priority principle of determining pain syndrome intensity, taking into account possible contraindications to the prescription of the most frequently used groups – analgesics and non-steroidal anti-inflammatory and antirheumatic drugs [24,44,45].
CUD CLOE 5Level of Certainty of Recommendation C (Level of Evidence - 5)
Comments: the following drugs and their combinations are used to reduce pain [1,6,12,44,45]:
differential approach to the choice of analgesic drug:
- mild pain – paracetamol**,
- moderate pain – combinations of paracetamol** + ibuprofen or paracetamol** + diclofenac, or paracetamol** and ketorolac, or paracetamol** and ketoprofen, or opioids in combination with non-opioid analgesics,
- severe pain – opioids (N02A) (morphine**, trimeperidine**, fentanyl**, tramadol**). In certain cases, patients as part of multimodal analgesia to reduce postoperative pain intensity, decrease opioid tolerance, and reduce the risk of developing and treating chronic pain syndrome may be prescribed "adjuvant" drugs from the group: other general anesthetics (N01AX) – #ketamine; gabapentinoids (N02BF) – gabapentin and pregabalin**[45,46,47]
The prescription of opioids is contraindicated in patients with traumatic brain injury.
All patients scheduled for surgical treatment of a maxillary fracture are recommended to undergo prophylaxis (surgical site infection prophylaxis, SSIP) of infectious complications in the surgical intervention area [46,47,48,49,50].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
All patients with a maxillary fracture undergoing SSIP are recommended a dose of systemic antibacterial drug (J01) corresponding to a single therapeutic dose of this drug [50].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
All patients with a maxillary fracture undergoing SSIP are recommended to administer an additional intraoperative single dose of a systemic antibacterial drug (J01) if the duration of surgery exceeds 2 half-lives of the drug, as well as in case of massive intraoperative blood loss [46,48,49,50].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
In patients with a maxillary fracture undergoing PAP, a single dose of a systemic antibacterial agent (J01) is recommended; if it is necessary to extend prophylaxis, the drug is discontinued no later than 24 hours after surgery, even in the presence of a drain [46,47,48,49,50].
GPP CLoE 5Level of Evidence/Grade of Recommendation C (level of evidence - 5).
All maxillary fractures require PAP, as they can all be tentatively considered open and classified as type II–III wounds.
Thus, in lower Le Fort I fractures, communication occurs via the periodontal ligament space; in intermediate Le Fort II fractures, the integrity of the maxillary sinus mucosa is breached; and in upper Le Fort III fractures, craniofacial disjunction occurs.
Algorithm for selecting a systemic antibacterial drug for perioperative prophylaxis of infectious complications in patients with zygomatic bone fractures [46,47,48,49,50].
First-line drugs | Alternative drugs* | Administration time | Route of administration | Notes |
|---|---|---|---|---|
#Cefazolin**b 2.0–3.0 g + Metronidazole** 0.5–1.0 g; or Cefuroxime** 1.5 g + Metronidazole** 0.5–1.0 g; or Amoxicillin + [clavulanic acid]** 1000 mg + 200 mg [48,49,50,52,53] | Vancomycin**a.c 15 mg/kg | 30–60 min before incision | Intravenous infusion | PAP is administered as a single dose, except in contaminated surgeries where PAP antibiotics are administered for no more than 24 hours postoperatively |
#Clindamycin** 0.6–0.9 g [48,49,50,52] ± #Gentamicin**d 1.5 mg/kg (not to exceed 120 mg) [49,50,52] |
Comments: a allergy to beta-lactam antibacterials, penicillins (J01C), and high risk of MRSA [48,52,53].
b for body weight greater than 120 kg, the dose should be 3 g [48,52,53].
c 120 minutes prior to incision when using vancomycin** [48].
d the gentamicin** dose is calculated based on ideal body weight.
In maxillary fractures with type IV "infected wound"—in case of old trauma, pre-existing infection, purulent discharge, or non-viable tissues—antibacterial therapy is recommended for all patients [46,47,48,49,50].
LoR CLoE 5Level of Recommendation C (Level of Evidence 5)
In patients with a maxillary fracture involving disruption of the maxillary sinus walls, the administration of drugs from the group of decongestants and other nasal preparations for topical use (R01A) is recommended to reduce edema of the maxillary sinus mucosa and the ostium to the nasal cavity, improve sinus drainage, and prevent inflammatory processes [26,51].
LoR CLoE 5Level of Recommendation C (Level of Evidence 5)
3.2. Temporary transport immobilization of the maxilla
Indications: suspected maxillary fracture.
Contraindications: unconscious state of the patient, nausea, vomiting (due to the risk of asphyxia).
Anesthesia: this type of management does not require anesthesia. Analgesia is administered as part of symptomatic pain management.
In patients with a maxillary fracture, it is recommended to apply an immobilizing bandage for bone fractures (temporary emergency immobilization) of the maxillary fragments to alleviate pain and reduce bleeding from the fracture line prior to further diagnostic workup and decision-making regarding the appropriateness of additional treatment modalities [1].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comments: emergency immobilization of the maxilla can be performed using a gauze chin-vertex bandage, a Pomerantseva-Urbanskaya elastic chin sling, a standard emergency bandage, a fixing elastic bandage (Reg. Cert. FSZ – 2011/09638), etc.
3.3. Orthopedic treatment method
Indications: presence of a maxillary fracture.
Contraindications: moderate to severe traumatic brain injury, instability of baseline hemodynamic parameters, nausea, vomiting (due to the risk of aspiration asphyxia). Marked displacement of maxillary fragments where conservative orthopedic management is inappropriate and immediate surgical-orthopedic or surgical intervention is required. Anesthesia: local (topical, infiltration, regional/nerve block) anesthesia is usually performed for this type of management. Systemic analgesia is also administered as part of symptomatic therapy.
Conservative orthopedic management is recommended in patients with a maxillary fracture to attempt reduction and immobilization of the fragments in a satisfactory position [1,3].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
Comments: this treatment method consists of securing dental arch bars (as designed by S.V. Vasiliev) or custom fabricated wire splints to the teeth on the upper and lower jaws. Fixation intermaxillary screws with a diameter of 1.5–2.0 mm (Reg. Cert. RZN 2018/726) placed into the interradicular spaces of the alveolar processes/parts of the jaws may also be used. Elastic rubber intermaxillary traction is applied between the splint hooks on the upper and lower jaws (or bone fixation screws). This treatment method requires subsequent application of an immobilizing chin sling bandage.
Gunning-type custom splint (Port's splint) is used to immobilize edentulous jaws in case of fractures. It consists of two acrylic bases (maxillary and mandibular) with acrylic occlusal rims fused monolithically along their occlusal surfaces. An opening is cut in the anterior portion of the rims for patient feeding. The splint is used in conjunction with a head bandage.
In all patients with maxillary fractures following orthopedic intervention, it is recommended to evaluate the restoration of occlusal relationships (habitual occlusion) [1].
GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)
In all patients with a maxillary fracture following orthopedic intervention, performing a follow-up radiographic examination or computed tomography of the facial skeleton is recommended to confirm anatomical alignment of the bone fragments [1].
GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)
3.4. Surgical-orthopedic treatment method
The combined surgical-orthopedic method of treatment can be used in patients with severe concomitant maxillofacial trauma due to its low invasiveness and short operative time as part of initial anti-shock "Damage Control" measures.
Surgical-orthopedic techniques, indications, contraindications, and anesthesia are described in more detail in the guidelines for the management of patients with concomitant maxillofacial trauma.
3.5. Surgical treatment
Indications: maxillary fracture with significant displacement of fragments.
Contraindications: extremely critical condition of the patient precluding accurate open reduction and rigid internal fixation of maxillary fragments.
Comments: In accordance with the strategy of delivering specialized surgical care to patients with severe concomitant shock-inducing trauma based on "Damage Control" principles, open reduction and stable fixation of bone fragments via an open surgical approach is performed after the patient's general condition has stabilized, taking into account the predicted risk of purulent-inflammatory complications.
Plate osteosynthesis for a maxillary fracture is recommended to be performed under general anesthesia. Intubation is preferably performed through the nasal passages (with or without endoscopic assistance) so that the endotracheal tube does not interfere with achieving optimal occlusal relationships during the procedure. If nasotracheal intubation cannot be accomplished due to severe nasal airway deformity, the endotracheal tube may be placed orally and subsequently brought out through a submental mini-incision [55,56].
GCP CLOE 5Grade of Recommendation – C (Level of Evidence – 5)
Comments: In cases of nasal septal deviation, severe bleeding, or technical difficulties, tracheal intubation may be performed via a submental incision or by placing a temporary tracheostomy.
In patients with a maxillary fracture accompanied by displacement of fragments and/or their pronounced mobility, it is recommended to perform maxillary osteosynthesis using metal titanium bone plates (Medical Device code 246140 – bone plate for fracture fixation with screws, non-absorbable, sterile***) or those made of biodegradable materials (Medical Device code 246280 – bone plate for fracture fixation with screws, absorbable***) and matching screws (Medical Device codes 190650 – bone screw for craniofacial surgery, non-absorbable, sterile*** and 190640 – bone screw for craniofacial surgery, absorbable***) [20,21,22,23,24,25,26,27,28,29,30].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
Comments: It is advisable to additionally apply a parietomental chin sling bandage.
In all patients with maxillary fractures who have preserved dentition, it is recommended to assess the restoration of occlusal relationships (habitual bite) after surgical intervention [1].
GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)
All patients with maxillary fracture following surgical intervention are recommended to undergo follow-up computed tomography of the facial skeleton in order to confirm the alignment of bone fragments in the anatomically correct position [1].
GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)
3.6 Nutritional Therapy
Patients with maxillary fracture who have impairment of all components of the eating process (sucking, chewing, and swallowing) are recommended the first jaw diet (feeding the patient via polyfunctional gastrointestinal tubes) [1].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comments: In this case, introducing food into the mouth is not only useless but also dangerous due to the risk of aspiration. Food is not only processed using a meat grinder but also rubbed through a fine sieve and even strained to eliminate hard-to-grind particles (plant fiber, meat veins, etc.). The cream-like consistency of the food allows it to pass freely directly into the stomach through polyfunctional gastrointestinal tubes inserted through the nose or mouth. If necessary, even greater dilution can be achieved by adding broth, milk, or boiled water.
Patients with a maxillary fracture who retain swallowing and sucking functions are recommended a second jaw diet for adequate nutrition [1].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comments: in this type of diet, food is brought to a puree consistency by passing it through a meat grinder, and for the necessary dilution, it is diluted with broth, milk, or even warm boiled water to a sour-cream-like consistency.
The difference between the first and second jaw diets lies only in the degree of component grinding.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
All patients who have undergone surgical treatment for a maxillary fracture are recommended rehabilitation measures aimed at the complete social and physical recovery of the patient [30].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
Comment: The need for patient rehabilitation is due to maxillofacial trauma. The presence of postoperative wounds (disruption of integrity) in this aesthetically significant anatomical region, their healing, pain syndrome of varying severity, and possible dysfunction of facial muscles, chewing, as well as neurological disorders can lead to significant social maladaptation and reduce the quality of life of this category of patients.
General principles of rehabilitation after surgical treatment of maxillary fractures:
1) Comprehensive assessment of the patient's initial condition and formulation of a rehabilitation program;
2) Drawing up a plan for diagnostic and therapeutic measures necessary for rehabilitation;
3) Multidisciplinary principle of organizing rehabilitation care;
4) Monitoring the effectiveness of ongoing therapy during the course of restorative treatment and at the end of the rehabilitation course.
Stages of patient rehabilitation after surgical treatment:
Stage 1 – early rehabilitation, from 7 to 10 days after surgery. During this period, the patient undergoes inpatient rehabilitation treatment for 3–5 days, after which further rehabilitation takes place on an outpatient basis for 10–15 days.
The most important tasks of Stage 1 rehabilitation are the control of hemostasis, the wound process, and the relief of postoperative pain, as well as the treatment of concomitant pathology if present.
Stage 2, from 15 to 45 days after surgery, aims to accelerate reparative processes and prevent the development of postoperative complications, traumatic maxillary sinusitis, extraarticular mandibular contracture, and visual organ pathology.
Programmed wound process: one of the most important aspects of postoperative patient recovery, allowing to avoid the development of late postoperative complications (scar deformity, prevention of inflammatory complications in the area of the postoperative wound and maxillary sinus, etc.).
Proper management of the wound process, starting from the 2nd day after surgery until complete healing of soft tissue wounds, implies: daily treatment of the wound area with antiseptic solutions, dressings with ointment applications (the composition of the ointment is determined by the stage of the wound process); microbiological control (in case of suspected purulent-septic complications and wound infection).
Compliance with oral hygiene is of paramount importance in ensuring a smooth early postoperative period. If the patient is unable to provide hygiene independently, it must be provided by specially trained nursing staff.
Medical treatment of the oral cavity consists of thoroughly cleaning splints and teeth from food debris by irrigating and rinsing the oral vestibule with antiseptic solutions (potassium permanganate**, chlorhexidine**, etc.). Baking soda (1 tablespoon per 1 liter of liquid) is added to these solutions to facilitate the washing away of fatty food particles. Rinsing is performed by irrigating with a stream of antiseptic from a syringe. After rinsing, splints are cleaned of food debris stuck between the splint, teeth, gums, ligatures, and rubber rings. This is done using a toothpick. After cleaning, the oral vestibule is irrigated again with antiseptic solutions. During dressing changes, it is necessary to control the position of the ribbon tooth splint (as proposed by S.V. Vasilyev) and the condition of the wire ligatures. If there are pressure sores from hooks on the mucous membrane of the lips, gums, or cheeks, they must be bent back to the appropriate position. Loose ligatures are tightened and bent toward the teeth. Intermaxillary traction should be replaced as it weakens, but at least once every 7 days.
Chewing gymnastics: one of the important components of postoperative rehabilitation is the normalization of chewing function. After removing the elastic intermaxillary traction, the patient is given recommendations regarding dietary restrictions, and the dynamics of the normalization of the range of motion of the mandible is monitored.
Pain management: the severity of pain sensations depends on the severity of the injury and the individual pain threshold. Systemic analgesics are selected individually by the attending physician depending on the intensity of pain, as well as the severity of psycho-emotional disorders.
In order to accelerate reparative procedures and reduce the inflammatory response, it is advisable to conduct physiotherapy procedures as recommended by a physical therapist [30].
Comments: in patients with traumatic brain injury, physiotherapy procedures are contraindicated.
When non-resorbable bone plates for fracture fixation with screws*** (MI code 246140) and non-resorbable bone screws for craniomaxillofacial surgery*** (MI code 190650) are used in surgical treatment, the question of the advisability of their removal after consolidation of the maxillary fragments is decided individually and strictly according to indications.
5. Prevention and Dispensary Observation
Based on indications for the prevention of postoperative complications in the ENT organs, visual system, and nervous system upon discharge, it may be recommended to undergo a preventive appointment (examination, consultation) with an otorhinolaryngologist, ophthalmologist, neurologist, or neurosurgeon [31].
LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)
All patients 6 weeks after surgery are recommended to undergo follow-up computed tomography of the facial skeleton to confirm fragment consolidation in the correct position and to rule out a post-traumatic inflammatory process in the maxillary sinus [35,36,37,38,39,40].
GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)
6. Organization of Medical Care
Indications for emergency hospitalization to a medical organization:
Radiologically confirmed diagnosis of maxillary fracture.
Indications for planned hospitalization in a medical organization:
No indications.
Comment: since a maxillary fracture is an emergency condition, all patients with this disease (condition) must be hospitalized on an emergency basis.
If more than 28 days have passed since the moment of injury (the fact of the last movement of fragments), this condition does not belong to this group of diseases and is coded according to ICD-10 as T90.2 – Sequel of skull and facial bone fracture.
Indications for patient discharge:
1) in the absence of indications for further inpatient treatment (uneventful postoperative period, satisfactory fragment position, absence of cerebrospinal fluid leak and progressive purulent-inflammatory diseases of the maxillofacial region of traumatic origin);
2) if the patient needs to be transferred to another medical institution;
3) at the request of the patient or their legal representative;
4) in cases of non-compliance by the patient with prescriptions or internal hospital regulations, provided this does not threaten the life of the patient and the health of others.
7. Additional Information
Factors negatively affecting treatment outcomes:
1) Development of infectious complications.
2) Non-compliance with the regimen of local contact hypothermia.
3) Non-compliance with personal oral hygiene.
4) Non-compliance by the patient with diet and masticatory activity restrictions.
5) Non-compliance with physical therapy recommendations in the postoperative period.
6) Participation in contact sports within 3 months.
7) Absence at follow-up examinations.
8) Non-compliance with other recommendations of the attending physician.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance evaluation |
|---|---|---|
1 | X-ray examination performed in at least 2 projections, or computed tomography of the maxillofacial region. | Yes/no |
2 | Computed tomography of the facial skull performed in case of surgical intervention before and after surgery. | Yes/no |
3 | An initial examination (consultation, assessment) was performed by a neurosurgeon, or an initial examination (consultation, assessment) by a neurologist when clinical signs of TBI and facial skin hypesthesia on the affected side are detected. | Yes/no |
4 | An initial otolaryngologist examination (consultation, assessment) was performed when clinical signs of ENT organ injury were detected. | Yes/no |
5 | An initial ophthalmologist examination (consultation, assessment) was performed when clinical signs of visual pathology were detected. | Yes/no |
6 | Perioperative antibiotic prophylaxis (PAP) was performed; analgesics, decongestants, and other topical nasal drugs were prescribed. | Yes/no |
Assessment of the restoration of occlusal relationships (habitual bite) in patients with preserved dentition was performed after surgical intervention. | Yes/no | |
8 | Anatomical alignment of bone fragments was achieved according to clinical and radiological data. | Yes/no |
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Appendix A1. Working Group Composition
Kulakov, A. A. – Academician of the Russian Academy of Sciences, MD, Professor, President of the Association of Maxillofacial Surgery Specialists LLC.
Braylovskaya, T. V. – MD, Associate Professor, Executive Secretary of the Association of Maxillofacial Surgery Specialists LLC.
Bayrikov, I. M. – Corresponding Member of the Russian Academy of Sciences, MD, Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.
Ivanov S.Yu. – Corresponding Member of the RAS, MD, Professor, Board Member of the Association of Maxillofacial Surgery Specialists.
Drobyshev, A.Yu. – MD, Professor, Vice-President of the LLC "Association of Specialists in Maxillofacial Surgery".
Yaremenko, A.I. – MD, Professor, Vice-President of the LLC "Association of Specialists in Maxillofacial Surgery".
Roginsky V.V. – MD, Professor, Member of the Association of Maxillofacial Surgery Specialists.
Belchenko, V.A. – MD, Professor, Board Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Topolnitsky, O.Z. – MD, Professor, Board Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Sysolyatin, P.G. – MD, Professor, Board Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Pankratov, A.S. – MD, Professor, Board Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Durnovo E. A. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.
Lepilin A. V. – MD, PhD, Professor, Board Member of the Association of Maxillofacial Surgeons.
Tarasenko, S.V. – MD, Professor, Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Epifanov, S. A. – MD, Associate Professor, Member of the Association of Maxillofacial Surgery Specialists LLC.
Bagnenko A.S. – Candidate of Medical Sciences, Associate Professor, Member of the "Association of Specialists in Maxillofacial Surgery".
Baranov, I.V. – PhD in Medical Sciences, Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Sviridenko, A.D. – Member of the LLC "Association of Specialists in Maxillofacial Surgery".
Stolyarenko, P.Yu. – PhD in Medical Sciences, Associate Professor, Member of the LLC "Association of Specialists in Maxillofacial Surgery".
All members of the working group are members of the All-Russian Public Organization "Association of Specialists in Maxillofacial Surgery". There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Maxillofacial surgeons
Trauma and orthopedic surgeons
Neurosurgeons
Otolaryngologists
Ophthalmologists
Physiotherapists
Mid-level medical personnel
Healthcare organizers
Medical insurance experts (including conducting medical and economic expertise)
Medical students, residents, postgraduate students.
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
These clinical guidelines were developed taking into account the following regulatory legal documents:
Article 76 of Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011, "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation", regarding the development and approval of clinical guidelines (treatment protocols) by medical professional non-profit organizations on the provision of medical care;
Order of the Russian Ministry of Health No. 422n dated June 14, 2019, "On Approval of the Procedure for Providing Medical Care in the Field of 'Maxillofacial Surgery'";
Order of the Ministry of Health of the Russian Federation No. 910n dated November 13, 2012, "On Approval of the Procedure for Providing Medical Care to Children with Dental Diseases"
Federal Law of the Russian Federation No. 326-FZ dated November 29, 2010 (as amended on July 3, 2016) "On Compulsory Medical Insurance in the Russian Federation";
Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care" (Registered with the Ministry of Justice of Russia on May 17, 2017, No. 46740);
Federal Law No. 178-FZ dated July 17, 1999 (as amended on May 29, 2024) "On State Social Assistance";
Directive of the Government of the Russian Federation No. 2045-r dated September 25, 2017, On the Strategy for Preventing the Spread of Antimicrobial Resistance in the Russian Federation for the Period up to 2030.
Directive of the Government of the Russian Federation No. 3053-r dated December 31, 2018, List of Medical Devices Implanted into the Human Body When Providing Medical Care Within the Framework of the State Guarantee Program of Free Medical Care for Citizens.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
The maxilla is one of the many bones that make up the facial skull. Usually, a fracture occurs in the area of connection with neighboring bones.
Maxillary fractures occur when the traumatic force is directed at the middle third of the face.
During trauma, damage most frequently occurs not only to the maxilla but also to adjacent bones.
A maxillary fracture with fragment displacement can lead to facial deformity, impaired chewing and vision functions, altered facial sensation, and impaired nasal breathing.
Complications arising after a maxillary fracture:
Enophthalmos and downward displacement of the eyeball, double vision.
Inflammation of the maxillary paranasal sinus, so-called sinusitis.
"Numbness" of the maxillary teeth and skin in the infraorbital region, nasal bridge, lip, and lower eyelid on the affected side.
Traumatic brain injury of varying severity, hemorrhages, cerebrospinal fluid leakage, etc.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable