Maxillary and
Periorbital
Fractures
Frederick Mars Untalan, MD
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Facial Injuries
 Dental Terminology
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Overview
 Classic tripod, orbital floor, LeFort
fractures better thought of as
orbitozygomaticomaxillary fractures
 Prec...
Epidemiology

Males : Females -- 4:1
 Predominantly in 20’s or 30’s
 Cause
 MVA > altercation > fall
 Site
 Nasal > ...
History
 Mechanism of InjuryMechanism of Injury
 Previous facial injuries / Dental AbN
 Premorbid history
 Loss of con...
Clinical Assessment of the
Face
 SYMPTOMS
 Diplopia
 Abnormal
Sensation
 Malocclusion
 Pain
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Clinical Assessment of the
Face
 GCS, Ocular exam, C-spine exam
 Cranial nerve exam, CSF rhinorrhea
 Inspect (including...
 CSF rhinorrhea – Halo sign
 Septal hematoma
 Hemotympanum
 Malocclusion
 Ocular Findings
 Diplopia/restricted EOM, ...
 Clinical Assessment of the Face
 Reliable Physical signs
 Bony facial asymmetry
 True V2 numbness
 Malocclusion
Clin...
Physical Exam
 Palpate for
midface
instability
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Physical Exam
 Often edema,
swelling, or patient’s
mental status make
physical exam
difficult
 CT is modality of
choice ...
Physical Exam
 Midface asymmetry
may indicate zygoma
fracture
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Forced Duction Testing
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Emergency Management
 C-Spine Injury
 10% C-Spine Fracture
 Head Injury
 50% - Loss of Consciousness
 5% Significant ...
Emergency Management
Hemorrhage
 Local Pressure
 Dressings / Packing
 Reduction Of Facial
Fractures
 Endovascular
Cons...
Radiographic Assessment of the Face
 Water’s view
 Panorex (Orthopantomogram)
 Mandible views
 CT scans
 Standard of ...
 Water’s view The “W” system
 PA view for visualization of maxillary sinuses,
maxilla, orbits, and zygomatic arches
 Ma...
CT areas to evaluate
 Vertical buttresses
 Zygomatic arch
 Orbital walls
 Bony palate
 Mandibular condyles
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Signs And Symptoms
 Pain / Tenderness
 Crepitus From Bony
Fractures
 Hypoesthesia
 Paralysis
 Malocclusion
 Visual D...
Soft Tissue Injuries
 Tetanus Prophylaxis
 Structures
 Facial Nerve
 Trigeminal Nerve
 Parotid Duct
 Lacrimal System...
Principles Of Craniomaxillofacial
Fracture Management
 Precise anatomic diagnosis
 Direct fracture exposure
 Reduction ...
Facial Fractures
The Upper Face
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Outline
 Facial Fracture Basics
 Nasal Fractures
 Naso-orbital-ethmoidal Fractures
 Frontal Sinus Fractures
 Zygomati...
Nasal Fractures
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Physical Exam
 Edema
 Crepitus
 Periorbital Ecchymosis
 Epistaxis
 Internal And External Lacerations
 Widened Nasal ...
Classification
Stranc and Robertson
 Lateral Impact
Injuries
 Unilateral vs.
Bilateral
 Frontal Impact
Injuries
 Plane...
Treatment
Lateral Impact Injuries
 Early Versus Delayed Treatment
 Closed Reduction (Local vs. General)
 Drainage of Se...
Treatment
Frontal Impact Injuries
 Plane I
 edema / ecchymosis distal nasal bridge
and tip
 possible septal distortion
...
Treatment
Frontal Impact Injuries
 Plane II
 Increased Comminution of the Nasal
Pyramid
 Bilateral
 Possible “Saddling...
Treatment
Frontal Impact Injuries
 Plane III
 Extend Into Pyriform Aperture And Medial
Orbital Rim

ie. Naso-Orbital-Et...
Complications
 Occur In Up To 70%
 Deviated Nasal Pyramid
 Nasal “Hump”
 Septal Deformity With Respiratory
Obstruction...
Naso-Orbital-Ethmoidal
Fractures
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Naso-Orbital-Ethmoidal
Fractures
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Naso-Orbital-Ethmoidal
Fractures
 Interorbital “Space”
 two ethmoidal labyrinths
 superior and middle turbinates
 perp...
Naso-Orbital-Ethmoidal
Fractures
 Interorbital space displaced backwards
 Medial Canthal Tendon and Lacrimal
Apparatus f...
Naso-Orbital-Ethmoidal
Fractures
 Flat nose
 Swollen medial canthal area
 Telecanthus (12-20%)
 Lack of skeletal suppo...
Naso-Orbital-Ethmoidal
Fractures
Telecanthus
 Normal intercanthal distance
(Stranc)
 White males: 33-34mm
 Females: 32-...
Naso-Orbital-Ethmoidal
Fractures
Classification Markowitz
 Type I - Single
central segment
 Type II -
Comminuted
central...
Naso-Orbital-Ethmoidal
Fractures
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Naso-Orbital-Ethmoidal
Fractures
Classification - Gruss
1 Isolated injury to bony naso-orbital region
2 Associated fractur...
Naso-Orbital-Ethmoidal
Fractures
Management
 Early open reduction
 Four Objectives:
 correct epicanthal folds
 restore...
Naso-Orbital-Ethmoidal
Fractures
Management
 Wide Exposure
 coronal incision
 “open sky” - transverse across root of no...
Naso-Orbital-Ethmoidal
Fractures
Management
 Correct nasofrontal separation
 Elevate nasal bones
 Reduce comminuted nas...
Frontal Sinus Fractures
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Frontal Sinus
Embryology
 Begin to Develop At 2 Years of Age
 Extension of the Ethmoid Air Cells
 Radiographically Evid...
Frontal Sinus
Anatomy
 Supraorbital / Temporal vs Frontal
Sinus
 Anterior Wall and/or Posterior Wall
 Nasofrontal Duct
...
Frontal Sinus
Diagnosis
 Signs And Symptoms
 Forehead Laceration
 CSF Rhinorrhea
 Supraorbital Nerve Anesthesia
 Depr...
Frontal Sinus
Diagnosis
 X-Ray
 Air Fluid Levels
 CT Scan
 Axial and Coronal Images
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Frontal Sinus
Treatment
 Operative Indications
 Anterior Table Displacement With Contour
Change
 Nasofrontal Duct Invol...
Frontal Sinus
Treatment
 Nasofrontal Duct
Injury
 Remove Mucosa
 Burr Inner Cortex
 Occlusion Of Duct
 Sinus Oblitera...
Frontal Sinus
Treatment
 Posterior Table
 Cranialization
1 Bicoronal Approach
2 Preserve Pericranial Flap
3 Dural Repair...
Frontal Sinus
Complications
 Early (within 6 months)
 Frontal Sinusitis
 Meningitis
 Late
 Mucocele
 Mucopyocele
 B...
Frontal Sinus
Complications
 Incidence Of Late Complications
 Freihofer

71 Fractures

2 Patients - Meningitis

1 Pat...
Orbital Fractures
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Orbital Blowout Injury
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Orbital Fractures
Blowout Fractures
Pure Blowout - only orbital floor or
medial wall injured
Impure Blowout - associated o...
Orbital Blowout Injury
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Orbital Blowout Injury
 Usually inferior and/or medial wall
 Cone will become more spherical
 Leads to enophthalmos, in...
Orbital Fractures
Physical Exam
 Diplopia
 Enophthalmos
 Inferior Displacement Palpebral Fissure
 Anesthesia of Infrao...
Orbital Fractures
Physical Exam
 Diplopia
 Commonly on Upward Gaze
 Primary (Central Gaze) or Secondary
(Perpheral)
 M...
Orbital Fractures
Forced Duction Test
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Orbital Fractures
Physical Exam
 Enophthalmos
 Inferior and Posterior Displacement of
Globe and Intraorbital Soft Tissue...
Orbital Fractures
Enophthalmos
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Orbital Fractures
Physical Exam
 No Diplopia + No Enophthalmos
?Significant Fracture
 Diplopia + No Enophthalmos
Incarce...
Orbital Fractures
Indications For Exploration
 Symptomatic Diplopia With Positive Forced Duction
Test
 Xray evidence of ...
Orbital Rim
Access
 A -- subciliary
 B -- lower eyelid
 C -- infraorbital
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Orbital Fractures
Incisions
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Orbital Fractures
Management
 Grafts
 Autologous Bone
 Cartilage
 Fascia lata
 Alloplastic Implants
 Teflon
 Silast...
Orbital Floor
 Dotted line
shows anatomic
goal of
restoration
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Orbital Fractures
Complications
 Infection
 Implant problems
 Persistent Diplopia (2-50%)
 Persistent Enophthalmos (15...
Orbital Fractures
Complications
 Superior Orbital Fissure Syndrome
 extension of fracture into SOF
 ophthalmoplegia wit...
Orbital Fractures
Complications
 Orbital Apex Syndrome
 same as superior orbital fissure syndrome
 plus blindness
http:...
Transconjunctival
Approach
 Conjunctiva is
being used to
protect globe
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Materials for reconstruction
 Autogenous tissues
 Avoid risk of infected implant
 Additional operative time, donor site...
Orbital Floor
Bone Grafting
 Need to support
floor full 4 cm
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 Alloplastic implants
 Decreased operative time, easily available,
no donor site morbidity, can provide stable
support
...
Orbital Floor Materials
 Marlex mesh
 needs 360 degree support
 better for concave anterior floor only
 Medpor
 needs...
Synthetic
Mesh
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Orbital Metallic
Mesh
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Orbital Roof
 Uncommon due to high levels of force
needed to fracture orbital roof
 Commonly with intracranial problems
...
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Orbital Roof Repair
 Repair roof higher on frontal bar
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From: Strong EB, Sykes JM. Zygoma Complex Fractures. Facial Plastic Surgery 1990;14(1):109.
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Periorbital & Zygomatic
bone Fractures
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Zygoma Fractures
 Results from lateral forceshttp://entbgh.blogspot.com/
Zygoma
Anatomy
 Tetrapod Structure
 Frontal Bone
 Temporal Bone
 Maxilla
 Greater Wing Of Sphenoid
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Zygoma
Anatomy
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Zygoma
Anatomy
 Muscular Attachments
 Masseter
 Temporalis
 Zygomaticus
 Zygomatic Head of Quadratus Labii
Superioris...
Zygoma
Physical Exam
 Circumorbital Swelling /
Ecchymosis
 Subconjunctival
Hemorrage
 Abnormal Sensation V2
Distributio...
Zygoma
Physical Exam
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Zygoma
Physical Exam
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Zygoma
Fracture Classification
 Knight
1 Undisplaced
2 Arch Fractures
3 Unrotated Body Fractures
4 Medially Rotated Body ...
Zygoma
Fracture Classification
 Manson
 Low Energy

minimal displacement

do not require operative reduction
 Middle ...
Zygoma
Radiology
 X-Ray
 Water’s View Most Useful
 CT Scan
 Coronal Cuts For Orbital Anatomy
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Zygoma Fractures
 Impacted zygoma may mask orbital floor defect
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Treatment of
Zygomaticomaxillary Complex
fractures
 Restore pre-injury facial configuration
 Prevent cosmetic deformity
...
Zygoma
 Ideally done
between 5-7 days
for resolution of
edema
 Pre- or intra-
operative steroids
can help with
edema
 A...
Zygoma
 reduction only - Minimally displaced, non
comminuted
 plating of lateral antrum, orbital rim, ZF
suture, and eve...
Zygoma Algorithm
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Zygoma
Management
 Undisplaced
 Nonoperative
 Displaced
 Isolated Zygomatic Arch - Gilles
Elevation
 Orbitozygomatic ...
Zygoma
Management
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ORIF of
Lateral Antral
Wall
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Gillies Reduction
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Post-Gillies Reduction
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Surgical Approaches
 Coronal
 Sublabial
 Transconjunctival
 Lateral Brow
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Coronal Approach
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Coronal Approach
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Coronal Approach
 Supraorbital
nerve may be
released for
more
exposure
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Hemicoronal
Approach
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Lateral Brow Incision
 Avoid shaving brow hairs
 Goal is the ZF suturehttp://entbgh.blogspot.com/
Sublabial
Approach
 Leave
mucosa to
sew to later
 Identify and
preserve V2
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Zygoma
Gilles Elevation
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Zygoma
Operative Exposure
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Zygoma
Operative Exposure
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Zygoma
Operative Exposure
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Zygoma
Complications - Early
 Bleeding
 Infection
 Exacerbation of Sinus Disease
 Malfunction of Extraocular Muscles
...
Zygoma
Complications - Late
 Nonunion / Malunion
 Diplopia (10% initial, 5%
permanent)
 Persistent V2
Anesthesia (24%)
...
Treatment of
Zygomaticomaxillary Complex
fractures
 Restore pre-injury facial configuration
 Prevent cosmetic deformity
...
 Soft diet and malar protection
 Closed reduction
 ORIF with plating of one to four
buttresses
 Provide fixation as ne...
Maxillary Fractures
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Types
 LeFort or Maxillary fractures
 Zygomaticomaxillary complex fractures
 Orbitozygomaticomaxillary complex
fracture...
Anatomy of the Maxilla
 Paired
embryologically
 Functionally
acts with
palatine bone
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Anatomy of the Maxilla
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LeFort fractures
 Rene LeFort 1901 in cadaver skulls
 Based on the most superior level
 Frequently different levels on ...
Facial Buttress system
From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative
O...
From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing Company 1988, pg76.
http...
Facial
buttress
system
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Buttresse
s
 Resist
occlusal
load
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Horizontal
Buttresses
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LeFort fractures
 Rene LeFort 1901 in cadaver skulls
 Based on the most superior level
 Frequently different levels on ...
LeFort
Fractures
 Experimentally
determined
weak points
 Can be in
combinations
bilaterally
 Useful
descriptor
 Result...
Forces of mastication
From: Banks P, Brown A. Fractures of the Facial Skeleton,
Oxford, Wright 2001 pg.6
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Facial Buttress system
From :Stanley RB. Maxillary and Periorbital Fractures. In :Bailey BJ ed., Head
and Neck Surgery-Oto...
From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962.
http://entbgh.b...
From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian
Publishing Company 1988, pg76.
http...
Maxillary Fractures
LeFort Fractures
 LeFort I
 Transverse Fracture That Separates
Maxillary Alveolus From Midface Skele...
Le Fort I
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Maxillary Fractures
LeFort Fractures
 Lefort II
 “Pyramidal” Fracture of Maxilla
 Separates Nasomaxillary Segment from
...
Le Fort II
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Maxillary Fractures
LeFort Fractures
 LeFort III
 Craniofacial Dysjunction
 Zygomaticofrontal Junction, Traverses
Later...
Le Fort III
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Maxillary Fractures
LeFort Fractures
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Modified LeFort
Classification
From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Su...
Donat, Endress, Mathog
classification
From: Donat TL et al. Facial Fracture Classification According to Skeletal Support
M...
Maxillary Fractures
Examination and Diagnosis
 Epistaxis
 Ecchymosis (periorbital, conjunctival, and
scleral)
 Malocclu...
Maxillary Fractures
Radiology
 X-Rays
 Bilateral Maxillary Sinus Opacification
 Pterygoid Plate Fracture On Lateral
Pro...
From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 386.
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From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 387.
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From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 393.http://entbgh.blogspot.com/
Maxillary Fractures
Complications
 Early
 Extensive Hemorrhage
 Airway Obstruction
 Infection
 CSF Leak
 Blindness
h...
Maxillary Fractures
Complications
 Late
 Palpable Hadware
 Non-Union / Malunion
 Plate Exposure
 Lacrimal System Obst...
Maxillary Fractures
Complications
 Late
 Diplopia
 Enophthalmos
 Orbital Dystopia
 Change In Facial Appearance

Faci...
Maxillary Fractures
Management
 Goals
 re-establish
midfacial height
and projection
 establish occlusal
relationship
 ...
Maxillary Fractures
Management
 Intermaxillary Fixation
 Open Reduction
 LeFort I

Bilateral Buccal Sulcus Incisions
...
Treatment
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Treatment
 Goal is functional and cosmetic
restoration
 Treatment must be individualized
 Various factors can affect ma...
Maxillary Fractures
Management
 Rigid Internal
Fixation
 Frontal Bone as a Guide
 Mandibuar Ramus Dictates
Facial Heigh...
Maxillary Fractures
Palatal Fractures
 8% of LeFort fractures
 Younger vs. Older
 <30 years

midline fracture
 >30 ye...
Maxillary Fractures
Palatal Fractures
 Stabilize before IMF
 Open reduction of palatal roof
 Pyriform aperture plate to...
Maxillary Fractures
Palatal Fractures
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Maxillary Fractures
Palatal Fractures
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Associated Injuries
 Brandt et al 1991
 59% caused by MVA had
intracranial injury
 10% caused by fall/beating had
intra...
Associated injuries
 Haug et al 1990
 402 patients
 Zygoma fractures:
 Lacerations 43%
 Orthopedic injuries 32%
 Add...
 Maxillary fractures:
 Lacerations and abrasions 75%
 Orthopedic injury 51%
 Other facial fractures 42%
 Neurologic i...
Midface
 “Rigid” fixation misnomer with small
plates and thin bones
 Semirigid fixation (wire) sometimes
preferable
 Ea...
Vertical Buttress Algorithm
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Midface Disimpaction
 May be necessary to restore
facial dimensions before fixation
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Palate
Fracture
 Wire can be
placed
posteriorly for
stabilization
before triangular
reduction
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ORIF of Midface
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Order of Repairs
 Work from stable to unstable
 Use occlusion as guide
 Generally stabilize mandible, zygoma
and palate...
Order of
Repairs
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Treatment of maxillary
fractures
 Early repair
 Single-stage
 Extended access approaches
 Rigid fixation
 Immediate b...
Maxillary fractures
 Steps of reconstruction-Rohrich and
Shewmake
 Reestablish facial height and width
 IMF with ORIF o...
Internal fixation vs. traditional
methods
 Klotch et al 1987
 43 patients
 22 treated with ORIF using AO
miniplates
 2...
 Most severe injuries in rigid internal
fixation group
 Shorter IMF, early return to diet, lower
percentage of tracheoto...
 Haug et al 1995
 134 patients treated by
maxillomandibular fixation or rigid
internal fixation
 Postoperative problems...
Treatment of maxillary
fractures
 Early repair
 Single-stage
 Extended access approaches
 Rigid fixation
 Immediate b...
Approaches
 Circumvestibular
 Facial degloving
 Bicoronal
 Transconjuctival
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From: Haug RH, Buchbinder D. Incisions For Access to Craniomaxillofacial Fractures.
Atlas of the Oral and Maxillofacial Su...
From: Haug RH, Buchbinder D. Incisions For Access to Craniomaxillofacial Fractures. Atlas
of the Oral and Maxillofacial Su...
Bicoronal approach
From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN
ed., Operative Otola...
From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN
ed., Operative Otolaryngology Head and ...
Cutting Edge Topics
 Bioresorbable plates
 Intraoperative CT
 3-D CT reconstruction
 Endoscopic assistance
http://entb...
Conclusion
 Goal is functional and cosmetic
rehabilitation
 Precise anatomic restoration key
 Treatment tailored to eac...
Conclusions
 High index of suspicion for associated
injuries- especially ocular
 Assessment of buttress system
 Wide ex...
Case Presentation
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 30 yo WF
 MVA
 PMH
unknown
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Maxillary and
Periorbital
Fractures
Frederick Mars Untalan, MD
http://entbgh.blogspot.com/
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Facial fractures the upper face

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Upper Midface Fractures (Quadripod Fractures, NasoOrbitoEthmoid Fractures Frontal Sinus Fractures)

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Facial fractures the upper face

  1. 1. Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/
  2. 2. http://entbgh.blogspot.com/
  3. 3. Facial Injuries  Dental Terminology http://entbgh.blogspot.com/
  4. 4. Overview  Classic tripod, orbital floor, LeFort fractures better thought of as orbitozygomaticomaxillary fractures  Precise anatomic reduction is key  Goal is functional and cosmetic rehabilitation http://entbgh.blogspot.com/
  5. 5. Epidemiology  Males : Females -- 4:1  Predominantly in 20’s or 30’s  Cause  MVA > altercation > fall  Site  Nasal > Zygoma > other  In altercations left zygoma fractured more often http://entbgh.blogspot.com/
  6. 6. History  Mechanism of InjuryMechanism of Injury  Previous facial injuries / Dental AbN  Premorbid history  Loss of consciousness  Medications, Allergies, Tetanus Status  Associated Injuries http://entbgh.blogspot.com/
  7. 7. Clinical Assessment of the Face  SYMPTOMS  Diplopia  Abnormal Sensation  Malocclusion  Pain http://entbgh.blogspot.com/
  8. 8. Clinical Assessment of the Face  GCS, Ocular exam, C-spine exam  Cranial nerve exam, CSF rhinorrhea  Inspect (including septum & TM)  Palpate (including midface stability)  Assess occlusion & intraoral exam http://entbgh.blogspot.com/
  9. 9.  CSF rhinorrhea – Halo sign  Septal hematoma  Hemotympanum  Malocclusion  Ocular Findings  Diplopia/restricted EOM, Subconj. Hem., hyphema, anisocoria, impaired VA Clinical Assessment of the Face http://entbgh.blogspot.com/
  10. 10.  Clinical Assessment of the Face  Reliable Physical signs  Bony facial asymmetry  True V2 numbness  Malocclusion Clinical Assessment of the Face http://entbgh.blogspot.com/
  11. 11. Physical Exam  Palpate for midface instability http://entbgh.blogspot.com/
  12. 12. Physical Exam  Often edema, swelling, or patient’s mental status make physical exam difficult  CT is modality of choice -- axial and coronal http://entbgh.blogspot.com/
  13. 13. Physical Exam  Midface asymmetry may indicate zygoma fracture http://entbgh.blogspot.com/
  14. 14. Forced Duction Testing http://entbgh.blogspot.com/
  15. 15. Emergency Management  C-Spine Injury  10% C-Spine Fracture  Head Injury  50% - Loss of Consciousness  5% Significant Intracranial Injury  Ocular Injury  25% - Some Degree of Injury http://entbgh.blogspot.com/
  16. 16. Emergency Management Hemorrhage  Local Pressure  Dressings / Packing  Reduction Of Facial Fractures  Endovascular Consultation  Ligation Of Vessels  IMAX http://entbgh.blogspot.com/
  17. 17. Radiographic Assessment of the Face  Water’s view  Panorex (Orthopantomogram)  Mandible views  CT scans  Standard of care for major facial trauma http://entbgh.blogspot.com/
  18. 18.  Water’s view The “W” system  PA view for visualization of maxillary sinuses, maxilla, orbits, and zygomatic arches  May also see nasal bone fractures Radiographic Assessment of the Face http://entbgh.blogspot.com/
  19. 19. CT areas to evaluate  Vertical buttresses  Zygomatic arch  Orbital walls  Bony palate  Mandibular condyles http://entbgh.blogspot.com/
  20. 20. Signs And Symptoms  Pain / Tenderness  Crepitus From Bony Fractures  Hypoesthesia  Paralysis  Malocclusion  Visual Disturbances  Deformity  Obstructive Respiration  Lacerations  Bleeding  Contusions  Facial Asymmetry http://entbgh.blogspot.com/
  21. 21. Soft Tissue Injuries  Tetanus Prophylaxis  Structures  Facial Nerve  Trigeminal Nerve  Parotid Duct  Lacrimal System http://entbgh.blogspot.com/
  22. 22. Principles Of Craniomaxillofacial Fracture Management  Precise anatomic diagnosis  Direct fracture exposure  Reduction / rigid internal fixation  Mandible fracture stabilization  Reconstruction of horizontal and vertical facial buttresses  Primary bone grafting  Periosteal and soft-tissue suspension and repair http://entbgh.blogspot.com/
  23. 23. Facial Fractures The Upper Face http://entbgh.blogspot.com/
  24. 24. Outline  Facial Fracture Basics  Nasal Fractures  Naso-orbital-ethmoidal Fractures  Frontal Sinus Fractures  Zygomatic Fractures  Maxillary Fractures  Orbital Fractures http://entbgh.blogspot.com/
  25. 25. Nasal Fractures http://entbgh.blogspot.com/
  26. 26. Physical Exam  Edema  Crepitus  Periorbital Ecchymosis  Epistaxis  Internal And External Lacerations  Widened Nasal Bridge  Septal Hematoma http://entbgh.blogspot.com/
  27. 27. Classification Stranc and Robertson  Lateral Impact Injuries  Unilateral vs. Bilateral  Frontal Impact Injuries  Plane I  Plane II  Plane III http://entbgh.blogspot.com/
  28. 28. Treatment Lateral Impact Injuries  Early Versus Delayed Treatment  Closed Reduction (Local vs. General)  Drainage of Septal Hematoma  Simple Repositioning of Deviated Nasal Bones and Septum  Completion Of The Fracture  Internal Packing and External Splint http://entbgh.blogspot.com/
  29. 29. Treatment Frontal Impact Injuries  Plane I  edema / ecchymosis distal nasal bridge and tip  possible septal distortion  closed reduction with internal support  possibly may require secondary septorhinoplasty http://entbgh.blogspot.com/
  30. 30. Treatment Frontal Impact Injuries  Plane II  Increased Comminution of the Nasal Pyramid  Bilateral  Possible “Saddling”  Initial Closed reduction  May Require Delayed Septal Reconstruction With Grafts http://entbgh.blogspot.com/
  31. 31. Treatment Frontal Impact Injuries  Plane III  Extend Into Pyriform Aperture And Medial Orbital Rim  ie. Naso-Orbital-Ethmoidal Fractures  Open Reduction an Internal Fixation of Frontal Process of Maxilla  Transnasal Reduction of Medial Canthal Ligaments http://entbgh.blogspot.com/
  32. 32. Complications  Occur In Up To 70%  Deviated Nasal Pyramid  Nasal “Hump”  Septal Deformity With Respiratory Obstruction http://entbgh.blogspot.com/
  33. 33. Naso-Orbital-Ethmoidal Fractures http://entbgh.blogspot.com/
  34. 34. Naso-Orbital-Ethmoidal Fractures http://entbgh.blogspot.com/
  35. 35. Naso-Orbital-Ethmoidal Fractures  Interorbital “Space”  two ethmoidal labyrinths  superior and middle turbinates  perpendicular plate of ethmoid  Medial Orbital Wall  anteriorly - lacrimal bone and lamina papyracea  posteriorly - body of sphenoid http://entbgh.blogspot.com/
  36. 36. Naso-Orbital-Ethmoidal Fractures  Interorbital space displaced backwards  Medial Canthal Tendon and Lacrimal Apparatus frequently injured  May extend into:  cribriform plate and anterior cranial fossa  optic foramen  Associated Orbit and Midface Fractures Common http://entbgh.blogspot.com/
  37. 37. Naso-Orbital-Ethmoidal Fractures  Flat nose  Swollen medial canthal area  Telecanthus (12-20%)  Lack of skeletal support on palpation of nose  CSF leak  Positive eyelid traction test http://entbgh.blogspot.com/
  38. 38. Naso-Orbital-Ethmoidal Fractures Telecanthus  Normal intercanthal distance (Stranc)  White males: 33-34mm  Females: 32-33mm  Consider >35mm abnormal (Manson) http://entbgh.blogspot.com/
  39. 39. Naso-Orbital-Ethmoidal Fractures Classification Markowitz  Type I - Single central segment  Type II - Comminuted central segment  Type III - Avulsed medial canthal tendon http://entbgh.blogspot.com/
  40. 40. Naso-Orbital-Ethmoidal Fractures http://entbgh.blogspot.com/
  41. 41. Naso-Orbital-Ethmoidal Fractures Classification - Gruss 1 Isolated injury to bony naso-orbital region 2 Associated fractures of the central maxilla 3 Associated LeFort II and III 4 Naso-orbital fractures with orbital dystopia 5 Naso-orbital fractures with bone loss http://entbgh.blogspot.com/
  42. 42. Naso-Orbital-Ethmoidal Fractures Management  Early open reduction  Four Objectives:  correct epicanthal folds  restore bony contour  reestablish lacrimal system continuity  medial canthoplasty / canthopexy http://entbgh.blogspot.com/
  43. 43. Naso-Orbital-Ethmoidal Fractures Management  Wide Exposure  coronal incision  “open sky” - transverse across root of nose  vertical midline nasal  subciliary  buccal sulcus  extend existing lacerations http://entbgh.blogspot.com/
  44. 44. Naso-Orbital-Ethmoidal Fractures Management  Correct nasofrontal separation  Elevate nasal bones  Reduce comminuted nasal bones  Bone graft where needed  Explore septum  Stabilize nasomaxillary buttresses http://entbgh.blogspot.com/
  45. 45. Frontal Sinus Fractures http://entbgh.blogspot.com/
  46. 46. Frontal Sinus Embryology  Begin to Develop At 2 Years of Age  Extension of the Ethmoid Air Cells  Radiographically Evident At ~ 8 Years  Do Not Reach Adult Size Until 12 or Older  10% - Unilateral Development  4% - Absent All Together  Drain Into Middle Meatushttp://entbgh.blogspot.com/
  47. 47. Frontal Sinus Anatomy  Supraorbital / Temporal vs Frontal Sinus  Anterior Wall and/or Posterior Wall  Nasofrontal Duct http://entbgh.blogspot.com/
  48. 48. Frontal Sinus Diagnosis  Signs And Symptoms  Forehead Laceration  CSF Rhinorrhea  Supraorbital Nerve Anesthesia  Depressed Frontal Region  Subconjunctival Ecchymosis http://entbgh.blogspot.com/
  49. 49. Frontal Sinus Diagnosis  X-Ray  Air Fluid Levels  CT Scan  Axial and Coronal Images http://entbgh.blogspot.com/
  50. 50. http://entbgh.blogspot.com/
  51. 51. Frontal Sinus Treatment  Operative Indications  Anterior Table Displacement With Contour Change  Nasofrontal Duct Involvement  Displaced Posterior Table http://entbgh.blogspot.com/
  52. 52. Frontal Sinus Treatment  Nasofrontal Duct Injury  Remove Mucosa  Burr Inner Cortex  Occlusion Of Duct  Sinus Obliteration http://entbgh.blogspot.com/
  53. 53. Frontal Sinus Treatment  Posterior Table  Cranialization 1 Bicoronal Approach 2 Preserve Pericranial Flap 3 Dural Repair 4 Remove Sinus Mucosa 5 Obliterate Nasofrontal Duct 6 Remove Intersinus Septum And Posterior Wall 7 Pericranial Flap To Floor Of Sinus http://entbgh.blogspot.com/
  54. 54. Frontal Sinus Complications  Early (within 6 months)  Frontal Sinusitis  Meningitis  Late  Mucocele  Mucopyocele  Brain Abcess  Osteomyelitis http://entbgh.blogspot.com/
  55. 55. Frontal Sinus Complications  Incidence Of Late Complications  Freihofer  71 Fractures  2 Patients - Meningitis  1 Patient - Mucopyocele With Osteomyelitis Of Frontal Bone http://entbgh.blogspot.com/
  56. 56. Orbital Fractures http://entbgh.blogspot.com/
  57. 57. Orbital Blowout Injury http://entbgh.blogspot.com/
  58. 58. Orbital Fractures Blowout Fractures Pure Blowout - only orbital floor or medial wall injured Impure Blowout - associated orbital rim fractures http://entbgh.blogspot.com/
  59. 59. Orbital Blowout Injury http://entbgh.blogspot.com/
  60. 60. Orbital Blowout Injury  Usually inferior and/or medial wall  Cone will become more spherical  Leads to enophthalmos, inferior displacement  Muscle entrapment causes diplopia http://entbgh.blogspot.com/
  61. 61. Orbital Fractures Physical Exam  Diplopia  Enophthalmos  Inferior Displacement Palpebral Fissure  Anesthesia of Infraorbital Nerve  Orbital Emphysema http://entbgh.blogspot.com/
  62. 62. Orbital Fractures Physical Exam  Diplopia  Commonly on Upward Gaze  Primary (Central Gaze) or Secondary (Perpheral)  Mechanical (incarceration of infraorbital tissue) or Nonmechanical (paresis)  Forced Duction Test http://entbgh.blogspot.com/
  63. 63. Orbital Fractures Forced Duction Test http://entbgh.blogspot.com/
  64. 64. Orbital Fractures Physical Exam  Enophthalmos  Inferior and Posterior Displacement of Globe and Intraorbital Soft Tissue  Etiology  Enlargement of the Bony Orbital Cavity  Escape of Orbital Fat or Fat Necrosis  Muscle Entrapment in Fracture Line  Soft Tissue Scarring and Contracture http://entbgh.blogspot.com/
  65. 65. Orbital Fractures Enophthalmos http://entbgh.blogspot.com/
  66. 66. Orbital Fractures Physical Exam  No Diplopia + No Enophthalmos ?Significant Fracture  Diplopia + No Enophthalmos Incarceration Only  No Diplopia + Enophthalmos Volume Discrepancy Only  Diplopia + Enophthalmos Incarceration + Volume Discrepancy http://entbgh.blogspot.com/
  67. 67. Orbital Fractures Indications For Exploration  Symptomatic Diplopia With Positive Forced Duction Test  Xray evidence of Extraocular Muscle Entrapment  Early Enophthalmos (>3mm)  Large Orbital Floor Defect  Abnormally Low Vertical Globe Level  Associated Orbital Rim or Other Craniofacial Fractures http://entbgh.blogspot.com/
  68. 68. Orbital Rim Access  A -- subciliary  B -- lower eyelid  C -- infraorbital http://entbgh.blogspot.com/
  69. 69. Orbital Fractures Incisions http://entbgh.blogspot.com/
  70. 70. Orbital Fractures Management  Grafts  Autologous Bone  Cartilage  Fascia lata  Alloplastic Implants  Teflon  Silastic  Titanium http://entbgh.blogspot.com/
  71. 71. Orbital Floor  Dotted line shows anatomic goal of restoration http://entbgh.blogspot.com/
  72. 72. Orbital Fractures Complications  Infection  Implant problems  Persistent Diplopia (2-50%)  Persistent Enophthalmos (15-22%)  Ectropion (1%)  Blindness http://entbgh.blogspot.com/
  73. 73. Orbital Fractures Complications  Superior Orbital Fissure Syndrome  extension of fracture into SOF  ophthalmoplegia with injury to III, IV or VI  anesthesia in V1 plus loss of corneal reflex  ptosis and proptosis  parasympathetic block  fixed, dilated pupil http://entbgh.blogspot.com/
  74. 74. Orbital Fractures Complications  Orbital Apex Syndrome  same as superior orbital fissure syndrome  plus blindness http://entbgh.blogspot.com/
  75. 75. Transconjunctival Approach  Conjunctiva is being used to protect globe http://entbgh.blogspot.com/
  76. 76. Materials for reconstruction  Autogenous tissues  Avoid risk of infected implant  Additional operative time, donor site morbidity , graft absorption  Calvarial bone, iliac crest, rib, septal or auricular cartilage http://entbgh.blogspot.com/
  77. 77. Orbital Floor Bone Grafting  Need to support floor full 4 cm http://entbgh.blogspot.com/
  78. 78.  Alloplastic implants  Decreased operative time, easily available, no donor site morbidity, can provide stable support  Risk of infection 0.4-7%  Gelfilm, polygalactin film, silastic, marlex mesh, teflon, prolene, polyethylene, titanium http://entbgh.blogspot.com/
  79. 79. Orbital Floor Materials  Marlex mesh  needs 360 degree support  better for concave anterior floor only  Medpor  needs medial/ lateral support  can use for anterior/posterior defect  Calvarial bone graft  Titanium mesh http://entbgh.blogspot.com/
  80. 80. Synthetic Mesh http://entbgh.blogspot.com/
  81. 81. Orbital Metallic Mesh http://entbgh.blogspot.com/
  82. 82. Orbital Roof  Uncommon due to high levels of force needed to fracture orbital roof  Commonly with intracranial problems http://entbgh.blogspot.com/
  83. 83. http://entbgh.blogspot.com/
  84. 84. Orbital Roof Repair  Repair roof higher on frontal bar http://entbgh.blogspot.com/
  85. 85. From: Strong EB, Sykes JM. Zygoma Complex Fractures. Facial Plastic Surgery 1990;14(1):109. http://entbgh.blogspot.com/
  86. 86. Periorbital & Zygomatic bone Fractures http://entbgh.blogspot.com/
  87. 87. Zygoma Fractures  Results from lateral forceshttp://entbgh.blogspot.com/
  88. 88. Zygoma Anatomy  Tetrapod Structure  Frontal Bone  Temporal Bone  Maxilla  Greater Wing Of Sphenoid http://entbgh.blogspot.com/
  89. 89. Zygoma Anatomy http://entbgh.blogspot.com/
  90. 90. Zygoma Anatomy  Muscular Attachments  Masseter  Temporalis  Zygomaticus  Zygomatic Head of Quadratus Labii Superioris http://entbgh.blogspot.com/
  91. 91. Zygoma Physical Exam  Circumorbital Swelling / Ecchymosis  Subconjunctival Hemorrage  Abnormal Sensation V2 Distribution  Diplopia or Globe Displacement  Increased Facial Width  Depressed Malar Prominence  Palpable Step Deformities  Unilateral Epistaxis  Hematoma Upper Buccal Sulcus  Trismus Due To Coronoid Process Impingement http://entbgh.blogspot.com/
  92. 92. Zygoma Physical Exam http://entbgh.blogspot.com/
  93. 93. Zygoma Physical Exam http://entbgh.blogspot.com/
  94. 94. Zygoma Fracture Classification  Knight 1 Undisplaced 2 Arch Fractures 3 Unrotated Body Fractures 4 Medially Rotated Body Fractures 5 Laterally Rotated Body Fractures 6 Complex Fractures - Additional Fractures Across Zygoma http://entbgh.blogspot.com/
  95. 95. Zygoma Fracture Classification  Manson  Low Energy  minimal displacement  do not require operative reduction  Middle Energy  High Energy  often part of panfacial fractures http://entbgh.blogspot.com/
  96. 96. Zygoma Radiology  X-Ray  Water’s View Most Useful  CT Scan  Coronal Cuts For Orbital Anatomy http://entbgh.blogspot.com/
  97. 97. Zygoma Fractures  Impacted zygoma may mask orbital floor defect http://entbgh.blogspot.com/
  98. 98. Treatment of Zygomaticomaxillary Complex fractures  Restore pre-injury facial configuration  Prevent cosmetic deformity  Prevent delayed visual disturbances  Repair within 5-7 days allows edema to decrease and avoids shortening of masseter with lateral and inferior rotation http://entbgh.blogspot.com/
  99. 99. Zygoma  Ideally done between 5-7 days for resolution of edema  Pre- or intra- operative steroids can help with edema  After 10 days masseter begins to shorten http://entbgh.blogspot.com/
  100. 100. Zygoma  reduction only - Minimally displaced, non comminuted  plating of lateral antrum, orbital rim, ZF suture, and even the zygomatic arch - for Increasing amounts of displacement & comminution  One can wire the ZF suture first to assist with reduction, then plate it after other areas stabilized http://entbgh.blogspot.com/
  101. 101. Zygoma Algorithm http://entbgh.blogspot.com/
  102. 102. Zygoma Management  Undisplaced  Nonoperative  Displaced  Isolated Zygomatic Arch - Gilles Elevation  Orbitozygomatic Fractures - Open reduction and Stabilization http://entbgh.blogspot.com/
  103. 103. Zygoma Management http://entbgh.blogspot.com/
  104. 104. ORIF of Lateral Antral Wall http://entbgh.blogspot.com/
  105. 105. Gillies Reduction http://entbgh.blogspot.com/
  106. 106. Post-Gillies Reduction http://entbgh.blogspot.com/
  107. 107. Surgical Approaches  Coronal  Sublabial  Transconjunctival  Lateral Brow http://entbgh.blogspot.com/
  108. 108. Coronal Approach http://entbgh.blogspot.com/
  109. 109. Coronal Approach http://entbgh.blogspot.com/
  110. 110. Coronal Approach  Supraorbital nerve may be released for more exposure http://entbgh.blogspot.com/
  111. 111. Hemicoronal Approach http://entbgh.blogspot.com/
  112. 112. Lateral Brow Incision  Avoid shaving brow hairs  Goal is the ZF suturehttp://entbgh.blogspot.com/
  113. 113. Sublabial Approach  Leave mucosa to sew to later  Identify and preserve V2 http://entbgh.blogspot.com/
  114. 114. Zygoma Gilles Elevation http://entbgh.blogspot.com/
  115. 115. Zygoma Operative Exposure http://entbgh.blogspot.com/
  116. 116. Zygoma Operative Exposure http://entbgh.blogspot.com/
  117. 117. Zygoma Operative Exposure http://entbgh.blogspot.com/
  118. 118. Zygoma Complications - Early  Bleeding  Infection  Exacerbation of Sinus Disease  Malfunction of Extraocular Muscles  Blindness http://entbgh.blogspot.com/
  119. 119. Zygoma Complications - Late  Nonunion / Malunion  Diplopia (10% initial, 5% permanent)  Persistent V2 Anesthesia (24%)  Orbital Dystopia  Chronic Maxillary Sinusitis (4-7%)  Scarring  Ectropion  Problems With Mandible Motion  Enophthalmos (3%)  Soft Tissue Descent With Loss of Malar Prominence http://entbgh.blogspot.com/
  120. 120. Treatment of Zygomaticomaxillary Complex fractures  Restore pre-injury facial configuration  Prevent cosmetic deformity  Prevent delayed visual disturbances  Repair within 5-7 days allows edema to decrease and avoids shortening of masseter with lateral and inferior rotation http://entbgh.blogspot.com/
  121. 121.  Soft diet and malar protection  Closed reduction  ORIF with plating of one to four buttresses  Provide fixation as necessary for stable reduction http://entbgh.blogspot.com/
  122. 122. Maxillary Fractures http://entbgh.blogspot.com/
  123. 123. Types  LeFort or Maxillary fractures  Zygomaticomaxillary complex fractures  Orbitozygomaticomaxillary complex fractures http://entbgh.blogspot.com/
  124. 124. Anatomy of the Maxilla  Paired embryologically  Functionally acts with palatine bone http://entbgh.blogspot.com/
  125. 125. Anatomy of the Maxilla http://entbgh.blogspot.com/
  126. 126. LeFort fractures  Rene LeFort 1901 in cadaver skulls  Based on the most superior level  Frequently different levels on either side  LeFort I  LeFort II  LeFort III http://entbgh.blogspot.com/
  127. 127. Facial Buttress system From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative Otolaryngology Head and Neck Surgery, Philadelphia, WB Saunders Company 1997:1143-1192. http://entbgh.blogspot.com/
  128. 128. From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing Company 1988, pg76. http://entbgh.blogspot.com/
  129. 129. Facial buttress system http://entbgh.blogspot.com/
  130. 130. Buttresse s  Resist occlusal load http://entbgh.blogspot.com/
  131. 131. Horizontal Buttresses http://entbgh.blogspot.com/
  132. 132. LeFort fractures  Rene LeFort 1901 in cadaver skulls  Based on the most superior level  Frequently different levels on either side  LeFort I  LeFort II  LeFort III http://entbgh.blogspot.com/
  133. 133. LeFort Fractures  Experimentally determined weak points  Can be in combinations bilaterally  Useful descriptor  Results from anterior forces http://entbgh.blogspot.com/
  134. 134. Forces of mastication From: Banks P, Brown A. Fractures of the Facial Skeleton, Oxford, Wright 2001 pg.6 http://entbgh.blogspot.com/
  135. 135. Facial Buttress system From :Stanley RB. Maxillary and Periorbital Fractures. In :Bailey BJ ed., Head and Neck Surgery-Otolaryngology, third edition, Philadelphia, Lippincott Williams & Wilkins 2001, pg 777.http://entbgh.blogspot.com/
  136. 136. From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962. http://entbgh.blogspot.com/
  137. 137. From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing Company 1988, pg76. http://entbgh.blogspot.com/
  138. 138. Maxillary Fractures LeFort Fractures  LeFort I  Transverse Fracture That Separates Maxillary Alveolus From Midface Skeleton  Runs Above Roots of Maxillary Teeth, Across Lower Pyriform Aperature, and Severs Pterygoid Process http://entbgh.blogspot.com/
  139. 139. Le Fort I http://entbgh.blogspot.com/
  140. 140. Maxillary Fractures LeFort Fractures  Lefort II  “Pyramidal” Fracture of Maxilla  Separates Nasomaxillary Segment from Zygomatic and Upper Lateral Midface  Fracture Line May Go Above or Beneath Medial Canthal Ligament Insertion  Lacrimal System May Be Involved http://entbgh.blogspot.com/
  141. 141. Le Fort II http://entbgh.blogspot.com/
  142. 142. Maxillary Fractures LeFort Fractures  LeFort III  Craniofacial Dysjunction  Zygomaticofrontal Junction, Traverses Lateral, Inferior, and Medial Orbit, Separates Frontal Process of Maxilla From Frontal Bones http://entbgh.blogspot.com/
  143. 143. Le Fort III http://entbgh.blogspot.com/
  144. 144. Maxillary Fractures LeFort Fractures http://entbgh.blogspot.com/
  145. 145. Modified LeFort Classification From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962. http://entbgh.blogspot.com/
  146. 146. Donat, Endress, Mathog classification From: Donat TL et al. Facial Fracture Classification According to Skeletal Support Mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314.http://entbgh.blogspot.com/
  147. 147. Maxillary Fractures Examination and Diagnosis  Epistaxis  Ecchymosis (periorbital, conjunctival, and scleral)  Malocclusion With Anterior Open Bite  Buccal Mucosa Hematoma  Tear in Intraoral Soft Tissues  Elongated, Retruded Appearance  “Donkey-Like” Facies  CSF Leak in 25-50% of LeFort II and III http://entbgh.blogspot.com/
  148. 148. Maxillary Fractures Radiology  X-Rays  Bilateral Maxillary Sinus Opacification  Pterygoid Plate Fracture On Lateral Projection  Fracture Through ZF and Nasofrontal Suture http://entbgh.blogspot.com/
  149. 149. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 386. http://entbgh.blogspot.com/
  150. 150. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 387. http://entbgh.blogspot.com/
  151. 151. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 393.http://entbgh.blogspot.com/
  152. 152. Maxillary Fractures Complications  Early  Extensive Hemorrhage  Airway Obstruction  Infection  CSF Leak  Blindness http://entbgh.blogspot.com/
  153. 153. Maxillary Fractures Complications  Late  Palpable Hadware  Non-Union / Malunion  Plate Exposure  Lacrimal System Obstruction  V2 Anesthesia  Devitalized Teeth  Extra-Occular Muscle Imbalance http://entbgh.blogspot.com/
  154. 154. Maxillary Fractures Complications  Late  Diplopia  Enophthalmos  Orbital Dystopia  Change In Facial Appearance  Facial height and width  Nasal Obstruction  Malocclusion http://entbgh.blogspot.com/
  155. 155. Maxillary Fractures Management  Goals  re-establish midfacial height and projection  establish occlusal relationship  maintain integrity of nose and orbits http://entbgh.blogspot.com/
  156. 156. Maxillary Fractures Management  Intermaxillary Fixation  Open Reduction  LeFort I  Bilateral Buccal Sulcus Incisions  LeFort II and III  Coronal and Lower Eyelid Incisions http://entbgh.blogspot.com/
  157. 157. Treatment http://entbgh.blogspot.com/
  158. 158. Treatment  Goal is functional and cosmetic restoration  Treatment must be individualized  Various factors can affect management strategies  Multi-trauma  Concomitant mandible injury  Only-seeing eye http://entbgh.blogspot.com/
  159. 159. Maxillary Fractures Management  Rigid Internal Fixation  Frontal Bone as a Guide  Mandibuar Ramus Dictates Facial Height  Stabilize Vertical Buttresses  Bone Grafts If Necessary http://entbgh.blogspot.com/
  160. 160. Maxillary Fractures Palatal Fractures  8% of LeFort fractures  Younger vs. Older  <30 years  midline fracture  >30 years  sagittal fractures adjacent to midline or alveolus http://entbgh.blogspot.com/
  161. 161. Maxillary Fractures Palatal Fractures  Stabilize before IMF  Open reduction of palatal roof  Pyriform aperture plate to unite maxillary segements  Dental splints to prevent occlusion http://entbgh.blogspot.com/
  162. 162. Maxillary Fractures Palatal Fractures http://entbgh.blogspot.com/
  163. 163. Maxillary Fractures Palatal Fractures http://entbgh.blogspot.com/
  164. 164. Associated Injuries  Brandt et al 1991  59% caused by MVA had intracranial injury  10% caused by fall/beating had intracranial injury http://entbgh.blogspot.com/
  165. 165. Associated injuries  Haug et al 1990  402 patients  Zygoma fractures:  Lacerations 43%  Orthopedic injuries 32%  Additional facial fractures 22%  Neurologic injury 27%  Pulmonary, abdominal, cardiac 7%, 4.1%, 1% http://entbgh.blogspot.com/
  166. 166.  Maxillary fractures:  Lacerations and abrasions 75%  Orthopedic injury 51%  Other facial fractures 42%  Neurologic injury 51%  Pulmonary 13%, abdominal 5.7%, cardiac 3.8% http://entbgh.blogspot.com/
  167. 167. Midface  “Rigid” fixation misnomer with small plates and thin bones  Semirigid fixation (wire) sometimes preferable  Early function can be achieved with soft diet only http://entbgh.blogspot.com/
  168. 168. Vertical Buttress Algorithm http://entbgh.blogspot.com/
  169. 169. Midface Disimpaction  May be necessary to restore facial dimensions before fixation http://entbgh.blogspot.com/
  170. 170. Palate Fracture  Wire can be placed posteriorly for stabilization before triangular reduction http://entbgh.blogspot.com/
  171. 171. ORIF of Midface http://entbgh.blogspot.com/
  172. 172. Order of Repairs  Work from stable to unstable  Use occlusion as guide  Generally stabilize mandible, zygoma and palate before midface before orbit and NOE http://entbgh.blogspot.com/
  173. 173. Order of Repairs http://entbgh.blogspot.com/
  174. 174. Treatment of maxillary fractures  Early repair  Single-stage  Extended access approaches  Rigid fixation  Immediate bone grafting  Re-suspension of soft tissues http://entbgh.blogspot.com/
  175. 175. Maxillary fractures  Steps of reconstruction-Rohrich and Shewmake  Reestablish facial height and width  IMF with ORIF of mandible  Zygomatic arch reconstruction restores facial width and projection  Reconstruction continues from stable bone to unstable and from lateral to medial http://entbgh.blogspot.com/
  176. 176. Internal fixation vs. traditional methods  Klotch et al 1987  43 patients  22 treated with ORIF using AO miniplates  21 treated with combination of intermaxillary fixation, and/or interosseous wiring, and/or primary bone grafting http://entbgh.blogspot.com/
  177. 177.  Most severe injuries in rigid internal fixation group  Shorter IMF, early return to diet, lower percentage of tracheotomy  No plate infections http://entbgh.blogspot.com/
  178. 178.  Haug et al 1995  134 patients treated by maxillomandibular fixation or rigid internal fixation  Postoperative problems in 60% vs 64% http://entbgh.blogspot.com/
  179. 179. Treatment of maxillary fractures  Early repair  Single-stage  Extended access approaches  Rigid fixation  Immediate bone grafting  Re-suspension of soft tissues http://entbgh.blogspot.com/
  180. 180. Approaches  Circumvestibular  Facial degloving  Bicoronal  Transconjuctival http://entbgh.blogspot.com/
  181. 181. From: Haug RH, Buchbinder D. Incisions For Access to Craniomaxillofacial Fractures. Atlas of the Oral and Maxillofacial Surgery Clinics of North America 1993;1(2):23. http://entbgh.blogspot.com/
  182. 182. From: Haug RH, Buchbinder D. Incisions For Access to Craniomaxillofacial Fractures. Atlas of the Oral and Maxillofacial Surgery Clinics of North America 1993;1(2):25. http://entbgh.blogspot.com/
  183. 183. Bicoronal approach From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative Otolaryngology Head and Neck Surgery, Philadelphia, WB Saunders Company 1997:1143-1192.http://entbgh.blogspot.com/
  184. 184. From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative Otolaryngology Head and Neck Surgery, Philadelphia, WB Saunders Company 1997:1143-1192. http://entbgh.blogspot.com/
  185. 185. Cutting Edge Topics  Bioresorbable plates  Intraoperative CT  3-D CT reconstruction  Endoscopic assistance http://entbgh.blogspot.com/
  186. 186. Conclusion  Goal is functional and cosmetic rehabilitation  Precise anatomic restoration key  Treatment tailored to each individual  Knowledge of anatomy and techniques will lead to superior results http://entbgh.blogspot.com/
  187. 187. Conclusions  High index of suspicion for associated injuries- especially ocular  Assessment of buttress system  Wide exposure via cosmetically acceptable incisions  Rigid fixation  Soft tissue resuspension http://entbgh.blogspot.com/
  188. 188. Case Presentation http://entbgh.blogspot.com/
  189. 189.  30 yo WF  MVA  PMH unknown http://entbgh.blogspot.com/
  190. 190. http://entbgh.blogspot.com/
  191. 191. http://entbgh.blogspot.com/
  192. 192. Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/

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