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. 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. 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. Clinical Assessment of the
Face
SYMPTOMS
Diplopia
Abnormal
Sensation
Malocclusion
Pain
http://entbgh.blogspot.com/
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. Clinical Assessment of the Face
Reliable Physical signs
Bony facial asymmetry
True V2 numbness
Malocclusion
Clinical Assessment of the
Face
http://entbgh.blogspot.com/
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/
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. Emergency Management
Hemorrhage
Local Pressure
Dressings / Packing
Reduction Of Facial
Fractures
Endovascular
Consultation
Ligation Of Vessels
IMAX
http://entbgh.blogspot.com/
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. 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. CT areas to evaluate
Vertical buttresses
Zygomatic arch
Orbital walls
Bony palate
Mandibular condyles
http://entbgh.blogspot.com/
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. 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. 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. 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. 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. Complications
Occur In Up To 70%
Deviated Nasal Pyramid
Nasal “Hump”
Septal Deformity With Respiratory
Obstruction
http://entbgh.blogspot.com/
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. 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. 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/
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. 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/
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/
58. Orbital Fractures
Blowout Fractures
Pure Blowout - only orbital floor or
medial wall injured
Impure Blowout - associated orbital rim
fractures
http://entbgh.blogspot.com/
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. Orbital Fractures
Physical Exam
Diplopia
Enophthalmos
Inferior Displacement Palpebral Fissure
Anesthesia of Infraorbital Nerve
Orbital Emphysema
http://entbgh.blogspot.com/
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/
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/
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. 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. Orbital Rim
Access
A -- subciliary
B -- lower eyelid
C -- infraorbital
http://entbgh.blogspot.com/
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/
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. 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/
82. Orbital Roof
Uncommon due to high levels of force
needed to fracture orbital roof
Commonly with intracranial problems
http://entbgh.blogspot.com/
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. 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/
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. 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. 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/
118. Zygoma
Complications - Early
Bleeding
Infection
Exacerbation of Sinus Disease
Malfunction of Extraocular Muscles
Blindness
http://entbgh.blogspot.com/
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. 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. 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/
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. 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. From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing Company 1988, pg76.
http://entbgh.blogspot.com/
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/
134. Forces of mastication
From: Banks P, Brown A. Fractures of the Facial Skeleton,
Oxford, Wright 2001 pg.6
http://entbgh.blogspot.com/
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. From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962.
http://entbgh.blogspot.com/
137. From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian
Publishing Company 1988, pg76.
http://entbgh.blogspot.com/
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/
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/
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. 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. 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. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 386.
http://entbgh.blogspot.com/
150. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 387.
http://entbgh.blogspot.com/
151. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 393.http://entbgh.blogspot.com/
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. Maxillary Fractures
Management
Goals
re-establish
midfacial height
and projection
establish occlusal
relationship
maintain integrity of
nose and orbits
http://entbgh.blogspot.com/
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/
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. 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. 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. 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/
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/
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/
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/
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. 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. 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. 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. 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. 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/
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. 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. 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. 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/
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. 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/