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Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
Maxillary and periorbital fractures
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Maxillary and periorbital fractures

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Maxillary and Periorbital Fractures

Maxillary and Periorbital Fractures

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  • 1. Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/
  • 2. http://entbgh.blogspot.com/
  • 3. 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/
  • 4. 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/
  • 5. Mechanisms • Assault • MVA • Gunshot wounds • Sports • Falls • Industrial accidents http://entbgh.blogspot.com/
  • 6. Anatomy http://entbgh.blogspot.com/
  • 7. Anatomy http://entbgh.blogspot.com/
  • 8. Anatomy of the Orbit • Bones: Frontal, Zygomatic, Ethmoid, Lacrimal, Maxilla, Palatal, Sphenoid http://entbgh.blogspot.com/
  • 9. Anatomy of the Orbit • Four-sided pyramid or cone http://entbgh.blogspot.com/
  • 10. Anatomy of the Orbit • Maximum vertical dimension 1.5 cm behind rim • Floor is concave and then convex http://entbgh.blogspot.com/
  • 11. Anatomy of the Orbit • Floor slopes into medial wall • Optic nerve superomedial to true apex http://entbgh.blogspot.com/
  • 12. Anatomy of Zygoma • Four superficial and two deep articulations • Intersection of arcs define malar prominence http://entbgh.blogspot.com/
  • 13. Anatomy of the Maxilla • Paired embryologically • Functionally acts with palatine bone http://entbgh.blogspot.com/
  • 14. Anatomy of the Maxilla http://entbgh.blogspot.com/
  • 15. Vertical Buttresses • Resist occlusal load http://entbgh.blogspot.com/
  • 16. 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/
  • 17. Horizontal Buttresses http://entbgh.blogspot.com/
  • 18. 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/
  • 19. Fracture Patterns http://entbgh.blogspot.com/
  • 20. 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/
  • 21. Facial buttress system From: Rowe NL, Williams JL. Maxillofacial Injuries. Edinburgh, Churchill Livingstone,1985, pg 19. http://entbgh.blogspot.com/
  • 22. 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/
  • 23. From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing Company 1988, pg76. http://entbgh.blogspot.com/
  • 24. Modified LeFort Classification From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962. http://entbgh.blogspot.com/
  • 25. LeFort Fractures • Experimentally determined weak points • Can be in combinations bilaterally • Useful descriptor • Results from anterior forces http://entbgh.blogspot.com/
  • 26. Le Fort I http://entbgh.blogspot.com/
  • 27. Maxillary Fractures LeFort I • Clinical findings: – Facial edema – Malocclusion of the teeth – Motion of the maxilla while the nasal bridge remains stable http://entbgh.blogspot.com/
  • 28. Le Fort II http://entbgh.blogspot.com/
  • 29. Maxillary Fractures LeFort II • Clinical findings: – Marked facial edema – Nasal flattening – Traumatic telecanthus – Epistaxis or CSF rhinorrhea – Movement of the upper jaw and the nose. http://entbgh.blogspot.com/
  • 30. Le Fort III http://entbgh.blogspot.com/
  • 31. Maxillary Fractures LeFort III • Clinical findings: – Dish faced deformity – Epistaxis and CSF rhinorrhea – Motion of the maxilla, nasal bones and zygoma – Severe airway obstruction http://entbgh.blogspot.com/
  • 32. http://entbgh.blogspot.com/
  • 33. http://entbgh.blogspot.com/
  • 34. Zygoma Fractures • Results from lateral forceshttp://entbgh.blogspot.com/
  • 35. Zygoma Tripod Fractures Clinical Features • Clinical features: – Periorbital edema and ecchymosis – Hypesthesia of the infraorbital nerve – Palpation may reveal step off – Concomitant globe injuries are common http://entbgh.blogspot.com/
  • 36. Zygoma Fractures • Impacted zygoma may mask orbital floor defect http://entbgh.blogspot.com/
  • 37. Orbital Blowout Fractures Clinical Findings • Periorbital tenderness, swelling, ecchymosis. • Enopthalmus or sunken eyes. • Impaired ocular motility. • Infraorbital anesthesia. • Step off deformity http://entbgh.blogspot.com/
  • 38. Orbital Blowout Injury http://entbgh.blogspot.com/
  • 39. Orbital Blowout Injury http://entbgh.blogspot.com/
  • 40. 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/
  • 41. Patient Evaluation http://entbgh.blogspot.com/
  • 42. Physical Exam • Can be very difficult in traumatized patient • Don’t forget trauma ABC’s (ATLS) • Look for occlusion, trismus, stability, asymmetry, extraocular movements, V2 anesthesia, stepoffs, bowstring test, lacerations and ecchymosis http://entbgh.blogspot.com/
  • 43. Physical Exam • Midface asymmetry may indicate zygoma fracture http://entbgh.blogspot.com/
  • 44. Physical Exam • Palpate for midface instability http://entbgh.blogspot.com/
  • 45. Forced Duction Testing http://entbgh.blogspot.com/
  • 46. 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/
  • 47. CT areas to evaluate • Vertical buttresses • Zygomatic arch • Orbital walls • Bony palate • Mandibular condyles http://entbgh.blogspot.com/
  • 48. Evaluation • ABC’s • History • Palpation of entire facial skeleton • Occlusion • Ophthalmologic exam / consultation • C-spine • Imaging – CT http://entbgh.blogspot.com/
  • 49. Imaging • CT has surpassed plain film xray • Allows precise diagnosis and surgical planning • Axial and coronal cuts http://entbgh.blogspot.com/
  • 50. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 386. http://entbgh.blogspot.com/
  • 51. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 387. http://entbgh.blogspot.com/
  • 52. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 393.http://entbgh.blogspot.com/
  • 53. Treatment http://entbgh.blogspot.com/
  • 54. Surgical exposure Bicoronal Periocular/transconjunctival Intraoral http://entbgh.blogspot.com/
  • 55. 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/
  • 56. http://entbgh.blogspot.com/
  • 57. 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/
  • 58. 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/
  • 59. 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/
  • 60. • 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/
  • 61. • Haug et al 1995 • 134 patients treated by maxillomandibula r fixation or rigid internal fixation • Postoperative problems in 60% vs 64% http://entbgh.blogspot.com/
  • 62. • Complication rates similar • Rigid fixation has benefits: – Airway protection – Enhanced nutrition – More rapid return to pretraumatic function http://entbgh.blogspot.com/
  • 63. http://entbgh.blogspot.com/
  • 64. 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/
  • 65. 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/
  • 66. Zygoma • Minimally displaced, non comminuted can be treated with reduction only • Increasing amounts of displacement and comminution may require plating of lateral antrum, orbital rim, ZF suture, and even the zygomatic arch • One can wire the ZF suture first to assist with reduction, then plate it after other areas stabilized http://entbgh.blogspot.com/
  • 67. Zygoma Algorithm http://entbgh.blogspot.com/
  • 68. ORIF of Lateral Antral Wall http://entbgh.blogspot.com/
  • 69. Gillies Reduction http://entbgh.blogspot.com/
  • 70. Post-Gillies Reduction http://entbgh.blogspot.com/
  • 71. Coronal Approach http://entbgh.blogspot.com/
  • 72. Coronal Approach http://entbgh.blogspot.com/
  • 73. Coronal Approach • Supraorbital nerve may be released for more exposure http://entbgh.blogspot.com/
  • 74. Hemicoronal Approach http://entbgh.blogspot.com/
  • 75. Lateral Brow Incision • Avoid shaving brow hairs • Goal is the ZF suture http://entbgh.blogspot.com/
  • 76. Sublabial Approach • Leave mucosa to sew to later • Identify and preserve V2 http://entbgh.blogspot.com/
  • 77. 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/
  • 78. Vertical Buttress Algorithm http://entbgh.blogspot.com/
  • 79. Midface Disimpaction • May be necessary to restore facial dimensions before fixation http://entbgh.blogspot.com/
  • 80. Palate Fracture • Wire can be placed posteriorly for stabilization before triangular reduction http://entbgh.blogspot.com/
  • 81. ORIF of Midface http://entbgh.blogspot.com/
  • 82. Orbital Floor • Best done 7-10 days • Other indications – 1-2 sq.cm of floor disrupted • Contraindications – hyphema, retinal tear, globe perforation – only seeing eye – medically unstable http://entbgh.blogspot.com/
  • 83. Orbital Floor • Dotted line shows anatomic goal of restoration http://entbgh.blogspot.com/
  • 84. Orbital Rim Access • A -- subciliary • B -- lower eyelid • C -- infraorbital http://entbgh.blogspot.com/
  • 85. Transconjunctival Approach • Conjunctiva is being used to protect globe http://entbgh.blogspot.com/
  • 86. Orbital Floor Bone Grafting • Need to support floor full 4 cm http://entbgh.blogspot.com/
  • 87. Synthetic Mesh http://entbgh.blogspot.com/
  • 88. Orbital Metallic Mesh http://entbgh.blogspot.com/
  • 89. Orbital Roof • Uncommon due to high levels of force needed to fracture orbital roof • Commonly with intracranial problems http://entbgh.blogspot.com/
  • 90. http://entbgh.blogspot.com/
  • 91. Orbital Roof Repair • Repair roof higher on frontal bar http://entbgh.blogspot.com/
  • 92. http://entbgh.blogspot.com/
  • 93. 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/
  • 94. http://entbgh.blogspot.com/
  • 95. http://entbgh.blogspot.com/
  • 96. http://entbgh.blogspot.com/
  • 97. Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/

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