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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 FracturesLeFort 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 forces
    http://entbgh.blogspot.com/
  • 35. Zygoma Tripod FracturesClinical 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 FracturesClinical 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 maxillomandibular 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/