The document discusses various types of facial fractures including orbital, frontal sinus, and panfacial fractures. It provides details on: - The anatomy of the orbit and types of orbital wall fractures. - Clinical evaluation including imaging techniques like CT scans. - Surgical management of fractures including approaches, reconstruction goals and materials used. - Specific challenges with fractures of the frontal sinus and naso-orbito-ethmoid complex given the thin sinus lining and importance of coronal flap access. - Classification and reconstruction considerations for severe panfacial fractures involving multiple facial bones.

1. FACIAL FRACTURES
II
DR. HADI MUNIB
ORAL AND MAXILLOFACIAL SURGERY RESIDENT

2. OUTLINE
• Orbital and Ocular Trauma
• Frontal Sinus and Naso-Orbito-Ethmoid Complex Fractures
• Panfacial Trauma
• References

3. ORBITAL AND OCULAR FRACTURES
• Anatomy:
• The orbit is the bony vault that houses the eyeball.
• It is a quadrangular-based pyramid that has its peak at the orbital apex.
• By age 5 years orbital growth is 85% complete and it is finalized between 7
years of age and puberty.

4. FRACTURE CONFIGURATION
• Isolated orbital wall fractures account for 4 to 16% of all facial fractures.
• If fractures that extend outside the orbit are included, such as those of the
zygomatic complex (ZMC) and naso-orbitoethmoid (NOE), then this accounts for
30 to 55% of all facial fractures.
• ZMC fractures are the most commonly occurring facial fracture, second only to
nasal fractures.
• By definition, ZMC fractures are the most common fracture with orbital
involvement.
• NOE fractures are usually caused by severe blunt midface trauma and may be
accompanied by CSF leakage.

5. FRACTURE CONFIGURATION
• Any persistent or copious clear nasal drainage should be tested to determine a β2-
transferrin level to rule out a CSF leak.
• Traumatic tele-canthus with NOE fractures is a result of a flattening of the nasal
bridge and a lateral splaying of the orbital rims and anterior lacrimal crest.
• Reduction and fixation of these bony segments and less frequently direct trans-nasal
wiring are necessary for adequate restoration of medial inter-canthal distance and
alignment.
• Adult Caucasians normal inter-canthal distance is 29 – 32 mm.

6. FRACTURE
CONFIGURATION
• Internal orbital fractures occur in numerous patterns and typically described by
their location and the size of the defect.
• Three basic patterns of internal orbital fractures: linear, blow-out, and complex.
• Linear internal orbital fractures;
• Maintain periosteal attachments and typically do not result in a defect with
orbital content herniation.
• Late Enophthalmos; significant enlargement of the orbital volume.

7. FRACTURE CONFIGURATION
• Blow-out fractures; The most common.
• Limited to one wall and typically are 2 cm or less in diameter.
• The most commonly involved wall is the anterior medial orbital floor, followed by the
medial wall and less frequently the orbital roof, which can present as a blow-in fracture.
• Reconstruction of orbital roof fracture may be indicated if a dural tear is suspected or to
prevent a “pulsatile globe.”
• Pulsatile Globe; This rhythmic inward and outward movement of the eye is due to the
cerebrovascular pulsation and the influence of respiration on the overlying cerebral
hemispheres.
• Usually happens after Edema resolves and the patient may end up having double vision

8. FRACTURE CONFIGURATION
• Complex internal orbital fractures;
• Extensive fractures affecting two or more orbital walls, > 2 cm in diameter,
Comminuted or unretrievable segments.
• Can often extend to the posterior orbit and may involve the optic canal.
• These complex fractures are usually associated with more severe trauma
and surrounding fractures such as Le Fort II,Le Fort III,and frontal sinus
fractures.

9. CLINICAL
EXAMINATION
• Complete History
• Imaging:
• CT or MRI can be ordered with defined parameters to provide meaningful results.
• Non-contrasted CT is the primary imaging modality currently used for evaluating
injuries from blunt or penetrating trauma and localizing most orbital foreign bodies.
• Plain Radiography is an inexpensive imaging modality but it’s inadequate in internal
orbital fractures.
• Waters’ projection allows visualization of the orbital roof and floor and is particularly
useful for evaluating orbital floor blow-out fractures.

11. OCULAR INJURIES – VISUAL
IMPAIRMENT
• Direct injury or forces transmitted to the globe by displaced fracture segments can result in
retro-bulbar hematoma, globe rupture, hyphemia, lens displacement, vitreous hemorrhage,
retinal detachment, and optic nerve injury.
• Compartment syndrome resulting from elevation of intra-orbital pressure, which leads to
central retinal artery compression, or ischemia of the optic nerve and can secondarily raise
the intraocular pressure which compromises the ocular blood supply.
• Retro-bulbar hematoma evacuation consists of a lateral canthotomy +/- inferior cantholysis,
and disinsertion of the septum along the lower eyelid in a medial direction.
• A small Penrose drain is left in place for 24 to 48 hours to ensure adequate drainage and to
prevent re-accumulation.

13. OCULAR INJURIES –
DIPLOPIA
• Double Vision
• Monocular diplopia is usually due to lens dislocation or opacification.
• Acute binocular diplopia, secondary to trauma, derives from one of three basic
mechanisms: edema or hematoma, restricted mobility, or neurogenic injury.

14. TELECANTHUS
• Severe mid-facial trauma (NOE) with displacement and splaying of the
bones that serve as attachments for medial canthal tendons.
• Best treated early (within 7–10 d) following injury to prevent scarring and
secondary maladaptive changes that compromise the re-establishment of
the more normal narrow inter-canthal distance.
• Coronal Incision

16. SURGICAL
MANAGEMENT

18. INFERIOR AND LATERAL ORBITAL
APPROACHES
• There are three basic incisions used for accessing the orbital floor: the infraorbital,
subciliary and trans-conjunctival.
• Subciliary and trans-conjunctival incisions are the most popular owing to their superior
esthetics and generous access and the fact that surgeons are familiar with their use.
• The subciliary is used less often owing to the amount of stretching on the unsupported
large skin flap and the resultant high rate of ectropion (permanent in 8%) and potential
skin necrosis, particularly in the elderly patient who has a history of heavy smoking.
• The anterior or superficial approach to the orbital septum (pre-septal) until the orbital rim
is encountered. This approach results in excellent esthetics, a simplified dissection, and a
decreased incidence of hematoma formation or skin necrosis.

20. PRIMARY RECONSTRUCTION
• The goals of acute or primary reconstruction of primary orbital fractures are to alleviate
any functional deficit and to restore the facial esthetics.
• Linear fractures are generally caused by blunt forces directly to the globe or partially to
the rim and most often result in an esthetic deformity such as enophthalmos or
hypoophthalmos.
• The goal of reconstruction is to restore the anatomic position of the bony rim and
associated facial bones and to reapproximate the normal bony orbital volume with a
reconstructive material.
• Numerous materials, such as porous polyethylene, bioresorbable polydioxanone, nylon,
gelatin film, titanium mesh, and autogenous bone grafts (split-thickness calvarium and,
less frequently, iliac crest) have been used

21. RECONSTRUCTION
• For linear and blow-out fractures; Thin (0.85 mm) porous polyethylene sheeting.
• This alloplastic material is extremely biocompatible and non-resorptive.
• More than adequate tensile strength and does not cause any capsule formation such as
seen with polymeric silicone sheeting.
• The pore size allows tissue ingrowth, which reduces the risk of migration
• Fixing the porous polyethylene sheeting to the anterior lateral orbital floor with a single
titanium screw
• Titanium mesh with fixation to surrounding intact orbital rims is quite useful when there
are severe or comminuted injuries and a cantilevering is required.

22. RECONSTRUCTION
• Blow-out fractures typically involve one orbital wall and are < 2 cm in diameter.
• Enophthalmos associated with orbital blow-out fractures is due to an enlargement of the
orbital bony volume that allows the orbital fat to be distributed within a larger
compartment.
• Blow-in fracture, may result in a decreased orbital volume.
• Exophthalmos and ocular motility disturbances are uncommon unless there are
surrounding severe associated fractures such as ZMC or frontal sinus fractures.

23. EXOPHTHALMOS VS. ENOPHTHALMOS

24. RECONSTRUCTION
• The goal of primary reconstruction of blow-out fractures is to restore the
configuration of the orbital walls, return prolapsed orbital contents to the orbit
proper, and eliminate any impingement or entrapment of orbital soft tissues.
• Bone
• Mesh
• Silastic
• PTFE
• Gore-te

26. FRONTAL SINUS AND NASO-ORBITO-ETHMOID
COMPLEX FRACTURES
• Fractures of the frontal bone and the naso-orbito-ethmoid (NOE) complex occur among 2
to 15% of patients with facial fractures.
• Most victims are male (66–91%) and young (usually 20–30 years of age)
• Motor vehicle or motorcycle collisions (44–85%)
• The entire surface area of the frontal sinus is covered with respiratory epithelium
ranging in thickness from 0.07 to 2.0 mm.
• Pseudostratified ciliated epithelium, mucus producing goblet cells, a thin basement
membrane and a thin lamina propria that contains seromucous glands

29. CLINICAL EVALUATION
• Periorbital ecchymosis and pain are the most common signs and symptoms associated with
fractures of the frontal bone.
• Subconjunctival hemorrhage may occur; what if the nose and zygomas are unaffected?
• Nasal deformity
• Edema and ecchymosis of the eyelids,
• Cerebrospinal fluid (CSF) leakage
• Hyposmia
• Traumatic Telecanthus
• Increased canthal angles and blindness

32. CLASSIFICATION
• Unilateral or bilateral, open or closed, and simple or comminuted
• Type I fracture maintains the attachment of the MCT to a large single naso-ethmoidal
fracture segment; repairing this type of fracture is straightforward.
• Type II fracture shows more comminution yet maintains the attachment of the medial canthus
to a sizable bony segment.
• Type III fractures display severe comminution with possible avulsion of the MCT from its
bony attachment

34. RECONSTRUCTION
• Coronal Flaps give the best access
• Gullwing or spectacle incisions result in unattractive scars that are highly visible because
of their prominence on the brow.
• Fixation with screws and any void remaining after reconstruction can be closed by placing
titanium mesh, methylmethacrylate, or other bone substitutes

36. DACRYOCYSTORHINOSTOMY
• The repair of the lacrimal drainage system through the creation of a new “ostomy” or track
from the lacrimal canaliculi to the nasal cavity.
• Techniques that have been described include open (external), endo-nasal, and soft tissue
conjuctivo-rhinostomy.

37. PANFACIAL FRACTURES
• Multiple Bone fractures
• Many surgeons still advocate closed reduction and division of care into
early (first 10 d), intermediate (10–60 d), and late (> 60 d) phases.
• Pillars of the face
• Up – Down
• Down - Up

43. REFERENCES
• Chapter 25: Frontal Sinus and Naso-Orbito-Ethmoid Complex Fractures
• Chapter 28: Panfacial Trauma

44. THANK YOU