Facial fractures the upper face

Maxillary and
Periorbital
Fractures
Frederick Mars Untalan, MD
http://entbgh.blogspot.com/

Facial Injuries
 Dental Terminology

Overview
 Classic tripod, orbital floor, LeFort
fractures better thought of as
orbitozygomaticomaxillary fractures
 Precise anatomic reduction
is key
 Goal is functional
and cosmetic
rehabilitation

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/

History
 Mechanism of InjuryMechanism of Injury
 Previous facial injuries / Dental AbN
 Premorbid history
 Loss of consciousness
 Medications, Allergies, Tetanus Status
 Associated Injuries

Clinical Assessment of the
Face
 SYMPTOMS
 Diplopia
 Abnormal
Sensation
 Malocclusion
 Pain

Face
 GCS, Ocular exam, C-spine exam
 Cranial nerve exam, CSF rhinorrhea
 Inspect (including septum & TM)
 Palpate (including midface stability)
 Assess occlusion & intraoral exam

 CSF rhinorrhea – Halo sign
 Septal hematoma
 Hemotympanum
 Malocclusion
 Ocular Findings
 Diplopia/restricted EOM, Subconj. Hem.,
hyphema, anisocoria, impaired VA
Face

 Clinical Assessment of the Face
 Reliable Physical signs
 Bony facial asymmetry
 True V2 numbness
 Malocclusion
Face

Physical Exam
 Palpate for
midface
instability

Physical Exam
 Often edema,
swelling, or patient’s
mental status make
physical exam
difficult
 CT is modality of
choice -- axial and
coronal

Physical Exam
 Midface asymmetry
may indicate zygoma
fracture

Forced Duction Testing

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

Emergency Management
Hemorrhage
 Local Pressure
 Dressings / Packing
 Reduction Of Facial
Fractures
 Endovascular
Consultation
 Ligation Of Vessels
 IMAX

Radiographic Assessment of the Face
 Water’s view
 Panorex (Orthopantomogram)
 Mandible views
 CT scans
 Standard of care for major facial trauma

 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

CT areas to evaluate
 Vertical buttresses
 Zygomatic arch
 Orbital walls
 Bony palate
 Mandibular condyles

Signs And Symptoms
 Pain / Tenderness
 Crepitus From Bony
Fractures
 Hypoesthesia
 Paralysis
 Malocclusion
 Visual Disturbances
 Deformity
 Obstructive
Respiration
 Lacerations
 Bleeding
 Contusions
 Facial Asymmetry

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 / rigid internal fixation
 Mandible fracture stabilization
 Reconstruction of horizontal and vertical facial
buttresses
 Primary bone grafting
 Periosteal and soft-tissue suspension and
repair

Facial Fractures
The Upper Face

Outline
 Facial Fracture Basics
 Nasal Fractures
 Naso-orbital-ethmoidal Fractures
 Frontal Sinus Fractures
 Zygomatic Fractures
 Maxillary Fractures
 Orbital Fractures

Nasal Fractures

Physical Exam
 Edema
 Crepitus
 Periorbital Ecchymosis
 Epistaxis
 Internal And External Lacerations
 Widened Nasal Bridge
 Septal Hematoma

Classification
Stranc and Robertson
 Lateral Impact
Injuries
 Unilateral vs.
Bilateral
 Frontal Impact
Injuries
 Plane I
 Plane II
 Plane III

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

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

Treatment
 Plane II
 Increased Comminution of the Nasal
Pyramid
 Bilateral
 Possible “Saddling”
 Initial Closed reduction
 May Require Delayed Septal
Reconstruction With Grafts

Treatment
 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

Complications
 Occur In Up To 70%
 Deviated Nasal Pyramid
 Nasal “Hump”
 Septal Deformity With Respiratory
Obstruction

Naso-Orbital-Ethmoidal
Fractures

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

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

Fractures
 Flat nose
 Swollen medial canthal area
 Telecanthus (12-20%)
 Lack of skeletal support on palpation of
nose
 CSF leak
 Positive eyelid traction test

Fractures
Telecanthus
 Normal intercanthal distance
(Stranc)
 White males: 33-34mm
 Females: 32-33mm
 Consider >35mm abnormal (Manson)

Fractures
Classification Markowitz
 Type I - Single
central segment
 Type II -
Comminuted
central segment
 Type III -
Avulsed medial
canthal tendon

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

Fractures
Management
 Early open reduction
 Four Objectives:
 correct epicanthal folds
 restore bony contour
 reestablish lacrimal system continuity
 medial canthoplasty / canthopexy

Fractures
Management
 Wide Exposure
 coronal incision
 “open sky” - transverse across root of nose
 vertical midline nasal
 subciliary
 buccal sulcus
 extend existing lacerations

Fractures
Management
 Correct nasofrontal separation
 Elevate nasal bones
 Reduce comminuted nasal bones
 Bone graft where needed
 Explore septum
 Stabilize nasomaxillary buttresses

Frontal Sinus Fractures

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/

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
 Depressed Frontal Region
 Subconjunctival Ecchymosis

Frontal Sinus
Diagnosis
 X-Ray
 Air Fluid Levels
 CT Scan
 Axial and Coronal Images

Frontal Sinus
Treatment
 Operative Indications
 Anterior Table Displacement With Contour
Change
 Nasofrontal Duct Involvement
 Displaced Posterior Table

Frontal Sinus
Treatment
 Nasofrontal Duct
Injury
 Remove Mucosa
 Burr Inner Cortex
 Occlusion Of Duct
 Sinus Obliteration

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

Frontal Sinus
Complications
 Early (within 6 months)
 Frontal Sinusitis
 Meningitis
 Late
 Mucocele
 Mucopyocele
 Brain Abcess
 Osteomyelitis

Frontal Sinus
Complications
 Incidence Of Late Complications
 Freihofer

71 Fractures

2 Patients - Meningitis

1 Patient - Mucopyocele With Osteomyelitis Of
Frontal Bone

Orbital Fractures

Orbital Blowout Injury

Orbital Fractures
Blowout Fractures
Pure Blowout - only orbital floor or
medial wall injured
Impure Blowout - associated orbital rim
fractures

Orbital Blowout Injury
 Usually inferior and/or medial wall
 Cone will become more spherical
 Leads to enophthalmos, inferior
displacement
 Muscle entrapment causes diplopia

Orbital Fractures
Physical Exam
 Diplopia
 Enophthalmos
 Inferior Displacement Palpebral Fissure
 Anesthesia of Infraorbital Nerve
 Orbital Emphysema

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

Orbital Fractures
Forced Duction Test

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

Orbital Fractures
Enophthalmos

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

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

Orbital Rim
Access
 A -- subciliary
 B -- lower eyelid
 C -- infraorbital

Orbital Fractures
Incisions

Orbital Fractures
Management
 Grafts
 Autologous Bone
 Cartilage
 Fascia lata
 Alloplastic Implants
 Teflon
 Silastic
 Titanium

Orbital Floor
 Dotted line
shows anatomic
goal of
restoration

Orbital Fractures
Complications
 Infection
 Implant problems
 Persistent Diplopia (2-50%)
 Persistent Enophthalmos (15-22%)
 Ectropion (1%)
 Blindness

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

Orbital Fractures
Complications
 Orbital Apex Syndrome
 same as superior orbital fissure syndrome
 plus blindness

Transconjunctival
Approach
 Conjunctiva is
being used to
protect globe

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

Orbital Floor
Bone Grafting
 Need to support
floor full 4 cm

 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

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

Synthetic
Mesh

Orbital Metallic
Mesh

Orbital Roof
 Uncommon due to high levels of force
needed to fracture orbital roof
 Commonly with intracranial problems

Orbital Roof Repair
 Repair roof higher on frontal bar

From: Strong EB, Sykes JM. Zygoma Complex Fractures. Facial Plastic Surgery 1990;14(1):109.

Periorbital & Zygomatic
bone Fractures

Zygoma Fractures
 Results from lateral forceshttp://entbgh.blogspot.com/

Zygoma
Anatomy
 Tetrapod Structure
 Frontal Bone
 Temporal Bone
 Maxilla
 Greater Wing Of Sphenoid

Zygoma
Anatomy

Zygoma
Anatomy
 Muscular Attachments
 Masseter
 Temporalis
 Zygomaticus
 Zygomatic Head of Quadratus Labii
Superioris

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

Zygoma
Physical Exam

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

Zygoma
Fracture Classification
 Manson
 Low Energy

minimal displacement

do not require operative reduction
 Middle Energy
 High Energy

often part of panfacial fractures

Zygoma
Radiology
 X-Ray
 Water’s View Most Useful
 CT Scan
 Coronal Cuts For Orbital Anatomy

Zygoma Fractures
 Impacted zygoma may mask orbital floor defect

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

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

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

Zygoma Algorithm

Zygoma
Management
 Undisplaced
 Nonoperative
 Displaced
 Isolated Zygomatic Arch - Gilles
Elevation
 Orbitozygomatic Fractures - Open
reduction and Stabilization

Zygoma
Management

ORIF of
Lateral Antral
Wall

Gillies Reduction

Post-Gillies Reduction

Surgical Approaches
 Coronal
 Sublabial
 Transconjunctival
 Lateral Brow

Coronal Approach

Coronal Approach
 Supraorbital
nerve may be
released for
more
exposure

Hemicoronal
Approach

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

Zygoma
Gilles Elevation

Zygoma
Operative Exposure

Zygoma
Complications - Early
 Bleeding
 Infection
 Exacerbation of Sinus Disease
 Malfunction of Extraocular Muscles
 Blindness

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

 Soft diet and malar protection
 Closed reduction
 ORIF with plating of one to four
buttresses
 Provide fixation as necessary for stable
reduction

Maxillary Fractures

Types
 LeFort or Maxillary fractures
 Zygomaticomaxillary complex fractures
 Orbitozygomaticomaxillary complex
fractures

Anatomy of the Maxilla
 Paired
embryologically
 Functionally
acts with
palatine bone

Anatomy of the Maxilla

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

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.

From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing Company 1988, pg76.

Facial
buttress
system

Buttresse
s
 Resist
occlusal
load

Horizontal
Buttresses

LeFort
Fractures
 Experimentally
determined
weak points
 Can be in
combinations
bilaterally
 Useful
descriptor
 Results from
anterior forces http://entbgh.blogspot.com/

Forces of mastication
From: Banks P, Brown A. Fractures of the Facial Skeleton,
Oxford, Wright 2001 pg.6

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/

From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962.

From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian
Publishing Company 1988, pg76.

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

Le Fort I

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

Le Fort II

Maxillary Fractures
LeFort Fractures
 LeFort III
 Craniofacial Dysjunction
 Zygomaticofrontal Junction, Traverses
Lateral, Inferior, and Medial Orbit,
Separates Frontal Process of Maxilla From
Frontal Bones

Le Fort III

Maxillary Fractures
LeFort Fractures

Modified LeFort
Classification
From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg
1993;51:962.

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/

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

Maxillary Fractures
Radiology
 X-Rays
 Bilateral Maxillary Sinus Opacification
 Pterygoid Plate Fracture On Lateral
Projection
 Fracture Through ZF and Nasofrontal
Suture

From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 386.

From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 387.

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

Maxillary Fractures
Complications
 Late
 Palpable Hadware
 Non-Union / Malunion
 Plate Exposure
 Lacrimal System Obstruction
 V2 Anesthesia
 Devitalized Teeth
 Extra-Occular Muscle Imbalance

Maxillary Fractures
Complications
 Late
 Diplopia
 Enophthalmos
 Orbital Dystopia
 Change In Facial Appearance

Facial height and width
 Nasal Obstruction
 Malocclusion

Maxillary Fractures
Management
 Goals
 re-establish
midfacial height
and projection
 establish occlusal
relationship
 maintain integrity of
nose and orbits

Maxillary Fractures
Management
 Intermaxillary Fixation
 Open Reduction
 LeFort I

Bilateral Buccal Sulcus Incisions
 LeFort II and III

Coronal and Lower Eyelid Incisions

Treatment

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

Maxillary Fractures
Management
 Rigid Internal
Fixation
 Frontal Bone as a Guide
 Mandibuar Ramus Dictates
Facial Height
 Stabilize Vertical
Buttresses
 Bone Grafts If Necessary

Maxillary Fractures
Palatal Fractures
 8% of LeFort fractures
 Younger vs. Older
 <30 years

midline fracture
 >30 years

sagittal fractures adjacent to midline or alveolus

Maxillary Fractures
Palatal Fractures
 Stabilize before IMF
 Open reduction of palatal roof
 Pyriform aperture plate to unite
maxillary segements
 Dental splints to prevent occlusion

Maxillary Fractures
Palatal Fractures

Associated Injuries
 Brandt et al 1991
 59% caused by MVA had
intracranial injury
 10% caused by fall/beating had
intracranial injury

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%

 Maxillary fractures:
 Lacerations and abrasions 75%
 Orthopedic injury 51%
 Other facial fractures 42%
 Neurologic injury 51%
 Pulmonary 13%, abdominal 5.7%, cardiac
3.8%

Midface
 “Rigid” fixation misnomer with small
plates and thin bones
 Semirigid fixation (wire) sometimes
preferable
 Early function can be achieved with soft
diet only

Vertical Buttress Algorithm

Midface Disimpaction
 May be necessary to restore
facial dimensions before fixation

Palate
Fracture
 Wire can be
placed
posteriorly for
stabilization
before triangular
reduction

ORIF of Midface

Order of Repairs
 Work from stable to unstable
 Use occlusion as guide
 Generally stabilize mandible, zygoma
and palate before midface before orbit
and NOE

Order of
Repairs

Treatment of maxillary
fractures
 Early repair
 Single-stage
 Extended access approaches
 Rigid fixation
 Immediate bone grafting
 Re-suspension of soft tissues

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

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

 Most severe injuries in rigid internal
fixation group
 Shorter IMF, early return to diet, lower
percentage of tracheotomy
 No plate infections

 Haug et al 1995
 134 patients treated by
maxillomandibular fixation or rigid
internal fixation
 Postoperative problems in 60% vs 64%

Approaches
 Circumvestibular
 Facial degloving
 Bicoronal
 Transconjuctival

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.

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.

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/

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/

Cutting Edge Topics
 Bioresorbable plates
 Intraoperative CT
 3-D CT reconstruction
 Endoscopic assistance

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

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

Case Presentation

 30 yo WF
 MVA
 PMH
unknown

Facial fractures the upper face

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