Maxillary and periorbital fractures

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

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

Mechanisms
• Assault
• MVA
• Gunshot wounds
• Sports
• Falls
• Industrial accidents

Anatomy

Anatomy of
the Orbit
• Bones: Frontal,
Zygomatic, Ethmoid,
Lacrimal, Maxilla, Palatal,
Sphenoid

Anatomy of
the Orbit
• Four-sided pyramid
or cone

Anatomy of
the Orbit
• Maximum
vertical
dimension 1.5
cm behind rim
• Floor is concave
and then convex

Anatomy of
the Orbit
• Floor slopes
into medial
wall
• Optic nerve
superomedial
to true apex

Anatomy of Zygoma
• Four
superficial
and two
deep
articulations
• Intersection
of arcs
define malar
prominence

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

Anatomy of the Maxilla

Vertical
Buttresses
• Resist
occlusal
load

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/

Horizontal
Buttresses

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.

Fracture Patterns

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.

Facial
buttress
system
From: Rowe NL, Williams JL.
Maxillofacial Injuries. Edinburgh,
Churchill Livingstone,1985, pg
19.

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

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

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

LeFort
Fractures
• Experimentally
determined weak
points
• Can be in
combinations
bilaterally
• Useful descriptor
• Results from
anterior forces

Le Fort I

Maxillary Fractures LeFort I
• Clinical findings:
– Facial edema
– Malocclusion of the
teeth
– Motion of the
maxilla while the
nasal bridge
remains stable

Le Fort II

Maxillary Fractures
LeFort II
– Marked facial edema
– Nasal flattening
– Traumatic telecanthus
– Epistaxis or CSF
rhinorrhea
– Movement of the
upper jaw and the
nose.

Le Fort III

Maxillary Fractures LeFort III
– Dish faced
deformity
– Epistaxis and CSF
rhinorrhea
– Motion of the
maxilla, nasal bones
and zygoma
– Severe airway
obstruction

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

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

Zygoma Fractures
• Impacted zygoma may mask orbital
floor defect

Orbital Blowout Fractures
Clinical Findings
• Periorbital tenderness,
swelling, ecchymosis.
• Enopthalmus or sunken
eyes.
• Impaired ocular
motility.
• Infraorbital anesthesia.
• Step off deformity

Orbital Blowout Injury

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

Patient Evaluation

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

Physical Exam
• Midface asymmetry
may indicate zygoma
fracture

Physical Exam
• Palpate for midface
instability

Forced Duction Testing

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

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

Evaluation
• ABC’s
• History
• Palpation of entire facial skeleton
• Occlusion
• Ophthalmologic exam / consultation
• C-spine
• Imaging – CT

Imaging
• CT has surpassed plain film xray
• Allows precise diagnosis and surgical planning
• Axial and coronal cuts

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/

Treatment

Surgical exposure
Bicoronal
Periocular/transconjunctival
Intraoral

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

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
maxillomandibula
r fixation or rigid
internal fixation
• Postoperative
problems in 60%
vs 64%

• Complication rates
similar
• Rigid fixation has
benefits:
– Airway protection
– Enhanced nutrition
– More rapid return to
pretraumatic
function

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

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
• 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

Zygoma Algorithm

ORIF of Lateral
Antral Wall

Gillies Reduction

Post-Gillies Reduction

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 suture

Sublabial
Approach
• Leave mucosa
to sew to later
• Identify and
preserve V2

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

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

Orbital Floor
• Dotted line shows
anatomic goal of
restoration

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

Transconjunctival
Approach
• Conjunctiva is
being used to
protect globe

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

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

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

Maxillary and periorbital fractures

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