Maxillary and periorbital fractures

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Maxillary and Periorbital Fractures

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Maxillary and periorbital fractures

  1. 1. Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/
  2. 2. http://entbgh.blogspot.com/
  3. 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. 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. 5. Mechanisms • Assault • MVA • Gunshot wounds • Sports • Falls • Industrial accidents http://entbgh.blogspot.com/
  6. 6. Anatomy http://entbgh.blogspot.com/
  7. 7. Anatomy http://entbgh.blogspot.com/
  8. 8. Anatomy of the Orbit • Bones: Frontal, Zygomatic, Ethmoid, Lacrimal, Maxilla, Palatal, Sphenoid http://entbgh.blogspot.com/
  9. 9. Anatomy of the Orbit • Four-sided pyramid or cone http://entbgh.blogspot.com/
  10. 10. Anatomy of the Orbit • Maximum vertical dimension 1.5 cm behind rim • Floor is concave and then convex http://entbgh.blogspot.com/
  11. 11. Anatomy of the Orbit • Floor slopes into medial wall • Optic nerve superomedial to true apex http://entbgh.blogspot.com/
  12. 12. Anatomy of Zygoma • Four superficial and two deep articulations • Intersection of arcs define malar prominence http://entbgh.blogspot.com/
  13. 13. Anatomy of the Maxilla • Paired embryologically • Functionally acts with palatine bone http://entbgh.blogspot.com/
  14. 14. Anatomy of the Maxilla http://entbgh.blogspot.com/
  15. 15. Vertical Buttresses • Resist occlusal load http://entbgh.blogspot.com/
  16. 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. 17. Horizontal Buttresses http://entbgh.blogspot.com/
  18. 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. 19. Fracture Patterns http://entbgh.blogspot.com/
  20. 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. 21. Facial buttress system From: Rowe NL, Williams JL. Maxillofacial Injuries. Edinburgh, Churchill Livingstone,1985, pg 19. http://entbgh.blogspot.com/
  22. 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. 23. From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing Company 1988, pg76. http://entbgh.blogspot.com/
  24. 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. 25. LeFort Fractures • Experimentally determined weak points • Can be in combinations bilaterally • Useful descriptor • Results from anterior forces http://entbgh.blogspot.com/
  26. 26. Le Fort I http://entbgh.blogspot.com/
  27. 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. 28. Le Fort II http://entbgh.blogspot.com/
  29. 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. 30. Le Fort III http://entbgh.blogspot.com/
  31. 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/
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  34. 34. Zygoma Fractures • Results from lateral forceshttp://entbgh.blogspot.com/
  35. 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. 36. Zygoma Fractures • Impacted zygoma may mask orbital floor defect http://entbgh.blogspot.com/
  37. 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. 38. Orbital Blowout Injury http://entbgh.blogspot.com/
  39. 39. Orbital Blowout Injury http://entbgh.blogspot.com/
  40. 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. 41. Patient Evaluation http://entbgh.blogspot.com/
  42. 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. 43. Physical Exam • Midface asymmetry may indicate zygoma fracture http://entbgh.blogspot.com/
  44. 44. Physical Exam • Palpate for midface instability http://entbgh.blogspot.com/
  45. 45. Forced Duction Testing http://entbgh.blogspot.com/
  46. 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. 47. CT areas to evaluate • Vertical buttresses • Zygomatic arch • Orbital walls • Bony palate • Mandibular condyles http://entbgh.blogspot.com/
  48. 48. Evaluation • ABC’s • History • Palpation of entire facial skeleton • Occlusion • Ophthalmologic exam / consultation • C-spine • Imaging – CT http://entbgh.blogspot.com/
  49. 49. Imaging • CT has surpassed plain film xray • Allows precise diagnosis and surgical planning • Axial and coronal cuts http://entbgh.blogspot.com/
  50. 50. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 386. http://entbgh.blogspot.com/
  51. 51. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 387. http://entbgh.blogspot.com/
  52. 52. From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg 393.http://entbgh.blogspot.com/
  53. 53. Treatment http://entbgh.blogspot.com/
  54. 54. Surgical exposure Bicoronal Periocular/transconjunctival Intraoral http://entbgh.blogspot.com/
  55. 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. 56. http://entbgh.blogspot.com/
  57. 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. 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. 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. 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. 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. 62. • Complication rates similar • Rigid fixation has benefits: – Airway protection – Enhanced nutrition – More rapid return to pretraumatic function http://entbgh.blogspot.com/
  63. 63. http://entbgh.blogspot.com/
  64. 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. 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. 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. 67. Zygoma Algorithm http://entbgh.blogspot.com/
  68. 68. ORIF of Lateral Antral Wall http://entbgh.blogspot.com/
  69. 69. Gillies Reduction http://entbgh.blogspot.com/
  70. 70. Post-Gillies Reduction http://entbgh.blogspot.com/
  71. 71. Coronal Approach http://entbgh.blogspot.com/
  72. 72. Coronal Approach http://entbgh.blogspot.com/
  73. 73. Coronal Approach • Supraorbital nerve may be released for more exposure http://entbgh.blogspot.com/
  74. 74. Hemicoronal Approach http://entbgh.blogspot.com/
  75. 75. Lateral Brow Incision • Avoid shaving brow hairs • Goal is the ZF suture http://entbgh.blogspot.com/
  76. 76. Sublabial Approach • Leave mucosa to sew to later • Identify and preserve V2 http://entbgh.blogspot.com/
  77. 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. 78. Vertical Buttress Algorithm http://entbgh.blogspot.com/
  79. 79. Midface Disimpaction • May be necessary to restore facial dimensions before fixation http://entbgh.blogspot.com/
  80. 80. Palate Fracture • Wire can be placed posteriorly for stabilization before triangular reduction http://entbgh.blogspot.com/
  81. 81. ORIF of Midface http://entbgh.blogspot.com/
  82. 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. 83. Orbital Floor • Dotted line shows anatomic goal of restoration http://entbgh.blogspot.com/
  84. 84. Orbital Rim Access • A -- subciliary • B -- lower eyelid • C -- infraorbital http://entbgh.blogspot.com/
  85. 85. Transconjunctival Approach • Conjunctiva is being used to protect globe http://entbgh.blogspot.com/
  86. 86. Orbital Floor Bone Grafting • Need to support floor full 4 cm http://entbgh.blogspot.com/
  87. 87. Synthetic Mesh http://entbgh.blogspot.com/
  88. 88. Orbital Metallic Mesh http://entbgh.blogspot.com/
  89. 89. Orbital Roof • Uncommon due to high levels of force needed to fracture orbital roof • Commonly with intracranial problems http://entbgh.blogspot.com/
  90. 90. http://entbgh.blogspot.com/
  91. 91. Orbital Roof Repair • Repair roof higher on frontal bar http://entbgh.blogspot.com/
  92. 92. http://entbgh.blogspot.com/
  93. 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. 94. http://entbgh.blogspot.com/
  95. 95. http://entbgh.blogspot.com/
  96. 96. http://entbgh.blogspot.com/
  97. 97. Maxillary and Periorbital Fractures Frederick Mars Untalan, MD http://entbgh.blogspot.com/

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