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Maxillary andMaxillary andPeriorbitalPeriorbital

FracturesFracturesResident: Gordon Shields, MDResident: Gordon Shields, MD

Faculty: Francis Quinn, MDFaculty: Francis Quinn, MD

Grand Rounds January 7, 2003Grand Rounds January 7, 2003

Department of Otolaryngology, UTMBDepartment of Otolaryngology, UTMB

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TypesTypes

MechanismsMechanisms

Associated InjuriesAssociated Injuries

AnatomyAnatomy

ClassificationClassification EvaluationEvaluation

TreatmentTreatment

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TypesTypes

LeFort or Maxillary fracturesLeFort or Maxillary fractures

Zygomaticomaxillary complexZygomaticomaxillary complex

fracturesfractures

OrbitozygomaticomaxillaryOrbitozygomaticomaxillary

complex fracturescomplex fractures

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MechanismsMechanisms

AssaultAssault

MVAMVA

Gunshot woundsGunshot wounds

SportsSports

FallsFalls Industrial accidentsIndustrial accidents

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Associated InjuriesAssociated Injuries

Brandt et al 1991Brandt et al 1991

59% caused by MVA had59% caused by MVA had

intracranial injuryintracranial injury

10% caused by fall/beating had10% caused by fall/beating had

intracranial injuryintracranial injury

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Associated injuriesAssociated injuries

Haug et al 1990Haug et al 1990

402 patients402 patients

Zygoma fractures:Zygoma fractures: Lacerations 43%Lacerations 43%

Orthopedic injuries 32%Orthopedic injuries 32%

Additional facial fractures 22%Additional facial fractures 22%

Neurologic injury 27%Neurologic injury 27%

Pulmonary, abdominal, cardiac 7%, 4.1%,Pulmonary, abdominal, cardiac 7%, 4.1%,

1%1%

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Maxillary fractures:Maxillary fractures:

Lacerations and abrasions 75%Lacerations and abrasions 75%

Orthopedic injury 51%Orthopedic injury 51%

Other facial fractures 42%Other facial fractures 42%

Neurologic injury 51%Neurologic injury 51%

Pulmonary 13%, abdominal 5.7%,Pulmonary 13%, abdominal 5.7%,cardiac 3.8%cardiac 3.8%

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Ocular injuryOcular injury

Al-Qurainy et al 1991Al-Qurainy et al 1991

363 patients with midface fractures363 patients with midface fractures

63% minor or transient ocular injury63% minor or transient ocular injury 16% moderately severe injury16% moderately severe injury

12% severe ocular injury (angle recession,12% severe ocular injury (angle recession,

retinal or vitreous injury, optic nerveretinal or vitreous injury, optic nerve

damagedamage 90.6% of patients had some ocular injury90.6% of patients had some ocular injury

2.5% lost vision in the affected eye2.5% lost vision in the affected eye

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Facial SkeletonFacial Skeleton

From: Netter FH. Atlas of Human Anatomy. Second Edition; East Hanover,Novartis,1997, plt. 1

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Facial SkeletonFacial Skeleton

From: Netter FH. Atlas of Human Anatomy. Second Edition; East Hanover,

Novartis,1997, plt. 2

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OrbitOrbit

7 bones composing the orbit: frontal, sphenoid,zygoma, maxilla, palatine, lacrimal, ethmoid

From: Netter FH. Atlas of Human Anatomy. Second Edition; East Hanover,Novartis,1997, plt. 1

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Forces of masticationForces of mastication

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

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Facial Buttress systemFacial 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.

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Facial Buttress systemFacial 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 Company1997:1143-1192.

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Facial buttress systemFacial buttress system

From: Rowe NL, Williams JL. MaxillofacialInjuries. Edinburgh, Churchill

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LeFort fracturesLeFort fractures

Rene LeFort 1901 in cadaverRene LeFort 1901 in cadaver

skullsskulls

Based on the most superior levelBased on the most superior level Frequently different levels onFrequently different levels on

either sideeither side

LeFort ILeFort I

LeFort IILeFort II

LeFort IIILeFort III

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

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Modified LeFortModified LeFort

ClassificationClassification

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

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Donat, Endress,Donat, Endress,

Mathog classificationMathog classification

From: Donat TL et al. Facial Fracture Classification According to SkeletalSupport Mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314.

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EvaluationEvaluation

ABCsABCs

HistoryHistory

Palpation of entire facial skeletonPalpation of entire facial skeleton

OcclusionOcclusion

Ophthalmologic exam /Ophthalmologic exam /consultationconsultation

C-spineC-spine

Imaging CTImaging CT

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ImagingImaging

CT has surpassed plain film xrayCT has surpassed plain film xray

Allows precise diagnosis andAllows precise diagnosis and

surgical planningsurgical planning Axial and coronal cutsAxial and coronal cuts

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From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby2003, pg 386.

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From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby 2003, pg387.

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From: Som PM, Curtin HD. Head and Neck Imaging;. Fourth Edition; St. Louis, Mosby2003, pg 393.

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Treatment of maxillaryTreatment of maxillary

fracturesfractures Early repairEarly repair

Single-stageSingle-stage

Extended access approachesExtended access approaches

Rigid fixationRigid fixation

Immediate bone graftingImmediate bone grafting Re-suspension of soft tissuesRe-suspension of soft tissues

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Maxillary fracturesMaxillary fractures

Steps of reconstruction-Rohrich andSteps of reconstruction-Rohrich and

ShewmakeShewmake

Reestablish facial height and widthReestablish facial height and width IMF with ORIF of mandibleIMF with ORIF of mandible

Zygomatic arch reconstructionZygomatic arch reconstruction

restores facial width and projectionrestores facial width and projection

Reconstruction continues from stableReconstruction continues from stable

bone to unstable and from lateral tobone to unstable and from lateral to

medialmedial

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Internal fixation vs.Internal fixation vs.

traditional methodstraditional methods

Klotch et al 1987Klotch et al 1987

43 patients43 patients 22 treated with ORIF using AO22 treated with ORIF using AO

miniplatesminiplates

21 treated with combination of21 treated with combination ofintermaxillary fixation, and/orintermaxillary fixation, and/orinterosseous wiring, and/orinterosseous wiring, and/orprimary bone graftingprimary bone grafting

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Most severe injuries in rigidMost severe injuries in rigid

internal fixation groupinternal fixation group

Shorter IMF, early return to diet,Shorter IMF, early return to diet,lower percentage of tracheotomylower percentage of tracheotomy

No plate infectionsNo plate infections

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Haug et al 1995Haug et al 1995

134 patients treated by134 patients treated by

maxillomandibular fixation ormaxillomandibular fixation orrigid internal fixationrigid internal fixation

Postoperative problems in 60% vsPostoperative problems in 60% vs

64%64%

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Complication rates similarComplication rates similar

Rigid fixation has benefits:Rigid fixation has benefits:

Airway protectionAirway protection

Enhanced nutritionEnhanced nutrition

More rapid return to pretraumaticMore rapid return to pretraumatic

functionfunction

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ApproachesApproaches

CircumvestibularCircumvestibular

Facial deglovingFacial degloving

BicoronalBicoronal

TransconjuctivalTransconjuctival

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From: Haug RH, Buchbinder D. Incisions For Access to CraniomaxillofacialFractures. Atlas of the Oral and Maxillofacial Surgery Clinics of North America 1993;1(2):23.

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From: Haug RH, Buchbinder D. Incisions For Access to CraniomaxillofacialFractures. Atlas of the Oral and Maxillofacial Surgery Clinics of North America

1993;1(2):25.

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From: Cheney ML. Facial Surgery: Plastic andReconstructive. Baltimore: Williams & Wilkins 1997.

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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.

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T t t fT t t f

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Treatment ofTreatment of

ZygomaticomaxillaryZygomaticomaxillary

Complex fracturesComplex fractures

Restore pre-injury facialRestore pre-injury facial

configurationconfiguration Prevent cosmetic deformityPrevent cosmetic deformity

Prevent delayed visualPrevent delayed visual

disturbancesdisturbances Repair within 5-7 days allowsRepair within 5-7 days allows

edema to decrease and avoidsedema to decrease and avoids

shortening of masseter withshortening of masseter with

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Soft diet and malar protectionSoft diet and malar protection

Closed reductionClosed reduction

ORIF with plating of one to fourORIF with plating of one to four

buttressesbuttresses

Provide fixation as necessary forProvide fixation as necessary for

stable reductionstable reduction

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Ellis and Kittidumkerng 1996Ellis and Kittidumkerng 1996 48 patients48 patients Reduced fracture with Carroll-GirardReduced fracture with Carroll-Girard

screwscrew 4.2% closed reductions4.2% closed reductions 31.2 % one point fixation31.2 % one point fixation 27.1% two point fixation27.1% two point fixation

27.1% three point fixation27.1% three point fixation 10.4% four point fixation10.4% four point fixation Used exposure and fixation needed toUsed exposure and fixation needed to

provide stable reductionprovide stable reduction

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Approaches to FZApproaches to FZ

buttressbuttress

From: Strong EB, Sykes JM. Zygoma Complex Fractures. Facial Plastic Surgery1990;14(1):108.

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Approaches to orbitalApproaches to orbital

floorfloor

From: Strong EB, Sykes JM. Zygoma Complex Fractures. Facial Plastic Surgery1990;14(1):109.

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Orbital explorationOrbital exploration

Shumrick et al 1997Shumrick et al 1997

97 patient with either ZMC or midface97 patient with either ZMC or midface

fracturesfractures All explored had significant traumaticAll explored had significant traumatic

disruptions, no enopthalmos ordisruptions, no enopthalmos or

diplopia in those not exploreddiplopia in those not explored

Based on their 7 criteria 22 ZMC andBased on their 7 criteria 22 ZMC and

11 midface underwent orbital11 midface underwent orbital

explorationexploration

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Persistent diplopia which failed toPersistent diplopia which failed to

improve in 7 or more days,improve in 7 or more days,

positive forced duction testing,positive forced duction testing,radiologic evidence ofradiologic evidence of

perimuscular tissue entrapmentperimuscular tissue entrapment

Cosmetically significant andCosmetically significant andclinically apparent enophthalmosclinically apparent enophthalmos

associated with abnormalassociated with abnormal

radiological findingsradiological findings

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Radiological evidence ofRadiological evidence of

significant comminution and orsignificant comminution and or

displacment of the orbital rimdisplacment of the orbital rim Radiological evidence ofRadiological evidence of

significant displacement orsignificant displacement or

comminution of greater than 50%comminution of greater than 50%of the orbital floor with herniationof the orbital floor with herniation

of soft tissue into maxillary sinusof soft tissue into maxillary sinus

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Combined orbital floor and medial wallCombined orbital floor and medial walldefects with soft tissue displacementdefects with soft tissue displacementnoted radiologically on CT scansnoted radiologically on CT scans

Radiological evidence of a fracture orRadiological evidence of a fracture orcomminution of the body of thecomminution of the body of thezygoma itself as determined by CTzygoma itself as determined by CT

Physical or radiological evidence ofPhysical or radiological evidence ofexophthalmos or orbital contentexophthalmos or orbital contentimpingement caused by displacedimpingement caused by displacedperiorbital fracturesperiorbital fractures

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Repair of the orbitRepair of the orbit

ApproachesApproaches

Transconjunctival with or withoutTransconjunctival with or without

lateral canthotomy/cantholysislateral canthotomy/cantholysis SubciliarySubciliary

Transconjunctival has lowerTransconjunctival has lower

incidence of ectropion/entropionincidence of ectropion/entropion

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Materials forMaterials for

reconstructionreconstruction

Autogenous tissuesAutogenous tissues

Avoid risk of infected implantAvoid risk of infected implant

Additional operative time, donor siteAdditional operative time, donor sitemorbidity , graft absorptionmorbidity , graft absorption

Calvarial bone, iliac crest, rib, septalCalvarial bone, iliac crest, rib, septal

or auricular cartilageor auricular cartilage

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Alloplastic implantsAlloplastic implants

Decreased operative time, easilyDecreased operative time, easily

available, no donor site morbidity,available, no donor site morbidity,can provide stable supportcan provide stable support

Risk of infection 0.4-7%Risk of infection 0.4-7%

Gelfilm, polygalactin film, silastic,Gelfilm, polygalactin film, silastic,

marlex mesh, teflon, prolene,marlex mesh, teflon, prolene,

polyethylene, titaniumpolyethylene, titanium

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Ellis and Tan 2003Ellis and Tan 2003

58 patients, compared titanium58 patients, compared titanium

mesh with cranial bone graftmesh with cranial bone graft Used postoperative CT to assessUsed postoperative CT to assess

adequacy of reconstructionadequacy of reconstruction

Titanium mesh group subjectivelyTitanium mesh group subjectively

had more accurate reconstructionhad more accurate reconstruction

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Soft tissueSoft tissue

resuspensionresuspension

Wide exposure allows moreWide exposure allows more

accurate fracture reduction butaccurate fracture reduction but

may lead to problems in softmay lead to problems in softtissue covering of facetissue covering of face

Need to close periosteum andNeed to close periosteum and

provide suspension sutures toprovide suspension sutures toprevent descent of soft tissuesprevent descent of soft tissues

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ConclusionsConclusions

High index of suspicion forHigh index of suspicion for

associated injuries- especiallyassociated injuries- especially

ocularocular Assessment of buttress systemAssessment of buttress system

Wide exposure via cosmeticallyWide exposure via cosmetically

acceptable incisionsacceptable incisions Rigid fixationRigid fixation

Soft tissue resuspensionSoft tissue resuspension