Download Fractures Of The Midfacial Skeleton The facial skeleton can be

Fractures Of The
Midfacial Skeleton
The facial skeleton can be roughly divided into 3 areas:
1) Lower third (mandible)
2) Upper third is formed by frontal bone
3) Middle third from the frontal bone to the level of upper teeth (or the upper
alveolus if edentulous)
* "Upper jaw fractures" or "fractures of the maxilla" are inaccurate terms, since
bones adjacent to the upper jaw are almost involved in such injuries,
"maxillofacial injuries " are associated with involvement of the overlying soft
tissues and neighboring structures as the eyes ,nasal airways, paranasal sinuses
and tongue.
Bones of the middle third of facial skeleton are comparatively fragile and they
fragment and comminute easily 'crumple zone' type arrangement.
In fact they articulate and interdigitate in a most complex fashion, it is difficult to
fracture one bone without disrupting its neighbours.
Etiology:
1)
2)
3)
4)
5)
6)
Road traffic Accident (RTA)
Fall form height
Occupational accidents
Altercations (fighting)
Sport injuries
Missile injures (war injures)
Surgical Anatomy:
The middle third of facial skeleton : is the area bounded superiorly by a line
drawn across the skull from the zygomaticofrontal suture across the frontonasal
and frontomaxillary sutures to the zygomaticofrontal suture on the opposite
side, and inferiorly by the occlusal plane of the upper teeth or the upper
alveolus (if edentulous ) .
The middle third is made up of the following bones:
1) Two maxillae
2) Two zygomatic bones
3) Two zygomatic processes of the temporal bone
4) Two palatine bones
5) Two nasal bones
1
6) Two lacrimal bones
7) The vomer
8) The ethmoid and its attached conchae
9) Two inferior conchae
10) The pterygoid plates of the sphenoid
Physical Characteristics of Midfacial Skeleton:
1) The middle third is made up of a considerable number of bones which are rarely;
if ever, fractured in isolation.
2) This type of structure is able to withstand considerable force from below but the
bones are easily fractured by relatively trivial forces from other directions.
Forces required to fracture the middle third is 1/5-1/3 of those required to
produce simple fracture of the mandible.
3) Because of its relative fragility, it acts as a cushion for trauma directed toward
the cranium from anterior or anterolateral direction.
- It is analogous to a " match box '' sitting below and in front a hard shell
containing the brain , and a rigid mandible from below.
- The frontal bone and body of the sphenoid form an inclined plane which lies at
an angle of about 45º to the occulsal plane (of upper teeth).
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Classification:
Following experimental trauma to the cadaver head carried out by Rene Le Fort in
1901, he discovered that the complex fracture patterns could be broadly subdivided
into 3 groups:
1- Le Fort I (Guérin or Low – level fracture):
The fracture line runs from the lateral margin of the anterior nasal aperture and passes
laterally above the canine fossa, then below the zygomatic buttress and along the
lateral antral wall and posteriorly above the tuberosity, then across the ptergyomaxillary fissure to fracture the lower third of the pterygiod lamina. This fracture
may be unilateral or bilateral and it causes detachment of the tooth-bearing portions
of the upper jaw from the cranial base.
2
2- Le Fort II (pyramidal or subzygomatic fracture):
This fracture runs from the thin middle area of the nasal bones down either side,
across the frontal processes of the maxillae, across the lacrimal bones and then
downwards and forwards laterally crossing the inferior orbital margin in the region of
the zygomatico-maxillary suture, down the infra-orbital foramen and along the lateral
wall of the antrum beneath the zygomatic buttress, across the pterygo–maxillary
fissure to fracture the middle area of the pterygoid laminae.
3- Le Fort III (high level or suprazygomatic fracture):
The fracture runs near the fronto-nasal suture, the nasal bones and lacrimal bones,
across the thin orbital plates of the ethmoid, around the optic foramen and
downwards laterally to the inferior orbital fissure, then the fracture line descends
across the upper posterior aspect of the maxillae, across the pterygo-maxillary fissure,
then fracturing the root of the pterygoid laminae. A further line of fracture passes
across the lateral wall of the orbit separating the zygomatic bone from the frontal
bone. In this type of injury the entire MTFS becomes detached from the cranial base.
A simple classification which is practical for the purposes of diagnosis and treatment
divide fractures into:
1.
2.
3.
4.
5.
6.
7.
Dentoalveolar fractures
Zygomatic complex fractures
Orbital floor fracture
Nasal complex fractures
Le Fort I (low–level fracture)
Le Fort II (pyramidal or subzygomatic fracture).
Le Fort III (high-level or suprazygomatic fracture).
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Clinical findings in the various types of fractures (Signs and Symptoms):
Dentoalveolar fractures:
A. Damage to the teeth:
1. Fracture of the crown of the tooth with or without pulp exposure.
2. Vertical splitting of upper premolar and molar teeth.
3. Fracture of the roots, should be detected by intra oral periapical x-ray.
4. Avulsion, intrusion or subluxation of teeth.
5. For unconscious patient who have missed, avulsed or fractured teeth; chest xray should be taken to exclude inhalation of teeth.
B. Damage to the lip:
1. Odema and ecchymosis of the inner aspect of the lip.
2. Ragged laceration of inner aspect of the lip.
3. The fractured crowns may be embedded in the upper lip and should be
detected by x-ray.
3
C. Alveolar fracture:
1. Fracture of the maxillary tuberosity and antral floor.
2. Comminuted fractures of the alveolus if the blow is violent which is
usually in the incisor area.
3. Bony deformity and crepitus.
***
Fracture of the zygomatic complex:
The zygomatic bone is intimately associated with the maxilla, frontal and temporal
bones and they are usually involved when a zygomatic bone fracture occurs, so it is
called zygomatic complex fracture. The zygomatic bone usually fractures in the
region of the zygomatico-frontal, zygomatico-temporal and zygomatico-maxillary
sutures. The zygomatic bone fracture may be simple or comminuted.
Classification of zygomatic complex fracture is according to the site of the fracture, the
degree and direction of the displacement:
a- Fracture of the body of the zygomatic complex involving the orbit:
1. Minimal or no displacement
2. Inward & downward displacement
3. Inward & posterior displacement
4. Outward displacement
5. Comminution of the complex as a whole
b- Fracture of the zygomatic arch alone not involving the orbit:
1. Minimal or no displacement
2. V-type in-fracture
3. Comminuted
 A practical classification of zygomatic fractures
 Segmental
a. Zygomatic arch
b. Infraorbital rim
 Minimally displaced
 Displaced
 Comminuted
a. Associated with midface or complex orbital fractures
b. Associated with soft tissue including ocular injury
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Summary of physical signs (zygomatic complex)
On inspection externally:
1. Circumorbital ecchymosis
2. Subconjunctival ecchymosis
3. Oedema of cheek
4. Flattening in the region of zygoma on injured side
5. Limitation of ocular movements
6. Diplopia
7. Strabismus
8. Enophthalmos
9. Limitation of lateral excursion of mandible to injured side
10. Limitation of opening or closing of mandible
11. Unilateral epistaxis on injured side
On palpation:
1. Tenderness over cheek bone
2. Tenderness & separation at frontozygomatic suture
3. Notch in lower rim of orbit in the region of the zygomaticomaxillary suture
4. Anaesthesia or paraesthesia of the cheek
On inspection intra-orally:
1. Ecchymosis in upper buccal sulcus in region of zygomaticomaxillary
buttress.
2. Possible gagging of occlusion in molar area on injured side
On palpation:
1. Tenderness in upper buccal sulcus in region of zygomatic buttress
2. Anaesthesia of upper gum
Summary of symptoms.The patient complain of:
1. Flattening of cheek
2. Swelling and bruising around the eye
3. Blood-shot eye
4. Double vision
5. Squint
6. One eye too far back
7. One eye lower than the other (hypoglobus)
8. Tenderness over the cheek
9. Anaesthesia of the cheek and gums
10. Lump on the lower orbital rim
11. Difficulty in either opening or closing the mouth
12. Inability to move the jaw towards the injured side
13. Gagging of the back teeth to the injured side
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Summary of clinical findings in zygomatic complex fractures 2015
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Flattening of cheek
Swelling of cheek
Anesthesia of cheek, temple, upper teeth and gingiva
Periorbital hematoma
Sub-conjunctival hemorrhage
Tenderness over orbital rim and frontozygomatic suture
Step deformity of infraorbital margin
Palpable separation at frontozygomatic suture
Ecchymosis and tenderness intra-orally over zygomatic buttress
Limitation of ocular movement
Diplopia
The diagram illustrating how inferior displacement of Whitnall's tubercle with the attached
Lockwood's suspensory ligament leads to alteration in the level of the globe.
Fractures of the zygomatic arch:
This fracture may occur with fracture of zygomatic bone, or may occur alone, in such
condition the only visible evidence of fracture is a depression of about 2.5 cm in
diameter over the zygomatic arch associated with limitation of mandibular opening or
closing. The depression is obvious immediately after fracture of the arch, but it often
becomes obscured by oedema shortly after injury and become visible again when the
swelling subsides in about a week.
Fractures of the zygomatic arch can be divided into two main groups:i- Minimal or no displacement
ii- The triple fracture of the arch with a depressed V- type displacement
iii- Comminution of the zygomatic arch
In the V-type-in fracture, the apex of the "V" may impinge on the coronoid process
and impede mandibular movement. In the comminuted fracture, the fragments
usually reposition themselves presumably as a result of movement of the temporalis
muscle and coronaid process beneath them.
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Orbital Floor Fracture (Blow out fracture):
Applied surgical anatomy:
The orbit is said to be roughly pyramidal in shape with its apex at the optic foramen,
but as the junctions between its walls are rounded it does in fact resemble a cone. It is
made up of the orbital portion of the maxillary bone and part of the zygomatic bone.
The eyeball is suspended by Lockwood's suspensory ligament from Whitnall,s
tubercle just below the zygomaticofrontal suture to the inner wall of the orbital rim
(lacrimal crest).
With this fracture, the fragments of bone are displaced downwards into the antral
cavity remaining attached to the orbital periosteum rather like a "trap-door". The
peri-orbital fat tends to herniate the defect and this has the effect of interfering with
the action of the inferior rectus and inferior oblique muscles (prevent upward
movement and outward rotation of the eye with resulting diplopia or double vision in
these directions of gaze). If a large amount of orbital fat is displaced through the
orbital floor defect it may result in enophthalmos.
It is important to recognize that two distinct types of orbital floor fractures can be
identified:
1. Those occurring as part of the natural fracture pattern in fractures (Impure) of the
zygomatic complex or Le Fort II and III type fractures of the middle third of the face.
2. Those occurring as an isolated orbital floor fracture (Pure), either as a so-called
‘blow-out’ or rarely as a localized elevation or ‘blow-in’ fracture.
Summary of possible clinical findings in isolated orbital floor fractures
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Periorbital ecchymosis
Sub-conjunctival haemorrhage
Diplopia
Limitation of eye movement especially in upward gaze
Globe retraction on upward gaze
Enophthalmos
Surgical emphysema of eyelids (leakage of air from the paranasal sinuses)
Paraesthesia within distribution of infraorbital nerve
The tethering of the inferior muscles can be demonstrated by the:
1) Forced duction test under local or general anesthesia
2) Cardinal positions of gaze (horizontal, vertical, torsional, or combination of
these)
3) Hess chart
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Radiology:
Radiopacity of the maxillary and ethmoidal air sinuses which appear cloudy due to
extravasation of blood into them via a fracture of the overlying bone. With standard
standard sinus views there may be the characteristic "hanging drop sign", which is
best demonstrated by Waters projection of the face (OM projection employing
a horizontal beam of X-ray emerging through the infra-orbital rim). CT scan
demonstrate the normal sigmoid outline of the orbital floor giving the so-called
'posteromedial bulge'.
***
Nasal complex fracture:
The nasal bone may be fractured alone. But the more usual fracture involves the
frontal processes of the maxillae, the nasal septum, vomer, perpendicular and
cribriform plates of ethmoid.
Summary of possible clinical findings in nasal complex fractures
* Bruising of skin over nasal bones
* Laceration of skin of bridge of nose
* Bilateral medial orbital ecchymosis
* Epistaxis
* Deformity of nose and inter-orbital area (septal deviation or saddle-type
depression)
* Crepitus of bones of nasal complex
* Unilateral or bilateral telecanthus
* Airway obstruction
* Septal laceration or haematoma
* Cerebrospinal rhinorrhea
* Epiphora due to damage to the nasolacrimal duct
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Possible planes of nasal fracture. 1. Nasal tip only 2. Nasal bones 3. Naso-orbito-ethmoid
complex.
'Rule of fifths' showing the assumed facial proportion on frontal view for assessing of
traumatic telecanthus.
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Normal intercanthal and interpupillary measurements (Caucasian).
Le Fort I fracture:
Summary of possible clinical findings in Le Fort I fractures
• Mobility of whole dentoalveolar segment of upper jaw and disturbed occlusion
• Palpable crepitation in upper buccal sulcus
• Cracked-Pot sound on percussion note from upper teeth
• Hematoma intraorally over root of zygoma
• Ecchymosis or laceration in palate
• Fractured cusps of check teeth (Subluxed, avulsed and fractured teeth)
• Bruising and swelling of upper lip and lower half of midface
Le Fort II fracture:
Summary of possible clinical findings peculiar to Le Fort II type fractures
• Step deformity at infraorbital margins
• Mobility of midface detectable at nasal bridge and infraorbital margins
• Anaesthesia or paraesthesia of cheek
• Possible diplopia
• Pupils tend to be level unless there is gross unilateral enophthalmos
• Nasal bones move with midface as a whole but often otherwise intact
• Cerebrospinal fluid rhinorrhoea may not be clinically delectable
• No tenderness over, or disorganization and mobility of zygomatic bones and arch
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Le Fort III fracture:
Summary of Signs and symptoms peculiar to Le Fort III fractures
1- Tenderness and separation at frontozygomatic suture.
2- Tenderness and deformity of zygomatic arch.
3- Lengthening of face "Dish-face".
4- Depression of ocular levels (hypoglobus).
5- Enophthalmos.
6- "Hooding" of eyes (pseudoptosis).
7- Lengthening and sometimes extreme disorganization of nasal skeleton.
8- Often cerebrospinal fluid rhinorrhea.
9- Tilting of occlusal plane with gagging on one side only.
10- Lateral displacement of midline of upper jaw.
11- Mobility of whole of facial skeleton as a single block.
Cerebrospinal fluid rhinorrhoea (CSF rhinorrhoea):
The possibility of CSF rhinorrhoea should be considered in all Le Fort II and III
fractures. In these types of fracture the escape of CSF into the nose is the result of
dural tear associated with fracture of the cribriform plate of the ethmoid.
In Le Fort II, III type fractures and in severe naso–ethmoidal injuries the cribriform
plate of the ethmoid is shattered and if there is an associated dural tear, CSF will
escape down the nostril or down to the throat due to blocking of the nose by blood
clot and the patient complains of a salty or metallic taste.
In most instances CSF leak arrest within few days, either spontaneously or as a result
of reduction and fixation of the #. Whenever there is a tear in the dura mater there is a
risk of meningitis either in the early days after injury or even many years later.
Detection:
The early recognition of CSF rhinorrhoea is difficult because CSF is masked by
epistaxis and later blood clots, there may be a discharge of "straw-coloured serum".
Many tests have been suggested but few are of any practical use. The nasal cavity
may contain at one time, blood and serum, normal nasal secretions and lacrimal fluid, as
well as CSF.
Laboratory investigation for the differentiation between CSF and the serum from the
blood clot, the CSF contains little protein. For the differentiation between CSF and
the nasal secretions of acute flu, CSF contains sugar but no mucin.
1. Glucose level using glucose oxidase sticks, however, so does lacrimal fluid which
contain glucose also (unreliable test). The quantity of glucose can be detected
using Dextrostix as CSF has a much higher glucose content. However, it is of no
value in the bleeding nose.
2. Protein content of CSF (of no use because it is impossible to obtain
uncontaminated samples of CSF).
3. Radioactive isotope preparation such as 111In DTPA administered intrathecally
and detected subsequently in the nasal cavity or gastric contents.
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Note: As a prophylactic measure, we shouldn’t give penicillin because it doesn’t
cross the blood-meningeal barrier in effective concentration so we should give the
patient 2g sulphadiazine followed by 1g, 6- hourly and continue the course until 48
hours after any CSF leak has ceased to prevent meningitis.
Radiographical examination of MTFS:
It is unnecessary to subject an ill patient to a protracted radiological examination but
when the patient general condition permits, then radiographs should be obtained to
evaluate the injury.
The radiographs required are:
1. Intraoral views (periapical and occlusal)
2. Extraoral views:
a- Occipito mental 15˚, 30˚ and 45˚
b- Submento–vertical
c- Postero–anterior (PA view)
d- True lateral (to midface, skull vault to include the cervical spine, and soft
tissue)
e- Orthopantomogram (OPG)
f- Occipitofrontal 25º, Fronto-occipital (Townes projection) for skull vault
g- CT scan
h- MRI
The 'elephant's head' approach to the assessment of zygomatic fractures. Fracture lines are
commonly seen at (1) infraorbital rim (2) frontozygomatic suture region (3) lateral wall of the
maxillary antrum (zygomatic buttress) and the zygomatic arch ('trunk').
(a) The 4 search lines (Campbell's lines) that can be systematically followed as an aid in
interpreting occipitomental radiographs. The 5th line was described by Trapnell. (b) OM
radiograph of a patient with Le Fort II and III type fracture.
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Main indications for CT in maxillofacial trauma
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Suspected or obvious fracture of the frontal bone.
Extensive fractures of the midface (including naso-orbito-ethmoid and
comminuted zygomatic complex fractures).
Isolated orbital trauma.
Displaced condylar neck fractures and complex injuries to the
temporomandibular joint.
Comminuted fractures of the mandible requiring complex repair.
Suspected pathological fracture of the mandible.
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Definitive treatment of MTFS fractures:
The definitive treatment is varying according to the type of fracture.
Steps (principles) of definitive treatment of fractures:
a- Reduction (manual, elastic traction or wires)
b- Fixation and immobilization
c- Follow up and rehabilitation
Diagram to illustrate sequencing of multiple facial fracture repair. The outer circle defines the
'frame' of stronger bones that are reduced and immobilized first (frontal bone, lateral orbital
margins, zygomas and mandible). The middle circle contains the 'contents' of this 'frame'
(essentially the maxillae) that are reduced and repaired next, and finally the nasal complex (inner
circle) is resorted.
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Dentoalveolar fractures:
A. Fractured teeth
1- Fractured teeth without pulp exposure:The fractured teeth should be pulp tested and X-rayed. The dead tooth must be
treated by root canal therapy. Conservative treatment is carried out to restore the
appearance.
2- Fractured teeth with pulp exposure:The exposed pulp should be touched with phenol or tricresol formalin to
to relieve acute pain, and then a decision has to be made to root fill or to extract
the tooth. Comminuted fracture of the teeth, or that which fractured beneath the
gum should be extracted.
3- Subluxated and avulsed teeth:Slightly subluxated teeth with good position should be left if slightly mobile. If
the tooth is severely subluxated it can be replaced in the correct position and
splinted, root canal filling is carried out when the tooth become firm. If the tooth
is avulsed from the socket, it can be replanted and splinted, and then root filled
(some prefer to fill the root then the apex is cut off and the tooth is replanted and
splinted in position). A tooth so treated usually becomes firm but resorption of the
root mainly eventually leads to its loss. However, the tooth may be preserved for
months or even few years.
B. Fracture of the alveolus & maxillary tuberosity
If the tuberosity is completely detached from the periosteum, it should be
carefully dissected out and the resulting soft tissue defect carefully sutured to
prevent oro-antral fistula (OAF). If the tuberosity with or without associated teeth
appears to be attached to the periosteum, the tuberosity can be left in position with
or without splinting. Splinting by arch bar or dental wires of the tooth attached to
the tuberosity fragment and fix it to other standing teeth in the maxilla for one
month usually result in union, but if the tooth in the tuberosity fragment requires
extraction it should be removed surgically after tuberosity has firm union. If the
tooth is painful, this surgical extraction must be carried out earlier, but the chance
of saving the tuberosity is greatly reduced.
If OAF is created as a result of fracture of the alveolar floor of the maxillary sinus,
a very careful soft tissue repair of the defect must be carried out immediately by
advancing a buccal flap. The patient should be given nasal inhalation
(Tinct, Benzoin Co) and epinephrine nasal drops 0.5-1%, and antibiotic for 7 days.
* Lacerated wounds in the lip and gum should be carefully explored and any
fragments of bony specules or teeth should be removed, and then sutured.
***
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Zygomatic complex fractures:
Zygomatic complex fractures with minimal displacement that, arc not causing
symptoms do not necessarily require treatment. 'The indications for treatment are as
follows:
1. To restore the normal contour of the face both for cosmetic (relative) reasons and
to re-establish skeletal protection for the globe of the eye.
2. To correct diplopia.
3. To remove any interference with the range of movement of the mandible.
4. When pressure on the infraorbital nerve results in significant numbness or
dysaesthesia.
Symptomless zygomatic complex fractures with minimal displacement doesn’t
require treatment. Sometimes a severely displaced zygomatic bone is left untreated if
the patient is old and medically compromised.
Reduction:The optimum time for reduction of a fractured zygoma is between the 5th-10th
postinjury day (this allows the gross edema to disperse, permit good assessment to
diplopia, provide an improved radiographs, and hematoma has not started to organize
into fibrous tissue).
Reduction of a recent fracture is carried out by:
1. Gillies approach, (1927 still the method of choice). A skin incision about 2-2.5cm
long is made between the bifurcation of the two branches of the superficial temporal
vein, and temporalis fascia is exposed and incised. A Bristow's elevator or Rowe's
zygomatic disimpaction forceps is passed down beneath the zygomatic bone which
is then gently lifted back into position. The temporal fascia is sutured with catgut and
the skin with silk.
2. Intraoral approach (Keen 1909). 1 cm incision in the buccal sulcus immediately
behind the zygomatic buttress and a pointed curved Monk's elevator is passed
subperiosteally.
Quinn, 1977 described a modification for correction of the medially displaced
zygomatic arch. This employs a lateral coronoid approach through an incision over
the anterior border of the ramus, a finger inserted into the wound, then an elevator
inserted medial to the arch and moved aneroposteriorly.
The disadvantage of intraoral approach is the possible herniation of buccal pad of fat.
3. Percutaneous approach(Poswillo, 1976). By inserting a hook through the skin
below and behind the zygomatic bone with application of outward traction. The main
disadvantages are blindness (if the instrument inserted in the inferior orbital fissure)
and visible scar.
4. Intranasal transantral approach. Employed by some "Oto-rhino-laryngologists"
but is not in common use. An opening is made into the antrum below the inferior
meatus, in the same location as intranasal antrostomy.
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Fixation:Following reduction, the bone may be stable or additional fixation is required.
Instability of the fragment commonly occurs when there has been delay in treatment;
the fractured ends of the bone tend to become rounded off by osteoclastic activity
(eburnation) and after the zygomatic bone has been elevated into place it falls back
into its original position, so it needs fixation.
Methods of fixation:-
1- Transosseous wiring at the frontozgomatic suture (lateral orbital rim):
The zygomatico–frontal fracture line is exposed by blunt dissection via an oblique
incision within the eyebrow or utilizing one of the skin wrinkles at the corner of
the eye (Crow's-foot). Small holes are drilled in the zygomatic process of frontal
bone and through the frontal process of zygomatic bone, utilizing 0.45mm mm soft
stainless
steel
wire
through
the
two
holes
and
twisted.
2-Transosseous wiring at the zygomatico–maxillary suture line (infra-orbital rim):
A semilunar incision about 1.5cm long made through the skin beneath the
lower orbital rim. Then holes are drilled in the adjacent fragments then fixed and
immobilized by 0.35 mm stainless steel wiring (infra-orbital rim is more delicate
than the lateral rim).
3-A combination of lateral & infra-orbital rim wiring.
4-Fixation with a pack in the maxillary sinus: (Temporary Support)
Used for 2 purposes → 1) support comminuted fracture of the body of zygomatic
complex 2) support comminuted orbital floor fracture.
This is done through an incision in the buccal sulcus, and then reflect a
mucoperiosteal flap, a hole into the maxillary sinus is usually seen to be present as
a result of the fracture, otherwise a window into the sinus is enlarged and the blood
clot and fragments of bone within it are evacuated, followed by reduction of
the zygomatic bone. Then the antrum is packed with ribbon gauze saturated with
Whitehead's varnish in order to hold the zygomatic bone in position. The pack is
normally left in place for about three weeks, and then removed through the original
incision in the buccal sulcus, after this the wound is sutured. Care must be taken
during packing the antrum not to displace any bony spicules of the orbital floor
against the optic nerve and ophthalmic artery which may cause loss of vision due
to damage to the retina. For this reason the pack should be directed chiefly to the
outer aspect of the antrum beneath the zygomatic bone.
Balloons or a Foley catheter in the antrum have been used instead of pack the
disadvantage of which is expanding uniformly in all directions so that the pressure
cannot be exerted in the correct sites with any degree of accuracy.
5-Pin fixation from zygomatic bone to the supra-orbital rim:
Is especially useful for
1) Excessively mobile zygoma.
2) Following surgical refracture of a badly displaced zygomatic bone which has
healed.
***
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Fracture of the zygomatic arch:
If the zygomatic arch alone is fractured, the fragments should be reduced via a Gillies
approach. Fixation is unnecessary as the temporalis fascia attach along the superior
aspect of the arch will effectively immobilize the fragments (in recent fracture).
***
Fractures of the orbital floor (Blow out fracture):
Fractures of the orbital floor may occur in association with fractures of the zygomatic
complex or in isolated fracture of the orbit. Treatment is indicated if there is:
1. Diplopia which does not resolve significantly during the first 10 days after injury.
2. A fracture with a large herniation of tissue into the antrum.
3. Incarceration of tissue sufficient to cause globe retraction and increase in intraocular pressure on upward gaze.
4. Significant enophthalmos (greater than 3mm).
Indications and relative contraindications for orbital floor repair
Indications
1. Significant restriction of eye movement (diplopia) with CT confirmation of
entrapment
2. Significant enophthalmos (greater than 3 mm)
3. Large 'blowout' defect (large herniation into the antrum)
4. Significant orbital dystopia
Relative contraindications
1. Visual impairment
2. Anticoagulant medication
3. Patient unconcerned
4. Proptosis
5. An already at 'risk' globe
Surgery in the form of grafting (bone graft or implant) the orbital floor mostly used
for correction of orbital floor fracture. However, grafting of the orbital floor may lead
to postoperative complications as persistent enophthalmos, persistent diplopia in
vertical gaze, persistent edema of the lower eye-lid, infection and chronic fistula,
extrusion of the implant (alloplastic sheets), dacryocystitis, depression of the globe,
tissue reaction to the implant, intra-orbital hemorrhage, and blindness.
No decision about operation need be made before 10 days have elapsed, which
allows time for edema to subside and the true ophthalmic situation to be revealed.
When there is no doubt concerning the interpretation of the various clinical and
radiological findings, Caldwell–Luc operation is suggested to ascertain the exact
extent of the injury by direct inspection of the roof of the maxillary sinus.
* If the depressed fragments can be reduced by gentle digital repositioning and there
is no actual bone loss, the maxillary sinus is evacuated of its blood clot and packed
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with ribbon gauze soaked in White head's varnish. The end of the pack is left
protruding from the wound in the buccal sulcus and can be withdrawn after 3 weeks.
It is important not to pack into the posterior-medial-superior aspect of the maxillary
sinus which lies beneath the optic foramen.
* If inspection of the orbital floor confirms actual bone loss, a graft to the orbital
floor is indicated. An incision is made in a natural skin crease immediately below
the lid margin. The incision should not be extended too far laterally as it may
interfere with lymphatic drainage. The skin is dissected off, the orbicularis oculi
muscle which is then incised at a slightly lower level than skin incision. The
periosteum is incised and the orbital contents are supported with a blunt retractor
while the orbital tissues are reflected upwards through the defect in the orbital floor.
The bony gap is then covered with a 0.5 – 1 mm thick sheet of Silastic or Teflon,
cut to a triangular shape and sufficiently large to be supported at its periphery on
sound bone. The periosteum is then sutured to prevent extrusion of the graft, and then
the muscle and the skin incisions are closed. Alternatively, autogenous bone graft
may be used for this purpose.
Possible complications of orbital floor exploration
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Intraorbital hemorrhage
Lower eyelid retraction and ectropion
Persistent edema of lower eyelid
Persistent enophthalmos
Persistent globe depression
Persistent diplopia in vertical gaze
Tissue reaction to implant
Extrusion of implant
Infection and chronic fistula formation
Dacryocystitis
Blindness
***
Nasal complex fracture:
Reduction:
Can be reduced under local anesthesia, but general anesthesia with a peroral
endotracheal intubation is desirable because hemorrhage may be profuse.
Walsham's and Asche's septal forceps are used for reduction of the fragments. The
unpadded blade of the walsham's forceps is passed up the nostril and the nasal bone
and associated fragment of the frontal process of the maxilla are secured between it
and the padded blade externally. The fragments are reduced into their correct position
and then the maneuver is repeated on the other side. Then the vomer and the
perpendicular plate of the ethmoid are reduced with the Asche's septal forceps, using
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one blade each side of the septum and then, if possible, the septal cartilage is grasped
and brought forwards and repositioned in its groove in the vomer. Then the index
finger and thumb of one hand are used to compress the lacrimal bones and medial
walls of the orbit on each side to achieve a narrow bridge to the nose.
Fixation:Sometimes when the fracture is not very severe, it is unnecessary to splint the nose
following the reduction. However, some types of splint fixation are advisable.
1. The most commonly used splint is a plaster-of-Paris splint consist of eight layers
of plaster-of-Paris bandage cut so as to produce a strip of plaster across the bridge
and covering either side of the nose. The bandage splint is molded into place while
wet and held while it sets, then fixed into position with strips of elastoplasts across
the forehead and down each side of the nose and pack the nostril with ribbon gauze. It
should never to connect the nasal splint to plaster–of–Paris head cap, because if the
head cap moves downward on the nose a little, it produces a depressed bridge of the
nose since the pressure is transmitted to the nasal splint. When the oedema over the
nasal region has subsided in a bout a week, apply a new, accurately fitting nasal
plaster. The plaster should be left in situ for about 3 weeks.
2. If the nasal fracture is too mobile, a lead plate splint on either side of the nose is
used. Two lead plates, each with upper and lower holes through the center, are fitted
on either side of the nose with a cotton-wool pads beneath the plates to prevent them
from chafing the skin. They are held in position by a mattress suture wiring with
0.35mm soft stainless steel wires which is passed through the holes in the lead plates,
the wires transfixing the tissues and passing beneath the nasal bones. The splint left in
situ for about 3 weeks.
3. Open reduction and direct wiring of the fragments for certain complicated nasoethmoidal fractures.
***
Reduction of Le Fort Fractures:
The optimum time for reduction of midface fractures is usually between the 5th-8th
postinjury days.
Le Fort I fracture:
The reduction is carried out by grasping the tooth-bearing portion of the upper jaw
and reducing it by using two pairs Rowe's disimpaction forceps in bilateral fracture.
The unpadded blade is passed up the nostril and the padded blade enters the mouth
and grip the palate. Standing behind the patient, the operator grips the handles of the
two pairs of forceps and manipulates the tooth-bearing fragment upward and forward
into it's correct position, while the assistant holding patient's head.
Le Fort II fracture:
Reduction of the tooth-bearing segment done by the use of two pairs Rowe's
disimpaction forceps, the same grip as in Le Fort I fracture. It should be gently
rocked free and manipulated upwards and forwards up to the inclined plane formed
by the frontal bone and body of the sphenoid. When the tooth-bearing portion is
adequately reduced, this fragment is immobilized and finally the associated nasoethmoidal fracture is reduced and fixed.
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Le Fort III fracture:
This injury usually include Le Fort I, II and III types fractures, also associated with
bilateral zygomatic complex and nasal complex fracture, so the reduction and fixation
should be done on the following order:
a- Reduction of zygomatic bones because it is impossible to disimpact the central Le
Fort II portion while zygomatic bone depressed.
b- Next, the tooth-bearing portion of upper jaw is reduced by grasping it between 2
pairs of Walsham's or Rowe's disimpaction forceps, after which fixation is carried.
c- The naso-ethmoidal section is then repositioned , finally the nasal complex is
immobilized.
* If it is necessary to pack the maxillary sinus to support the zygomatic bone or the
orbital floor, this is done after all other treatment is completed and no further
manipulation of the facial skeleton should be done with an antral pack in position,
which may in this stage cause severe damage to the eye.
Immobilization of Le Fort I, II and III type fractures:The fixation of a mobile fracture of the MTFS presents a difficult problem because
there is no suitable adjacent structure to which it can be immobilized.
Forms of immobilization may be classified as follows:
A- Extra-oral immobilization
B- Immobilization within the tissues
A-Extra-oral immobilization:
1. CRANIOMANDIBULAR
a. "Box-frame" system
b. "Halo-frame"
c. Plaster-of-Paris headcap
2. CRANIOMAXILLARY
a. Supra-orbital pins
b. Zygomatic pins
c. "Halo-frame"
3. SUSPENSION
From "halo-frame"or plaster-of-Paris headcap using cheek wire
B- Immobilization within the tissues:
1. DIRECT FIXATION
a. Transosseous wiring of fracture sites:
i. Frontozygomatic
ii. Infra-orbital
iii. Midline of palate
b. Transfixation with kirschner wire or Steinmann pin
i. Transfacial
ii. Zygomaticoseptal
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2. INTERNAL WIRE SUSPENSION
a. Circumzygomatico - mandibular
b. Zygomaticomandibular
c. Inferior orbital border - mandibular
d. Frontomandibular
e. Pyriform fossa – mandibular
f. Nasal septum – mandibular
3. SUPPORT
a. Antral pack
b. Antral balloon
c. External acrylic splint
d. Silicone elastomer wedge
Extra oral immobilization:
* suspension from plaster–of-Paris head cap:
plaster-of-Paris head cap is mostly used in extra-oral immobilization, however
it does not achieve adequate stability. Some surgeons prefer to use halo frame
which is a metal frame and it encircles three-quarters of the skull and leave the
occiput free and is attached to the skull by four pins. The upper and lower jaws are
connected to the head cap by anterior connecting rods and by transbuccal cheek
wires. If the patient has teeth, an arch bars are fixed to the upper and lower teeth or a
silver- copper alloy cap splint is cemented over the upper and lower teeth, and if the
patient is edentulous a Gunning splint is wired to the jaws by circumferential wires.
The transbuccal cheek wires are most helpful for elevating the tuberostiy region of
the tooth-bearing fragment during reduction, and together with the anterior
connecting rod they provide a stable three point fixation from the head cap. The
wire passes through the cheek with the aid of awl, cannula or long straight needle.
* Indirect skeletal pin fixation:
This is done by inserting extra oral pins into the mandible and zygomatic bone or into
the mandible and frontal bone on each side and connecting them by bars and
universal joints. Zygomatico-mandibular immobilization used for Le Fort I and II
fractures. Fronto-mandibular method used for fixation and immobilization of Le Fort
III fractures. In both methods the middle third is sandwiched between two stable parts
of the facial skeleton.
Disadvantages:
All are cumbersome, conspicuous, and may lengthen the period of hospitalization.
***
Immobilization within the tissues:
Advantages of this method over the extra oral means:1-No need for special laboratory work for construction of splints.
2- Invisible and less postoperative discomfort.
3-The patient can be discharged from the hospital earlier.
4- Suitable for cerebrally irritated or mentally retarded patient.
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Types of immobilization within the tissues:
1. Direct fixation:
i.Transosseous wiring at the zygomatico–maxillary and zygomatico-frontal
fracture lines. Also used in midline splits of the palate.
ii.Transfixation with Kirschner wires:
By inserting a Kirschner wire through the body of one zygomatic bone into the
other side, so that the wire transfixes the maxillae.
Also by inserting a Kirschner wire through each zygomatic bone and
down into the nasal septum, the two wires transfixing the nasal septum
from opposite side.
These transfixation techniques produce a surprising rigid fixation and at
the completion of treatment the wire can be removed under local anesthesia.
2. Internal wire suspension:
Was firstly introduced by Adams 1942, the underlying principle of which was "to
suspend a mobile part below to firm part above the fracture by means of
subcutaneous wires".
Advantages:
To the patient → comfortable, well-tolerated and inconspicuous
To the surgeon → rapid, accurate, dependable, and technical facilities are not
required.
Disadvantages:
* Is not a rigid fixation
* Oblique upward and backward pull (in lateral frontal & circumzygomatic
suspension) which may lead to subsequent relapse.
The suspension wires are connected to arch bar or circumferential wires around
the lower border of the mandible in the lower canine region, and the fractured
middle third is sandwiched between the mandible and the base of the skull.
The wires are passed through the tissues with the aid of long curved needles, awls
or cannulas.
The suspension achieved by:a-Fronto–mandibular:
The wire passes through the zygomatic process of frontal bone and attached to
mandibular circumferential wire or arch bar→ for immobilization of Le Fort III
fracture.
b-Zygomatico–mandibular:
The wires passes through a small hole drilled in the body of the zygomatic bone
and secured to the mandible, → for immobilization of Le Fort I & II fractures.
c-Circumzygomatico-mandibular:
Wires are passes over the zygomatic arch and secured to mandibular
circumferential wire or arch bar, →for immobilization of Le Fort I & II
fractures.
d-Infra orbital-mandibular:
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Wires pass through a small hole through the lower border of the orbit and
secured to the mandible, → for immobilization of Le Fort I fracture.
e- Pyriform fossa–mandibular:
The wires passes through a hole drilled in the lateral bony wall of the nasal
cavity and secured to the mandible, → for immobilization of Le Fort I fracture.
f-Nasal septum-mandibular:
Wires passes through a hole drilled in the nasal septum and secured to the
mandible, but this fixation is not stable as the other fixations.
None of these suspension techniques produce an absolutely rigid fixation and some
anteroposterior movements of the fragments are possible, but these are controlled by
combining the suspension with MMF (intermaxillary fixation) by interdental eyelet
wiring or arch bars. To facilitate removal of the wires when treatment is completed,
the wires are cut and passed through the holes and back into the mouth.
3. Support:
a. Antral pack:
To support zygomatic bone or orbital blow-out fractures
b. Antral balloons:
Produce uniform pressure and may cause ischemic necrosis of antral mucosa.
c. Silicone elastomer wedge
d. External acrylic splint
****************
Various incisions used for surgical access to the orbito-zygomatic region. (a) Coronal or hemicoronal. (b) Extended preauricular. (c) Lateral brow. (d) Supratarsal fold. (e) Lateral canthus. (f)
Subciliary. (g) Midtarsal. (h) Transconjunctival. (i) Paranasal.
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Surgical approaches to midface and upper face fracture
1. Incisions for surgical exposure of the maxilla
a. Vestibular
b. Palatal
C. Midface degloving procedure
2-Incisions for surgical exposure of the zygomatic complex and orbit)
a. Supero-lateral orbital rim
Lateral eyebrow
Supratarsal fold
Extended preauricular
Coronal and hemi-coronal (scalp flap)
b. Lateral orbital rim, body and arch of zygoma
Lateral canthal (crow's foot crease)
Extended preauricular
Coronal and hemi-coronal (scalp flap)
c. Inferior orbital rim and orbital floor
Midtarsal or orbital rim
Subciliary (lower blepharoplasty')
Transconjunctival (with or without lateral canthotomy)
d. Medial orbital wall
Paranasal (Lynch incision)
Transcaruncular (+/- transconjunctival approach)
3. Incisions for surgical exposure the frontonasal region
a. Local skin incisions (forehead, paranasal or nasal bridge)
b. Coronal (bi-temporal scalp flap)
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Late complications of fractures of the MTFS:
*Complications from the Head Injuries:
1. Postconcusional syndrome → consist of headache, insomnia, diplopia,
intolerance to noise, changes in disposition, intellectual impairment and
intolerance to alcohol.
2. Aerocele or a cerebral abscess within few weeks of the accident
3. Meningitis
4. Epilepsy occasionally develops
*Complications arising from the Fracture:
1. Bony Deformity: this may be cosmetic deformity or may, in addition, be functional
problems.
1) Flattening of the zygomatic complex may be associated with diplopia and
enophthalmos. Restricted mouth opening as a result of depressed healed zygomatic
body fracture or arch that interferes with the coronoid process of the mandible.
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2) Dish-face deformity or over-long faces (flattening of the entire profile) in cases of
inadequately reduced Le Fort fractures. There may be gagging of molar teeth with
anterior open bite.
3) Considerable deformity of the orbit and forehead.
4) Mis-shapen nose, deviation and obstruction of nasal airway due to failure to
correct naso-ethmoidal complex. CSF rhinorrhoea of delayed onset as a result of
extensive damage to the cribriform plate and posterior wall of the frontal sinus.
2. The lacrimal system:
Epiphora and Dacryocystitis resulted from partial or complete obstruction of the
nasolacrimal duct which is a common complication of Le Fort II and nasal complex
fractures.
3. Ophthalmic Complication:
Residual ophthalmic problems arise from 3main causes → deformity of bony orbit,
neurological damage, and damage to the globe of the eye and its soft-tissue adnexae.
1) Diplopia and enophthalmos.
2) Strabismus, ptosis, superior orbital fissure syndrome which consist of
(ophthalmoplegia, ptosis, proptosis and fixed dilated pupils), partial or
complete blindness (orbital apex syndrome) as a result of optic nerve damage.
3) Disturbances of vision and diplopia caused by direct muscle damage.
4. Other Neurological Damage:
1) Anosmia as a result of fracture of cribriform plate of the ethmoid.
2) Anaesthesia or paraesthesia of the cheek, upper lip and maxillary teeth.
5. Non-union:
Is very uncommon. However it can occur in very extensive comminution or actual
bone loss such as may be produced by a missile injury.
Possible components of post-traumatic deformity in inadequately treated severe
midface fractures:
1. Retrusion of upper dentition.
2. Anterior or lateral open bite.
3. Intraoral fistulae into nose or maxillary sinus.
4. Expansion or contraction of the orbital volume.
5. Orbital dystopia.
6. Tethering of ocular muscles.
7. Depression of the nasal bridge.
8. Deviation of the nasal septum.
9. Telecanthus.
10. Obstruction of drainage of the paranasal sinuses, particularly maxillary and
frontal.
11. Contour deficiency of the frontal bone with distortion of the orbital roof.
12. Persistent cerebrospinal rhinorrhea.
13. Varying degrees of soft tissue scarring and mal-alignment.
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