Maxillary and Periorbital Fractures

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Maxillary and Periorbital Fractures

• Michael E. Decherd, MD
• Shawn D. Newlands, MD, PhD
• January 26, 2000

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Overview

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

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Epidemiology

• Males Females -- 41
• Predominantly in 20s or 30s
• Cause
• MVA gt altercation gt fall
• Site
• Nasal gt Zygoma gt other
• In altercations left zygoma fractured more often

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Anatomy
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Anatomy
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Anatomy of the Orbit

• Bones Frontal, Zygomatic,
  Ethmoid, Lacrimal, Maxilla, Palatal, Sphenoid

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Anatomy of the Orbit

• Four-sided pyramid or cone

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Anatomy of the Orbit

• Maximum vertical dimension 1.5 cm behind rim
• Floor is concave and then convex

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Anatomy of the Orbit

• Floor slopes into medial wall
• Optic nerve superomedial to true apex

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Anatomy of Zygoma

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

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Anatomy of the Maxilla

• Paired embryologically
• Functionally acts with palatine bone

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Anatomy of the Maxilla
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Vertical Buttresses

• Resist occlusal load

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Horizontal Buttresses
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Fracture Patterns
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LeFort Fractures

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

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Le Fort I
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Le Fort II
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Le Fort III
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Zygoma Fractures

• Results from lateral forces

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Zygoma Fractures

• Impacted zygoma may mask orbital floor defect

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Orbital Blowout Injury
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Orbital Blowout Injury
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Orbital Blowout Injury

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

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Patient Evaluation
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Physical Exam

• Can be very difficult in traumatized patient
• Dont forget trauma ABCs (ATLS)
• Look for occlusion, trismus, stability,
  asymmetry, extraocular movements, V2 anesthesia,
  stepoffs, bowstring test, lacerations and
  ecchymosis

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Physical Exam

• Midface asymmetry may indicate zygoma fracture

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Physical Exam

• Palpate for midface instability

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Physical Exam -- Ophthalmologic Considerations

• Ophthalmologic Minimums
• Visual acuities (subjective and objective)
• Pupillary function
• Ocular motility
• Anterior chamber for hyphema
• Fundoscopic exam
• If in question ophthalmologic consultation is
  indicated

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Eye Algorithm

• If obtunded, afferent pupillary defect may
  indicate visual loss

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Afferent Pupillary Defect
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Ophthalmologic Exam
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Ophthalmologic Exam

• Hyphema is blood in anterior chamber
• Hx - vision worse supine, clears upright
• Can cause increased IOP

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Ophthalmologic Exam

• Tonometer measures IOP
• Greatly increased IOP causes pulsatile optic disk

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Ophthalmologic Exam

• Retinal detachment requires ophthalmologic
  attention

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Ophthalmologic Exam

• Iridodialysis (torn iris
• Opacified cornea

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Ophthalmologic Exam

• Fluorescsein reveals corneal abrasion
• Dislocated lens

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Ophthalmologic Exam

• Subconjunctival ecchymosis may indicate orbital
  fracture

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Forced Duction Testing
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Physical Exam

• Often edema, swelling, or patients mental status
  make physical exam difficult
• CT is modality of choice -- axial and coronal

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CT areas to evaluate

• Vertical buttresses
• Zygomatic arch
• Orbital walls
• Bony palate
• Mandibular condyles

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Treatment
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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

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Order of Repairs

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

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Order of Repairs
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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

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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

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Zygoma Algorithm
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ORIF of Lateral Antral Wall
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Gillies Reduction
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Post-Gillies Reduction
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Surgical Approaches

• Coronal
• Sublabial
• Transconjunctival
• Lateral Brow

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Coronal Approach
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Coronal Approach
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Coronal Approach

• Supraorbital nerve may be released for more
  exposure

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Hemicoronal Approach
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Lateral Brow Incision

• Avoid shaving brow hairs
• Goal is the ZF suture

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Sublabial Approach

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

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Midface

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

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Vertical Buttress Algorithm
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Midface Disimpaction

• May be necessary to restore facial dimensions
  before fixation

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Palate Fracture

• Wire can be placed posteriorly for stabilization
  before triangular reduction

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ORIF of Midface
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Orbital Floor

• When to explore? (Shumrick study)
• Persistent diplopia with positive forced duction
• Obvious enophthalmos
• Comminuted orbital rim by CT
• gt50 floor disruption by CT
• Combined floor/medial wall defects by CT
• Fracture of zygoma body by CT
• Blow-in fx with exophthalmos by PE or CT

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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

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Orbital Floor

• Dotted line shows anatomic goal of restoration

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Orbital Rim Access

• A -- subciliary
• B -- lower eyelid
• C -- infraorbital

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Transconjunctival Approach
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Transconjunctival Approach

• Conjunctiva is being used to protect globe

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Lateral Canthotomy and Cantholysis

• Allows wider exposure

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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

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Synthetic Mesh
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Orbital Floor Bone Grafting

• Need to support floor full 4 cm

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Orbital Metallic Mesh
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Orbital Roof

• Uncommon due to high levels of force needed to
  fracture orbital roof
• Commonly with intracranial problems

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Orbital Roof Repair

• Repair roof higher on frontal bar

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Cutting Edge Topics

• Bioresorbable plates
• Intraoperative CT
• 3-D CT reconstruction
• Endoscopic assistance

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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

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Case Presentation
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• 30 yo WF
• MVA
• PMH unknown

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