facial fractures - the upper face
TRANSCRIPT
![Page 1: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/1.jpg)
Facial Fractures:The Upper Face
Doug Humphreys
Division Of Plastic Surgery
Dalhousie University
![Page 2: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/2.jpg)
Outline
• Facial Fracture Basics• Nasal Fractures• Naso-orbital-ethmoidal Fractures• Frontal Sinus Fractures• Zygomatic Fractures• Maxillary Fractures• Orbital Fractures
![Page 3: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/3.jpg)
Emergency Management
A - Airway
B - Breathing
C - Circulation / Hemorrhage
![Page 4: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/4.jpg)
Emergency ManagementHemorrhage
• Local Pressure• Dressings / Packing• Reduction Of Facial
Fractures• Endovascular
Consultation• Ligation Of Vessels
– IMAX
![Page 5: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/5.jpg)
Emergency Management
• C-Spine Injury– 10% C-Spine Fracture
• Head Injury– 50% - Loss of Consciousness– 5% Significant Intracranial Injury
• Ocular Injury– 25% - Some Degree of Injury
![Page 6: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/6.jpg)
Signs And Symptoms
• Pain / Tenderness• Crepitus From Bony Fractures• Hypoesthesia• Paralysis • Malocclusion• Visual Disturbances
• Deformity• Obstructive Respiration• Lacerations• Bleeding• Contusions• Facial Asymmetry
![Page 7: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/7.jpg)
Soft Tissue Injuries
• Tetanus Prophylaxis• Structures
– Facial Nerve– Trigeminal Nerve– Parotid Duct– Lacrimal System
![Page 8: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/8.jpg)
Principles Of Craniomaxillofacial Fracture Managemtent
• Precise anatomic diagnosis• Direct fracture exposure• Reduction / rigid internal fixation
– Mandible fracture stabilization– Reconstruction of horizontal and vertical facial
buttresses
• Primary bone grafting• Periosteal and soft-tissue suspension and repair
![Page 9: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/9.jpg)
Nasal Fractures
![Page 10: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/10.jpg)
Anatomy
• Upper Vault– nasal bones, ethmoid, superior edge of septum,
vomer
• Middle Vault– upper lateral cartilages, most of septum,
maxilla
• Lower Vault– alar cartilages, inferior edge of septum
![Page 11: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/11.jpg)
Physical Exam
• Edema• Crepitus• Periorbital Ecchymosis• Epistaxis• Internal And External Lacerations• Widened Nasal Bridge• Septal Hematoma
![Page 12: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/12.jpg)
ClassificationStranc and Robertson
• Lateral Impact Injuries– Unilateral vs. Bilateral
• Frontal Impact Injuries– Plane I– Plane II– Plane III
![Page 13: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/13.jpg)
TreatmentLateral Impact Injuries
• Early Versus Delayed Treatment• Closed Reduction (Local vs. General)• Drainage of Septal Hematoma• Simple Repositioning of Deviated Nasal
Bones and Septum– Completion Of The Fracture
• Internal Packing and External Splint
![Page 14: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/14.jpg)
TreatmentFrontal Impact Injuries
• Plane I– edema / ecchymosis distal nasal bridge and tip– possible septal distortion– closed reduction with internal support– possibly may require secondary
septorhinoplasty
![Page 15: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/15.jpg)
TreatmentFrontal Impact Injuries
• Plane II– Increased Comminution of the Nasal Pyramid– Bilateral– Possible “Saddling”– Initial Closed reduction– May Require Delayed Septal Reconstruction
With Grafts
![Page 16: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/16.jpg)
TreatmentFrontal Impact Injuries
• Plane III– Extend Into Pyriform Aperture And Medial
Orbital Rim• ie. Naso-Orbital-Ethmoidal Fractures
– Open Reduction an Internal Fixation of Frontal Process of Maxilla
– Transnasal Reduction of Medial Canthal Ligaments
![Page 17: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/17.jpg)
Complications
• Occur In Up To 70%– Deviated Nasal Pyramid– Nasal “Hump”– Septal Deformity With Respiratory Obstruction
![Page 18: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/18.jpg)
Naso-Orbital-Ethmoidal Fractures
![Page 19: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/19.jpg)
Naso-Orbital-Ethmoidal FracturesAnatomy
![Page 20: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/20.jpg)
Naso-Orbital-Ethmoidal FracturesAnatomy
• Interorbital “Space”– two ethmoidal labyrinths– superior and middle turbinates– perpendicular plate of ethmoid
• Medial Orbital Wall– anteriorly - lacrimal bone and lamina papyracea– posteriorly - body of sphenoid
![Page 21: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/21.jpg)
Naso-Orbital-Ethmoidal FracturesAnatomy
• Interorbital space displaced backwards• Medial Canthal Tendon and Lacrimal
Apparatus frequently injured• May extend into:
– cribiform plate and anterior cranial fossa– optic foramen
• Associated Orbit and Midface Fractures Common
![Page 22: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/22.jpg)
Naso-Orbital-Ethmoidal FracturesPhysical Exam
• Flat nose• Swollen medial canthal area• Telecanthus (12-20%)• Lack of skeletal support on palpation of
nose• CSF leak• Positive eyelid traction test
![Page 23: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/23.jpg)
Naso-Orbital-Ethmoidal FracturesTelecanthus
• Normal intercanthal distance (Stranc)– White males: 33-34mm– Females: 32-33mm
• Consider >35mm abnormal (Manson)
![Page 24: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/24.jpg)
Naso-Orbital-Ethmoidal FracturesClassification - Markowitz
• Type I - Single central segment
• Type II - Comminuted central segment
• Type III - Avulsed medial canthal tendon
![Page 25: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/25.jpg)
Naso-Orbital-Ethmoidal FracturesClassification
![Page 26: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/26.jpg)
Naso-Orbital-Ethmoidal Fractures
![Page 27: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/27.jpg)
Naso-Orbital-Ethmoidal FracturesClassification - Gruss
1 Isolated injury to bony naso-orbital region2 Associated fractures of the central maxilla3 Associated LeFort II and III4 Naso-orbital fractures with orbital dystopia5 Naso-orbital fractures with bone loss
![Page 28: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/28.jpg)
Naso-Orbital-Ethmoidal FracturesManagement
• Early open reduction• Four Objectives:
– correct epicanthal folds– restore bony contour– reestablish lacrimal system continuity– medial canthoplasty / canthopexy
![Page 29: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/29.jpg)
Naso-Orbital-Ethmoidal FracturesManagement
• Wide Exposure– coronal incision– “open sky” - transverse across root of nose– vertical midline nasal– subciliary– buccal sulcus– extend existing lacerations
![Page 30: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/30.jpg)
Naso-Orbital-Ethmoidal FracturesManagement
• Correct nasofrontal separation– Elevate nasal bones
• Reduce comminuted nasal bones• Bone graft where needed• Explore septum• Stabilize nasomaxillary buttresses
![Page 31: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/31.jpg)
Naso-Orbital-Ethmoidal FracturesManagement
• Medial Canthus Repair– Transnasal Wires
• Through central fragment• Posterior and Superior to lacrimal apparatus• Three sets of wire
– bone reduction– medial canthus reattachment– reapproximate skin to nasal skeleton
![Page 32: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/32.jpg)
Naso-Orbital-Ethmoidal FracturesLacrimal System Injury
• Incidence– <20%
• Routine exploration not justified• Persistent dacryocystitis of obstruction
– Dacryocystorhinostomy
![Page 33: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/33.jpg)
Naso-Orbital-Ethmoidal FracturesComplications
• Telecanthus– related to inadequate / delayed treatment
• Lacrimal system obstruction / infection• Meningitis
![Page 34: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/34.jpg)
Frontal Sinus Fractures
![Page 35: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/35.jpg)
Frontal SinusEmbryology
• Begin to Develop At 2 Years of Age– Extension of the Ethmoid Air Cells
• Radiographically Evident At ~ 8 Years• Do Not Reach Adult Size Until 12 or Older• 10% - Unilateral Development• 4% - Absent All Together• Drain Into Middle Meatus
![Page 36: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/36.jpg)
Frontal SinusAnatomy
• Usually Small– 5 cm3 in adults
• Anterior Wall Thicker Than Posterior• Close To Other Structures
– Posteriorly (cribiform plate, dura mater, frontal lobes)
– Inferiorly (orbit, nasofrontal duct)
![Page 37: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/37.jpg)
Frontal SinusAnatomy
• Supraorbital / Temporal vs Frontal Sinus
• Anterior Wall and/or Posterior Wall
• Nasofrontal Duct
![Page 38: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/38.jpg)
Frontal SinusDiagnosis
• Signs And Symptoms– Forehead Laceration– CSF Rhinorrhea– Supraorbital Nerve Anesthesia– Depressed Frontal Region– Subconjunctival Ecchymosis
![Page 39: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/39.jpg)
Frontal SinusDiagnosis
• X-Ray– Air Fluid Levels
• CT Scan– Axial and Coronal Images
![Page 40: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/40.jpg)
![Page 41: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/41.jpg)
Frontal SinusTreatment
• Operative Indications– Anterior Table Displacement With Contour
Change– Nasofrontal Duct Involvement– Displaced Posterior Table
![Page 42: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/42.jpg)
Frontal SinusTreatment
• Nasofrontal Duct Injury– Remove Mucosa– Burr Inner Cortex– Occlusion Of Duct– Sinus Obliteration
![Page 43: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/43.jpg)
Frontal SinusTreatment
• Posterior Table–Cranialization
1 Bicoronal Approach2 Preserve Pericranial Flap3 Dural Repair4 Remove Sinus Mucosa5 Obliterate Nasofrontal Duct6 Remove Intersinus Septum And Posterior Wall7 Pericranial Flap To Floor Of Sinus
![Page 44: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/44.jpg)
Frontal SinusComplications
• Early (within 6 months)– Frontal Sinusitis– Meningitis
• Late – Mucocele– Mucopyocele– Brain Abcess– Osteomyelitis
![Page 45: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/45.jpg)
Frontal SinusComplications
• Incidence Of Late Complications– Freihofer
• 71 Fractures• 2 Patients - Meningitis• 1 Patient - Mucopyocele With Osteomyelitis Of
Frontal Bone
![Page 46: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/46.jpg)
Zygomatic Fractures
![Page 47: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/47.jpg)
ZygomaAnatomy
• Tetrapod Structure– Frontal Bone– Temporal Bone– Maxilla– Greater Wing Of Sphenoid
![Page 48: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/48.jpg)
ZygomaAnatomy
![Page 49: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/49.jpg)
ZygomaAnatomy
• Muscular Attachments– Masseter– Temporalis– Zygomaticus– Zygomatic Head of Quadratus Labii Superioris
![Page 50: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/50.jpg)
ZygomaPhysical Exam
• Circumorbital Swelling / Ecchymosis• Subconjunctival Hemorrage• Abnormal Sensation V2 Distribution• Diplopia or Globe Displacement• Increased Facial Width
• Depressed Malar Prominence• Palpable Step Deformities• Unilateral Epistaxis• Hematoma Upper Buccal Sulcus• Trismus Due To Coronoid Process Impingement
![Page 51: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/51.jpg)
ZygomaPhysical Exam
![Page 52: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/52.jpg)
ZygomaPhysical Exam
![Page 53: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/53.jpg)
ZygomaRadiology
• X-Ray– Water’s View Most Useful
• CT Scan– Coronal Cuts For Orbital Anatomy
![Page 54: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/54.jpg)
ZygomaFracture Classification
• Knight1 Undisplaced2 Arch Fractures3 Unrotated Body Fractures4 Medially Rotated Body Fractures5 Laterally Rotated Body Fractures6 Complex Fractures - Additional Fractures Across
Zygoma
![Page 55: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/55.jpg)
ZygomaFracture Classification
• Manson– Low Energy
• minimal displacement• do not require operative reduction
– Middle Energy– High Energy
• often part of panfacial fractures
![Page 56: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/56.jpg)
ZygomaManagement
• Undisplaced– Nonoperative
• Displaced– Isolated Zygomatic Arch - Gilles Elevation– Orbitozygomatic Fractures - Open reduction
and Stabilization
![Page 57: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/57.jpg)
ZygomaManagement
![Page 58: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/58.jpg)
ZygomaGilles Elevation
![Page 59: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/59.jpg)
ZygomaOperative Exposure
![Page 60: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/60.jpg)
ZygomaOperative Exposure
![Page 61: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/61.jpg)
ZygomaOperative Exposure
![Page 62: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/62.jpg)
ZygomaComplications - Early
• Bleeding• Infection• Exacerbation of Sinus Disease• Malfunction of Extraocular Muscles• Blindness
![Page 63: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/63.jpg)
ZygomaComplications - Late
• Nonunion / Malunion• Diplopia (10% initial, 5% permanent)• Persistent V2 Anesthesia (24%)• Orbital Dystopia• Chronic Maxillary Sinusitis (4-7%)
• Scarring• Ectropion• Problems With Mandible Motion• Enophthalmos (3%)• Soft Tissue Descent With Loss of Malar Prominence
![Page 64: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/64.jpg)
Maxillary Fractures
![Page 65: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/65.jpg)
Maxillary FracturesFacial Buttresses
![Page 66: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/66.jpg)
Maxillary FracturesLeFort Fractures
![Page 67: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/67.jpg)
Maxillary FracturesLeFort Fractures
• LeFort I– Transverse Fracture That Separates Maxillary
Alveolus From Midface Skeleton– Runs Above Roots of Maxillary Teeth, Across
Lower Pyriform Aperature, and Severs Pterygoid Process
![Page 68: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/68.jpg)
Maxillary FracturesLeFort Fractures
• Lefort II– “Pyramidal” Fracture of Maxilla– Separates Nasomaxillary Segment from
Zygomatic and Upper Lateral Midface– Fracture Line May Go Above or Beneath
Medial Canthal Ligament Insertion– Lacrimal System May Be Involved
![Page 69: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/69.jpg)
Maxillary FracturesLeFort Fractures
• LeFort III– Craniofacial Dysjunction– Zygomaticofrontal Junction, Traverses Lateral,
Inferior, and Medial Orbit, Separates Frontal Process of Maxilla From Frontal Bones
![Page 70: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/70.jpg)
Maxillary FracturesExamination and Diagnosis
• Epistaxis• Ecchymosis (periorbital, conjunctival, and scleral)• Malocclusion With Anterior Open Bite• Buccal Mucosa Hematoma• Tear in Intraoral Soft Tissues• Elongated, Retruded Appearance
– “Donkey-Like” Facies• CSF Leak in 25-50% of LeFort II and III
![Page 71: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/71.jpg)
Maxillary FracturesRadiology
• X-Rays– Bilateral Maxillary Sinus Opacification– Pterygoid Plate Fracture On Lateral Projection– Fracture Through ZF and Nasofrontal Suture
![Page 72: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/72.jpg)
Maxillary FracturesManagement
• Goals– re-establish midfacial
height and projection– establish occlusal
relationship– maintain integrity of
nose and orbits
![Page 73: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/73.jpg)
Maxillary FracturesManagement
• Intermaxillary Fixation• Open Reduction
– LeFort I• Bilateral Buccal Sulcus Incisions
– LeFort II and III• Coronal and Lower Eyelid Incisions
![Page 74: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/74.jpg)
Maxillary FracturesManagement
• Rigid Internal Fixation– Frontal Bone as a
Guide– Mandibuar Ramus
Dictates Facial Height– Stabilize Vertical
Buttresses– Bone Grafts If
Necessary
![Page 75: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/75.jpg)
Maxillary FracturesComplications
• Early– Extensive Hemorrhage– Airway Obstruction– Infection– CSF Leak – Blindness
![Page 76: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/76.jpg)
Maxillary FracturesComplications
• Late– Palpable Hadware– Non-Union / Malunion– Plate Exposure– Lacrimal System Obstruction– V2 Anesthesia– Devitalized Teeth– Extra-Occular Muscle Imbalance
![Page 77: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/77.jpg)
Maxillary FracturesComplications
• Late– Diplopia– Enophthalmos– Orbital Dystopia– Change In Facial Appearance
• Facial height and width
– Nasal Obstruction– Malocclusion
![Page 78: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/78.jpg)
Maxillary FracturesPalatal Fractures
• 8% of LeFort fractures
• Younger vs. Older– <30 years
• midline fracture
– >30 years• sagittal fractures adjacent to midline or alveolus
![Page 79: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/79.jpg)
Maxillary FracturesPalatal Fractures
• Stabilize before IMF• Open reduction of palatal roof• Pyriform aperture plate to unite maxillary
segements• Dental splints to prevent occlusion
![Page 80: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/80.jpg)
Maxillary FracturesPalatal Fractures
![Page 81: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/81.jpg)
Maxillary FracturesPalatal Fractures
![Page 82: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/82.jpg)
Orbital Fractures
![Page 83: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/83.jpg)
Orbital FracturesAnatomy
• Seven Bones– Frontal– Maxilla– Zygoma– Ethmoid– Lacrimal Bone– Greater and Lesser
Wings of Sphenoid– Palatine
![Page 84: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/84.jpg)
Orbital FracturesAnatomy
![Page 85: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/85.jpg)
Orbital FracturesAnatomy
![Page 86: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/86.jpg)
Orbital FracturesAnatomy
• Inferior Wall– Vulnerable– Thin Maxillary Roof– Infraorbital Canal– Curvature of Floor
• Medial Wall– Thin Lacrimal Bone And Lamina Paprycea of Ethmoid– Medial Canthal Ligament and Lacrimal Sac
![Page 87: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/87.jpg)
Orbital FracturesBlowout Fractures
Pure Blowout - only orbital floor or medial wall injured
Impure Blowout - associated orbital rim fractures
![Page 88: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/88.jpg)
Orbital FracturesBlowout Fractures
![Page 89: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/89.jpg)
Orbital FracturesPhysical Exam
• Diplopia• Enophthalmos• Inferior Displacement Palpebral Fissure• Anesthesia of Infraorbital Nerve• Orbital Emphysema
![Page 90: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/90.jpg)
Orbital FracturesPhysical Exam
• Diplopia– Commonly on Upward Gaze– Primary (Central Gaze) or Secondary (Perpheral)– Mechanical (incarceration of infraorbital tissue) or
Nonmechanical (paresis)– Forced Duction Test
![Page 91: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/91.jpg)
Orbital FracturesForced Duction Test
![Page 92: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/92.jpg)
Orbital FracturesPhysical Exam
• Enophthalmos– Inferior and Posterior Displacement of Globe
and Intraorbital Soft Tissue– Etiology
• Enlargement of the Bony Orbital Cavity• Escape of Orbital Fat or Fat Necrosis• Muscle Entrapment in Fracture Line• Soft Tissue Scarring and Contracture
![Page 93: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/93.jpg)
Orbital FracturesEnophthalmos
![Page 94: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/94.jpg)
Orbital Fractures
![Page 95: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/95.jpg)
Orbital FracturesPhysical Exam
• No Diplopia + No Enophthalmos?Significant Fracture
• Diplopia + No EnophthalmosIncarceration Only
• No Diplopia + EnophthalmosVolume Discrepancy Only
• Diplopia + EnophthalmosIncarceration + Volume Discrepancy
![Page 96: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/96.jpg)
Orbital FracturesIndications For Exploration
• Symptomatic Diplopia With Positive Forced Duction Test
• Xray evidence of Extraocular Muscle Entrapment• Early Enophthalmos (>3mm)• Large Orbital Floor Defect• Abnormally Low Vertical Globe Level• Associated Orbital Rim or Other Craniofacial Fractures
![Page 97: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/97.jpg)
Orbital FracturesIncisions
![Page 98: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/98.jpg)
Orbital FracturesManagement
• Grafts– Autologous Bone– Cartilage– Fascia lata
• Alloplastic Implants– Teflon– Silastic– Titanium
![Page 99: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/99.jpg)
Orbital FracturesComplications
• Infection• Implant problems• Persistent Diplopia (2-50%)• Persistent Enophthalmos (15-22%)• Ectropion (1%)• Blindness
![Page 100: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/100.jpg)
Orbital FracturesComplications
• Superior Orbital Fissure Syndrome– extension of fracture into SOF– ophthalmoplegia with injury to III, IV or VI– anesthesia in V1 plus loss of corneal reflex– ptosis and proptosis– parasympathetic block
• fixed, dilated pupil
![Page 101: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/101.jpg)
Orbital FracturesComplications
• Orbital Apex Syndrome– same as superior orbital fissure syndrome– plus blindness
![Page 102: Facial Fractures - The Upper Face](https://reader033.vdocuments.mx/reader033/viewer/2022061106/544969e5b1af9f52038b468a/html5/thumbnails/102.jpg)
The End