maxillary fractrures final yr

8/3/2019 Maxillary Fractrures Final Yr

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Maxillary andPeriorbital

Fractures

Satish Kumaran.P

Consultant (Head & Neck Services)

AMGH,Bangalore


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Overview

Classic tripod, orbital floor, LeFort fracturesbetter thought of as

orbitozygomaticomaxillary fractures

Precise anatomic reduction is key

Goal is functional

and cosmetic

rehabilitation


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Epidemiology

Males : Females -- 4:1

Predominantly in 20s or 30s

Cause

MVA > altercation > fall

Site

Nasal > Zygoma > other

In altercations left zygoma fractured more

often


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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 1.5cm behind rim

Floor is

concave andthen convex


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Anatomy of Zygoma

Four

superficial

and two deep

articulations

Intersection

of arcs define

malarprominence


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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

occlusalload


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HorizontalButtresses


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Fracture Patterns


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Le Fort II


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Le Fort III


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Orbital Blowout Injury


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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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AfferentPupillary

Defect


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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

detachmentrequires

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 makephysical exam

difficult

CT is modality ofchoice -- 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 ofRepairs


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Zygoma

Ideally done between5-7 days for

resolution of edema

Pre- or intra-

operative steroids

can help with edema

After 10 days

masseter begins toshorten


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Zygoma

Minimally displaced, non comminuted canbe treated with reduction only

Increasing amounts of displacement and

comminution may require plating of lateralantrum, orbital rim, ZF suture, and even the

zygomatic arch

One can wire the ZF suture first to assistwith reduction, then plate it after other areas

stabilized

Z Al ith


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Zygoma Algorithm


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ORIF ofLateral Antral

Wall

Gilli R d i


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Gillies Reduction

P Gilli R d i


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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 bereleased 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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SublabialApproach

Leave mucosato sew to later

Identify and

preserve V2


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Midface

Rigid fixation misnomer with small plates

and thin bones

Semirigid fixation (wire) sometimespreferable

Early function can be achieved with soft

diet only

V ti l B tt Al ith


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Vertical Buttress Algorithm

Midf Di i ti


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Midface Disimpaction

May be necessary to restore facial

dimensions before fixation


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Palate

Fracture

Wire can beplaced posteriorly

for stabilization

before triangularreduction

ORIF of Midface


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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 enophthalmosComminuted orbital rim by CT

>50% floor disruption by CT

Combined floor/medial wall defects by CTFracture 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 RimAccess

A -- subciliary B -- lower eyelid

C -- infraorbital


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Transconjunctival

Approach


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Transconjunctival

Approach

Conjunctiva isbeing used to

protect globe

l h d h l i


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Lateral Canthotomy and Cantholysis

Allows widerexposure


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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


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p

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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maxillary fractrures final yr

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