1. Maxillary and Periorbital Fractures
Michael E. Decherd, MD
Shawn D. Newlands, MD, PhD
January 26, 2000

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

3. Epidemiology Males : Females -- 4:1 Predominantly in 20’s or 30’s
Cause
MVA > altercation > fall
Site
Nasal > Zygoma > other
In altercations left zygoma fractured more often

4. Anatomy

5. Anatomy

6. Anatomy of the Orbit
Bones: Frontal, Zygomatic, Ethmoid, Lacrimal, Maxilla, Palatal, Sphenoid

7. Anatomy of the Orbit
Four-sided pyramid or cone

8. Anatomy of the Orbit Maximum vertical dimension 1.5 cm behind rim
Floor is concave and then convex

9. Anatomy of the Orbit Floor slopes into medial wall
Optic nerve superomedial to true apex

10. Anatomy of Zygoma Four superficial and two deep articulations
Intersection of arcs define malar prominence

11. Anatomy of the Maxilla Paired embryologically
Functionally acts with palatine bone

12. Anatomy of the Maxilla

13. Vertical Buttresses
Resist occlusal load

14. Horizontal Buttresses

15. Fracture Patterns

16. LeFort Fractures Experimentally determined weak points
Can be in combinations bilaterally
Useful descriptor
Results from anterior forces

17. Le Fort I

18. Le Fort II

19. Le Fort III

20. Zygoma Fractures
Results from lateral forces

21. Zygoma Fractures
Impacted zygoma may mask orbital floor defect

22. Orbital Blowout Injury

23. Orbital Blowout Injury

24. Orbital Blowout Injury
Usually inferior and/or medial wall
Cone will become more spherical
Leads to enophthalmos, inferior displacement
Muscle entrapment causes diplopia

25. Patient Evaluation

26. Physical Exam Can be very difficult in traumatized patient
Don’t forget trauma ABC’s (ATLS)
Look for occlusion, trismus, stability, asymmetry, extraocular movements, V2 anesthesia, stepoffs, bowstring test, lacerations and ecchymosis

27. Physical Exam
Midface asymmetry may indicate zygoma fracture

28. Physical Exam
Palpate for midface instability

29. 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

30. Eye Algorithm
If obtunded, afferent pupillary defect may indicate visual loss

31. Afferent Pupillary Defect

32. Ophthalmologic Exam

33. Ophthalmologic Exam Hyphema is blood in anterior chamber
Hx - vision worse supine, clears upright
Can cause increased IOP

34. Ophthalmologic Exam Tonometer measures IOP
Greatly increased IOP causes pulsatile optic disk

35. Ophthalmologic Exam
Retinal detachment requires ophthalmologic attention

36. Ophthalmologic Exam
Iridodialysis (torn iris
Opacified cornea

37. Ophthalmologic Exam Fluorescsein reveals corneal abrasion
Dislocated lens

38. Ophthalmologic Exam
Subconjunctival ecchymosis may indicate orbital fracture

39. Forced Duction Testing

40. Physical Exam
Often edema, swelling, or patient’s mental status make physical exam difficult
CT is modality of choice -- axial and coronal

41. CT areas to evaluate Vertical buttresses Zygomatic arch Orbital walls
Bony palate
Mandibular condyles

42. Treatment

43. 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

44. Order of Repairs Work from stable to unstable Use occlusion as guide
Generally stabilize mandible, zygoma and palate before midface before orbit and NOE

45. Order of Repairs

46. 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

47. 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

48. Zygoma Algorithm

49. ORIF of Lateral Antral Wall

50. Gillies Reduction

51. Post-Gillies Reduction

52. Surgical Approaches
Coronal
Sublabial
Transconjunctival
Lateral Brow

53. Coronal Approach

54. Coronal Approach

55. Coronal Approach
Supraorbital nerve may be released for more exposure

56. Hemicoronal Approach

57. Lateral Brow Incision
Avoid shaving brow hairs
Goal is the ZF suture

58. Sublabial Approach Leave mucosa to sew to later
Identify and preserve V2

59. Midface “Rigid” fixation misnomer with small plates and thin bones
Semirigid fixation (wire) sometimes preferable
Early function can be achieved with soft diet only

60. Vertical Buttress Algorithm

61. Midface Disimpaction
May be necessary to restore facial dimensions before fixation

62. Palate Fracture
Wire can be placed posteriorly for stabilization before triangular reduction

63. ORIF of Midface

64. Orbital Floor When to explore? (Shumrick study)
Persistent diplopia with positive forced duction
Obvious enophthalmos
Comminuted orbital rim by CT
>50% 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

65. Orbital Floor Best done 7-10 days Other indications Contraindications
1-2 sq.cm of floor disrupted
Contraindications
hyphema, retinal tear, globe perforation
only seeing eye
medically unstable

66. Orbital Floor
Dotted line shows anatomic goal of restoration

67. Orbital Rim Access
A -- subciliary
B -- lower eyelid
C -- infraorbital

68. Transconjunctival Approach

69. Transconjunctival Approach
Conjunctiva is being used to protect globe

70. Lateral Canthotomy and Cantholysis
Allows wider exposure

71. 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

72. Synthetic Mesh

73. Orbital Floor Bone Grafting
Need to support floor full 4 cm

74. Orbital Metallic Mesh

75. Orbital Roof
Uncommon due to high levels of force needed to fracture orbital roof
Commonly with intracranial problems

77. Orbital Roof Repair
Repair roof higher on frontal bar

78. Cutting Edge Topics Bioresorbable plates Intraoperative CT
3-D CT reconstruction
Endoscopic assistance

79. 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

80. Case Presentation

81. 30 yo WF
MVA
PMH unknown