1. Major Midface Trauma Steven Edlund DDS Lecturer Dept of Oral and Maxillofacial Surgery

2. Goals learn the basics a maxillofacial trauma exam understand how to identify common fractures and their complications basics of treatment fractures laceration management and complications

3. Specific Objectives (test material) understand the importance of always performing an exam in the same sequence know how to examine cranial nerves know what an aferrent pupilary defect is know how to identify a Lefort I,II, or III fracture, a zygoma and zygomatic arch fracture, orbital floor fracture, frontal sinus fracture, and naso-orbital-ethmoidal (NOE) fracture from a physical exam understand the role of radiology (particularly CT) in the evaluation and management of midface trauma define Lefort I, II, and III fractures and understand how they differ from Lefort osteotomies (may be helpful to look up the osteotomies from other lectures) know the areas of fracture in zygoma fractures know what NOE fractures are, and know what nasal fractures are and timing of treatment understand the basics of managing facial fractures (when surgery is appropriate, surgical approaches, goals of treatment) understand the importance of evaluation the facial nerve in pre-auricular lacerations know the order of treatment in laceration repair

4. Trauma Exam Know your ABC’s –A- airway –B- breathing –C- circulation –D- differential diagnosis Patient stability is first and foremost goal

5. Trauma Exam Continued Always proceed in an orderly fashion –Form a pattern and always follow it 1.General overview Facial/cervical symmetry 2.Top down- lacerations, contusions, foreign bodies, palpate for boney steps and mobility Scalp Forehead Orbits/eyes-entrapment, APD Nose-deviation, rhinorrhea Ears-Battles sign, otorhea Midface/ZMC Intraoral-dental occlusion Mandible Neck

6. Radiographic Evaluation Decisions on radiographic evaluation needed are based on findings in clinical exam CT- axial, coronal, and 3D reconstruction

7. Plane films Panoramic –Screening maxilla and mandible PA skull –Skull and mandibular fractures Lateral skull –Nose, sinus, maxilla

8. Plane films continued Waters view –Maxilla, maxillary sinus Submental vertex –Zygomztic arch

9. CT vs plane films CT has become the standard of care where available, for evaluation of midface skeletal trauma Both have strengths and weaknesses, but plane films are rarely ordered today

10. Fractures Basic classification –Greenstick- seen in children; more like a bend than a clean break –Simple- clean break along a single line with minimal disruption of soft tissues; can be displaced or non- displaced. –Compound- broken bone that is displaced through the integument –Cominuted- multiple little pieces; looks like its shatteren

11. Lefort Fractures Defined by Renee LeFort in early 1900’s Dropped skulls and viewed midface fracture patterns Basic patterns were found based on the direction of the blow to the face These fractures can occur in combination Can often be detected with bimanual palpation and manipulation

12. LeFort I Separates the maxilla and pterygoid plates from the skull, in a transverse direction, at the level of the lateral aspect of the piriform rims and the inferior aspect of the maxillary sinuses, including the alveolar process and teeth if present.

13. LeFort II Often referred to as a pyramidal fracture Involves the pterygoid plates Extends superiorly through the sinus to the medial aspect of the orbit. Separates the pterygoid plates, medial wall of the orbit, and nasal bones as a unit

14. LeFort III Craniofacial disjunction Extends from the pterygoid plates through the frontal-zygomatic suture and across the orbit involving the nasal bones. Rare to see as a single unit; other fractures usually involved

15. Zygoma fracture Most commonly fractured bone in the midface “Trimalar” fracture –Frontal-zygomatic suture –Maxillary-zygomatic suture –Temporal zygomatic suture Examine for infraorbital and vestibular ecchymosis, Rowe’s sign; palpate for boney steps on all three sutures. Facial flatness on affected side

16. Zygoma fracture

17. Frontal bone fracture Contour change, ecchymosis, soft to palpation, often associated with nasal and orbital fractures. CT exam necessary to determine if the anterior and/or posterior sinus walls are involved.

18. Frontal sinus repair Eliminate sinus mucosa lining- eliminates mucocele, alows direct visualization of posterior wall Plugging the ducts- eliminates communication to the nasal cavity Fat graft- obliterates empty space Cranialization- done if posterior wall involved

19. Frontal sinus repair

20. Nasal-orbital-ethmoid fracture Involves the nasal bone, orbital process of the ethmoid, and the attacment of the medial canthal ligament. Flatness of the nasal bridge, hypertelorism, widened medial canthal distance Exam-

21. NOE fracture

22. Surgical approaches to the midface Bicoronal flap- frontal sinus, zygoma, NOE –Across the cranium in the hair bearing region, can extend to the preauricular area for better access Gillies- Zygoma, zygomatic arch –Incision in temporal hair bearing region with dissection under the superficial layer of deep temporal facia to the zygoma/arch Keen- intraoral, buccal vestibule approach to zygoma Infraorbital, subcilliary,trans-conjunctival, upper blephararoplasty, lateral brow- approaches to the orbit

23. Bicoronal flap

24. Gillies

25. Orbital approaches

26. Goals in surgical repair Stabilize acute problems- ABC’s, retrobulbar hematoma Prevent infection and long term complications Restore function Restore esthetics

27. Restoring facial structure Restore facial struts- –Vertical- nasomaxillary, zygomatic, pterygomaxillary –Horizontal-frontal, zygomatic, maxillary, mandibular

28. Plates vs wires Use of plating systems has increased the ability to restore stability in the facial struts –Easier to use, less time consuming, can restore stability around contours.

29. Lacerations Important to examine patient when cleaned Investigate lacerations for foreign bodies, damage to underlying structures (fracture, nerve, gland and duct damage) Importance of preauricular lacerations –Nerve damage, arborization, OR

30. Basic principles of laceration management Hemostasis Anesthesia Irrigation Conserve viable tissue, remove necrotic tissue, undermine Layered closure Evert wound margins Support wound closure Antibiotics (topical and PO) and tetanus (booster within last 5 years) Suture removal Home care instructions

32. Case report- putting it all together

36. Questions?