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- 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
- 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
- 24. Orbital Blowout Injury • Usually inferior and/or medial wall • Cone will become more spherical • Leads to enophthalmos, inferior displacement • Muscle entrapment causes diplopia
- 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
- 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
- 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
- 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
- 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
- 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
- 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 – 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
- 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
- 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
- 81. • 30 yo WF • MVA • PMH unknown