Download - Maxillofacial trauma 2

Transcript

Maxillofacial Trauma

[Type text] Page 1

Maxillofacial trauma

Dr. Firas kassab

Maxillofacial Trauma

Dr. Firas Kassab Page 2

Outline

Scope, problems, priorities

Diagnosis

Types of Fractures

Bone Anatomy

Bone Fracture

Bone Healing

Nasal Bone Fractures

Mandibular Fractures

Zygomatic and Orbital Fractures

Maxillary Fractures

Nasoethmoidal fractures

Maxillofacial Trauma

Dr. Firas Kassab Page 3

OBJECTIVES

Identify the causes of CMF injuries

Discuss the initial management of CMF trauma

Discuss the bone and fracture biology

Discuss the principles of internal fixation

Discuss the different CMF fractures

INTRODUCTION

Maxillofacial fractures usually occur as the result of massive facial trauma. There is

extensive facial swelling, midface mobility of the underlying bone on palpation,

malocclusion of the teeth with anterior open bite, and possibly leakage of

cerebrospinal fluid (cerebrospinal rhinorrhea) secondary to fracture of the cribriform

plate of the ethmoid bone. Double vision (diplopia) may be present, owing to orbital

wall damage.

Involvement of the infraorbital nerve with anesthesia or paresthesia of the skin of

the cheek and upper gum may occur in fractures of the body of the maxilla. Nose

bleeding may also occur in maxillary fractures. Blood enters the maxillary air sinus

and then leaks into the nasal cavity.

SCOPE

For this morning we’re going to talk about maxillofacial trauma. The principles will be the

same probably if you have trauma of the bones in other parts of the body. And of course if

you have trauma you will be learning the same principles as of dealing with other traumas

of the body. We’re going to deal more with the trauma of the facial skeleton which

includes:

Maxillofacial Trauma

Dr. Firas Kassab Page 4

Mandible

Zygoma

Orbital

Maxilla

Nasal bone

Naso-orbitoethmoidal

Craniofacial defects

CAUSES

Assault

Motor Vehicle Accidents

Sports injuries

Falls especially among elderly patients

Work-related

Pathological fractures

Automobile accidents, fisticuffs, and falls are common causes of facial fractures.

Fortunately, the upper part of the skull is developed from membrane (whereas the

remainder is developed from cartilage); therefore, this part of the skull in children is

relatively flexible and can absorb considerable force without resulting in a fracture.

PROBLEMS

Airway

o Swelling of the soft tissues

o Hemorrhage

o Fractures

Maxillofacial Trauma

Dr. Firas Kassab Page 5

You will be asked to handle the airway. You will have a lot of swelling, hemorrhage

and fractures which will obstruct the airway such that when confronted with this

situation, you come up with the ABCs.(see below in first aid)

Shock

Hypovolemia

Pain

Consciousness- associated CNS injuries

Cervical vertebral injuries

PRIORITIES :

For the ABCs, number one is airway then breathing and circulation .It is the same for

other types of trauma. If the patient is stable with good airway, breathing and

circulation, then you can address the other problems/injuries.

First Aid

Airway

Breathing

Circulation

Resuscitation

Exclusion of other injuries

DIAGNOSIS :

diagnose your patients with trauma.

History

For craniomaxillary fractures, this will probably be one of the shortest histories you

will get. Why? Because you’re just going to ask for the following:

Nature of injury (NOI)

Maxillofacial Trauma

Dr. Firas Kassab Page 6

Place of injury (POI)

Date of injury (DOI)

Time of injury (TOI)

Why do you need these things? Because probably this is a medico-legal case. Aside

from the four, you just get:

Direction of the force

Kind of force applied to the patient

Examination

Then you can now do your PE which focuses on inspection, palpation and

auscultation

Inspection

Palpation

Auscultation

When you do your physical exam, you also look for these:

Deformity- changes in the patient’s facial shape

Bleeding/hematoma

Trismus- inability of the patient to open his mouth; If you’re able to open your

mouth for 2 cms, you are normal. Anything below that would be abnormal.

Tenderness- if you palpate and there is pain

Dental Problems – fractures of the tooth, loosening of the teeth

Movement of the Face – sometimes you have patients with flattening of the cheeks,

and if you hold on to the cheeks and try to move them, they will have some

crepitation or movement if the face, that is a sign of a fracture

Ophthalmologic findings especially enophthalmos and exophthalmos

Enophthalmos- eye goes inward

Exophthalmos- eye/contents of orbit move out of the orbit

Hypertelorism- both eyes are beyond the normal horizontal plane; one eye moves

laterally

Signs of fractures of the facial bones include deformity, ocular displacement, or

abnormal movement accompanied by crepitation and malocclusion of the teeth.

Maxillofacial Trauma

Dr. Firas Kassab Page 7

Anesthesia or paresthesia of the facial skin will follow fracture of bones through

which branches of the trigeminal nerve pass to the skin.

Then you might have to do several or special tests.

Types Of Fractures

What are types of fractures? This is just an overview.

Complete- total loss of continuity; Imagine this microphone, if you have cortex on

top, medulla on middle and cortex again on the bottom. In a complete fracture, you

have fracture on all these 3. But for example, you only have fracture on the cortex

and medulla but not on the other cortex, then that is an incomplete fracture.

Incomplete- with continuity

Simple- consists of 2 pieces or fragments, overlying mucosa and skin are intact

Comminuted- consists of 3 or more fragments

Compound- with an open wound

Complex- involving a long fracture line; it’s like when you break it on the proximal

side and moves along the longitudinal plane up to the other side.

Complicated- involves both the maxilla and mandible (Panfacial Fracture); so here

you have two areas involved.

Greenstick- involves one cortical plate; here, you are mainly talking about pediatric

fractures.

Maxillofacial Trauma

Dr. Firas Kassab Page 8

FACIAL BONE

Your facial bone is a

Dynamic tissue- it constantly undergoes resorption and remodelling

Structure determined by

Material properties

Mechanical and metabolic function

The shape of the head is spherical and it is made as such that when the skull is hit,

it is hit tangentially.

ANATOMY

Architecture of bone

Maxillofacial Trauma

Dr. Firas Kassab Page 9

Cortex- compact osseous tissue: hard part of the bone

Medulla- cancellous or spongy bone

Bone Cells

Osteoblasts- associated with formation of osseous tissue; appears on surface of

bone undergoing development

Osteocytes- osteoblasts which has become embedded within the bone matrix; are

the ones that produce bone materials

Osteoclast- multinucleated giant cell; derived from the stromal cells of the bone

marrow; are the ones regulating formation of the bone. If there is more bone in one

area, the osteoclast will try to resorb that bone

By the action of all these 3 bone cells, your bone becomes dynamic. By dynamic, we

mean that once it becomes fractured, it will heal by itself.

Other Bone Structures

Haversian Canals - cylindrical, branching and anastomosing canals; Contain blood

vessels with small amount of connective tissues

Volkmann’s Canals- connect Haversian canals with each other, and external surface

of the bone and bone marrow cavity

Periosteum at the edge

Bone Marrow would be in the middle which is a part of your cancellous bone (not

compact with a lot of cells embedded in them)

Endosteum- thin connective tissue layer lining the walls of the bone cavity, filled with

bone marrow

Haversian System (OSTEON)

Unit structure of compact bone

Irregular cylindrical, branching and

anastomosing structure with thick

walls and a narrow lumen

(Haversian Canal) and your

haversian canal forms your haversian system.

Surrounded by concentrically arranged lamella of bone

Directed/move along the long axis of the bone

Maxillofacial Trauma

Dr. Firas Kassab Page 10

This is an example of your haversian system. In the middle, it moves longitudinally.

BONE FRACTURE

Now if you have a fracture, imagine a long bone with a discontinuity along that bone and

the force is transmitted along that bone and a break in that bone happens, then there’s

fracture already.

Continuity is destroyed and normal force transmission is absent

Leads to rupture of blood vessels with hematoma formation

Localized avascularity of the fragment ends

Thrombosis of vessels within haversian and Volkmann’s canals

No treatment until function is impaired

Imagine your mandible, if you have a fracture in your mandible but the patient is still

able to chew and chewing is the major function of your mandible then no treatment

is necessary.

Main aim: Re-establish function

If you are asked in the exam what is the treatment of choice when a mandible is

fractured but the patient is still able to chew, probably the answer is to just leave it as is

because it can still function anyway.

Bone Healing

Maxillofacial Trauma

Dr. Firas Kassab Page 11

The fracture won’t stay as it is, of course you’ll have bone healing. And you have

two types of bone healing:

Indirect bone-healing

Aka: secondary osseous and soft tissue healing

Occurs via pluripotential cells: bone, periosteum and soft tissue

Direct Bone healing

Aka: Primary osseous healing

Two types:

Contact healing

Gap healing

Indirect Bone-Healing :

Occurs via pluripotential cells

bone, periosteum and soft tissue

Results from mechanical instability of the fracture

leading to resorption of fracture ends

Callus formation (which happens later in the process)

This is one statement that we need to understand. You have indirect bone healing

because there Is mechanical instability of the fracture. If you have a fracture in the

radius and the patient still moves his arm/elbow and there is instability, even if you

splint it or if you put a cast, the arm will still be able to move. Meaning there is still

mechanical instability. And because the fracture ends move against each other, this

will lead to resorption of fracture ends. Healing will still take place and formation of

callus happens.

stages of callus formation

o Deposition of granulation tissue

Hematoma formation

Periosteum stripped away from bone surface

Migration of Neutrophils and Macrophages into hematoma- this is because of the

open blood vessels

Maxillofacial Trauma

Dr. Firas Kassab Page 12

Phagocytosis of hematoma and necrotic debris

Ingrowth of capillaries and fibroblasts

o Osteoid synthesis.

Transformation of granulation tissue into interfragmentary connective tissue

The next stage is the transformation of that granulation tissue into interfragmentary

connective tissue. You have development of new osteoprogenitor cells, production of

osteoid.

Osteoid synthesis proceeds to produce a connective tissue between the fracture

ends.

The newly formed osteoid will be arranged in a haphazard manner in a woven-bone

pattern.

o Remodelling into fibrocartilage

Osteoid is layed in a haphazard manner producing woven bone pattern. This

becomes your fibrocartilage. And this becomes your callus. There are two:

External Callus- which is found on the side; outside the axis of the bone

Internal Callus—which is found in the center; in between your bone fragments

o Mineralization

Once bone ends are closely apposed, ossification between fracture ends occurs.

There is changing into bone already.

3rd week: callus well established but mechanically weak (woven bone)

o Haversian remodelling

Your haversian system/osteons will move from one fracture segment into the other.

You should understand that your osteons are the basic structure of your bone. And

they will have to move from one fracture end to another for that bone to be fully

healed. This happens within the next few months

Osteoclastic erosion and organized osteoblastic osteoid synthesis takes place

Replace woven bone with compact, organized lamellar bone

In the next few months, the Haversian system (osteons) will replace your woven

bone. It will later become a compact, lamellized bone

This transformation happens after 6 weeks. It will remodel

Maxillofacial Trauma

Dr. Firas Kassab Page 13

Direct Bone Healing

Aka Primary osseous healing

It happens only if you have perfect anatomic repositioning of fractured segments

back to their normal position and stable fixation

Lack of callus formation: stage 1,2,3,4 will not undergo callus formation

Disappearance of the fracture lines: happens immediately after direct bone healing

So how do we achieve that?

Synergism between contact and gap healing

Close apposition of segments provides mechanical stability

Osteons are in direct contact

Allowing transverse bridging of the haversian system with no intervening callus

formation

2 types

Contact healing

Gap healing

Direct or primary healing only occurs when there is no motion across the fracture line.

Maxillofacial Trauma

Dr. Firas Kassab Page 14

Contact Healing

Seen after stable anatomic repositioning

Contact healing only happens when there is perfect anatomic repositioning of your fracture

ends and stable fixation. There is no callus formation. Immediately after direct bone

healing, there is disappearance of suture lines. This happens when there is a synergism

between contact healing and gap healing. There should be close apposition of segments

and there should be mechanical stability. Your osteons/haversian systems are in direct

contact allowing transverse bridging of your haversian system with no callus formation.

o Perfect interfragmentary contact

o No possibility for any cellular or vascular ingrowth

o Cutting cones (haversian system) are able to cross this interface from one

fragment to the other by remodelling the haversion canal..

o Only seen directly beneath the mini plate.

Gap Healing

Takes place in gaps with a width greater than 200 um

Osteoblasts deposit osteoid on the fragment ends. This space is very small such that the

cones will be able to traverse without any problem. Seen on the inner side of the

mandible

Seen on the inner side of the mandible

Undergoes several stages as well

Stages of Haversian remodelling

o Gaps are filled with transversely-oriented lamellar bone completed within 4-6

weeks

o Replacement by axially-oriented osteons. In 10 weeks, you have newly re-

constructed cortical bone.

Contact healing and gap healing are seen especially when you put your implants.

Maxillofacial Trauma

Dr. Firas Kassab Page 15

It appears that the bridging of a bony gap by bone can only occur in the absence of

motion across that gap. The more motion is present, the greater the amount of

callus will be needed to stabilize the fragments so that healing by bone can

eventually occur. Conversely, the more stable a repair is (and thus less motion is

present), the less callus will form and the greater the likelihood that bone will

directly bridge fracture and heal the injury. It of course follows that when callus is

unable to stabilize a fracture, bone will never form; the fracture remains bridged by

fibrous tissue, thus forming a fibrous union (alternately known as a ―non-union,‖ a

―fibrous non-union,‖ or a ―pseudoarthrosis.‖ To accomplish a stable repair, it is

necessary to understand the biomechanics of the facial skeleton, and even more

important, it is critical to use this understanding when applying fixation. Otherwise,

motion will tend to occur when the repair is loaded in function, and complications

are then more likely to occur.

Delayed Healing

Factors detrimental to bone healing

Poor blood supply

Poor general nutritional status

Poor apposition in the fracture ends

Foreign bodies in the fractures

Infection

Corticosteroid intake

Successful Healing

Minimum Requirements For Successful Bone Healing

Biological Requirement

o You need functioning cells that participate in the various phases of the

healing process.

Maxillofacial Trauma

Dr. Firas Kassab Page 16

These functioning cells should be able to reach the site of repair

Adequate nutritional supply is needed

Good blood supply is a primary prerequisite

Mechanical Requirement

o Immobilization- You need to immobilize the fractures for that to heal.

o Interfragmentary Motion

Tissues are continuously torn and squeezed.

Tolerance

o Connective tissue 100%

o Cartilage 10-15%

o Bone 2%

Let us look at the different tissues in the body. If you have a break in your skin, that

skin will still heal even if you move the skin. The skin, or any other connective

tissue, will be able to tolerate that 100%. If there is movement in your cartilage,

only 10-15 % will tolerate that and will heal. If there is movement in your bone, the

bone will not be able to tolerate that and will not heal. Such that, if there is still

movement in your bone, you will not achieve bone healing.

OPERATIVE TREATMENT OF FRACTURES

Aim:

o Rapid recovery of form and function

o Relief of pain

o Avoidance of late complications

o Short hospitalization time

o Early return to work

Optimal, not maximal, stability is required.

Maxillofacial Trauma

Dr. Firas Kassab Page 17

Nasal Bone Fractures

Nasal Bone Anatomy

Anatomy: The two nasal bones form the

bridge of the nose. Their lower borders,

with the maxillae, make the anterior nasal

aperture. The nasal cavity is divided into

two by the bony nasal septum, which is

largely formed by the vomer. The superior

and middle conchae are shelves of bone

that project into the nasal cavity from the

ethmoid on each side; the inferior conchae

are separate bones.

The nasal bone is the most frequently traumatized bone. It is very prominent in

the face, and would probably be the first to be injured when there is trauma

o It is most predisposed to fractures is at the junction of the thin, broad

and lower portions of the nasal bone

o It is intimately related to the nasal septum

o Nasal septal fracture or dislocation may co-exist with nasal bone fractures.

Fractures of the nasal bones, because of the prominence of the nose, are the most

common facial fractures. Because the bones are

lined with mucoperiosteum, the fracture is

considered open; the overlying skin may also be

lacerated. Although most are simple fractures and

are reduced under local anesthesia, some are

associated with severe injuries to the nasal septum

and require careful treatment under general

anesthesia.

Signs

Maxillofacial Trauma

Dr. Firas Kassab Page 18

Stepdown deformity- If you touch nasal bridge, you feel that there is a sudden

downward deformity.

Nasal Fracture Stepdown Deformity

o Epistaxis

o Nasal obstruction secondary to fracture

o Septal deviation

o Mucus and blood clots

o Crepitations (sound heard or felt during palpation of the nose)

o All external manifestations may be masked by severe soft tissue edema

especially in a patient seen a few hours after injury. Especially if there is

swelling.

Management

The most appropriate treatment for a nasal injury is the least invasive one that will

fully correct the deformity without long-term complications or relapse. Non-displaced

fractures that do not result in any defects are best managed with observation alone .

1. Closed reduction

Indications:

Fractures which are non-comminuted

Mild to moderate

Recent fractures

Use Ashe forceps/hemostat

Should be done within 7-10 days in adults,

2-4 days in children

Closed nasal reduction is best for simple injuries such as an isolated, unilateral nasal

bone fracture with medial displacement.

One of the most important reasons for failure of closed nasal reduction is concurrent

nasal septal fracture.

Maxillofacial Trauma

Dr. Firas Kassab Page 19

Closed reduction We just get the fractured bone and elevate that. Pull that upward

and that will actually replace the bone back to its original anatomic position. Most of the

time, we put the patient into general anesthesia because it is painful. Some of the

indigent patients would prefer to have this done under local anesthesia. We introduce

anesthetics in the infraorbital rim, inside the nose and the lip.

Instruments needed for reduction of simple nasal fractures

o fiber optic headlight

o intranasal specula

o scalpel knife

o Ashe forceps - for displaced septum

o Walsham forceps - for impacted nasal bones

o nasal splint

o tape and bandage

2. Open reduction

For more severe trauma (e.g. bilateral, depressed fracture with septal and

cartilaginous involvement), an open approach is the best means of producing a

satisfactory outcome.

Disadvantages of using open reduction for majority of nasal fractures are the higher

treatment costs and the increased risk of surgical complications.

Open reduction should be limited to those cases in which it would yield significantly

better results than more conservative measures to justify the drawbacks. Indications

include:

o Bilateral fractures with dislocation of the nasal dorsum and significant septal

pathologic changes

o Bilateral fractures with major dislocation with or without significant septal

pathologic states

o Infrastructure of the nasal dorsum

o Fractures of the cartilaginous pyramid without dislocation of the upper lateral

cartilages.

3. Alternative Reduction Methods

Maxillofacial Trauma

Dr. Firas Kassab Page 20

External compression plating

Percutaneous wire fixation

Complications of Nasal Fractures

o Subperichondrial fibrosis with partial obstruction

o Synechiae

o Obstruction of the nasal vestibule

o Osteitis

o Malunion of the nasal fractures with deviation

MANDIBULAR FRACTURES

Anatomy

The mandible (lower jaw) is a U-shaped structure with several areas:

Symphysis – found in the middle in between middle incisors. Any fracture in this area is

called a symphyseal fracture.

Parasymphysis – Between lateral incisors and canine, make an imaginary line going

down to the inferior border of the mandible. Any fracture there is considered

parasymphyseal.

Body – from lateral incisors to 3rd molar; between angle and parasymphysis.

Angle - junction of ramus and body of mandible.

Maxillofacial Trauma

Dr. Firas Kassab Page 21

Alveolar area – tooth bearing portion

Condyle – attached to glenoid fossa

Coronoid process

Ramus- From the angle going up

The mandible or lower jaw is the largest and strongest bone of the face, and it

articulates with the skull at the temporomandibular joint. The mandible consists of a

horseshoe-shaped body and a pair of rami. The body of the mandible meets the ramus

on each side at the angle of the mandible.

Traumatic impact is transmitted around the ring, causing a single fracture or multiple

fractures of the mandible, often far removed from the point of impact.

Signs And Symptoms

Malocclusion patient is unable to close the mouth and appose the teeth normally.

When the patient has an abnormal bite.

Hyposthesia of lower lip and gingiva – due to damaged inferior alveolar nerve

Sublingual hematoma

Mucosal disruption

Pain and tenderness over fracture

Tooth loosening

Trismus- inability of the mouth to open more than 2 cm

Facial deformation/Swelling

Investigation Of Mandibular Fractures

Imaging Studies

o Radiology

Panorex (Panoramic

X-ray)

Mandible series

(frontal, lateral,

oblique

Study models

Maxillofacial Trauma

Dr. Firas Kassab Page 22

Photography- compare it with pretrauma pictures of the patient

For the mandible, most surgeons prefer plain x-rays, or more commonly panoramic

topography, and often both as the imaging techniques of choice.

Management Of Mandibular Fractures :

In the dentate mandible, the first priority is reestablishment of the proper occlusal

relationship of teeth.

As discussed earlier, we require immobilization for the fractures to heal. You may

either use splinting or compression.

Splinting

o Application of a more or less stiff device to the fractured bone.

o But this does not completely abolish fracture mobility.

2 types of Splinting:

External splinting

Reduce fractures without surgical intervention

May be fixed to teeth, or applied to mucosal or skin covered surfaces

In your long bone, the splint will be the cast. You apply that to your skin. Even with

the cast, the patient will still be able to move his hand and move the fracture ends.

So it does not completely abolish fracture mobility

Internal Splinting

o The stabilizing devices are fixed directly to the fracture segments

o Some interfragmentary motion

o Interfragmentary wire sutures and flexible plates. Even if you put these

directly to the bone, you will still have some interfragmentary motion

Compression/ Internal fixation

Excludes interfragmentary motion

Consists of pressing together 2 surfaces, either bone to bone or implant to bone. You

compress the bone together. This is achieved only by using your implants.

Biological advantages:

Maxillofacial Trauma

Dr. Firas Kassab Page 23

When you compress, there is undisturbed healing because it guarantees absolute

stability even under conditions of function. If you compress the mandible, even if the

patient uses his mandible, the fractured ends will not move against each other.

Immobilization is the key to healing.

Allows load sharing between the bone and the implant.

Provides maximum strength with minimum fixation material.

A load-sharing repair depends on the integrity of the

underlying bone, and the fixation appliance is positioned so

as to ensure that the forces in function are borne by bone

itself. A small plate across the tension zone will ensure the

solid bone is pushed together in function so that it shares

the load with the fixation appliance. Miniplate fixation,

compression plate fixation, and lag screw fixation all

represent load-sharing repairs and require adequate bone

contact to succeed.

Closed Reduction

Barton’s Bandage – an internal splint

Maxillofacial Trauma

Dr. Firas Kassab Page 24

Intermaxillary fixation (IMF) for 6 weeks

– There are rubber bands applied to the

teeth. The patient will be unable to move the

mouth. There will still be some

interfragmentary motion.

Intermaxillary Fixation. This is another

example of an internal splint. If you have

Barton’s bandage of Intermaxillary fixation,

the fractures will heal but it will take 6 weeks

before it heals. He will not be able to eat for 6 weeks and so he needs an NGT. Imagine

how discomforting this is.

Eyelet wires

Arch bars – A good arch bar will re-establish proper occlusal relationship of teeth

and will also provide a good tension band across the alveolar portion of the fracture.

NGT

Liquid feedings

Open Reduction

o Direct visual access to the fracture. You open up the skin or the mucosa to

visualize the fracture.

o Anatomical reduction of bone fragments

o Fixation

Wire osteosynthesis The wires are pliable

.They will not be able to totally abolish fracture

mobility. Although they are applied directly to

the bone, this is still considered as internal

splint. Not compression.

Interosseous Wiring :

Maxillofacial Trauma

Dr. Firas Kassab Page 25

Screw Fixation- compression/ internal fixation

Plate Fixation- compression/ internal fixation

Miniplates

Reconstruction Plates

Maxillofacial Trauma

Dr. Firas Kassab Page 26

Plates and Screws. It is only if you have internal fixation, that you can totally abolish

fracture mobility and go through direct bone healing, and achieve healing faster compared

to indirect bone healing.

Post Operative Care

Airway

o Avoidance of IMF in post op period

o Nasopharyngeal airway

o Tracheostomy

Analgesia

Antibiotics

Fluids and diet

Maxillofacial Trauma

Dr. Firas Kassab Page 27

ZYGOMATIC FRACTURES AND ORBITAL FRACTURES

Anatomy

The zygomatic bones (cheek bones, malar bones), forming the prominences of the

cheeks, lie on the inferolateral sides of the orbits and rest on the maxillae.

The anterolateral rims, walls, floor, and much of the infraorbital margins of the orbits

are formed by these quadrilateral

bones.

The zygomatic bones articulate with

the frontal, sphenoid, and temporal

bones and the maxillae. Inferior to

the nasal bones is the pear-shaped

piriform aperture, the anterior nasal

opening in the cranium

The zygomatic arch is formed by the

union of the temporal process of the

zygomatic bone and the zygomatic

process of the temporal bone

Bones of the Orbit

Frontal

Greater wing of sphenoid

Lesser wing of sphenoid

Ethmoid

Lacrimal

Zygomatic

Superior Orbital Fissure

Located between the greater and lesser wings, it communicates with the orbit and

transmits the ophthalmic veins and nerves (CN III, CN IV, CN V1, CN VI, and sympathetic

fibers) entering the orbit.

Contains:

Maxillofacial Trauma

Dr. Firas Kassab Page 28

Superior and inferior division of oculomotor n.

Trochlear n.

ophthalmic n. - lacrimal and nasociliary branches

superior and inferior divisions of ophthalmic rim (vein)

sympathetic fibers of cavernous sinus

Inferior Orbital Fissure

Contains:

zygomatic branch of the maxillary nerve

ascending branch of pterygopalatine ganglion

inferior orbital fissure separates the mandible from sphenoids

Signs of Zygomatic/Orbital Fracture:

Black eye

Lateral subconjuctival hemorrhage

Swollen or flattened cheek

Diplopia/Restricted Eye Movements

Hypoesthesia of the cheek

Trismus

Proptosis

Enophthalmos: imagine your orbit as a glass of water, and you put a ping pong ball

on top and if you break the glass, the ping pong ball will actually go downward and

that is what we call enophthalmos

Tripod Fracture

involves the zygomatico-frontal, zygomatico-maxillary and zygomatico-

temporal suture lines (due to inherent weakness)

tripod fractures they usually begin with pre-injury weakness of the facial bone and

foramen

Maxillofacial Trauma

Dr. Firas Kassab Page 29

Principles Of Treatment

Restore the patient to pre-injury facial configuration

Prevent cosmetic deformity

Prevent delayed visual disturbances

Repair within 5-7 days allows edema to decrease and avoids shortening of

masseter with lateral and inferior rotation

Treatment

1- Closed Reduction

Gillies Temporal Approach

incise at hairline (temporal area), insert

a metal rod going towards maxilla and

pull out zygoma

Your tripod fracture will cause a portion

of the cheek to move either medially or

laterally. If t move medially, we make a small incision by the hairline get a piece of

metal rod, insert that rod, then push the cheek out

Maxillofacial Trauma

Dr. Firas Kassab Page 30

Cheek Hook

get a hook, pull out the bone so it will return to the normal configuration

Transbuccal hook approach

make a small incision inside oral cavity, insert the hook and pull zygoma out

2- Open Reduction

Perform a coronal incision and expose the fracture and then plate the fracture

Frontozygomatic

Inferior orbital

Oral

Bitemporal

Fixation

Miniplate osteosynthesis

1 mm thin plate

Microplate osteosynthesis

½ mm thin plate

Resorbable materials

BLOWOUT FRACTURES

Compression of orbital contents deforms the orbital floor, walls, and roof.

Open door or trap door deformity

Your globe will move inward, X-rays will show a TEARDROP SHAPE SIGN

Maxillofacial Trauma

Dr. Firas Kassab Page 31

Types Of Blowout Fracture

Pure Blowout Fracture No involvement of the orbital rim, only the floor is involved

With entrapment of EOMs

Must be differentiated from simple orbital floor fractures

Impure Blowout Fracture

Orbital rim involved

Often associated with malar, NOE, Le Fort and Frontal Sinus fractures

Signs And Symptoms

Diplopia

Restricted eye movements

Enophthalmos

Superior Orbital Fissure Syndrome

Symptoms of Superior Orbital Fissure Syndrome

Diplopia

Paralysis of EOMs

Exopthalmos

Ptosis

Blindness (apex)

Maxillofacial Trauma

Dr. Firas Kassab Page 32

Usual mechanism is a blow to the eye whereby the diameter of the causative force is

usually bigger than the diameter of the orbit

This forces the orbit downward since the orbital space is limited posteriorly and the

orbital floor has least resistance.

Lamina papyracea: thinnest portion of the

orbital bone

Usually the orbit herniates through the

fracture

Presence of continuity between the sinus

and the orbit

Orbital emphysema: air in radiograph

Tear drop sign: represents the herniated orbital contents, periorbital fat and inferior

rectus muscle

CT scan provides better evaluation since it can detect the fracture and hemorrhage

in different planes

Maxillofacial Trauma

Dr. Firas Kassab Page 33

Treatment

Open Reduction Internal Fixation (ORIF)

Orbital Defect Reconstruction Plates

Silicone implants

Autologous Bone

If the patient cannot afford the titanium implant, we

just get a piece p bone from the

calvarium, one cortical level, then we lay

that on the defect.

Titanium mesh(implants)

MAXILLARY FRACTURES

Buttresses Of The Facial Skeleton

Nasomaxillary

Zygomaticomaxillary

Pterygomaxillary

What are your buttresses? They are preformed structures in the face which are

stronger than the other areas of the face. These are the structures that hold the

maxilla together. If you have fractures and disruption of the buttresses, these are

the areas you have to compress or plate for you to be able to achieve correct

treatment of your maxillary fractures. You have to manage all of these buttresses

first.

will not be able to withstand the forces of occlusion

Reconstruction is made either through wires or plates.

Maxillofacial Trauma

Dr. Firas Kassab Page 34

The buttresses are strong because of your bite; the pressure of biting is transverse

to the buttresses. If the buttresses are fractured, the maxilla and mandible will

collapse.

Imaging

Radiographs

Occipitomental

Lateral

CT

MR

Angiography

Photography

Study models

Anatomical Classication

Le Fort I

Le Fort II

Le Fort III

The Le Fort classification describes various midfacial fracture patterns ranging from

isolated detachment of the alveolar process (Le Fort I) to separation of the midfacial

bones from the anterior skull base (Le Fort III).

Maxillofacial Trauma

Dr. Firas Kassab Page 35

Le Fort Type I

(Transverse Maxillary

Fracture)

Le Fort Type II

(Pyramidal Fracture)

Le Fort Type III

(Craniofacial

Dysjunction)

Broken pterygoid plates

+ fracture that runs

horizontally above the

anterior maxillary

alveolar process

Broken pterygoid plates +

fracture that runs along

maxillary sinus, inferior orbital

rim, orbital floor, medial

orbital wall, & nasofrontal

suture

Broken pterygoid plates

+ zygomatic arch

fracture + craniofacial

separation

LE FORT I

Low level fracture

Often mobile

Mild swelling

Disturbed occlusion

Deviated midline

If you have patient with a history of facial trauma, when

you hold the teeth and you pull that out, the alveolus

(tooth-bearing structure) will move anteriorly, that is your

anterior drawer sign. Only the tooth bearing segment

moves, then that is a sign of your Le Fort I fracture.

LE FORT II

Sub-zygomatic pyramidal

Gross swelling

Immobile

Anterior Open Bite

Altered Sensation

Maxillofacial Trauma

Dr. Firas Kassab Page 36

Long faced appearance

CSF rhinorrhea

When you pull anteriorly, even the nasal bridge will move

anteriorly, the drawer sign will include the whole nasal

bridge. Be careful because the infraorbital may already be

affected hence increased sensation to pain.

LE FORT III

Suprazygomatic craniofacial dysjunction

Gross swelling

Immobile

Altered occlusion

Long face

Flattened cheek

CSF rhinorrhea

The whole face is disjoint from the skull. When you pull,

even the cheeks and the inferior orbital rim will move

anteriorly.

Maxillofacial Trauma

Dr. Firas Kassab Page 37

Treatment

Conservative

Closed Reduction

Open Reduction

External Fixation

Internal Fixation

Wires: again wires are not internal fixation, just

internal splints

Suspension

Osteosynthesis

Summary of Anterior Drawer Sign

Le Fort I Alveolus moves anteriorly

Le Fort II Alveolus and nasal bridge moves anteriorly

Le Fort III Alveolus, nasal bridge, cheeks and inferior orbital rim move anteriorly

Maxillofacial Trauma

Dr. Firas Kassab Page 38

Screws

Plates

Internal Fixation

NASOETHMOIDAL INJURIES

Trauma to central midface

Traumatic telecanthus or hypertelorism

Telecanthus – the canthal ligament has moved laterally during traumatic injuries.

Maxillofacial Trauma

Dr. Firas Kassab Page 39

Nasal deformity

Orbital wall involvement

Enophthalmos

Diplopia

The main structural buttress of the nasoethmoid: Frontal process of the Maxilla

Contains insertion of the medial canthal ligament

o TYPE I NOE Fracture

Has a large central fragment

represent a single noncomminuted central fragment without medial canthal tendon

disruption

o TYPE II NOE Fracture

Involve comminution of the central fragment, but the medial canthal tendon remains

firmly attached to a definable segment of bone.

Maxillofacial Trauma

Dr. Firas Kassab Page 40

o TYPE III NOE Fracture

Are uncommon and result in severe central fragment comminution with disruption

and detachment of the medial canthal tendon insertion.

TREATMENT

The objectives of definitive surgical treatment of NOE fractures are reduction and

fixation of unstable fracture segments to stable structures

SUMMARY

Initial management of craniomaxillaryfacial trauma involves the ABC’s of emergency

Successful bone healing requires immobilization

Internal fixation abolishes inter=fragmentary motion