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

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Presentation on theme: "Maxillary and Periorbital Fractures Michael E. Decherd, MD Shawn D. Newlands, MD, PhD January 26, 2000."— Presentation transcript:

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

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

24 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 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 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

55 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 –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 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

76

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

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