Neligan Vol 3 Chapter 03 Main

SECTION I
Craniofacial Trauma
3
Facial fractures
Eduardo D. Rodriguez, Amir H. Dorafshar, and Paul N. Manson
SYNOPSIS

The teachings of John Converse, Nicholas Georgiade and Reed Dingman provided the benchmark for an entire generation of surgeons in facial injury repair. The treatment concepts discussed in this chapter were developed at the University of Maryland Shock Trauma Unit and ultimately employed at the International Center for Facial Injury Reconstruction at Johns Hopkins. The proportion of severe injuries seen at these centers is high. The treatment concepts, however, may be modied for common fractures and less signicant injuries. Greater emphasis has been placed on minimizing operative techniques and limited exposures, whereas the decade of the eighties witnessed craniofacial principles of broad exposure and xation at all buttresses for a particular fracture across all degrees of severity. Presently, the treatment of injuries is organized both by severity and anatomic area to permit the smallest exposure possible to achieve a good result (CT based facial fracture treatment).
in over 50% of all victims. Seatbelts and airbags have reduced the severity and incidence of facial injury, but primary and secondary enforcement of the laws vary in effectiveness with ethnicity, education and geographic location.2 A unique aspect of facial injury treatment is that the aesthetic result may be the chief indication for treatment. In other cases, injuries may require surgery to restore function, but commonly, both goals are evident. Although there are few facial emergencies, the literature has under-emphasized the advantages of prompt denitive reconstruction and early operative intervention to achieve superior aesthetic and functional results. Economic, sociologic and psychologic factors operating in a competitive society make it imperative that an expedient and well-planned surgical correction be executed in order to return the patient to an active and productive life, while minimizing disability.
Initial assessment
Management begins with an initial physical examination and is followed by a radiologic evaluation accomplished with computerized tomographic (CT) scanning. CT scans must visualize soft tissue and bone. It is no longer feasible or economically justiable to obtain plain radiographs with certain exceptions, such as the panorex mandible examination or dental lms. The availability of regional Level I and II trauma centers has provided improved trauma care for severely or multiply-injured patients earlier and safer.
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Introduction
Over 4 million people are injured in automobile accidents in the United States yearly.1 Statistics on the number of facial injuries vary widely based on social, economic and geographic differences. The causes of facial injuries in the United States include motor vehicle accidents, assaults, altercations, bicycle and motorcycle accidents, home and industrial accidents, domestic violence and athletic injuries. The automobile is frequently responsible for some of the most devastating facial injuries, and injuries to the head, face and cervical spine occur
Timing of treatment
Timing is important in optimizing the management of facial injuries. Bone and soft tissue injuries in the facial area should be managed as soon as the patients general condition permits. Time and time again it has been the authors impression that early, skillful facial injury management decreases permanent facial disgurement and limits serious functional disturbances.3,4 This does not mean that one can be cavalier about
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Facial fractures
deciding who might tolerate early operative intervention. Indeed, the skillful facial surgeon must have as complete a knowledge of their ancillary injuries as well as those of the face. Classically, facial soft tissue and bone injuries are not acute surgical emergencies, but both the ease of obtaining a good result and the quality of the result are better with early or immediate management. Less soft tissue stripping is required, bones are often easily replaced into their anatomic position and easier fracture repairs are performed. There are few patients, however, whose injuries cannot be denitively managed within a short time. Exceptions to acute treatment include patients with ongoing or signicant blood loss (i.e., pelvic fractures), elevated intracranial pressures, coagulation problems, and abnormal pulmonary ventilation pressures. Under local anesthesia, however, lacerations are debrided and closed, IMF applied and grossly displaced fractures reduced. Many patients with mild brain injuries or multi-system traumas do not have criteria preventing operative management. These patients may receive facial injury management at the time that other injuries are being stabilized. Indeed it is not uncommon in the University of Maryland Shock Trauma Unit for several teams to operate on a patient at the same time in several anatomic areas.
Clinical examination of the face

A careful history and thorough clinical examination form the basis for the diagnosis of almost all facial injuries. Thorough examination of the face is indicated even if the patient has only minor wounds or abrasions. Abrasions, contusions and lacerations may be the most apparent symptom of an underlying fracture, which will surface later as a problem. A facial laceration may be the only sign of a penetrating injury to the eye, nose, ear or cranium. Lacerations may often be repaired during the treatment of other bodily injuries without the need for an additional operative session and should therefore not be deferred. Supercial lacerations or abrasions may leave disguring scars, despite their apparent inconsequential appearance if they are not adequately managed. Careful cleansing of all wounds, meticulous debridement, and a layered closure minimize conspicuous permanent deformity.
Blunt trauma craniofacial injuries

Bone injuries are suggested by soft tissue symptoms such as contusions, abrasions, ecchymosis, edema and distortion of the facial proportions. These symptoms prompt radiographic evaluation to conrm or exclude fractures. Subconjunctival hemorrhage with ecchymosis and edema of the orbit and a palpebral hematoma suggest a zygomatic or orbital fracture. Bilateral hematomas suggest Le Fort, nasal-ethmoid or anterior cranial fossa fractures. Ecchymotic, contused intra-oral tissue, loose teeth, and malocclusion suggest the possibility of a jaw fracture. Facial bone fractures may be diagnosed on the basis of malocclusion or an open bite deformity due to fracture displacement involving the upper or the lower jaw. A fracture of the mandibular condyle for instance, may produce pain, deviation with motion to the side of the injury and inability to occlude the jaws properly. Pain with movement of the jaw (trismus) may result from a fracture of the zygoma or upper or lower jaw. Dystopia, enophthalmos, proptosis or diplopia
indicate zygomatic, orbital or maxillary fractures. A thorough palpation of all of the facial bones should be performed, systematically, checking for tenderness, crepitus or contour defects. An orderly examination of all facial structures should be accomplished, progressing from either superior to inferior or inferior to superior in a systematic fashion. Symptoms and signs produced by facial injuries include: pain or localized tenderness; crepitation of bone movement; hypesthesia or anesthesia in the distribution of a sensory nerve; paralysis in the distribution of a motor nerve; malocclusion; visual acuity disturbance; diplopia; facial asymmetry; facial deformity; obstructed respiration; lacerations; bleeding and contusions. The clinical examination should begin with the evaluation for symmetry and deformity, inspecting the face comparing one side with the other. Palpation of all bony surfaces follows in an orderly manner. The forehead, orbital rims, nose, brows; zygomatic arches; malar eminence; and border of the mandible should be evaluated (Fig. 3.2). A thorough inspection of the intra-oral area should be made to detect lacerations, loose teeth or abnormalities of the dentition (Fig. 3.3). Palpation of the dental arches follows the inspection, noting mobility of dental-alveolar arch segments. The maxillary and mandibular dental arches are carefully visualized and palpated to detect an irregularity of the bone, loose teeth, intra-oral lacerations, bruising, hematoma, swelling, movement, tenderness or crepitus. An evaluation of sensory and motor nerve function in the facial area is performed. The presence of hypesthesia or anesthesia in the distribution of the supraorbital, infraorbital or mental nerves suggests a fracture along the bony path of these sensory nerves (cranial nerve V). Cutaneous branches of these nerves might have been interrupted by a facial laceration as well. FIGS 3.2, 3.3 APPEAR ONLINE ONLY Extraocular movements (cranial nerves III, IV and VI) and the muscles of facial expression (cranial nerve VII) are examined in the conscious, cooperative patient. Pupillary size and symmetry, speed of pupillary reaction, globe turgor, globe excursion, eyelid excursion, double vision and visual acuity and visual loss are noted. A funduscopic examination and measurements of globe pressure should be performed. The presence of a hyphema, corneal abrasion, visual eld defect, visual loss, diplopia, decreased vision, or absent vision should be noted and appropriate consultation requested. A penetrating ocular injury or globe rupture should be suspected where any laceration in the eyelids or periorbital area is present. The presence of a periorbital hematoma with the eye swollen shut should not deter a clinician from examining the globe. It should be emphasized, however, that gentleness must be exercised to avoid extrusion of lens or vitreal contents through a globe laceration by vigorous manipulation. It is only by means of a thorough clinical examination that globe ruptures and penetrating globe injuries are not missed. The excursion and deviation of the jaws with motion, the presence of pain upon opening the jaw, the relationship of the teeth, the ability of the patient to bring the teeth into occlusion, the symmetry of the dental arches and the proper intercuspal dental relationship are important clues to the diagnosis of fractures involving the dentition. One nger in the ear canal and another over the condylar head can detect condylar movement, or crepitus either by patient movement or when the jaw is pulled forward (Fig. 3.4). The presence of a gingival laceration or a fractured or missing tooth or a split alveolus should imply the possibility of more signicant maxillary or mandibular injuries, which
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Upper facial fractures
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must be conrmed by CT. Fractures of the mandible may be detected by pulling the jaw forward or by applying manual pressure on the anterior portion of the mandible while supporting the angle. Instability, crepitus and pain may be noted when this maneuver is performed. Edema and hemorrhage may mask the perception of facial asymmetry. Bleeding from laceration of vessels accompanying facial fractures may disguise a cerebrospinal uid leak. Bleeding or uid draining from the ear canal may indicate a laceration in the ear canal, a condylar dislocation, or a middle cranial fossa fracture with a CSF leak. Bleeding from the nose may indicate nasal or septal injuries, Le Fort, nasoethmoidal, or orbital fractures or anterior cranial fossa fractures. Mobility of the middle-third of the facial skeleton indicates a fracture of the Le Fort type (Fig. 3.5). Anterior or cribriform plate fractures or middle basilar skull fractures should be suspected when CSF rhinorrhea is present. Central nervous system injury is implied by paralysis of one or more of the cranial nerves, impaired consciousness, depressed sensorium, unequal pupillary size, extremity paralysis, abnormal neurological reexes, convulsions, delirium, or irrational behavior. FIG 3.4, 3.5 APPEAR ONLINE ONLY
Approximately one-third of fractures involve the anterior table alone, and 60% involve the anterior table and posterior table and/or ducts. The remainder involves the posterior wall alone. Some 40% of frontal sinus fractures have an accompanying dural laceration.11
Clinical examination
Lacerations, bruises, hematomas, and contusions constitute the most frequent signs of frontal bone or sinus fractures. Skull fractures must be suspected if any of these signs are present. Anesthesia of the supraorbital nerve may be present. Cerebrospinal uid rhinorrhea may occur. There may or may not be subconjunctival or periorbital ecchymoses with or without air in the orbit or intracranial cavity. In some cases, a depression may be observed over the frontal sinus, but swelling is usually predominant in the rst few days after the injury, which may obscure the underlying bony deformity. Small fractures of the frontal sinus may be difcult to detect, especially if they are nondisplaced. Therefore, occasionally the rst presentation of a frontal sinus fracture may be an infection or symptom of frontal sinus obstruction, such as mucocele, or abscess formation.12,13 Infection in the frontal sinus have the potential to cause signicant morbidity due to its proximity to the brain location near the brain.14 Infections include meningitis, extradural or intradural abscess, intracranial abscess, osteomyelitis of the frontal bone, or osteitis in devitalized bone fragments.1523
Computerized tomographic scans

The denitive radiographic evaluation is the craniofacial CT scan with axial, coronal and sagittal sections of bone and soft tissue windows.57 However, the clinical examination remains the most sensitive detection of the character and functional implications of the facial injury. CT evaluation of the face can dene bone fractures, whereas, the soft tissue views allow for soft tissue denition of the area of the fracture. 3D CT Scans810 allow comparison of symmetry and volume of the two sides of the facial bones. Specialized views, such as those of the orbital apex, allow for a special magnied visualization. Fractures missed in CT scans are those in which there is little or no bony displacement or lms where reading occurs from soft tissue views or thicker cuts.
Nasofrontal duct
The development of a frontal sinus mucocele is linked to obstruction of the nasofrontal duct,1 which is involved with fractures in over nearly half of the cases of frontal sinus injury. The duct passes through the anterior ethmoidal air cells to exit adjacent to the ethmoidal infundibulum. Blockage of the nasofrontal duct prevents adequate drainage of the normal mucosal secretions and predisposes to the development of obstructive epithelial lined cysts or mucoceles. Mucoceles2426 may also develop when islands of mucosa are trapped by scar tissue within fracture lines and attempt to grow after the injury producing a mucus membrane lined cystic structure which is obstructed. The sinus is completely obliterated only when the duct is also deprived of its lining and when the bone is burred, eliminating the foramina of Breschet,27 in which it has been demonstrated that mucosal ingrowth occurs along veins in the walls of the sinuses.28,29 Regrowth of mucosa can also occur from any portion of the frontal sinus, especially if incompletely debrided. The reported average interval between the primary injury and development of frontal sinus mucocele is 7.5 years.
Upper facial fractures

Frontal bone and sinus injury patterns
The frontal sinuses are paired structures that have only an ethmoidal anlage at birth. They have no frontal bone component initially. They begin to be detected at 3 years of age, but signicant pneumatic expansion does not begin to occur until approximately age 7 years. The full development of the frontal sinuses is complete by the age of 1820.11 The frontal sinuses are lined with respiratory epithelium, which consists of a ciliated membrane with mucus secreting glands. A blanket of mucin is essential for normal function and the cilia beat this mucin in the direction of the nasofrontal ducts. The exact function of the paranasal sinuses is still incompletely determined. When injured, they serve as a focus for infection, especially if duct function is impaired. Their structure, however, often protects the intracranial contents from injury by absorbing energy. The predominant form of frontal sinus injury is fracture. Fracture involvement of the frontal sinus has been estimated to occur in 212% of all cranial fractures and severe fractures occur in 0.72% of patients with cranial or cerebral trauma.11
Radiography
Frontal bone and sinus fractures are best demonstrated using CT Scans. Hematomas or air uid levels in the frontal sinus may be visualized as well as potential injuries to the nasofrontal duct. Persisting air-uid levels can imply the absence of duct function.
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Facial fractures
Surgical treatment
The best technique of exposure in major fractures involving the frontal bone is the coronal incision. This allows a combined intracranial and extracranial approach, making visualization of all areas possible, including repair of dural tears, debridement of any necrotic sections of frontal lobe, and repair of the bone structures. Frontal sinus fractures should be characterized by describing both the anatomic location of the fractures and their displacement. The indications for surgical intervention in frontal sinus fractures include depression of the anterior table, radiographic demonstration of involvement of the nasofrontal duct with presumed future nonfunction, obstruction of the duct with persistent air uid levels, mucocele formation, and fractures of the posterior table that are displaced and presumably have lacerated the dura.30,31 Some authors recommend exploration of any posterior table fracture or any fracture in which an air uid level is visible. Others have a more selective approach, exploring posterior wall fractures only if their displacement exceeds the width of the posterior table. This distance suggests simultaneous
dural laceration. Simple linear fractures of the anterior and posterior sinus walls which are undisplaced are observed by many clinicians. Any depressed frontal sinus fracture of the anterior wall potentially requires exploration and wall replacement in an anatomical position to prevent contour deformity. Most of these patients will have no compromise of nasofrontal duct function, however, some do and these should have the sinus defunctionalized. The anterior wall of the sinus may be explored by an appropriate local laceration or a coronal incision, or more recently endoscopically. Anterior wall fragments are elevated and plated into position. If it is desired that the nasofrontal duct3234 and sinus be obliterated because of involvement, the mucosa is thoroughly stripped, even into the recesses of the sinus, and the nasofrontal ducts occluded with well-designed formed-to-t calvarial bone plugs (Fig. 3.6). If most of the posterior bony wall is intact, the entire frontal sinus cavity may be lled either with fat or cancellous bone. The iliac crest provides a generous source of rich cancellous bone.35 Alternatively, the cavity may be left vacant, a process called osteoneogenesis. The cavity lls slowly with a combination of bone and brous tissue, but is more frequently
Fig. 3.6 (A) Nasofrontal duct. (B) Bone plug for nasofrontal duct and galeal ap. (C) Bone obliteration of frontal sinus. (D) Back table surgery for bone replacement. (E) Bone reconstruction and cranialization of the frontal sinus; intracranial neurosurgery. (F) Postoperative result.
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Orbital fractures
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infected in the authors experience than sinuses treated with cavity lling.36 If the posterior table is missing, no grafting need be performed for localized defects, but it is emphasized that the oor of the anterior cranial fossa should be reconstructed with bone. In cranialization, the posterior wall of the frontal sinus is removed, effectively making the frontal sinus a part of the intracranial cavity. The dead space may be lled with cancellous bone37 or left open. Any communication with the nose by the nasofrontal duct or with the ethmoid sinuses should be sealed with carefully designed bone grafts. The orbital roof should be reconstructed primarily by thin bone grafts placed external to the orbital cavity. An intracranial exposure is often required for this orbital roof reconstruction. The use of a galeal ap38,39 in the treatment of extensive frontal bone defects designed with a pedicle of the supercial temporal artery can be a useful method for vascularized soft tissue obliteration of frontal bone problems.
Orbital fractures
Orbital fractures may occur as isolated fractures of the internal orbit (also called pure) or may involve both the internal orbit and the orbital rim (also called impure) (Fig. 3.7).4042
Surgical anatomy of the orbit

In fracture treatment, the orbits are conceptualized in thirds progressing from anterior to posterior. Anteriorly, the orbital rims consist of thick bone. The middle-third of the orbit consists of thin bone and the bone structure thickens again in the posterior portion of the orbit. The orbital bone structure is thus analogous to a shock-absorbing device in which the middle portion of the orbit breaks rst, followed by the rim. The optic foramen is situated at the junction of the lateral and medial walls of the orbit posteriorly and is well above the horizontal plane of the orbital oor. The foramen is located 4045 mm behind the inferior orbital rim.
Complications
Complications of frontal bone and sinus fractures include: CSF uid rhinorrhea Pneumocephalus and orbital emphysema Absence of orbital roof and pulsating exophthalmos Carotid-cavernous sinus stula.
Orbital physical examination

The examination should detect edema, corneal abrasion, laceration, contusion and hematoma. The simultaneous presence of a subconjunctival hematoma and a periorbital hematoma
Fig. 3.7 (A) Mechanism of blow-out fracture from displacement of the globe itself into the orbital walls. The globe is displaced posteriorly, striking the orbital walls and forcing them outward, causing a punched out fracture the size of the globe. (B) Force transmission fracture of orbital oor.
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Facial fractures
Fig. 3.9 Blow-out fracture in a child produced by a snowball. Note the nearly complete immobility of the ocular globe and the enophthalmos. Such severe loss of motion implies actual muscle incarceration, an injury that is more frequent in children than in adults. This fracture deserves immediate operation with release of the incarcerated extraocular muscle system. It is often accompanied by pain on attempted rotation of the globe and sometimes nausea and vomiting. These symptoms are unusual in orbital oor fractures without true muscle incarceration.
Fig. 3.8 The combination of a palpebral and subconjunctival hematoma is suggestive of a fracture somewhere within the orbit. There is frequently a zygomatic or orbital oor fracture present when these signs are conrmed.
conned to the distribution of the orbital septum is evidence of a facial fracture involving the orbit until proven otherwise by radiographs (Fig. 3.8). The extraocular movements should note double vision or restricted globe movement. Visual acuity may be recorded by the patients ability to read newsprint or an ophthalmic examination card such as the Rosenbaum Pocket card. Visual eld examinations should be performed. All patients must be frequently checked for light perception and pupillary afferent defects preoperatively and postoperatively. Globe pressure may be assessed by tonometry and should be less than 15 mm. The results of a fundus examination should be recorded. The presence of no light perception indicates optic nerve damage or globe rupture. Light perception without usable vision indicates optic nerve damage, retinal detachment, hyphema, vitreous hemorrhage or anterior or posterior chamber injuries. Globe and eye injuries require expert ophthalmologic consultation.
Radiographic evidence of extensive fracture, such that enophthalmos would occur. Enophthalmos or exophthalmos (signicant globe positional change) produced by an orbital volume change. Visual acuity decit, increasing and not responsive to medical dose steroids, implying that optic canal decompression would be indicated. Blow-in orbital fractures that involve the medial or lateral walls of the orbit, and severely constrict orbital volume, creating increased intraorbital pressure.
Blow-out fractures of the oor of the orbit

A blow-out fracture is caused by the application of a traumatic force to the rim, globe or soft tissues of the orbit. Blow-out fractures are generally assumed to be accompanied by a sudden increase in intraorbital pressure.
Blow-out fractures in younger individuals

In children, the mechanism of entrapment is more frequently trapdoor than the blow-out or punched out fracture seen in adults. As opposed to incarceration of fat adjacent to the inferior rectus muscle, children more frequently scissor or capture the muscle directly in the fracture site. This may be suggested on physical examination with near immobility of the eye when upgaze is attempted on the affected side (Fig. 3.9). Trapdoor fractures with actual muscle incarceration are an urgent situation that demands immediate release of the incarcerated muscle.4347 A number of authors have recently emphasized that a better prognosis is possible if the muscle is released early. The patient with true muscle entrapment may experience pain on attempted eye motion as well as nausea, vomiting, and an oculocardiac reex,48 which consists of nausea, bradycardia, and hypotension.
Radiographic evidence of fracture

CT scans performed in the axial, coronal and sagittal planes, using both bone and soft tissue windows, are essential to dene the anatomy of the orbital walls and soft tissue contents, and the relation of the extraocular muscles to the fracture.
Indications for surgical treatment

The indications for surgical treatment include: Double vision caused by incarceration of muscle or the ne ligament system, documented by forced duction examination and suggested by CT scans.
Surgical treatment
The surgical treatment of orbital fractures has three goals: Disengage entrapped structures and restore ocular rotatory function.
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Orbital fractures
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Replace orbital contents into the usual connes of the normal bony orbital cavity, including restoration of both orbital volume and shape. Restore orbital cavity walls, which in effect replaces the tissues into their proper position and dictates the shape into which the soft tissue can scar.
The timing of surgical intervention

In isolated blow-out fractures, it is not necessary to operate immediately unless true muscle incarceration or severe restriction of limitation is present. In the presence of signicant edema, retinal detachment or other signicant globe injuries, such as hyphema, it is advisable to wait a number of days. Signicant orbital fractures are best treated by early surgical intervention. The authors rmly believe that the earlier signicant orbital volume or muscle derangement can be corrected, the better the aesthetic and functional result.
Operative technique for orbital fractures

Endoscopic approaches for orbital oor fractures
Recently, endoscopic approaches through the maxillary sinus have permitted direct visualization of the orbital oor and manipulation of the soft tissue and oor repair with this approach, which avoids an eyelid incision (Fig. 3.10).4952 FIG
3.10 APPEARS ONLINE ONLY
Fig. 3.11 The forced duction test. (A) Forceps grasp the ocular globe at the insertion of the inferior rectus muscle, which is approximately 710 mm from the limbus. (B) Clinical photograph. A drop of local anesthetic instilled into the conjunctival sac precedes the procedure.
Identication of the intact ledge may be veried on CT scan (best shown on sagittal images).59,60 The ledge is the anatomical mark for which the implant material should be landed posteriorly to reestablish continuity of the orbital oor.
Cutaneous exposures
A number of incisions have been employed to approach the orbital oor: Lower eyelid incision. These have the least incidence of lower eyelid ectropion of any lid incision location but tend to be the most noticeable and prone to lymphedema.5355 Subciliary skin muscle ap incision. This incision near the upper margin of the lid leaves the least conspicuous cutaneous scar.5658 However, they are prone to have the highest incidence of lid retraction. Transconjunctival incision. A preseptal or retroseptal dissection plane can be established.
The forced duction test

Limitation of forced rotation of the eyeball is the forced duction test or the eyeball traction test (Fig. 3.11). This test provides a means of differentiating entrapment of the extraocular muscles from weakness, paralysis or contusion. The forced duction test should be performed: (1) before dissection; (2) after dissection; (3) after the insertion of each material used to reconstruct the orbital wall; (4) just prior to closure of the incisions. It is vital that these measurements be compared. It is absolutely imperative that any reconstructive material does not interfere with globe movement in any way, and it is absolutely essential to prove this before any incisions are closed. A full range of all oculo-rotatory movements must accompany restoration of proper eye position.
Surgical treatment
Generally, a corneal protector is placed over the eye to protect the globe and cornea from instruments, retractors or rotating drills. The inferior rectus muscle, the orbital fat and any orbital soft tissue structures should be carefully dissected free from the areas of the blow-out fracture. Intact orbital oor must be located around all the edges of the displaced blowout fracture. The oor must be explored sufciently far back into the orbit that the posterior edge of the intact orbital oor beyond any defect can be identied. Many individuals call this the ledge, and it may be the orbital process of the palatine bone. Placing a freer periosteal elevator into the maxillary sinus and feeling the back of the sinus can verify the position of the ledge. The ledge is located just above the back of the maxillary sinus 3538 mm behind the orbital rim.
Restoration of continuity of the orbital oor

The purpose of the orbital oor replacement, whether a bone graft or an inorganic implant, is to reestablish the volume and the shape of the orbital cavity. This replaces the orbital soft tissue contents and allows scar tissue to form in an anatomic position (Fig. 3.12).
Bone grafts for orbital oor reconstruction

Split calvarial, iliac, or split rib bone grafts provide the ideal physiological substitute material for reconstruction of the internal orbital fractures.61,62 It is not known whether bone grafts resist bacterial colonization better than inorganic implants, but that is the presumption. Bone grafts are presumed to survive at the 5080% level.
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Fig. 3.12 Medial orbital wall fracture. (A) Coronal CT scan image illustrating medial orbital wall fracture. (B) Postoperative three-dimensional CT scan demonstrating repair of medial orbital wall repair using titanium alloplastic mesh implant.
Inorganic implants
The inorganic implant offers the advantage of obtaining the material necessary for the reconstruction of the orbital oor without the need for a second operation for bone graft harvest. Inorganic implants are certainly satisfactory for limited size defect orbital fractures, and some authors utilize titanium mesh alone for large defects where stabilization of a bone graft becomes impractical. The incidence of late infection is certainly less than 1%, and displacement should not occur if the material has been properly anchored.
of the globe. A popular theory was fat atrophy, but computerized volume studies shown prove that fat atrophy is only signicant in 10% of orbital fractures.
Retrobulbar hematoma
In severe trauma, retrobulbar hematoma may displace the ocular globe. Retrobulbar hematoma is signaled by globe proptosis, congestion and prolapse of the edematous conjunctiva. Diagnosis is conrmed by a CT scan imaged with soft tissue windows and is treated by lateral canthotomy. It is usually not possible to drain retrobulbar hematomas as they are diffuse. They may not permit, if large in volume, primary restoration of the bony volume of the orbit and one may have to complete the internal portion of the orbital reconstruction several weeks later when the hemorrhage, swelling and congestion have subsided.
Postoperative care
All patients must be frequently checked for light perception preoperatively and postoperatively. Pupillary reactivity must be accessed before and after orbital surgery and at least twice daily for the rst several days. Blindness has sometimes occurred more than 24 hours following orbital fracture treatment.
Ocular (globe) injuries and blindness

The incidence of ocular injuries following orbital fractures is between 14% and 30%.71 The incidence depends on the scrutiny of the examination and the recognition of minor injuries, such as corneal abrasion. Ocular globe injury may vary in severity from a corneal abrasion to loss of vision to globe rupture, retinal detachment, vitreous hemorrhage, or a fracture involving the optic canal. Blindness, or loss of an eye, is remarkably infrequent, despite the severity of some of the injuries sustained because of the shock absorber type construction of the orbit. The incidence of blindness following facial fracture repair has been estimated to be about 0.2%.72
Complications of orbital fractures

Diplopia
Extraocular muscle imbalance and subjective diplopia are usually the result of muscle contusion, but can be the result of incarceration of either the muscle or the soft tissue adjacent to the muscles, or result of nerve damage to the third, fourth, and sixth cranial nerves.6365
Enophthalmos
Enophthalmos,6670 the second major complication of a blowout fracture, has a number of causes. The major cause is enlargement of the orbital volume with herniation of the orbital soft tissue structures into an enlarged cavity. This allows soft tissue structural displacement with a remodeling of the shape of the soft tissue into a sphere. Another postulated mechanism of enophthalmos is the cicatricial retraction
Implant migration, late hemorrhage around implants and implant xation

Migration of an implant anteriorly may occur with extrusion if the implant is not secured to the orbital oor or to a plate that attaches to the rim. Spontaneous late proptosis can be caused by hemorrhage from long standing low grade infection around orbital implants or obstruction of the lacrimal system.73
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Midfacial fractures
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Ptosis of the upper lid

True ptosis of the upper lid should be differentiated from pseudoptosis resulting from the downward displacement of the eyeball in enophthalmos. True ptosis results from loss of action of the levator palpebrae superioris. Ptosis in the presence of enophthalmos should not be treated until the globe position has been stabilized by enophthalmos correction.
Scleral show, ectropion and entropion: vertical shortening of the lower eyelid
Vertical shortening of the lower eyelid with exposure of the sclera below the limbus of the globe in the primary gaze (scleral show) may result from downward and backward displacement of the fractured inferior orbital rim. The septum and lower lid are xed length structures and are therefore dragged downward by their tendency to adhere to the abnormally positioned orbital rim. Release of the septum orbitale attachment to the orbital rim and restoration of the position of the orbital rim by osteotomy may be required.
oblique muscles; cranial nerve IV causing paralysis of the superior oblique muscle; cranial nerve VI producing paralysis of the lateral rectus muscle; and the ophthalmic division of the trigeminal nerve (V) causing anesthesia in the brow, medial portion of the upper lid, medial upper nose, and ipsilateral forehead. All symptoms of the superior orbital ssure syndrome may be partial or complete in each of the nerves. When accompanied by visual acuity change or blindness, the injury implies concomitant involvement of the combined superior orbital ssure (CN III, IV, V & VI) and optic foramen (CN II). If involvement of both the optic nerve and superior orbital ssure occur, this symptom complex is called the orbital apex syndrome.76
Midfacial fractures
Nasal fractures
Types and locations of nasal fractures
Lateral forces,77 account for the majority of nasal fractures and produce a wide variation of deformities, depending on the age of the patient, intensity and vector of force. Younger patients tend to have fracture dislocations of larger segments, whereas older patients with more dense, brittle bone often exhibit comminution. Kazanjian and Converse78 and Murray and associates79 conrmed that most nasal fractures occur in thin portions of the nasal bone. In the Kazanjian and Converse series, 80% of a series of 190 nasal fractures occurred at the junction of the thick and thin portions of the nasal bones. A direct force of moderate intensity from the lateral side may fracture only one nasal bone with displacement into the nasal cavity (plane I). When forces are of increased intensity, some displacement of the contralateral nasal bone occurs and the fracture may be incomplete or greensticked, requiring completion of the fracture to centralize the nasal processes (plane II). In more severe (plane III) frontal impact injuries, the frontal process of the maxilla may begin to fracture and may be depressed on one side. This depression rst arises at the pyriform aperture and then involves the entire structure of the frontal process of the maxilla, and is in effect the beginning of a hemi-nasoethmoidal fracture, displaced inferiorly and posteriorly (plane III lateral impact fractures are identical to Type I hemi-nasoethmoidal fractures) (Fig. 3.13). These fractures are greensticked at the internal angular process of the frontal bone and most of the displacement is inferior. The sidewall of the nose drops on one side, the septum telescopes and displaces and the nasal airway is effectively closed on the ipsilateral side by the septum and sidewall displacing towards each other. In stronger blows, the septum begins to collapse from an anteroposterior perspective as the comminution increases. The medial displacement of the pyriform aperture into the nose effectively blocks the ipsilateral nasal airway. As anteroposterior blows result in decreased stability, the septum telescopes losing height and the nasal bridge drops. Violent blows result in multiple fractures of the nasal bones and frontal processes of the maxilla, lacrimal bone, septal cartilages and the ethmoidal areas, the nasoethmoidal orbital fracture.
Lid lamellae and their relation to contracture

The problem should be dened as occurring in anterior lid lamellae (skin or orbicularis) or posterior lid lamellae (septum, lower lid retractors and conjunctiva) and a plan for operative intervention developed. Only in the actual performance of the operation can the surgeon dene the true nature of the problem, release the adhesions and stabilize the lid with appropriate grafts. These procedures generally do not elevate the lower lid by more than 3 mm.
Infraorbital nerve anesthesia

Infraorbital nerve anesthesia is extremely disconcerting to patients who experience it, especially initially. The area of sensory loss usually extends from the lower lid to involve the medial cheek, the lateral portion of the nose, including the ala and the ipsilateral upper lip. The anterior maxillary teeth may be involved if the branch of the infraorbital nerve in the anterior maxillary wall is involved. Decompression of the infraorbital nerve from pressure of the bony fragments within the infraorbital canal may be indicated either acutely or late after fracture treatment especially if the zygoma demonstrates medial displacement into the infraorbital canal with impaction into the nerve.
The superior orbital ssure syndrome and the orbital apex syndrome
Signicant fractures of the orbital roof extend posteriorly to involve the superior orbital ssure and optic foramen. Involvement of the structures of the superior orbital ssure produces a symptom complex known as the superior orbital ssure syndrome.74,75 This consists of partial or complete involvement of the following structures: the two divisions of the cranial nerve III, superior and inferior, producing paralysis of the levator, superior rectus, inferior rectus, and inferior
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58
SECTION I
Facial fractures
Fig. 3.13 Frontal impact nasal fractures are classied by degrees of displacement, as are lateral fractures. (A) Plane I frontal impact nasal fracture. Only the distal ends of the nasal bones and the septum are injured. (B) Plane II frontal impact nasal fracture. The injury is more extensive, involving the entire distal portion of the nasal bones and the frontal process of the maxilla at the piriform aperture. The septum is comminuted and begins to lose height. (C) Plane III frontal impact nasal fractures involve one or both frontal processes of the maxilla, and the fracture extends to the frontal bone. These fractures are in reality nasoethmoidal-orbital fractures because they involve the lower two-thirds of the medial orbital rim (central fragment of the nasoethmoidal-orbital fracture), as well as the bones of the nose.
Fig. 3.14 Palpation of the columella (A) and dorsum (B) detects superior rotation of the septum and lack of dorsal support. There is an absence of columellar support and dorsal septal support.
Fractures and dislocations of the nasal septum

Fractures and dislocations of the septum may occur independently or concomitantly with fractures of the distal nasal bone framework. Most commonly, the two injuries occur together but frontal impact nasal fractures carry the worst prognosis regarding preservation of nasal height (Fig. 3.14).80 Because of the intimate association of the bones of the nose with the nasal cartilages and bony nasal septum, it is unusual to observe fractures of either structure without damage to the other. In particular, the caudal or cartilaginous portion of the septum is almost always injured in nasal fractures.81 The caudal portion of the septum has a degree of exibility and bends to absorb moderate impact. The rst stage of nasal septal injury is fracturing and bending, and the next stage involves overlap between fragments which reduces nasal
height. In mid level severity injuries, the septum fractures, often initially with a C-shaped or double transverse component in which the septum is fractured and dislocated out of the vomerine groove.82 Displacement of the fractured segment occurs with partial obstruction of the nasal airway. The cartilage may be fractured in any plane, but the most frequent location of the fracture is that described with horizontal and vertical components separating the anterior and posterior portions of the septum. As the cartilage heals, it can exhibit progressive deviation with warping forces due to the stresses created by the perichondrium.8386 Cartilage is thought to possess an inherent springiness, which internal stresses are released when tearing of the perichondrium on one side of the cartilage occurs. If the perichondrium and cartilage are torn, the septum deviates away from the torn area toward the intact perichondrial side.
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Midfacial fractures
59
Fig. 3.16 (A) Preoperative and (B) postoperative images of a 20-year-old male who sustained a Le Fort II type injury during a wrestling match.
Severe fractures of the septum are additionally associated with telescoping displacement, resulting in a collapse with a Z-shaped overlapping and displacement of the septum.87 The septum is shortened, giving rise to a retruded appearance in prole of the cartilage and also the columellar portion of the nose. Slight loss of the dorsal nasal height can give rise to a nasal hump, at the junction of the septum with the nasal bones.
Treatment of fractures and dislocations of the septum

The nasal septum should be straightened and repositioned as soon after the injury as possible. When fractures of the nasal bones and septum occur simultaneously, it is important to ensure that at the time of reduction, the bone fragments can be freely deviated in all directions to ensure completion of the fractures. In terms of the nasal bones, they should be able to be deviated freely in both lateral directions to indicate satisfactory completion of any greensticked fractures. Incomplete fractures will cause the nasal bones to slowly spring back toward their original deviated position. When the reduction is incomplete, there is early recurrence of displacement. This is true for both the nasal bones and septum. When the nasal bones are reduced, the intimate relationship of the nasal bones with the upper and lower lateral cartilages tends to reduce the upper septal cartilage as well. Displacement of the cartilaginous septum out of the vomerine groove will not be reduced with nasal bone reduction alone. The correction of the position of the bony and cartilaginous septum must be completed with an Asch forceps, and the septal fragments maintained in position with an intranasal splint (Fig. 3.15). In some cases, the septum should be reunited with the anterior nasal spine with a direct wire or suture. When nasal fractures are treated more than 1 week after the injury, and especially after 2 weeks, it may not be possible to obtain the desired result with a single operation. Partial healing may make the reduction of the displaced or overlapped fragments difcult and less stable, and these patients often require a subsequent rhinoplasty with osteotomies.96 Although some individuals have performed open reductions routinely in nasal fractures, this amounts to resecting telescoped portions of the septum and creating additional osteotomies, and it is the author s opinion that such procedures are generally best performed secondarily when the initial swelling has disappeared and bone healing complete.
The treatment of nasal fractures

Most nasal fractures are initially reduced by closed reduction (Fig. 3.15). In more severe frontal impacts where loss of nasal height and length occurs, particularly in Plane II or nasoethmoidal orbital fractures, the use of open reduction and primary bone or cartilage grafting is benecial to restore the support of the nose to its original volume, lling the original soft tissue envelope preventing soft tissue contracture (Fig. 3.16).88 It is helpful to perform a closed reduction before edema prevents accurate palpation and visual inspection to conrm the reduction. FIG 3.15 APPEARS ONLINE ONLY
Open reduction and the use of supporting K wires

In severe nasal injury (i.e., plane II nasal injury), open reduction with bone or cartilage grafting to restore nasal height may be required. Semi-closed reductions89 may be performed with limited incisions using small K wires to stabilize the nasal bones.90,91 Internal splinting92 may be required. Some nasal fractures are sufciently dislocated that they can only be stabilized with an open rhinoplasty reduction.93,94 In practice, closed reduction of most nasal fractures is frequently deferred until the edema has partially subsided and the accuracy of the reduction may be conrmed by visual inspection and palpation.95 Treatment may be postponed for 57 days when required. After 2 weeks, it becomes more difcult to reduce a nasal fracture, as partial healing in malalignment has occurred and soft tissue contracture has occurred.
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SECTION I
Facial fractures
A more predictable result is usually obtained with secondary elective (late) rhinoplasty. Acute open reductions of the septum usually are performed by removal of overlapped cartilage and therefore inevitably result in a loss of nasal height. All patients with nasal fractures should be warned that a late rhinoplasty may be indicated for correction of deviation of the nose, loss of or irregular nasal height or nasal airway obstruction.
and extended in two-thirds of cases to involve either the frontal bone, zygoma or maxilla. One-third are unilateral and two-thirds are bilateral injuries. The central feature characterizing nasoethmoidal orbital fractures is the displacement of the section of the medial orbital rim carrying the attachment of the medial canthal ligament. Fractures that separate the frontal process of the maxilla and its canthal-bearing tendon allow canthal displacement.
Complications of nasal fractures

Untreated hematomas of the nasal septum may result in subperichondrial brosis and thickening with partial nasal airway obstruction. The septum in these cases may be as thick as 1 cm in areas, and may require thinning. In the case of repeated trauma, the cartilages of the septum may be largely replaced with calcied material. Submucous resection of thickened portions of the nasal septum may be required, and in many patients turbinate outfracture, or partial resection of enlarged turbinates may be advisable. Synechiae may form between the septum and the turbinates in areas where soft tissue lacerations occur and the tissues are in contact.97 These may be treated by division with placement of a splint or a nonadherent petrolatum impregnated gauze material between the cut surfaces for a period of 5 days. During this time, partial epithelialization begins. Obstruction of the nasal vestibule may occur as a result of malunited fractures of the piriform margin, especially if displaced medially. It also occurs from telescoping and overlap of the nasal septum or lateral dislocation of the nasal septum into the airway. Soft tissue contracture and loss of vestibular lining produce narrowing, is difcult to correct without grafting material. Osteotomy of the bone fragments can correct displaced fractures; however, contracture due to loss of soft tissue may require excision of the scar and replacement with mucosal or composite grafts within the nasal vestibule or ap reconstruction. Residual osteitis or infection of the bone or cartilage is occasionally seen in the compound fractures of the nose. These conditions are usually treated by repeated conservative debridements until the infected fragments are removed or sequestered. Debridement and antibiotic therapy constitute the preferred regimen of treatment. Secondary grafting may be performed where needed after an absence of infection and inammation has persisted for 6 months. Chronic pain is infrequent, and usually affects the external nasal branches.98 Malunion of nasal fractures is common after closed reductions, since the exact anatomic position of the bone fragments can be difcult to detect by palpation alone, and the presence of closed splinting may not prevent subsequent deviation owing to the release of interlocked stresses,99101 following fracture of the cartilage. Any external or internal deformity of signicance may require a corrective rhinoplasty.
Surgical pathology
The bones that form the skeletal framework of the nose are projected backwards between the orbits when subjected to strong traumatic forces. The bones involved are situated in the upper central portion of the middle third of the face anterior to the anatomic crossroads between the cranial, orbital, and nasal cavities. A typical cause of a nasoethmoidal orbital fracture is a blunt impact applied over the upper portion of the bridge of the nose caused by projection of the face against a blunt object such as a steering wheel or dashboard. The occupant of an automobile, for instance, is thrown forward, striking the nasofrontal area. A crushing injury with comminuted fractures is thus produced in the upper central midface. Bursting of the soft tissues, due to the severity of the impact and penetrating lacerations of the soft tissues resulting from projection of objects may transform the closed fractures into an open, and/or comminuted injury. If the impact force suffered by the strong nose and anterior frontal sinus is sufcient to cause backward displacement of these structures, no further resistance is offered by the delicate matchbox-like structures of the interorbital space; indeed, these structures collapse and splinter like a pile of matchboxes struck by a hammer.102
Interorbital space
The term interorbital space designates an area between the orbits and below the oor of the anterior cranial fossa. The interorbital space contains two ethmoidal labyrinths, one on each side and consists of the ethmoidal cells, the superior and middle turbinates, and a median thicker plate of septal bone and the perpendicular plate of the ethmoid.
Traumatic telecanthus and hypertelorism

Traumatic telecanthus is an increase in the distance between the medial canthal ligaments in all but the rst stage of nasoethmoidal orbital fractures, the patient has a characteristic appearance of telecanthus. The eyes may appear far apart, as in orbital hypertelorism.103,104 Traumatic orbital hypertelorism105 (as opposed to telecanthus) is a deformity characterized by an increase in the distance between the orbits and the ocular globes.106
The appearance of patients who suffer nasoethmoidal orbital fractures is typical. A signicant frontal impact nasal fracture is generally present, with the nose attened and appearing to have been pushed between the eyes. There is a loss of dorsal nasal prominence, and an obtuse angle is noted between the lip and columella. Finger pressure on the nose may document inadequate distal septal or proximal bony support. The medial
Nasoethmoidal orbital fractures

Nasoethmoidal orbital fractures are severe fractures of the central one third of the upper midfacial skeleton. They comminute the nose, the medial orbital rims and the piriform aperture. Nasoethmoidal fractures are isolated in one-third
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Classication of nasoethmoidal orbital fractures
61
Fig. 3.17 (A) Finger pressure on the nasal dorsum and columella documents the lack of skeletal support in nasoethmoid fractures. (B) If the ngertips are pressed over the medial orbital rim (not the nasal bones), a click or movement conrms a mobile nasoethmoidal-orbital fracture.
canthal areas are swollen and distorted with palpebral and subconjunctival hematomas. Ecchymosis and subconjunctival hemorrhage are the usual ndings. Directly over the medial canthal ligaments, crepitus or movement may be palpated with external pressure deeply over the canthal ligament (Fig. 3.17). A bimanual examination of the medial orbital rim is helpful if the diagnosis is uncertain. The bimanual examination is performed by placing a palpating nger deeply over the canthal ligament, and placing a clamp inside the nose with its tip directly under the nger. The frontal process of the maxilla may then, if fractured, be moved between the index nger and the clamp, indicating instability conrming both the diagnosis and the need for an open reduction. The clamp, if placed under the nasal bones (and not the medial orbital rim medial canthal ligament attachment) can erroneously identify a nasal fracture as canthal instability.
Radiographs
CT scans are essential to document the injury. The diagnosis of a nasoethmoidal orbital fracture on radiographs requires at a minimum four fractures that isolate the frontal process of the maxilla from adjacent bones. These include: (1) fractures of the nose; (2) fractures of the junction of the frontal process of the maxilla with the frontal bone; (3) fractures of the medial orbit (ethmoidal area); and (4) fractures of the inferior orbital rim extending to involve the pyriform aperture and orbital oor. These fracture lines, therefore, dene the central fragment of bone bearing the medial canthal ligament as free, and, depending on periosteal integrity, the medial orbital rim could displace.
Classication of nasoethmoidal orbital fractures

Nasoethmoidal fractures are classied according to a pattern established by Markowitz and colleagues107 types IIII, the bimanual examination and the CT scan.108110
Type I is an incomplete fracture, mostly unilateral but occasionally bilateral, which is displaced only inferiorly at the infraorbital rim and piriform margin. Inferior alone approaches are necessary (Fig. 3.18). Bilateral nasoethmoidal orbital fractures can section the entire nasoethmoidal area as a single unit. These are not true nasoethmoidal orbital fractures, since telecanthus cannot occur. The entire central fragment is usually rotated and posteriorly displaced, and considerable canthal distortion occurs. Conceptually, these are treated with superior and inferior approaches as the fractures are complete at peripheral buttresses. These types of fractures do not require a canthal repositioning because the canthus is not unstable and remains attached to a large bone fragment. Type II nasoethmoidal orbital fractures are comminuted nasoethmoidal fractures with the fractures remaining outside the canthal ligament insertion. The central fragment may be dealt with as a sizeable bone fragment and united to the canthal ligament-bearing fragment of the other side with a transnasal wire reduction. The remainder of the pieces of the nasoethmoidal orbital skeleton are reduced and then stabilized by junctional plate and screw xation to the frontal bone, the infraorbital rim and to the Le Fort I level of the maxilla. They may be unilateral or bilateral (Fig. 3.19). Type III nasoethmoidal orbital fractures either have avulsion of the canthal ligament (uncommon) or the fractures extend underneath the canthal ligament insertion. The fracture fragments are small enough that a reduction would require that the canthus be detached to accomplish the bone reduction. Therefore, canthal ligament reattachment is required, a separate step accomplished with a separate set of transnasal wires for both the bone of the medial orbital rim and the canthus. In general, the bony reduction of the intercanthal distance should be 57 mm per side less than the desired soft tissue distance (Fig. 3.20).
Treatment of nasoethmoidal orbital fractures

The technique of treatment in nasoethmoidal orbital fractures consists of a thorough exposure of the nasoorbital region by means of three incisions: a coronal (or an appropriate
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SECTION I
Facial fractures
Fig. 3.18 (A,B) Lateral image of 3D craniofacial computer tomography scan of a type 1 naso-orbital ethmoidal fracture injury pattern pre- and post-open reduction and internal xation of midface fractures using the inferior alone approach.
Fig. 3.19 (A) Frontal 3D craniofacial computer tomography scan of a type II naso-orbital ethmoidal fracture injury pattern in a 23-year-old female who sustained craniofacial injuries following being struck by a motor vehicle as a pedestrian. (B) Pre- and post-open reduction and internal xation of midface fractures. (C) Postoperative frontal photograph view of patient approximately 12 months from surgery.
Fig. 3.20 (A) Frontal 3D craniofacial computer tomography scan of type III naso-orbital ethmoidal and a Le Fort II type injury pattern in a 33-year-old who sustained craniofacial injuries following being thrown off a motorcycle without a helmet. (B) Pre- and post-open reduction and internal xation of midface and mandibular fractures. (C) Postoperative frontal photograph view of patient 6 months from surgery.
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Fractures of the zygoma
63
laceration or local incision), a lower eyelid incision, and a gingival buccal sulcus incision. In some cases, a laceration may be present over the forehead or nose, which provides sufcient access for a localized fracture to be treated. Nasal and forehead laceration are common, but often they are not quite long enough to provide sufcient exposure. Judgment must be exercised in the extension of these lacerations, as the scar deformity from extension is sometimes worse than making a separate coronal incision. The primary principle underlying open treatment of nasoethmoidal orbital fractures involves the preservation of all fragments of bone and their accurate reassembly.111 Despite the anatomic reassembly of the bone fragments of the nose, primary bone grafting is usually necessary to improve the true nasal height and to preserve the smooth contour of the dorsum of the nose. Occasionally, the bone onto which the canthal ligament is attached is so comminuted that a canthal detachment and reinsertion of the ligament into a structurally sound bone graft (a new central fragment) is created.
The importance of the central fragment in nasoethmoid orbital fractures

In all cases of nasoethmoidal orbital fractures, one must identify and classify what is happening to the bone of the medial orbital rim, which bears the medial canthal attachment, as it has a direct relationship to the treatment techniques of the various fractures. Displacement of this medial canthal bone fragment is the sine qua non of the nasoethmoidal injury, and the correct denition and management of this fragment, the central fragment, determines the outcome of the fracture. The most essential feature of a nasoethmoidal reduction is the transnasal reduction of the medial orbital rims by a wire placed posterior and superior to the canthal ligament insertion. The medial orbital rim with its attached canthal-bearing segment is then dislocated anteriorly and laterally, brought clearly into view next to the nasal bones, where its supercial position facilitates drilling and wire passing of the central fragment. Nasal bone fragments can be temporarily dislocated or removed to permit better exposure of the medial orbital rim segments. Removing the nasal bones is especially helpful in passing a transnasal wire from the posterior and superior aspect of one central fragment (medial orbital rim canthal bearing bone fragment) to the other. Following the placement of two transnasal wires, one should pass one extra wire for soft tissue reapproximation to bone. The medial orbital rims are linked to adjacent nasal and frontal bone fragments. Junctional plate and screw xation is employed after the initial interfragment wiring is tightened. It should be emphasized that the transnasal reduction wires must be passed posterior and superior to the lachrymal fossa in order to provide the proper direction of force to recreate the preinjury bony position of the central fragments. The transnasal reduction is not a transnasal canthopexy, as it usually does not involve the canthal ligament. It is a reduction only of the central bony fragment of the nasoethmoidal orbital fracture.
may be grasped by one or two passes of 2-0 nonabsorbable suture adjacent to the medial commissure of the eyelids.114,115 This area is accessed through a separate 3 mm external incision on the skin of the canthus oriented vertically or horizontally. Probes may be placed through the lachrymal system to avoid needle penetration of the lachrymal ducts. The lachrymal system may be intubated with disposable Quickert tubes where required. The 2-0 nonabsorbable suture is then passed into the internal aspect of the coronal incision by dissecting above the medial canthal ligament medially, and the suture connected to a separate set of #28 transnasal wires, one set for each canthal ligament, separate from those required for the bone reduction of the central fragment. The transnasal canthal ligament wires are tightened only as the last step of the reduction, after medial orbital and nasal bone grafting are completed and just before closure of the incision. Each set of canthal wires is tightened gently after a manual reduction of the canthus to the bone with forceps is performed, to reduce stress on the canthal sutures. The canthal reduction wire pairs are then twisted over a screw in the frontal bone.
Lacrimal system injury

Interruption of the continuity of the lacrimal apparatus demands specic action. Most lacrimal system obstruction occurs from bony malposition or damage to the lacrimal sac or duct.116,117 The most effective treatment involves satisfactory precise repositioning of the fracture segments. If transection of the soft tissue portion of the canalicular lacrimal system has occurred, it should be repaired over ne tubes with magnication.118
Complications of nasoethmoidal orbital fractures

The early diagnosis and adequate treatment of nasoethmoidal orbital fractures achieves optimal aesthetic results with the least number of late complications. Depending on the quality of initial treatment and the results of healing, further reconstructive surgery may be required in some cases. Late complications, such as frontal sinus obstruction, occur in less than 5% of isolated nasoethmoidal orbital fractures.119,120 Deformities and functional impairment are late complications can be minimized by early diagnosis and proper open reduction. The presence of a nasoethmoidal orbital fracture may be obscured by the swelling of other facial injuries and may escape detection. Only after several weeks nasal deformity and enophthalmos may become more evident.121,122

The zygoma is a major buttress of the midfacial skeleton. It forms the malar eminence, giving prominence to the cheek, and forms the lateral and inferior portions of the orbit. The zygomatic bone has a quadrilateral shape with several processes that extend to reach the frontal bone, the maxilla, the temporal bone (zygomatic arch), and orbital processes (Fig. 3.21). The zygoma meets the maxilla medially at the inferior orbital rim and inferiorly at the maxillary alveolus. The
Canthal reattachment
If the canthal ligament requires reattachment (the canthal tendon is rarely stripped from bone), the canthal tendon112,113
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SECTION I
Facial fractures
zygomatic bone articulates with the external angular process of the frontal bone superiorly, and with the greater wing of the sphenoid in the lateral orbit. In the inferior orbit, it articulates with the maxilla. On the inner surface, beyond the orbital rim, it is concave and then convex and participates in the formation of the temporal fossa. The bone has its broadest and strongest attachment with the frontal bone and then with the maxilla. Thinner and weaker attachments occur with the sphenoid and through the zygomatic arch. The zygoma forms the greater portion of the lateral and inferior orbit including the anterior half of the lateral wall of the orbit. In most skulls, the zygoma forms the lateral and superior wall of the maxillary sinus. The bone furnishes attachments for the masseter, temporalis, zygomaticus major and minor, and the zygomatic head of the quadratus labii superiorus muscles. The zygomaticotemporal and zygomaticofacial nerves123 pass through respectively, to innervate the soft tissues over the region of the FIG 3.21 zygomaticofrontal junction and malar eminence.
APPEARS ONLINE ONLY
Physical diagnosis and surgical pathology of zygoma fractures

Although the zygoma is a sturdy bone, it is frequently injured because of its prominent location. Moderately severe blows are absorbed by the bone and transferred to its buttresses. Severe blows may cause separation of the zygoma at its articulating surfaces and high energy injuries may cause shattering of the body of the zygoma, often through weak areas such as the zygomaticofacial foramen. As the zygoma is disrupted, it is usually displaced in a downward, medial, and posterior direction. The direction of displacement, however, varies with the direction of the injuring force and with the pull of the muscles, such as that of the masseter. The zygoma may be shattered, resulting in comminution not only of the body, but the zygomas articulating attachments. The zygoma is the principle buttressing bone between the maxilla and the cranium. Fractures usually involve the inferior orbital rim and result in hematoma which is limited by the orbital septum. Periorbital and subconjunctival hematomas are the most accurate physical signs of an orbital fracture associated with a zygoma fracture. Numbness of the infraorbital nerve is a common symptom as well. The infraorbital nerve runs in a groove in the posterior portion of the orbit and enters a canal in the anterior third of the orbit behind the infraorbital rim.124 It may be crushed in a fracture, as the fracture occurs in the weak area of bone penetrated by the infraorbital foramen. Direct force to the lateral face may result in isolated fractures of the temporal extension of the zygoma (zygomatic arch), and the zygomatic process of the temporal bone. The zygomatic arch may be fractured in the absence of a fracture of the remainder of the zygoma and its articulations. Medial displacement of an isolated arch fracture is usually observed, and if its displacement is sufcient, the arch itself may impinge against the temporalis muscle and coronoid process of the mandible resulting in restricted mandibular motion. Fractures in the posterior portion of the zygomatic arch may enter the glenoid fossa and produce stiffness or a change in occlusion because of the swelling in the joint or muscles. In high energy injuries or gunshots, fragments of bone can be driven through the temporal muscle and make
contact with the coronoid process and precipitate the formation of a brous or bony ankylosis, necessitating excision of the bone of the coronoid process and scar tissue as a secondary procedure. Fracture dislocation of the zygoma with sufcient displacement to impinge on the coronoid process requires considerable backward dislocation of the malar eminence. About half of fracture dislocations of the zygoma result in separation at the zygomaticofrontal suture, which is palpable through the skin over the upper lateral margin of the orbit. Level discrepancies or step deformities at the infraorbital margin can usually be palpated in the presence of inferior and medial orbital rim displacement. The lateral and superior walls of the maxillary sinuses are involved in fractures of the zygoma, and the resulting tear of the maxillary sinus lining results in the accumulation of blood within the sinus with unilateral epistaxis. The lateral canthal attachment is directed towards Whitnalls tubercle located approximately 10 mm below the zygomaticofrontal suture. The ligament extends toward a shallow eminence on the internal aspect of the frontal process of the zygoma. When the zygoma is displaced inferiorly, the lateral attachment of the eyelids is also displaced inferiorly giving rise to an antimongoloid slant of the palpebral ssure. The globe follows the inferior displacement of the zygoma with a lower (inferior) position after fracture dislocation. Displacement of the orbital oor allows displacement of the rim. Dysfunction of the extraocular muscles may be noted as a result of the disruption of the oor and lateral portion of the orbit. The mechanism of diplopia is usually muscular contusion. Displacement of the globe and orbital contents may also occur as a result of downward displacement of Lockwoods suspensory ligament, which forms an inferior sling for the globe and orbital contents. Lockwoods ligament attaches to the lateral wall of the orbit adjacent to Whitnalls tubercle. Fragmentation of the bony orbital oor may disrupt the continuity of the suspensory ligaments of the globe and orbit, and orbital fat may be extruded from the intramuscular cone and herniate into the maxillary sinus, where it may become incarcerated or attached to sinus lining or bone segments by the development of adhesions. Double vision is usually transient in uncomplicated fractures of the zygoma which always involve the orbital oor. Diplopia may persist when the fracture is more extensive, especially if a fracture extends to comminute the inferior orbital oor. This diplopia may result from muscle contusion, incarceration of perimuscular soft tissue, or actual muscle incarceration or simply drooping of the muscular sling. The orbital portion of the fracture communicates with fractures of the inferior orbital rim. Frequently, one or two small maxillary fragments at the inferior orbital rim are fractured adjacent to its junction with the zygoma, and are called buttery fragments. These rim fractures result in considerable instability of the rim with inferior and posterior displacement. The orbital septum attaches to the orbital rim and is also displaced downward and backward creating a downward pull on the lower eyelid. The infraorbital nerve travels obliquely from lateral to medial across the oor of the orbit.125 In the posterior portion of the orbit, the nerve is in a groove and in the anterior portion of the orbit is located in a canal. Adjacent to the orbital rim, the canal turns downward and exits approximately 10 mm
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Classication of zygoma fractures
65
below the upper edge of the inferior orbital rim. The foramen is aligned parallel with the medial margin of the cornea when the eye is in straightforward gaze. The infraorbital nerve is often compressed by fractures, since the canal and groove represent a weak portion of the bone. Laceration of the nerve in the canal, when crushed by impaction of bone fragments may result in permanent anesthesia. The nerve is frequently contused, and although temporary symptoms of infraorbital nerve hypesthesia are present initially they usually partially resolve. After zygomatic fractures, sensory disturbances of a more minimal nature have been detected in up to 40% of patients.126130 Persistent total anesthesia following fracture may represent an indication for exploration and decompression of the infraorbital nerve with neurolysis, although the efcacy of the procedure has not been conrmed in large series. Knight and North131 proposed a classication in 1961 of fractures of zygoma, based on the direction of anatomic displacement and pattern created by the fracture. This classication, which was used for predicting the success of a closed reduction, is presented for acquaintance with classical knowledge about post reduction stability. The Knight and North classication, claried by Yanagisawa,132 identied fractures with complete dislocation of the zygomaticofrontal suture, and comminuted fractures with external rotation as unstable. Presently, surgical practice is to explore the zygoma and the articular processes involved in complete fractures, in an effort to achieve direct anatomic alignment and provide xation. In current practice, closed reductions are only employed in isolated zygomatic arch fractures. Limited reductions are very popular today, such as the use of the gingival buccal sulcus approach alone.133,134 Such an approach is indicated in fractures which are greensticked at the Z-F suture, have a minimal or linear orbital oor component which would be reduced by the zygomatic reduction, and are displaced principally at the Z-M buttress at the maxillary alveolus. These limited reductions reduce the number of the incisions and thus the morbidity of open reduction, accounting for rapid and efcient procedures with reduced scarring and no eyelid morbidity.
Frequently, zygomatic fracture displacement is minimal and requires no treatment (25%). Most displaced zygomatic fractures are medially and posteriorly dislocated. In about 5075% of those, an anterior gingival sulcus approach alone can be utilized.
Minimalist approach for fractures without zygomaticofrontal suture diastasis

In this approach, the gingivobuccal sulcus is opened and the anterior face of the maxilla and zygoma are degloved. The infraorbital rim and infraorbital nerve are visualized from an inferior direction. Palpation with a nger on the rim avoids entry of elevators into the orbit as the maxilla and zygoma are dissected. The infraorbital nerve is protected by the dissection and is immediately seen after detaching the levator anguli oris muscle. The zygoma may often be reduced by placing the tip of an elevator in the lateral aspect of the maxillary sinus directly underneath the malar eminence (not into the orbit!), and levering the body of the zygoma rst outward and then forward. Alternately, a Carrol-Girard Screw (Walter Lorenz Co., Jacksonville, FL) can be placed in the malar eminence through a percutaneous incision, and manipulated (Fig. 3.22). Another reduction approach involves placing a hook elevator beneath the anterior zygomatic arch and malar eminence and raising both the arch and the body of the zygoma. In gingival buccal sulcus approaches, after the reduction maneuver has been completed, zygomatic stability depends upon a relatively intact, greensticked, zygomaticofrontal suture. The oor of the orbit can be inspected with an endoscope through the maxillary sinus. It is also possible to tell from a pre operative CT the degree of orbital oor comminution. Fractures with orbital oor comminution require a gingival approach and an inferior eyelid incision. FIG 3.22 APPEARS ONLINE ONLY
Endoscopic conrmation of orbital oor integrity

In the endoscopic conrmation of orbital integrity, nger pressure on the globe ballottes the soft tissue and allows the perception of integrity of oor support to be determined by an endoscope placed in the maxillary sinus, visualizing the area of movement and degree of soft tissue prolapse. If there is signicant motion over an area which exceeds a nickel in size, the orbital oor should be repaired endoscopically through the sinus. This may be accomplished with an alloplastic material such as Medpor,135137 or by replacement of the orbital oor fracture fragments themselves, uniting them to intact bone with rigid xation.

Zygoma fractures may be classied into those that require an anterior treatment approach for treatment and those fewer fractures that require a simultaneous anterior and posterior approach.
Fractures with Z-F suture diastasis

If the Z-F suture demonstrates diastasis, then an exposure of this suture needs to be accomplished for stabilization. This could be accomplished through the lateral portion of an upper blepharoplasty incision (<1 cm) which is made directly over the Z-F suture 810 mm above the lateral canthus). Palpating the frontal process of the zygoma between the thumb and index nger, the frontal process can be marked precisely in eyelid skin. The incision should be short and not progress laterally out of eyelid skin, as it will scar noticeably. Alternately, the Z-F suture may be approached through a brow laceration or by superior dissection from a subciliary or conjunctival
Anterior approach
The anterior approach may be partial or complete and potentially involves up to three incisions: (1) access to the zygomaticofrontal suture; (2) access to the inferior orbital rim; and (3) access to the zygomaticomaxillary buttress, anterior maxilla and malar prominence. Sometimes (1) and (2) may be accomplished with the same incision, such as a subciliary incision with canthal detachment. Many surgeons prefer not to detach the canthus because of the need to accurately replace it back on the frontal process.
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Facial fractures
Fig. 3.23 (A,B) Frontal 3D craniofacial computer tomography scan of a right zygomaticomaxillary fracture in a 22-year-old male who sustained craniofacial injuries following a sports related injury, pre- and post-open reduction and internal xation of the right zygomaticomaxillary complex and orbital oor fractures. (C) Postoperative frontal photograph view of patient 3 months following surgery.
lower lid incision by canthal detachment. Another approach is through the lateral conjunctiva. The inferior portion of the orbit may be approached through a midtarsal, lower orbital rim, subciliary, or conjunctival incision. The conjunctival fornix incision produces the least cutaneous scarring but the exposure may be restricted by fat prolapse. The treatment of a zygoma fracture has recently become quite specic, and directed only at areas that require open reduction for conrmation of alignment or for xation (Fig. 3.23).
Posterior approach (coronal incisions)

Fractures with extreme posterior displacement, and those with lateral displacement of the zygomatic arch benet from the addition of a coronal incision. The coronal incision allows exposure of the entire zygomatic arch and roof of the glenoid fossa for precise arch reconstruction. It also exposes the Z-F suture and the lateral orbital wall. Any sagittally oriented split of the glenoid fossa should be reduced rst, following which reduction and xation of the remainder of the zygomatic arch may be accomplished, conrming alignment in the lateral wall of the orbit and medial position of the arch. When the orbital process of the zygoma comes in line with the broad surface of the greater wing of the sphenoid, the arch is of the proper length and medial position (which guarantees the proper projection of the malar eminence). Medially displaced arch fractures, whether isolated or part of a more extensive zygomatic fracture, may be managed through Gilles or Dingman approaches, to be described later.
Treatment of fractures of the zygoma

Closed reduction
Formerly, closed reduction techniques were employed for most zygomatic fractures. The Knight and North classication,138 were meant to identify those fractures which were stable following closed reduction. In practice, many fractures
can be treated adequately with closed reduction, and especially where cost is an issue, this treatment would have to be considered. Those fractures amenable to closed reduction include medial displaced isolated arch fractures, and simple large segment or single piece zygoma fractures in which the displacement is medial and posterior, without comminution at the buttresses, and the fracture at the Z-F suture is incomplete. An elevator placed beneath the malar eminence allows the zygoma to be popped back into position. The stability of closed reduction depends on the integrity of periosteal attachments and principally greensticking at the Z-F suture. The force of contraction of the masseter muscle tends to create displacement.139 Zingg and colleagues achieved stability in closed reductions by impaction against adjacent articulating bones.140,141 Displacement at the Z-F suture,142 comminution of the inferior orbital rim or Z-M buttress, and lateral displacement of the arch and body are characteristics that were found to predict a poor result from closed reduction. Disappointment and frustration in the management of zygomatic fractures has been experienced after use of closed reduction. Complications include residual diplopia, malunion, and deformity, all of which indicate incomplete reduction or displacement following initial reduction. A more complete exposure of the fracture sites, including the zygomaticomaxillary buttress, has been recommended.143145 Their exposures provide the ability to visualize the anatomic accuracy of the reduction. In zygomatic fractures accompanied by Le Fort fractures, considerable lateral displacement of the zygoma is often observed with comminution of the arch. In cases of extreme posterior dislocation, exposure and anatomic reduction of the arch through a coronal incision restores proper anterior projection and alignment in the lateral orbit between the greater wing of the sphenoid and the orbital process of the zygoma.
Buttress articulations and alignment

Six points of alignment with adjacent bone may be conrmed with craniofacial exposure: Z-F suture, infraorbital rim, zygomaticomaxillary buttress, greater wing of the sphenoid, orbital
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High energy zygoma fractures
67
oor, and zygomatic arch. The orbital oor may require reconstruction with bone or articial materials such as Medpor or titanium. The inferior orbital ssure is an area where under correction of volume of the orbit is frequent, as are the inferiomedial buttress and the medial orbital wall.
Methods of reduction
Reduction through the maxillary sinus
Lothrop146 employed a Caldwell-Luc maxillary antrostomy. The elevator contacts the posterior surface of the malar eminence. Upward, outward, and superiorly directed forces reduced the zygoma. A Carroll-Girard screw (Walter Lorenzo, Jacksonville, FL) may also be utilized percutaneously (Fig. 3.22), or from an intraoral approach.
Temporal approach
A temporal approach for the reduction of zygomatic fractures was described by Gilles and colleagues.147 An incision is made behind the temporal hairline, and dissection accomplished to expose the temporalis muscle. An elevator was placed behind the zygomatic arch or under the malar eminence, depending on the areas of reduction required (Fig. 3.24). A small, 2 cm incision placed vertically within the temporal hair heals with an inconspicuous scar. The elevator must be placed deep to the deep temporal fascia, visualizing the temporalis muscle. The bone may be palpated with one hand to document the accuracy of reduction, while the other hand guides the elevator into position and corrects the displacement by force application. A folded towel placed in the temporal area protects the thin temporal bone from fracture. A gentle elevation often clicks the arch into position. Moving the elevator back and forth with repeated elevation movements may disrupt the periosteum holding the arch fragments together, and an open reduction would then be required. FIG 3.24 APPEARS ONLINE ONLY
Dingman approach
An incision (or laceration) is used in the lateral brow approximately 1.5 cm in length. A periosteal elevator is passed through the incision behind the malar eminence and into the temporal fossa. The elevator is used to control the position of the zygoma, and to reduce it by upward, forward, and outward forces. After the reduction, the orbital oor can be explored and reduced.148
the masseter muscle, and suggested that stability with less than 3 plates would be possible. Elliss conclusions were based upon actual human measurements of bite forces after zygomatic fracture treatment. Davidson and colleagues151 studied combinations of wires and plates at the anterior xation sites and determined that 3 point xation was ideal at preventing displacement. Miniplates were recommended as at least one strong buttress as well as 2 and 3 point xation. Plate bending and bone splitting at the screw or drill holes was the mechanism of failure. Kasrai and collegues152 studied the miniplate versus the bioresorbable systems. Titanium provided 39% of the strength of the nonfractured area and bioresorbable systems provided 13% of the intact breaking strength. Deformation or bending of miniplates was the primary mode of failure. Manson et al. and Solomon153,154 performed experiments with stainless steel systems and found bone fractures were the primary mode of failure. This study implied that the titanium and resorbable systems are considerably less strong than the bone itself, but the stainless steel system compared favorably to the bone strength. Rohrich and Watumull155 found plate xation to be superior to wire xation after a thorough study. They also found that xed deformities were quite challenging to correct. OHara et al.156 demonstrated that 2 and 3 point xation with miniplates were superior to other methods of xation. Rohner and colleagues157 studied combinations of plate xation and concluded that the addition of xation within the lateral wall of the orbit was one of the most stable constructs. They demonstrated that titanium systems had one-third and bioresorbable <10% of the strength of the intact zygomatic complex. Plate bending was the cause of the failure of the titanium system, whereas plate and screw breakage was the cause of the failure in the resorbable system. Gosain et al.158 demonstrated in parietal calvarial bone that in compression and distraction, titanium miniplates were considerably stronger than the bioresorbable systems. Therefore, there seems to be justication for using 3 plates, one each at the zygomaticofrontal suture, infraorbital rim and zygomaticomaxillary buttress. The upper 2 plates could be of the 1.3 mm system, and the lower plate of the 1.5 or 2.0 mm system.
High energy zygoma fractures

Violent injury to the zygoma results in shattering of the bone into multiple fragments. The method of management of complicated fractures must include a thorough visualization of the body, the frontal and maxillary processes of the zygoma and the zygomatic arch.159,160 The zygomaticomaxillary buttress is restored by direct intraoral plate and screw xation and wire reduction at the Z-F suture, infraorbital rim and perhaps the zygomatic arch for temporary positioning. An eyelid incision may provide exposure of the inferior rim and lateral wall. Wires allow minimal adjustments to improve reduction before application of rigid xation. The entire lower and lateral zygoma may be exposed with an eyelid incision, dissecting the lateral canthal ligament off Whitnalls tubercle. The lateral aspect of the incision may therefore be retracted upward to expose the zygomaticofrontal suture. The lateral wall of the orbit is best inspected through a lower lid or coronal incision. The canthal ligament may be detached for
Fixation required to achieve stability

Several individuals have examined zygomatic stability following open reduction. Rinehart et al.149 studied cadaver heads and used 1, 2, or 3 miniplates and accessed stability of noncomminuted zygoma fractures submitted to static and oscillating loads to simulate the effect of the masticatory apparatus on postoperative displacement. Neither single miniplate nor triple wire xation was enough to stabilize the zygoma against simulated masseter forces, however 3 miniplates were sufcient which stabilized the Z-F, Z-M and infraorbital rim areas. Del Santo and Ellis150 felt that Rinehart and Marsh overestimated the postoperative forces that could be generated by
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Facial fractures
Fig. 3.25 (A) Frontal 3D craniofacial computer tomography scan of a Le Fort II type injury in a 33-year-old who sustained craniofacial injuries following a high speed motor vehicle collision. (B) Pre- and post-open reduction and internal xation of the left orbital and zygomaticomaxillary complex.
exposure. In the lateral wall, one conrms alignment of the orbital process of the zygoma with the greater wing of the sphenoid (Fig. 3.25).
The maxillary sinus approach, with and without endoscopic assistance

The maxillary sinus approach may include endoscopic visualization of the orbital oor and the sinus ostea. The orbital oor may be, replaced and stabilized with either small plates or by insertion of an alloplastic material. The sinus should have any blood or bone fragments removed and discarded. One should be able to irrigate freely into the nose through the sinus, conrming the integrity of the maxillary sinus ostea.
The intraoral approach

This approach is one of the most important approaches for reduction of zygomatic fractures. A gingivobuccal incision is made 1 cm above the attached gingiva, and then deepened through the buccinator straight to the anterior maxillary wall until the periosteum is identied. The periosteum is incised and reected superiorly as a mucoperiosteal ap, exposing the entire anterior wall and lateral buttress of the maxilla and all of the anterior and lateral portions of the zygomaticomaxillary buttress. The dissection may be extended medially to the piriform aperture as required. The dissection then progresses superiorly and the entire malar eminence exposed. One should visualize the anterior edge of the masseter muscle inserting on the lower aspect of the malar prominence. The infraorbital foramen is reached after detaching the levator anguli oris muscle. The infraorbital foramen is seen just above this muscle, and the contents of the infraorbital canal protected by careful dissection. A Kelly clamp or elevator may then be placed through the anterior wall of the fractured maxillary sinus (Caldwell-Luc) with the tip placed directly under the malar eminence. Gentle pressure is used to elevate the body of the zygoma anteriorly and laterally. An elevator may also be placed intraorally underneath the arch and medial arch fractures reduced. Impacted or partially healed fractures
may be dislodged by passing the osteotome through the line of the fracture, completing the fracture. The zygomaticomaxillary buttress may be reconstructed by using either temporary positioning wires or a loose reduction with a plate and a single screw in each fragment. A bone graft may be placed into any gap in the Z-M buttress or over the anterior wall of the maxillary sinus. An L-shaped plate is generally used at the zygomaticomaxillary buttress, and its solid xation depends on at least two stable screws beyond the areas of fracture in intact bone on each side. Fixation with a 1.5 or 2 mm system at the Le Fort I level is recommended. Tooth roots inferiorly should be avoided. In practice, screws which penetrate teeth have not had the frequency of adverse sequelae initially predicted. The buttery buttress bone pieces may be screwed to the plate. Since the zygoma conceptually requires three or four incisions for visualization of all of its buttress alignments, and since one can only look through one incision at a time, the use of temporary interfragment wire positioning for several of these fracture sites allows temporary control of displacement of the zygoma fracture while one is looking through the other fracture exposures. The technique allows more control of the displacement prior to rigid xation. In zygomatic fractures demonstrating only medial displacement, management with an anterior approach is satisfactory. A coronal incision is not required. The medially displaced zygomatic arch may be managed by a supplemental Gillestype approach used to perform a closed reduction of the arch segment. Anterior approaches permit the reduction of the anterior portion of the zygoma. Small plate and screws can then be used to span the fracture sites and provide positive xation once the buttress alignment has been conrmed. Two screws per fragment in solid bone provide good immobilization. Often, a ve-hole plate is selected for the Z-F suture with the central hole placed over the fracture site. Screws placed in comminuted bone do not provide secure xation. In providing plate and screw xation for a comminuted fracture of the orbital rim, the fragments may be removed, pieced together on a back table with a plate applied, and then the center fragments reinserted into the defect. Alternately, the defect can be spanned by a plate and then the intervening fragments individually screwed to the plate.
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Compound comminuted fractures of the zygoma
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Compound comminuted fractures of the zygoma

Fractures of the zygoma may be compounded intraorally or extraorally when the force is severe enough to cause soft tissue wounds. A thorough inspection of the wound must be made to rule out the presence of foreign material, grass, debris, road dirt, and blood clots. Wood fragments are especially hazardous since they are colonized, driven in the soft tissue, and are not easily perceived at the time of wound inspection. In isolated zygomatic arch fractures that demonstrate the tendency for medial displacement, some individuals use a protective splint, externally, to prevent displacement of the arch. If the reduction is performed carefully and precisely, the segments of the fractures are wedged, and the arch fracture will be stable without external support.
Delayed treatment of fractures of the zygoma

Repositioning after 2 weeks frequently requires osteotomy of the fracture sites to mobilize for reduction. After the bone has been mobilized, an inspection of each fracture site should be conducted to remove any area of brous ankylosis or any proliferative bone which was not present originally as its presence may prevent proper alignment. Plate and screw xation then unites the segments. In fractures treated late, the masseter muscle may require division or mobilization from the inferior surface of the malar eminence and arch in order to allow the bone to be repositioned superiorly. The masseter muscle contracts in length in the case of the malreduced fracture, and it may not be able to be extended to length after several weeks have elapsed. Fractures treated delayed are more safely treated with osteotomy than mobilization by blunt forces. Mobilization of partially healed fractures may result in new fracture lines extending deep within the orbit, occasionally precipitating blindness. These forcible reduction techniques carry the risk of radiating fractures extending into the apex of the orbit, with cranial nerve injury.
Fig. 3.26 (A) Soft tissue and bone deformity with enophthalmos, lateral canthal dystopia, ectropion, and soft tissue slippage in the midface. The lateral mandibular dentition is rotated lingually. (B) Enophthalmos, skeletonization of the orbital rim, scleral show, and retraction (balling up) of midface soft tissue; slippage of the thick tissue off the malar eminence is caused by lack of soft tissue closure and lack of stabilization and xation of the soft tissue onto the bone.
Late complications
Late complications of zygomatic fractures include nonunion, malunion, double vision, infraorbital nerve anesthesia or hypesthesia, and chronic maxillary sinusitis. Scarring may result from laceration or malpositioned incisions. Generally, ectropion and scleral show are mild, and resolve spontaneously. About 10% of patients having subciliary incisions of the lower eyelid develop a temporary ectropion. Gross downward dislocation of the zygoma results in diplopia and orbital dystopia (Fig. 3.26). Usually, more than 5 mm of inferior globe dystopia is required to produce diplopia. Treatment164,165 involves zygomatic mobilization by osteotomy with bone grafting to augment the malar eminence when malar projection is decient. The position of the eye must be restored with intraorbital bone grafts or alloplastic material. Infection is not common, and usually responds to sinus or lacrimal drainage. Preexisting maxillary sinusitis or obstruction predisposes to infection, and the maxillary sinus should be cleared by endoscopic surgery before an elective osteotomy is performed.
Complications of zygomatic fractures

Bleeding and maxillary sinusitis
Bleeding into the maxillary sinus is usually of short duration. It may be necessary to irrigate blood clots from the antrum and to remove bone fragments, which sequester. Rarely, the ostea of the maxillary sinus will be occluded by the fractures, and require endoscopic sinus surgery. In those patients with preexisting sinus disease, acute exacerbation may be a complicating factor. Proper sinus drainage into the nose must be conrmed by free irrigation of saline into the nose at the time of Caldwell-Luc exposure. Otherwise, a persistent oral antral stula may result in the sublabial area. Malfunction of the extraocular muscles occurs as a result of damage from fracture forces (contusion) or less frequently interference by segments of bone, orbital oor injury or fat or muscle entrapment. Several cases of blindness have occurred after malar fracture reduction.161163
Orbital complications
Orbital complications consist of diplopia, visual loss, globe injury, enophthalmos or exophthalmos, and lid malposition (Fig. 3.26). Impacted fractures of the zygomatic arch which abut the coronoid process may result in ankylosis. The gunshot wound is especially prone to this problem. If the zygomatic arch cannot be repositioned, coronoidectomy through an intraoral route usually frees the mandible from the ankylosis and permits normal function. It is important that the patient vigorously exercise to preserve and improve the range of motion obtained, which may take 6 months.
Numbness
Persistent anesthesia or hypesthesia in the distribution of the infraorbital nerve usually lasts only a short time. If total
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Facial fractures
anesthesia exists for over 6 months, it is likely that the nerve is severely damaged or perhaps transected. If the nerve is impinged by bone fragments, especially in a medially and posteriorly impacted zygoma fracture, reduction or decompression of the infraorbital canal and neurolysis are indicated. Bone spurs, or constricting portions of the canal should be removed so that the nerve has an adequate opportunity for regeneration and relief of pressure. The nerve must be explored throughout the oor of the orbit so that it is free from any compression by bone fragments, scar tissue or callus. Anesthesia is annoying, especially immediately after the injury. Patients generally partially accommodate to the neurological decit. Some spontaneous reinnervation may occur from adjacent facial regions as well as regrowth of axons through the infraorbital nerve. Usually some vague sensation is then present.
Frontal attachment Cranial base Orbital buttress Nasoethmoid region
Nasofrontal buttress Zygomatric buttress Mandibular buttress
Oral-antral stula
An oral-antral stula requires debridement of bone or mucosa, conrmation of maxillary sinus drainage into the nose and closure with a transposition mucosal ap for cover. A 2-layer closure is required. A bone graft may be placed in between the layers of soft tissue. The buccal fat pad can be mobilized and sewn into the defect prior to the mucosa being sutured over it. Rarely, a distant ap is required for difcult persistent stulae.
Pterygomaxillary buttress
Plate complications
Complications include screw loosening or extrusion, plate exposure requiring removal and tooth root penetration by screws. Prominent plates over the zygomatic arch is directly due to associated soft tissue atrophy (temporalis) and to malreduction of the zygomatic arch laterally. Probably 10% of plates placed at the Le Fort I level need to be removed for exposure, non healing wound or cold sensitivity.
Midface buttresses
The midface is a system of sinus cavities where certain thicker areas (or buttresses) are present and provide considerable structural support. The important midface supporting skeleton consists of horizontal and vertical structural supports connected by thin plates of bone. The areas of structural support are the thicker pillars and must be anatomically reconstructed or repositioned to reestablish the preinjury facial bone architecture. The vertical supports consist of the nasal septum in the midline and the nasomaxillary, zygomaticomaxillary, and pterygoid buttresses anteriorly and laterally (Fig. 3.27). The nasomaxillary buttress extends along the pyriform aperture through the frontal process of the maxilla superiorly to the internal angular process of the frontal bone. The zygomaticomaxillary buttress extends through the bony mass of the body of the zygoma and through the frontal process of the zygoma to the external angular process of the frontal bone. Posteriorly, the pterygoid plates provide posterior stabilization of the vertical height of the midface and form the third or posterior maxillary buttress. The horizontal buttresses of the midface consist of the inferior orbital rims, the associated
Fig. 3.27 The verticeal buttresses of the midfacial skeleton. Anteriorly, the nasofacial buttress skirts the piriform aperture inferiorly and composes the bone of the medial orbital rum superiorly to reach the frontal bone at its internal angular process. Laterally the zygomaticomaxillary buttress extends from the zygomatic process of the frontal bone through the lateral aspect of the zygoma to reach the maxillary alveolus. A component of the zygomaticomaxillary buttress extends laterally through the zygomatic arch to reach the temporal bone. Posteriorly, the pterygomaxillary buttress is seen. It extends from the posterior portion of the maxilla and the pterygoid fossa to reach the cranial base structures. The mandibular buttress forms a strong structural support for the lower midface in fracture treatment. This support for maxillary fracture reduction must conceptually be achieved by placement of both jaws in intermaxillary xation. The other transverse maxillary buttresses include the palate, the inferior orbital rims, and the superior orbital rims. The superior orbital rims and lower sections of the frontal sinus are also known in the supraorbital regions as the frontal bar and are technically frontal bone and not part of the maxilla. (From Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an approach to the management of Le Fort fractures. Plast Reconstr Surg 1980;66:54.)
orbital oor, the zygomatic arch and the palate at the level of the maxillary alveolus.166
Inspection
Epistaxis, bilateral ecchymosis (periorbital, subconjunctival, scleral) facial edema, and subcutaneous hematoma are suggestive of fractures involving the maxillary bone. The swelling is usually moderate to severe indicating the severity of the fracture. Malocclusion with an anterior open bite and rotation of the maxilla suggest a fracture of the maxilla. The maxillary segment is frequently displaced downward and posteriorly, resulting in a class III malocclusion and premature occlusion in the posterior dentition with an anterior open bite. On internal examination, there may be tearing of the soft tissues in the labial vestibule of the lip or the palate, ndings
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Le Fort classication of facial fractures
71
that indicate the possibility of an alveolar or palate fracture. Hematomas may be present in the buccal or palatal mucosa. The face, after several days, may have an elongated, retruded appearance, the so-called donkey-like faces suggestive of a craniofacial disjunction. An increase in mid-facial length is seen.
intermaxillary xation. The latter maneuver manually reduces the fracture, reduces movement and bleeding, and is the single most important treatment of a maxillary fracture.
Alveolar fractures
Simple fractures of the portions of the maxilla involving the alveolar process and the teeth can usually be digitally repositioned and held in reduction while an arch bar is applied to these teeth. The arch bar may be acrylated for stability, or an open reduction may utilize unicortical plates and screws to unite the alveolar fragment to the remainder of the maxilla. The position of the teeth may be maintained by ligating the teeth in the fractured segment to adjacent teeth with the use of an arch bar and interdental wiring technique. Fixation of the alveolar segment should be maintained for at least four to twelve weeks or until clinical immobility has been achieved.170
Palpation
The bone should be palpated with the tips of the ngers both externally through the skin and internally intraorally. Bilateral palpation may reveal step deformities of the zygomaticomaxillary suture, indicating fractures of the inferior orbital rims. These ndings suggest a pyramidal fracture of the maxilla or conrm the zygomatic component of a more complicated injury, such as a Le Fort III fracture. Intraoral palpation may reveal fractures of the anterior portion of the maxilla or fractured segments of the alveolar bone.
Digital manipulation
Manipulation of the maxilla may conrm movement in the entire middle third of the face, including the bridge of the nose. This movement is appreciated by holding the head securely with one hand and moving the maxilla with the other hand (Fig. 3.5). Crepitation may be heard when the maxilla is manipulated in loose fractures. The manipulation test for maxillary mobility is not entirely diagnostic because impacted or greenstick fractures may exhibit no movement but still possess bone displacement.

Le Fort (1901) completed experiments that determined the areas of structural weakness of the maxilla which he designated lines of weakness. Between the lines of weakness were areas of strength. This classication led to the Le Fort classication of maxillary fractures, which identies the patterns of midfacial fractures (Fig. 3.28).171 It should be emphasized that the usual Le Fort fracture consists of combinations of these patterns in that pure bilateral Le Fort I, Le Fort II, or Le Fort III fractures are less common than combination patterns.172 The level of fracture is frequently different on one side from the other, and usually the fracture is more comminuted on the side of the injury.
Malocclusion of the teeth

If the mandible is intact, malocclusion of the teeth is highly suggestive of a maxillary fracture. It is possible, however, that the malocclusion relates to a preinjury condition. A thorough study of the patients dentition with reference to previous dental records and pictures is helpful.
Goals of Le Fort fracture treatment

Goals in the treatment of Le Fort fractures include: Restoration of midfacial height and projection Providing proper occlusion Restoring the integrity of the nose and orbit The structural supports between the areas of the buttress and maxillary alveolus must also be restored to provide for the proper soft tissue contour.
Cerebral spinal rhinorrhea or otorrhea

Cerebral spinal uid may leak from the anterior or middle cranial fossa in high Le Fort fractures and is then apparent in the nose or ear canal. A uid leak signies the presence of a dural stula extending from the intracranial subarachnoid space through the skull and into the nose or ear.167 Frequently the drainage is obscured by bloody secretions in the immediate post injury period.168,169
Radiological examination
Maxillary fractures are easily demonstrated in craniofacial CT scans, with the exception that fracture lines in minimally displaced fractures are more difcult to see. The presence of bilateral maxillary sinus opacity should always suggest the possibility of a maxillary fracture.
Transverse (Guerin) fractures or Le Fort I level fractures

Fractures which traverse the maxilla horizontally above the level of the apices of the maxillary teeth section the entire alveolar process of the maxilla, vault of the palate and the inferior ends of the pterygoid processes in a single block from the upper craniofacial skeleton. This type of injury is known as the Transverse, Le Fort I or Guerin fracture. This horizontal fracture extends transversely across the base of the maxillary sinuses and is almost always bilateral. The fracture level varies from just beneath the zygoma to just above the oor of the maxillary sinus and the inferior margin of the pyriform aperture (Fig. 3.29).
Treatment of maxillary fractures

Treatment of maxillary fractures is initially oriented toward the establishment of an airway, control of hemorrhage, closure of soft tissue lacerations and placement of the patient in
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SECTION I
Facial fractures
P P1
Z N
P1
Fig. 3.28 The Le Fort classication of midfacial fractures. (A) The Le Fort I (horizontal or transverse) fracture of the maxilla, also known as Guerin fracture. (B) The Le Fort II (or pyramidal) fracture of the maxilla. In this fracture, the central maxilla is separated from the zygomatic areas. The fracture line may cross the nose through its cartilages or through the middle nasal bone area, or it may separate the nasal bones from the frontal bone through the junction of the nose and frontal sinus. (C) The Le Fort III fracture (or craniofacial disjunction). In this fracture, the entire facial bone mass is separated from the frontal bone by fracture lines traversing the zygoma nasoethmoid, and nasofrontal bone junctions. (D) Buttresses of the midface. N, nasofrontal buttress; Z, zygomatic buttress; P , pterygomaxillary buttress; P1, posterior height and anteroposterior projection must be maintained in complicated fractures. This is especially true in Le Fort fractures accompanied by bilateral subcondylar fractures. (AC from Kazanjian VH, Converse J. Surgical Treatment of Facial Injuries, 3rd edn. Baltimore MD: Williams & Wilkins; 1974.)
Fig. 3.29 Frontal 3D craniofacial computer tomography scan of a Le Fort I type injury pre- and post-open reduction and internal xation.
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Pyramidal fractures or Le Fort II level fractures

Blows to the central maxilla, especially those involving a frontal impact, frequently result in fractures with a pyramidally shaped central maxillary segment. This is a Le Fort II central maxillary segment and the fracture begins above the level of the apices of the maxillary teeth laterally and posteriorly in the zygomaticomaxillary buttress and extends through the pterygoid plates in the same fashion as the Le Fort I fracture. Fracture lines travel medially and superiorly to pass through the medial portion of the inferior orbital rim and extend across the nose to separate a pyramidally-shaped central maxillary segment from the superior cranial and midfacial structures. The fracture line centrally may traverse the nose high or low to separate superior cranial from midfacial structures (Fig. 3.30).
Craniofacial dysjunction or Le Fort III fractures

Craniofacial dysjunction may occur when the fracture extends through the zygomaticofrontal suture and the nasal frontal suture and across the oor of the orbits to effectively separate all midfacial structures from the cranium. In these fractures, the maxilla is usually separated from the zygoma, but occasionally (5% of Le Fort III fractures) the entire midface may be a large single fragment, which is often only slightly displaced and immobile. These fractures are usually minimally displaced and present only with black eyes and with subtle occlusal problems. The Le Fort III segment may or may not be separated through the nasal structures. In these fractures, the entire midfacial skeleton is incompletely detached from the base of the skull and suspended by the soft tissues and greensticked fracture (Fig. 3.31).173
Le Fort I level fractures

In fractures of the Le Fort I type, placing the patient in intermaxillary xation may be all that is necessary in the case of a minimally mobile fracture. In most cases, however, the Le Fort I level should be opened through a gingival buccal sulcus incision and the fractures reduced and stabilized with plate and screw xation at the bilateral nasomaxillary and zygomaticomaxillary buttresses. The primary consideration in Le Fort I fracture treatment is to reestablish a functional dental occlusion and this should be accomplished as soon as possible. Proper midfacial height and projection are achieved by open reduction.
Le Fort II level fractures

In the case of a simple Le Fort II level fracture, the patient is rst placed in intermaxillary xation. The fracture should be opened at the Le Fort I level through a gingival buccal sulcus incision and through both lower eyelids to provide reduction and xation at the zygomaticomaxillary and nasomaxillary buttresses and at the inferior orbital rims. The need
Fig. 3.30 Frontal 3D craniofacial computer tomography scan of a Le Fort II type injury pre- and post-open reduction and internal xation.
Fig. 3.31 Frontal 3D craniofacial computer tomography scan of a Le Fort III type injury pre- and post-open reduction and internal xation.
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SECTION I
Facial fractures
for opening fractures crossing the nose must be assessed by the CT scan and the displacement at the nasofrontal junction.
drainage of the maxillary sinus by enlarging its orice may be required.
CSF rhinorrhea
High Le Fort (II, III) level fractures may be associated with fractures of the cribriform area, which produce cerebrospinal uid rhinorrhea and/or pneumocephalus. Antibiotic therapy may be utilized in these fractures at the discretion of the attending surgeon. Although antibiotic prophylaxis in CSF rhinorrhea has been quite widely employed, it is difcult to prove that antibiotics have substantially reduced the incidence of meningitis accompanying cerebrospinal uid rhinorrhea when administered over a prolonged period. Blowing of the nose and placement of obstructing nasal packing should be avoided.
Le Fort III fractures

Open reduction of Le Fort III fractures generally involves combining procedures at the Le Fort I, Le Fort II and zygomatic levels reduction in a single operation.
Postoperative care of maxillary fractures

The postoperative management of fractures of the maxilla consists of the usual general care of the facial fracture patient, including three times daily dental and oral hygiene, lip lubrication, mouthwashes, skin care and abrasion and laceration cleansing and lubrication with antibiotic ointments. Provision of adequate nutrition may be accomplished with a nasogastric tube or percutaneous gastrostomy. A liquid diet may be permitted with IMF, and a soft diet if the IMF is released. Cleansing and aspiration of the nose and mouth is very important. The presence of a fever in patients with facial fractures should always prompt a sinus evaluation by radiographs if the fever cannot be explained by other sources. Any foul odor to the breath necessitates inspection, cleaning and/ or a return to the operating room for irrigation and a thorough examination.
Blindness
Blindness is a rare complication of fractures of the orbit, and as such, may complicate fractures of the Le Fort II and III level. It is rare for the optic nerve to be severed by bone fragments. The most common etiology is a traumatic shock to the nerve or swelling of the nerve within the tight portion of the optic canal or interference with the capillary blood supply of the optic nerve by swelling and edema.
Late complications
Late complications of fractures of the maxilla include those referable to the orbit and zygoma, since these areas form a portion of the upper Le Fort (II and III) fractures. Specic complications referable to the maxilla include nonunion, malunion, plate exposure, lacrimal system obstruction, infraorbital and lip hypesthesia or anesthesia, and devitalization of teeth. There may be changes in facial appearance due to differences in midfacial height and projection, and differences in the transverse width of the face or dental arch.
Complications of maxillary fractures

Airway
In almost all cases of extensive fractures, the airway is partially compromised by posterior displacement of the fracture fragments and by edema and swelling of the soft tissues in the nose, mouth, throat and oor of the mouth. In some patients, a nasopharyngeal airway may assist in establishing a route for ventilation. In other patients, intubation or tracheostomy may be indicated to provide a secure airway.
Nonunion and bone grafting

True nonunion of the maxilla is rare and usually follows failure to provide even the most elementary type of intermaxillary xation or open reduction. If nonunion occurs, the treatment consists of exposure of the fracture site, resection of the brous tissue in the fracture site, reduction of the displaced segments, removal of any proliferative bone edges, placement of bone grafts in all the existing gaps, and stabilization by plate and screw xation.
Bleeding
Hemorrhage may be managed by carefully identifying and ligating vessels in cutaneous lacerations, and by tamponade in closed midface injuries with anterior posterior nasopharyngeal packing, manual reduction of the displaced maxilla and placing the teeth in intermaxillary xation. Angiographic embolization and the combination of external carotid and supercial temporal artery ligation are usually unnecessary.
Malunion
In multiple (complex) pan facial fractures, malunion may result from inadequate diagnosis, inadequate reduction or inadequate xation. The period of intermaxillary xation and observation may need to be longer when the injury is more comminuted.
Infection
Maxillary fracture wounds are less complicated by infection than are mandibular fractures. Although, they are contaminated at the time of the injury, by entry into adjacent sinuses, fractures of the teeth and open intraoral wounds. Fractures passing through the sinuses do not usually result in infection unless there has been preexisting nasal or sinus disease, or in case of persistent obstruction of the sinus orice by displaced bone fractures or blood clot. If the maxillary sinuses are obstructed, a nasal-antral window or preferably endoscopic
Malocclusion
If malocclusion is detected, it may respond to elastic traction. Once partial healing has occurred, attempts to reestablish occlusion with elastics may simply extrude or loosen the
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Lower facial fractures
75
teeth. Revision of the reduction after removal of the internal xation devices or a new osteotomy may be necessary. When new (secondary) osteotomies are necessary, generally a Le Fort I osteotomy for repositioning of the tooth bearing segment of the maxilla is preferred as opposed to a higher level osteotomy. Occasionally, segmental osteotomies of the maxillary arch may be necessary to achieve optimal dental relationships.
IMF screws
This is a rapid method of immobilizing the teeth in occlusion, given good dentition and uncomplicated fracture types. The number and position of the IMF screws is based on the fracture type, fracture location and surgeon preference. Screws must be positioned superior to the maxillary tooth roots and inferior to the mandibular tooth roots (Fig. 3.32). The prominence, position, and anatomic conguration of the mandible are such that it is one of the most frequently injured facial bones. Following automobile accidents, the mandible is the most commonly encountered fracture seen at many major trauma centers. The mandible is a movable, predominantly U-shaped bone, consisting of horizontal and vertical segments. The horizontal segments consist of the body and the symphysis centrally. The vertical segments consist of the angles and rami, which articulate with the skull through the condyles and temporomandibular joints. The mandible is attached to other facial bones by muscles and ligaments and articulates with the maxilla through the occlusion of teeth. The mandible is a strong bone, but has several weak areas that are prone to fracture. The body of the mandible is composed principally of dense cortical bone with a small substantia spongiosa, through which blood vessels, lymphatics, and nerves pass. The mandible is thin at the angles where the body joins with the ramus and can be further weakened by the presence of an unerupted third molar or a previous dental extraction.176 The mandible is also weak at the condylar neck, cuspid root (the longest root) and mental foramen, through which the mental nerve and vessels extend into the soft tissues of the lower lip. The weak areas for fractures are the subcondylar area, angle, distal body, and the mental foramen.177179 Timely loss of teeth results in atrophic changes of the alveolar bone
Nasolacrimal duct injury

The nasolacrimal duct may be transected or obstructed by the fractures extending across the middle-third of the facial skeleton between the Le Fort I and Le Fort III levels. Anatomic repositioning of the fracture fragments of the medial portion of the maxilla and nasoethmoidal orbital area provides the best protection against obstruction. Obstruction of the lacrimal system produces dacryocystitis174 and may require external drainage.
Lower facial fractures

Mandible fractures
Craniofacial fractures frequently involve the jaws. Fischer et al.175 in 2001, looked at mandible fractures that were caused by motor vehicle collisions and found associated injuries in 99%. Fractures of the jaws invariably produce malocclusion. Knowledge of the dentition is thus an absolute prerequisite for the proper treatment of jaw fractures. Restoration of the occlusion usually indicates anatomic reduction and proper positioning of the jaws and facial bones.
Dental wiring and xation techniques

Arch-bars
Prefabricated arch-bars are ligated to the external surface of the dental arch by passing 24 or 26 gauge steel wires around the arch-bar, and around the necks of the teeth. The wires are twisted tightly to individual teeth to hold the arch-bars in the form of the dental arch. If segments of teeth are missing, or if anterior support of the arch-bar is needed to balance the forces generated by elastic traction anteriorly, the arch-bar may be stabilized by additional wires passed to the skeleton (skeletal wires). Suspension wires may be passed through drill holes at the piriform margin or around screws. This is particularly applicable in children where the structure of the teeth tends to render arch-bars less stable. The mandibular arch-bar may also be stabilized by wires passed to a screw at the lower mandibular border, or by circummandibular wiring. It cannot be over emphasized that the stability and alignment of a fracture reduction depends greatly on the alignment of the teeth achieved by this initial application of arch-bars. Dental relationships are used to describe tooth movements and interdental relations. A malocclusion can sometimes be corrected by the simple use of orthodontic rubber bands. At the end of a course of fracture treatment, if there is mobility at the fracture site, xation may be easily reestablished for a short period by reapplying IMF.
Fig. 3.32 The use of intermaxillary xation screws for intermaxillary xation. These devices do not provide the stability or exibility obtained from arch bars and full intermaxillary xation. Numbers of patients have been thought to be in good occlusion with this technique when actually they were in an open bite, were malreduced, and required osteotomy or fracture revision. Crossed wires may also be used to buttress the screw support obtained. (Courtesy of Synthes Maxillofacial, Paoli, PA.)
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SECTION I
Facial fractures
Condyle Coronoid
Third molar
Ramus
Alveolar process Angle Canine root Mental foramen Parasymphysis Body
Fig. 3.33 Classication of mandibular fractures.
and alters the structural characteristics of the mandible. Fractures often occur through the edentulous areas rather than through the areas better supported by adequate tooth and alveolar bone structures.180 Mandibular movements are determined by the action of reciprocally placed muscles attached to the bone. When fractures occur, displacement of the segments is inuenced by the pull of the muscles attaching to the segments. The direction of the fracture line may oppose forces created by these muscles.
symphysis or the body area. The fracture will be demonstrated by abnormal movement, and the condition and the symptom reinforced by the presence of discomfort. The mandible may be pulled forward with one hand while the other hand is placed one nger in the ear canal and one nger over the condylar process (Fig. 3.4). Abnormal mobility or crepitus indicates a fracture in the condylar/subcondylar area, or ligament laxity, indicating a temporal mandibular joint injury. The most reliable nding in the fractures of the mandible, in dentulous patients, is the presence of a malocclusion. Often, the most minute malocclusion caused by the fracture is quite obvious to the patient. The patient may be unable to move the jaw (dysfunction), and request liquid foods that require minimal jaw movement and mastication. Speech is difcult because of pain on motion of the mandible. Crepitation may be noticeable by manipulation of the fracture site. Often, the necessary manipulation produces such discomfort that it is not wise to demonstrate this physical sign. Swelling is usually quite obvious and frequently associated with ecchymosis and a hematoma. Often, an intraoral laceration is present over fractures in the horizontal portion of the mandible. There is frequently deviation to one side or the other; a nding that supports the diagnosis of a fracture. Tenderness over the fracture site is present, especially in the region of the temporomandibular joint. Such tenderness is highly suggestive of a fracture.
Muscles inuencing mandibular movement

Muscle function is an important variable inuencing the degree and direction of muscular displacement of the fractured mandible. Overcoming the forces of mandibular displacement is also important in designing reduction and xation. The posterior group of muscles is commonly referred to as the muscles of mastication and includes the temporalis, masseter, and medial and lateral pterygoid muscles. The overall activity is to move the mandible in a general upward, forward, and medial direction.
Classication of mandibular fractures

Mandibular fractures are classied according to location (Fig. 3.33), condition of teeth, direction of fracture and favorability for treatment, presence of compound injury through the skin or mucosa, and anatomical fracture pattern.
Clinical examination and diagnosis

Pain and tenderness are usually present upon motion over the fracture and may be noted immediately as a result of injury. Fractures occurring along the course of the inferior alveolar nerve may produce numbness in the distribution of the nerve, which represents numbness of the ipsilateral lower lip (mental nerve) and ipsilateral teeth. The patient is unable to open the mouth or bring the teeth into proper occlusion (trismus). The patient may refuse to eat or to brush his teeth, which then causes discomfort and an abnormal, foul-smelling odor (fetor oris). Excessive saliva is often produced as a result of local irritation (drooling). Small gingival or mucosal lacerations between teeth indicate the possibility of a fracture. These gaps make the fracture compound into the mouth.
The temporomandibular joint

The function and anatomy of this joint are important in considering injuries of the mandibular condyle. It is a ginglymodiarthrodial joint capable of a hinge-like action, as well as gliding and rotating action. The joint is composed of the articular head, condyle, and glenoid fossa. The glenoid fossa forms a portion of the oor of the middle cranial fossa. The articular surface of both the condyle and the temporal fossa is covered with a thin, smooth, layer of cartilage surrounded by connective tissue, which differentiates into an inner and outer layer. The inner layer or synovial membrane secretes a viscous uid lubricant that minimizes friction and aids smooth joint functioning. The outer layer of the connective tissue is intimately associated with ligaments that surround the joint, and provides an enveloping capsule within which the articular surfaces function. The joint is separated into two distinct chambers, one above and the other below an articular disc composed of brocartilage known as the meniscus. Movement of the articular disc is controlled by the attachments of the lateral pterygoid muscle that insert, through the capsule of the joint, into the anterior disc and by the attachment of the disc to the posterior portion of the joint capsule. The hinge,
Diagnosis
Bimanual manipulation of the mandible causes mobility or distraction at the fracture site, especially when the fracture occurs in the body or parasymphysial area. One hand should stabilize the ramus, while the other manipulates the
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Treatment of class I fractures
77
rotating, and gliding movements of the temporomandibular joint are controlled by muscles attached to the mandible. The movement of the disc is regulated by its ligaments, and injuries to the ligaments result in abnormal disc motion, which produce clicking, rocking, and pain.
Fractures inuencing displacement of fractured mandibular segments

The direction and extent of displacement depends on the site of the fracture, direction of the fracture and direction of muscle pull, direction and intensity of displacement forces, and presence or absence of teeth in the fragments. In fractures of the mandible, the segments may be displaced in the direction of the strongest muscular action.
posteriorly forward and medially, displacement would take place in a medial direction because of the medial pull of the elevator muscles of mastication (vertically unfavorable, or VU). The fracture that passes from the lateral surface of the mandible posteriorly and medially is a favorable fracture because the muscle-pull tends to prevent displacement. It is called a vertically favorable fracture (VF).
The presence or absence of teeth in the fractured segments

Upper displacement of the posterior segment is prevented by occlusal contact of the lower against the upper teeth. The elevator muscles of the mandible pull the posterior segment forward. The anterior group of muscles depresses the anterior segments of the mandible, separating the teeth anterior to the fracture from the upper teeth. A single tooth in the posterior fragment may be extremely important, and should be retained, as the tooth acts as an occlusal stop and provides some stability for fracture alignment.182,183
Direction and angulation of the fracture line

Kelsey Frye and colleagues181 described fractures as favorable or unfavorable according to their direction and bevel of displacement (Fig. 3.34). The muscular forces on some fracture fragments are opposed by the direction and bevel of the fracture line. Thus, in some fractures, the muscular force would pull the fragments into a position favorable for healing, whereas in other fractures, the muscular pull is unfavorable and separation of the fracture fragments occurs by action of the muscular forces. Mandibular fractures that are directed downward and forward are classied as horizontally favorable (HF) because the posterior group of muscles and the anterior group of muscles pull in antagonistic directions, favoring stability at the fracture site. Fractures running from above, downward, and posteriorly are classied as horizontally unfavorable (HU). The bevel of the fracture may also inuence a displacement medially. If a fracture runs from
Treatment principles of mandibular fractures

Establish proper occlusion. Anatomically reduce the fractured bones into their normal position. Utilize xation techniques that hold the fractured bone segments in occlusion and normal position until healing has occurred. Open reduction internal xation (ORIF) can often permit limited function while healing is occurring. Control infection. Methods of xation vary with age, general health, surgical training, and facilities available for treatment. A satisfactory end-result may be accomplished by a number of methods. No method is without its specic requirements and approaches, and of course, advantages, disadvantages, cost, and complications.
Treatment of class I fractures

A
Fig. 3.34 (A,C) The direction and bevel of the fracture line does not resist displacement due to muscle action. The arrows indicate the direction of muscle pull. (B,D) The bevel and direction of the fracture line resist displacement and oppose muscle action. The direction of the muscle pull in fractures beveled in this direction would tend to impact the fractured bone ends. (After Fry WK, Shepherd PR, McLeod AC, et al. The Dental Treatment of Maxillofacial Injuries. Oxford: Blackwell Scientic; 1942.)
Class I fractures are those in which there are teeth on each side of the fracture. Although many of these fractures can be managed by intermaxillary xation (IMF) alone in favorable fractures, if function is desired and post treatment displacement is to be prevented, (i.e., the mandible being used as a basis for Le Fort fracture treatment) internal xation is also preferred. If IMF alone is to be used, the period of xation should constitute 46 weeks.184,185 Many mandibular fractures, even if favorable, are best managed by ORIF. Miniplates may be used for noncomminuted, nonbone gap fractures where impaction of the bone bears a signicant portion of the load of fracture stabilization.186,187 This technique prevents displacement and permits light function. ORIF is especially appealing to patients because the teeth do not need to remain wired, which permits intake of soft foods, oral hygiene and an early return to work. These desirable aspects might not justify open treatment, if external incisions are required which would produce permanent scars.188
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SECTION I
Facial fractures
horizontal mandible but frequently is at the angle. The type and strength of plate needed to control the nontoothbearing fragment and displacement of the fracture will vary according to the direction and bevel of the fracture and the position of the teeth and surrounding muscles. Generally, a larger inferior border plate with a smaller superior border plate is preferred with three screws placed in solid, nonfractured bone to each side of the fracture. The third screw represents insurance against one of the primary two screws becoming loose. One screw inserted in the compression mode may or may not be utilized. Compression screws impact the bone ends under pressure, but can unfavorably change the occlusion.
Fig. 3.35 Large reconstruction plate spans fractures of the entire body. (Courtesy of Synthes Maxillofacial, Paoli, PA.)
Comminuted fractures
Comminution negatively inuences stability, and generally increases the degree of fracture displacement.189 Three screws are utilized for fracture stabilization placed in nonfractured bone on each side of the fracture defect. ORIF is indicated for all class II fractures. Upper and lower border plates are preferred in the horizontal mandible and two plates also in the vertical mandible where possible.
A soft diet, compared with liquid food required for a period of 46 weeks of IMF, is of temporary signicance and should not inuence the surgeons treatment method, if a permanent scar would be necessary.
General principles of reduction and xation

The principle underlying all mandibular fracture treatment is superior and inferior border stabilization. The general method of fracture xation involves arch-bar placement and the use of a superior border unicortical noncompression miniplate. The inferior border is aligned and approximated by a stabilization plate. In severely displaced fractures, provisional stabilization with an inferior border wire assists the proper arch-bar application. The use of the locking plate minimizes the requirement for precise plate bending. Comminuted fractures (Fig. 3.35) require larger xation plates, and are conceptually fractures with bone loss, where the plate itself bears the entire load of xation. In general, fractures of the symphysis-parasymphysis area are broadly exposed with an intraoral degloving technique. Periosteal attachments should be retained where possible, as the periosteal blood supply is often the only remaining circulation (the medullary blood supply is generally injured by the fracture). Adequate exposure, especially for plate and screw xation, demands wider soft tissue mobilization. Experience has shown that free bone fragments will generally survive if stabilization is sufcient and if they are covered by wellvascularized soft tissue. The periosteum, therefore, is not thought to be so important a blood supply that preservation is preferential to improper fracture reduction or inadequate fracture stabilization. A mentalis muscle stump on the bone should always be preserved and the muscle must be repaired during soft tissue closure. In general, both a muscular and mucosal closure of intraoral incisions is always preferred to mucosal closure alone.
Treatment of class III fractures

Class III fractures have no teeth on either side of the fracture. Nondisplaced, immobile fractures conceptually may be treated by a soft diet with close follow up. The majority of class III fractures however, should be managed with rigid xation with superior and inferior border xation. Precise positioning techniques are required in sequence in combined Le Fort and mandibular fractures, such as IMF, dentures or splints.
Extraoral approach to open reduction

The position of an external mandibular incision should always respect the location of the marginal mandibular branch of the facial nerve (Fig. 3.36). The subperiosteal dissection technique also respects neurovascular structures such as the mental nerve. Careful subperiosteal dissection establishes the extent and pattern of the fracture, conrming the impression given from the CT. The fragments at the inferior border of the fracture are aligned with clamps. The occlusal reduction should be checked at this point, and loose arch bar wires on the minor segment are tightened. IMF is then conrmed or established. Usually, a superior border plate is now utilized at the upper border of the mandible and xated with unicortical screws. The occlusion is again checked, alignment of the fractures re-conrmed, and a lower border plate and screws applied. A larger plate may be utilized. Generally, a large plate is initially over bent so that it stands 23 mm off the fracture site. Screw length may be determined by a depth gauge, and bicortical placement is preferred. If a larger plate is used, as the bicortical screws are tightened, the overbent plate attens itself against the outer border of the mandible and reduces the lingual cortex properly. If compression is desired only the rst two screws (one on each side of the
Treatment of class II fractures

In class II fractures, teeth are present only one side of the fracture site and these fractures must have an open reduction. This type of fracture may occur in any portion of the
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Treatment of class III fractures
79
Fig. 3.36 Intraoperative photograph of comminuted mandibular fracture in a 23-year-old male following attempted homicidal gunshot wound to the face pre- and post-open reduction and internal xation via the extra-oral approach using multiple miniplates. Lateral 3D craniofacial computer tomography postoperative scan following open reduction and internal xation of comminuted mandibular fractures.
fracture) are inserted in compression mode; the remainder of the screw holes must be drilled in neutral mode. The compression mode is never used in comminuted or bone defect fractures. After the xation is secure, any initial positioning wires are removed and the musculature repaired. Care must be taken in suture placement to avoid the marginal mandibular branch of the facial nerve, which is located up to 12 cm below the inferior edge of above the inferior mandible.190 The platysma muscle and the skin are closed in layers, and a dependent drain placed. The cutaneous wound is closed in layers with subcuticular sutures to avoid suture marks.
aspect of the mucosa, and mucosal and muscular layers separately incised.
Indications for ORIF of mandibular fractures

Favorable or unfavorable class I fractures where stability is desired. Class II and class III fractures. Comminuted fractures. Displaced fractures and those subject to rotation. Edentulous fractures. The desire to avoid IMF in the postoperative period. Combined fractures of the upper and lower jaws. Uncooperative (head injured) patients. The objectives are the reduction and xation of the fractured segments to make a solid, one-piece mandible. The objective may also include the achievement of rigidity to obtain active and pain-free mobilization without jeopardizing the bone healing process or risk fracture displacement. This latter aim is achieved by accurate anatomic reduction with the patient in proper occlusion and secure soft tissue closure. The emphasis is therefore on simultaneous occlusal and basal bone repositioning and xation (superior and inferior border).
Intraoral approach to open reduction

Any fracture in the horizontal or vertical mandible is usually amenable to an intraoral approach.191194 This is the preferred exposure for any symphysis or parasymphysis fracture, and for noncomminuted angle fractures. The body region is also able to be reduced but may require a percutaneous Trocar approach for drilling and screw placement. In the intraoral approach, the fracture site is exposed through an appropriately placed mucosal incision. The incision is generally brought about a centimeter out of the sulcus on the buccal
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SECTION I
Facial fractures
The surgical technique must emphasize the protection of the soft tissue, and minimize the aesthetic deformity from incisions and exposures, and return the soft tissue to its normal position around the bone.
Selection of internal xation devices for mandibular fractures

Edward Ellis, 3rd195,196 claried the issues regarding the selection of internal xation devices for mandibular fractures. Normal bite forces must be initially countered by xation devices; however, patients who have sustained mandible fractures do not generate normal bite forces for months after the injury. Rigid xation is dened as internal xation that is stable enough to prevent micromotion of the bony fragments under normal function. Most of the time, we do not achieve that; however, it has been recognized that rigidity of the bone fragments is not necessary for healing of the fracture to occur under functional loading. Ellis uses the term functionally stable xation to apply to those forms of internal xation recognized as not rigid but which satisfy the goals of maintaining fragment alignment, permitting healing during limited active use of the bone. Ellis also discusses the concepts of load bearing versus load sharing xation. Load bearing xation devices are of sufcient strength and rigidity that the devices bear the entire loads applied to the mandible during functional activities without impaction of the bone ends (i.e., 2.4 mm reconstruction plate). Load sharing is a form of internal xation that is of insufcient stability to bear all the functional loads applied across the fracture (i.e., 2.0 mm miniplate). It relies on the impaction of the bone on each side of the fracture to bear the majority of the functional load. Compression plates have the ability to compress the fractured bony margins helping to bring them closer together and imparting additional stability by increasing the frictional interlocking between bone edges. While the functional load bearing factors are of advantage, if the plate is not perfectly applied there may be a geometric rearrangement of the fracture fragments over the rst few weeks caused by the dissipation of the
compression forces that can alter the occlusion. This is especially true in oblique fractures. Improper application of the compression plate may cause widening of the mandible if not properly overbent prior to application of the rst two screws. In these cases, the lingual cortices may not contact even though the buccal cortices appear perfectly reduced. Slight over bending of the plate prevents this problem. Locking plate and screw systems function as internal external xators achieving stability by locking the screw to the plate.197 The potential advantages of these xation devices are that precise adaptation of the plate to the underlying bone is not necessary. As the screws are tightened they lock to the plate, thus stabilizing the segments without the need to compress the bone to the plate. This makes it impossible for the screw insertion to alter the reduction. This theoretically makes it less important to have good plate bending, as other plates must be perfectly adapted to the contour of the bone. Theoretically this hardware should be less prone to inammatory complications from loosening of hardware since loose hardware propagates an inammatory response and promotes infection.
Champy or miniplate system

Mandibular xation by the use of smaller miniplates, such as those advocated by Champy and colleagues in 1978198,199 for mandibular fractures, speeded exposure and was more tolerant for mandibular shape and occlusion versus more rigid plates adaption as the screws were tightened. The malleable plates minimized malreductions from plate bending errors common to stiff larger plates. This technique did not result in maximum rigidity achieved with the large plates, but was generally sufcient for good immobilization without great movement at the fracture site for most fractures.200 As such, it was much more user friendly than more rigid systems and rose in popularity to surpass the use of rigid plate systems. Champy recommended two plates (upper and lower border) in the anterior (symphysis and parasymphysis) portion of the mandible, and a single plate along the superior border in the angle and upper border of the distal ramus (Fig. 3.37). The need for additional xation must be assessed
Fig. 3.37 (A) Three-quarter view of 3D craniofacial computer tomography preoperative scan on 16-year-old male who sustained a left mandibular angle fracture and right mandibular parasymphysial fracture following an altercation. (B) Intraoperative photograph of open reduction and internal xation of left mandibular angle fracture using the Champy technique. (C) Three-quarter view of 3D craniofacial computer tomography postoperative scan.
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Selection of internal xation devices for mandibular fractures
81
Fig. 3.38 (A) Placement of two horizontal lag screws to reduce and stabilize a parasymphysis fracture using a trocar device. (Courtesy of Synthes Maxillofacial, Paoli, PA.) (B) Intraoperative photograph of open reduction and internal xation of mandibular symphyseal fracture using lag screws.
carefully, and this technique should be avoided in comminuted fractures and in the multiply-fractured mandible. The technique can only be used where the bone at the fracture site can be compressed by the plate to bear some of the load of the fracture across the impacted bone ends. The use of a brief initial period of rest in IMF (1 week) is used by some practitioners for soft tissue rest and provides an initial period of occlusion where less stress is placed on the fracture and more importantly the soft tissue.
Lag screw technique

This technique is indicated in noncomminuted parasymphysis or symphysis fractures,201203 where a long length of screw can be tolerated (Fig. 3.38). Generally, these screw lengths require 3545 mm anteriorly. A specic technique is utilized where the rst cortex in the bone is over-drilled to the major diameter of the screw. The second segment of the screw path is drilled to the minor diameter of the screw. Only the screw head will engage bone in the rst section of the path, and therefore, as the screw is tightened into the second section of the fracture, the screw head impacts the cortex toward the fracture site as it is tightened. Generally, two lag screws are recommended for each fracture to be stable, for if one becomes loose, the fracture would be unstable by virtue of the rotation. With only one screw, the fracture could still rotate around the single screw. A sleeve or drill guide is used to protect soft tissue. Oblique body or angle fractures may be lag screwed with 23 screws for stability. In screw placement, the angle between the bone and the direction of the screw should bisect a 90 angle from the bone in a plane parallel to the bone.
Fig. 3.39 Three-quarter view of 3D craniofacial computer tomography demonstrating malunion and continuity defect of left mandibular angle fracture with tooth in line of fracture.
Third molars in mandibular angle fractures

Extraction of an impacted 3rd molar must be carefully considered and in some circumstances, where the 3rd molar is partially erupted and inamed, it should be removed at the time of fracture treatment to avoid potential complications (Fig. 3.39).204
Otherwise, it makes little sense to do osteotomies to remove a fully impacted 3rd molar, as further damage to the bone and mucosa in the area of the fracture may actually cause bone necrosis, further expose the fracture to the intraoral environment and contribute to bone instability and infection. Bony support of the fracture may be lost following extraction, and a linear fracture may be converted to a comminuted, less stable fracture by 3rd molar removal. The fracture site is often less vascularized following 3rd molar removal by virtue of periosteal stripping. Fully impacted 3rd molars can be electively removed when fracture healing is completed, unless the operative treatment of the fracture exposes the tooth or tooth removal is necessary to achieve alignment of the fracture.205207
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Antibiotic use
Intravenous administration of antibiotics at the time of the surgery is recommended.208210 This is especially helpful in patients undergoing delayed treatment, patients having long operations, patients with badly contused soft tissue where the fracture treatment is delayed and where the tissues are heavily contaminated, and where multiple intraoral lacerations are present. It is also indicated in patients who are medically compromised, have poor nutritional status or have systemic illness or local conditions of poor dental hygiene, periodontal or dental infections.
hardware removal. Often, the fracture has healed and a repeat osteosynthesis is not necessary. Migration of loose hardware into soft tissue away from the fracture site occasionally occurs.214
Increased facial width and rotation of the mandible

Broadening of the distance between mandibular angles is produced by rotation of the lateral mandibular segments lingually at the occlusal surface of the teeth.215 The distance between the mandibular angles increases as the mandible and lower face widen. This rotation (aggravated by tight IMF and the presence of subcondylar fractures) produces a malocclusion of the buccal cusps and a characteristic broadening and rounding of the face, which is aesthetically and functionally unacceptable. The lingual and palatal open bite is best observed in a dental model obtained after reduction looking internally at the posterior dentition. It may also be noticed on opening the mouth by observing the lingually oblique inclination of the lateral mandibular dentition. This complication cannot be treated by orthodontia, and requires refracture. The use of a long, strong, reconstruction plate to keep the mandibular angles rotated properly and the width narrow is required. In symphysis and parasymphysis fractures, the body and angle segments of the mandible must be held upright by the anteriorly placed plate.
Antibiotic prophylaxis for mandibular fractures

Abubaker and Rollert211 in 2001 published a prospective randomized double-blind study where they did not discern a benet of postoperative oral antibiotics in uncomplicated mandible fractures. Their criteria for infection included purulent drainage from the fracture site, increased facial swelling beyond postoperative day 7, and stula formation at the surgical site or fracture with drainage and fever associated with local evidence of infection, such as swelling, erythema and tenderness. Conceptually, mandible fractures involving tooth bearing regions of the angle and body can be classied as class III or contaminated wounds. Fractures whose treatment is delayed would be classed as class IV or infected wounds. The risk of potential infection in these wounds without the use of prophylactic antibiotics ranges from 22% to 50%. Many studies have indicated that the risk of infection should be as low as 10% with prophylactic antibiotics. In mandible fractures treated by experienced practitioners, the incidence of infection should be as low as 5% or 7%. Chole and Yuee212 concluded that antibiotic prophylaxis was of value only in certain procedures. However, they noted that the majority of the studies surveyed were retrospective and the criteria used for diagnosis were subjective. Chole and Yuee reduced the incidence of infection from 42% to 8.9% in compound mandibular fractures by antibiotic use in facial fractures. Angle fractures have the most signicant risk for infection and body fractures are second in overall frequency. Zallen and Curry213 in an editorial discussing this recommend preoperative, intraoperative and postoperative antibiotics for 5 days.
Nonunion
Nonunion and pseudoarthrosis are uncommon after plate and screw xation.216218 However, their presence may be masked by rigid xation and surgeons should be aware of cases in which plate removal will unmask a poor union. This condition requires re-xation of the fracture after a thorough debridement at the site of poor fracture healing. Revision of xation and bone grafting of any fracture gap under a reconstruction plate is required.
Osteomyelitis
Soft tissue infection is common in mandibular fracture treatment, but true bone infection, osteomyelitis, is not. Local infection may almost always be managed with drainage and antibiotics. The xation must be conrmed as adequate and intraoral closure inspected, and any instability in the fracture xation noted and corrected. Less commonly, devitalized soft tissue and bone fragments that are dead or exposed must be debrided. Fracture stability must be maintained, and may need to be achieved by removal of current xation devices and reapplication of longer, stronger reconstruction plates, whose screw xation is outside the area of problem. In the uncommon persistent infection, the surgeon may wish to convert to external xation, removing all internal xation devices, but most cases may be stabilized with the repeat application of a reconstruction plate, which generally requires the use of a noncompression reconstruction plate with at least four screws on each side of the fracture located distinctly away from the fracture or infection site. No screws should be placed in an area of questionable bone. Serial debridement of devitalized bone and soft tissue may be required to conrm the absence of infection and adequacy of debridement. Secondary bone grafting should be conducted when the soft
Complications after fracture treatment

Malocclusion
Malocclusion is commonly the result of insufcient or inaccurate alignment in initial reduction that is especially common when IMF is poorly applied or loose. Other causes include inadequate nal reduction, inadequate plate contour, or failure of xation. Although subtle malocclusions may be corrected by grinding the occlusal facets of the teeth or orthodontics, any signicant malocclusion requires refracture and/or osteotomy.
Hardware infection and migration

Loose hardware generally creates soft tissue irritation, producing a foreign body response and infection requiring
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Edentulous mandible fractures
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tissue and local area have been cleared of infection by debridement, drainage, antibiotics and dressing changes.
Condylar and subcondylar fractures

One must consider dislocation, angulation between the fragments, fracture override (which translates to ramus vertical length shortening) fracture angulation and bone gaps between the fragments. In children, growth considerations219 create a capacity for both regeneration and remodeling, which is not present in later years.220,221 Adults are capable only of partial restitutional remodeling. High condylar (intracapsular) fractures (head and upper neck) are generally treated with closed reduction with a limited (2-week) period of postoperative IMF, followed by early controlled mobilization utilizing elastics for reestablishing occlusion in a rest position.222 Most neck and low subcondylar fractures with good alignment, reasonable contact of the bone ends and preservation of ramus vertical height without condylar head dislocation may be treated by IMF for 46 weeks, with weekly or biweekly observation of the occlusion for at least 4 additional weeks after release of xation in light function if fracture alignment is reasonable.223,224 Some shortening of the ramus height is almost inevitable with a closed approach to condylar/subcondylar fracture treatment,225228 which may lead to a premature contact in the ipsilateral molar occlusion. Angulation between the fractured fragments in excess of 30 and fracture gap between the bone ends exceeding 45 mm, lateral override, and lack of contact of the ends of the fractured fragments should be a consideration justifying open reduction (Fig. 3.40). Loss of ramus height is rst heralded by a premature contact in the molar dentition on the fractured side, which produces a subtle open bite in the contralateral occlusion. ORIF of subcondylar fractures is preferred for any low, dislocated, fracture in conjunction with a multiply-fractured mandible, or a low fracture, which occurs simultaneous with Le Fort fractures, where the maxilla requires support from the intact mandible.229
Open treatment of a dislocated condylar head fracture brings with it the possibility of condylar head necrosis due to stripping of its blood supply, the possibility of damage to the temporal branch of the facial nerve if a pre-auricular incision is used, or the marginal mandibular branch if a lower (retromandibular or Risdon) incision is used.230
Edentulous mandible fractures

These fractures represent less than 5% of the mandibular fractures.231234 Fractures commonly occur through the most atrophic portions where the bone is thin and weak. The body is a common site for fracture, as compared to the angle and subcondylar region in dentulous patients.235 Many fractures are bilateral or multiple, and displacement of a bilateral edentulous body fracture is often severe and a challenging condition to treat. The fractures in the horizontal mandible may be closed or open to the oral cavity. Closed fractures demonstrating minimal displacement may be treated with a soft diet and avoidance of dentures, however, in these cases, observation is critical to be sure that healing occurs within several weeks without further displacement. In practice, most fractures are better treated with a load-bearing plate. The edentulous mandible is characterized by the loss of the alveolar ridge and the teeth.236 The bone atrophy may be minimal if there is sufcient height (>20 mm) of the mandibular body to ensure good bone healing. In cases with moderate atrophy, the height of the mandibular body ranges from 1020 mm, and healing is usually satisfactory but not as certain if the height were >20 mm. Small plates with few screws often fail, as there is insufcient bone to provide buttressing support for the fracture treatment, and the plate must bear the entire load of the fracture. Large reconstruction (locking) plates with three screws per side are recommended (Fig. 3.41). In cases where the mandibular height is <10 mm (severe atrophy), one can assume that the patient has a disease of poor bone healing. Complications following edentulous mandible fractures directly parallel the extent of mandibular atrophy. Obwegeser
Fig. 3.40 (A,B) Lateral view of 3D craniofacial computer tomography on a 20-year-old female involved in a motor vehicle collision who sustained craniofacial injuries, pre- and post-open reduction and internal xation of a right mandibular subcondylar fracture via a retromandibular extra-oral approach. Note that the patient also had a Le Fort II type fracture that was treated with closed reduction and interdental xation. (C) Lateral prole view photograph of patient 1 year postoperatively.
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Fig. 3.41 Lateral view of 3D craniofacial computer tomography on a 64-year-old edentulous female, with a history of osteogenesis imperfecta who was referred for treatment of a malunion of a left mandibular fracture postoperative open reduction and internal xation using a load bearing mandibular plate and iliac bone grafting via an extra-oral approach.
and Sailer,237 in 1973 documented that 20% of the complications in edentulous mandible fractures were seen in the 10 20 mm mandibular height group, and 80% of the complications (i.e., poor or unsatisfactory bone union) were experienced in cases demonstrating a mandibular height <10 mm. Virtually no complications were seen in fractures exceeding 20 mm in height. This experience caused some authors238,239 to recommend primary bone grafting, if there was no intraoral communication, for the severely atrophic edentulous mandible (10 mm in height) that required open reduction.240 It should be emphasized, however, that some severely atrophic mandible fractures may be treated without xation (soft diet alone) if there is minimal instability and no displacement. In this treatment technique, the patients dentures should be removed until healing has occurred.
severely the patient is injured, cutaneous wounds can be cleansed and closed, devitalized tissue removed, and the patient placed in intermaxillary xation. This is the minimum urgent treatment of a signicant maxillary or mandibular injury and may always be accomplished, despite the condition of the patient. Presently, a one-stage restoration of the architecture of the craniofacial skeleton is the preferred method of treatment for severely comminuted, multiply-fractured facial bones.241 Open reduction of all fracture sites is performed with plate and screw xation, supplementing bone defects with bone grafts. Although local incisions may be useful in selected cases, regional incisions such as the coronal, transconjunctival, upper and lower gingival buccal sulcus and the retromandibular incisions provide the complete exposure. In some cases, these exposures may be avoided because of the use of a suitable laceration. In each subunit of the face, the important dimension to be considered rst is facial width. In less severe fractures, correction of facial width is not challenging and an anterior alone approach is sufcient. Control of facial width in more severe injuries requires more complete dissection and alignment of each fracture component with all the peripheral and cranial base landmarks. Reconstructions which emphasize control of facial width are in fact the scheme which reciprocally restores facial projection. The timing of soft tissue reduction is critical. Repositioning of the bone and replacement of the soft tissue must be accomplished before the soft tissue has developed signicant memory (internal scarring) in the pattern of an abnormal bone conguration if a truly natural result is to be achieved. Soft tissue replacement requires: (1) layered closure; (2) reattachment of this closed soft tissue to the facial skeleton at several points, so that the tissue is rst realigned and then repositioned onto an anatomically assembled craniofacial skeleton.
Order of procedure
Various sequences have been suggested such as top to bottom, bottom to top, outside to inside, or inside to outside. In reality, it does not make any difference what the order is, as long as the order makes sense and leads to a reproducible, anatomically accurate bone reconstruction, however, in our experience, it is more predictable to stabilize the occlusion in comminuted fractures by relating the maxilla to the mandible, than by relating the inferior maxilla to the superior maxilla.
The panfacial injury

Conceptually, panfacial fractures involve all three areas of the face: frontal bone, midface, and mandible. In practice, when two out of these three areas are involved, the term panfacial fracture has been applied.
Complications of panfacial fractures

Complications of panfacial fractures include complications referable to the bone and the soft tissue. The most common bony facial deformities following midface fracture treatment relate to lack of projection, enophthalmos, malocclusion, and increased facial width (Fig. 3.42). Positional deformities seen in the frontal region that lead to midfacial subunit malposition are posterior and inferior positioning of the superior orbital rims and attened frontal contour. The most common soft tissue deformities are descent, diastasis, fat atrophy, ectropion, thickening and rigidity. Lack of periosteal closure over the zygomaticofrontal suture produces
The treatment of panfacial fractures

The optimal time for the easiest treatment of these injuries is within hours of the accident, before the development of massive edema and soft tissue rigidity that follow these injuries. This early treatment is only possible when other systems are not injured or are evaluated to exclude signicant problems, managed and stabilized. However, no matter how
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Low velocity gunshot wounds
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Fig. 3.42 Lack of restoration of the preinjury appearance, even if the underlying bone is nally replaced into its proper anatomic position, is the result of scarring within soft tissue. Examples of soft tissue rigidity accompanying malreduced fractures include the conditions of enophthalmos, medial canthal ligament malposition, short palpebral ssure, rounded canthus, and inferiorly displaced malar soft tissue pad. The lower lip has a disrupted mentalis attachment. Secondary management of any of these conditions is more challenging and less effective than is primary reconstruction. A unique opportunity thus exists in immediate fracture management to maintain expansion shape and position of the soft tissue envelope and to determine the geometry of soft tissue brosis by providing an anatomically aligned facial skeleton as support. Excellent restoration of appearance results from primary soft tissue positioning.
Fig. 3.43 Skeletonization of the frontal process of the zygoma from failure to close the temporal fascia to the orbital periosteum over the frontal process.
the appearance of temporal wasting because of the gap in the temporal aponeurosis and skeletalization of the frontal process of the zygoma (Fig. 3.43). Incisions for arch exposure made higher in the posterior layer of the deep temporal fascia with dissection through the fat to reach the zygomatic arch produce fat atrophy by direct fat damage (interference with its middle temporal blood supply). Incisions in the deep temporal fascia just immediately above the arch minimize damage to this fat.
Postoperative care
Patients with large segment fractures may be adequately stabilized by plate and screw xation to permit early release of intermaxillary xation. Patients with comminuted midface or panfacial fractures are best served by varying periods of postoperative intermaxillary xation in addition to plate and screw xation. Intermaxillary xation has more importance than has been emphasized in the recent literature. It is an unexcelled positioning and stabilizing device for the lower midface segment, both acutely at the initial reduction and postoperatively as required.
reconstruction. Recently, immediate reconstruction,242,243 and immediate soft tissue closure with serial-second-look procedures has become the standard of care.244,245 The philosophy of delayed closure of these difcult wounds is no longer appropriate and delays effective rehabilitation of the affected individuals, some of whom represent suicide attempts.246 Recent experiences emphasize the safety and efcacy of immediate soft tissue closure and bone reconstruction in an anatomically correct position. These two principles prevent soft tissue shrinkage and loss of soft tissue position and provide improved functional and aesthetic results with shorter periods of disability and an improved potential for rehabilitation both functionally and aesthetically. Ballistic injuries are classied into low, medium, and highenergy deposit injuries.247,248 In formulating a treatment plan for ballistical injuries, it is helpful to identify the entrance and exit wounds, the presumed path of the bullet, and to appreciate the mass and velocity of the projectile, so that the extent of internal areas of tissue injury can be predicted. Conceptually, the separate categories of soft tissue and bone injury, and soft tissue loss and bone loss must all be individually assessed (four separate components) for each injury, and the areas of each recorded. The areas of injury and the areas of loss are each precisely outlined according to a facial pattern, which allows a treatment plan to be developed for early and intermediate treatment for the lower, middle and upper face.

Low energy deposit ballistic weapons usually involve projectiles that have a limited mass and travel at speeds of <1000 feet per second. In general, low velocity gunshot wounds involve little soft tissue and bone loss and have limited
Gunshot wounds of the face

The treatment of gunshot and shotgun wounds of the face remains controversial, in that most authors advocate delayed
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associated soft tissue injury outside the exact path of the bullet. It is thus appropriate that they be treated with denitive stabilization of bone and primary soft tissue closure. Limited debridement of involved soft tissue is necessary. Small amounts of bone may need to be debrided or replaced with a primary bone graft, which can be performed primarily safely in the upper face. Because of the lack of signicant associated soft tissue injury, little potential for progressive death or progressive necrosis of soft tissue exists, and these injuries may be treated as facial fractures with overlying lacerations both conceptually and practically.
close distribution, at close range, is capable of causing massive injury. In civilian practice, many of these injuries represent shotgun wounds or high-energy rie injuries, and they often result from suicide attempts or assaults. Close range shotgun wounds are characterized by extensive soft tissue and bone destruction.
Treatment
Intermediate and high velocity ballistic injuries to the face must be managed with a specic treatment plan that involves stabilization of existing bone and soft tissue in anatomic position, and maintenance of this bone and soft tissue stabilization throughout the period of soft tissue contracture and bone and soft tissue reconstruction. Wounds from intermediate and high-energy missiles usually demonstrate areas of both soft tissue and bone loss, as well as areas of soft tissue and bone injury. Usually, less loss of bone and soft tissue is present than is rst suspected. It is important to reassemble the existing
Intermediate and high velocity ballistic injuries to the face

Shotgun pellets have a large mass and are considered intermediate energy deposit projectiles. They travel at speeds of approximately 1200 feet per second, and when grouped in a
Fig. 3.44 (A,B) Frontal photographs of a 34-year-old male following a self-inicted gunshot wound injury to the face demonstrating severe midfacial and mandibular fractures. (C) Intraoperative photographs following open reduction and internal xation of mandibular fractures using a load bearing mandibular plate and a monocortical miniplate xation via an extra-oral approach. (D,E) Frontal 3D craniofacial computer tomography scan of the patient pre- and post-open reduction and internal xation of midfacial and mandibular fractures. (F) Postoperative photograph 1 year following surgery.
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bone and soft tissue, and then at intervals to carryout serial surgical debridement second look procedures, which re-open the soft tissue to dene additional areas of soft tissue necrosis, drain hematoma and/or developing uid collections, and assure bone integrity. These second look procedures are imperative if primary reconstruction is attempted. Thus, the emphasis is on primary soft tissue, skin to skin or skin to mucosa closures, with stabilization of existing bone fragments in anatomical position. Re-exploration for additional debridement occurs at 48-hour intervals, or at an interval determined by the surgeon. These second look procedures are necessary and are continued until all soft tissue loss ceases and wound hematoma and uid collections are controlled. In each classication, a zone of injury is identied where fractures are present without signicant bone or soft tissue
loss. Fractures in the zone of injury are managed as routine facial fractures. When soft tissue and bone loss are present, it is important to stabilize existing bone in its anatomical position until soft tissue reconstruction can be completed. The soft tissue should be closed as far as possible to stretch and maintain length and shape of the soft tissue. In some cases, it may be possible to plan a more complex reconstruction of bone and soft tissue simultaneously by a composite free tissue transfer (Fig. 3.44). The use of local tissue for soft tissue reconstruction, such as a local ap, ultimately provides the best cutaneous match and aesthetic result, but they may only be sufcient for the skin and require a deeper free ap reconstruction over which the cutaneous segment is stretched. These local aps can be rotated over free tissue transfers to improve their color and contour match.
Bonus images for this chapter can be found online at http://www.expertconsult.com

Fig. 3.1 Cutaneous incisions (solid line) available for open reduction and internal xation of facial fractures. The conjunctival approach (dotted line) also gives access to the orbital oor and anterior aspect of the maxilla, and exposure may be extended by a lateral canthotomy. Intraoral incisions (dotted line) are also indicated for the Le Fort I level of the maxilla and the anterior mandible. The lateral limb of an upper blepharoplasty incision is preferred for isolated zygomaticofrontal suture exposure if a coronal incision is not used. A horizontal incision directly across the nasal radix is the one case in which a local incision can be tolerated over the nose. In many instances, a coronal incision is preferable unless the hair is short or the patient is balding. Fig. 3.2 Palpation of the superior and inferior orbital rims. (A) The superior orbital rims are palpated with the pads of the ngertips. (B) Palpation of the inferior orbital rims. One should feel for discontinuity and level discrepancies in the bone of the rim and evaluate both the anterior and vertical position of the inferior orbital rims, comparing the prominence of the malar eminence of the two sides of the face. Fig. 3.3 An intraoral examination demonstrates a fracture, a gingival laceration, and a gap in the dentition. These alveolar and gingival lacerations sometimes extend along the oor or roof of the mouth for a considerable distance. Fig. 3.4 Condylar examination. The mandible is grasped with one hand, and the condyle area is bimanually palpated with one nger in the ear canal and one nger over the head of the condyle. Abnormal movement, or crepitation, indicates a condylar fracture. In the absence of a condylar fracture, a noncrepitant movement of the condylar head should occur synchronously with the anterior mandible. Disruption of the ligaments of the condyle will permit dislocations of the condylar head out of the fossa in the absence of fracture. Fig. 3.5 With the head securely grasped, the midface is assessed for movement by grasping the dentition. Loose teeth, dentures, or bridgework should not be confused with mobility of the maxilla. Le Fort fractures demonstrate, as a rule, less mobility if they exist as large fragments, and especially if they are a single fragment, than do lower Le Fort fractures. More comminuted Le Fort fractures demonstrate extreme mobility (loose maxillary fractures). Fig. 3.10 Endoscopic approach through the maxillary sinus permits direct visualization of the orbital oor and manipulation of the soft tissue and oor repair. Fig. 3.15 Reduction of a nasal fracture. (A) After vasoconstriction of the nasal mucous membrane with oxymetazoline-soaked cotton applicators, the nasal bones are outfractured with the handle of a #3 scalpel without the blade. (B) The septum is then straightened with an Asch forceps. Both the nasal bones and the septum should be able to be freely dislocated in each direction (C) if the fractures have been completed. If the incomplete fractures have been completed properly, the nasal bones may then be molded back into the midline and remain in reduction (D). Care must be taken to avoid placing the reduction instruments into the intracranial space through a fracture or congenital defect in the cribriform plate. The cribriform plate (vertical level) may be detected with a cotton-tipped applicator by light palpation and its position noted and avoided with reduction maneuvers. (E) Steri-Strips and adhesive tape are applied to the nose, and a metal splint is applied over the tape. The tape keeps the edges of the metal splint from damaging the skin. A light packing material is placed inside the nose (such as Adaptic or Xeroform gauze) to minimize clot and hematoma in the distal portion of the nose. Fig. 3.21 The zygoma and its articulating bones. (A) The zygoma articulates with the frontal, sphenoid, and temporal bones and the maxilla. The dotted area shows the portion of the zygoma and maxilla occupied by the maxillary sinus. (B) Lateral view of the zygoma. (From Kazanjian VH, Converse J. Surgical Treatment of Facial Injuries, 3rd edn. Baltimore MD: Williams & Wilkins; 1974.) Fig. 3.22 (A) A Carroll-Girard screw may be placed through a small incision in the malar eminence into the body of the zygoma and the position of the zygomatic bone manipulated. (B) The screw is placed in position to align the rim. Fig. 3.24 (A) Incision marked and checking position of elevator. (B) Elevator placed beneath deep temporal fascia supercial to muscle to reach depressed segment of arch, which is elevated in a smooth maneuver.
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Facial fractures
Access the complete reference list online at http://www.expertconsult.com

36. Rodriguez ED, Stanwix MG, Nam AJ, et al. Twentysix-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques. Plast Reconstr Surg. 2008;122(6):18501866. Landmark article describing the longest experience with treating frontal sinus fractures and provides an algorithm for its treatment based on their outcomes, to minimize long-term complications. 104. Tessier P, Guiot G, Rougerie J, et al. Osteotomies cranio-naso-orbital-facials. Hypertelorism Ann Chir Plast. 1967;12:103. An article by the father of craniofacial surgery describing the possibilities of an intracranial approach for orbital reconstructive surgery. 107. Markowitz B, Manson P, Sargent, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: The importance of the central fragment in treatment and classication. Plast Reconstr Surg. 1991;87:843853. Landmark article on the classication types of nasoethmoidorbital region. Knowledge of this fracture pattern classication assists with the treatment of this complex surgical condition. 144. Gruss JS, MacKinnon SE, Kassel EE, et al. The role of primary bone grafting in complex craniomaxillofacial trauma. Plast Reconstr Surg. 1985;75:17. 145. Manson PN, Su CT, Hoopes JE. Structural pillars of the facial skeleton. Plast Reconstr Surg. 1980;66:54. Signicant article describing the anatomical buttresses of the craniofacial skeleton that are required for reconstruction to maintain facial width and height. 171. Le Fort R. Etude experimentale sur les fractures de la machoire superieur. Rev Chir Paris. 1901;23:208, 360, 479. Original article describing the various fracture patterns associated with traumatic craniofacial injury. We associate the author s name to the different types of fracture patterns recognized. 190. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg. 1962;29:2166. 195. Ellis 3rd E. Treatment methods for fractures of the mandibular angle. Int J Oral Maxillofac Surg. 1999;28(4):243252. 198. Champy M, Lodde JP, Schmidt R, et al. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg. 1978;6:14. 243. Clark N, Birely B, Manson PN, et al. High-energy ballistic and avulsive facial injuries: Classication, patterns, and an algorithm for primary reconstruction. Plast Reconstr Surg. 1996;98:583601.
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History
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History
In the 1980s, the application of craniofacial exposures improved the ability to restore the pre-injury facial appearance by providing access to the entire facial skeleton (Fig. 3.1). These techniques had their adverse sequela of soft tissue and nerve damage and displacement of soft tissue position on the facial skeleton. Current facial injury treatment minimizes potentially morbid exposures. The techniques of extended open reduction, immediate bone grafts, and microvascular tissue transfer have made impossible injuries manageable. The principle of immediate skeletal stabilization in anatomic position has been enhanced by the use of rigid xation. Soft tissue position and volume over this expanded skeleton has been maintained, particularly preventing soft tissue shrinkage, displacement and contracture. These
techniques improve the functional and aesthetic results of facial fracture treatment. It is axiomatic, however, that soft tissue incisions rst be repaired in layers and then replaced at their proper position onto the facial skeleton. In the last 30 years, the improvements in automobile construction and the trafc regulation have offered much protection from facial injury. The use of restraints, airbags and padded surfaces, the multi-laminated windshield, the improved design of rearview mirrors and steering wheels have all reduced the frequency and severity of facial injuries.1 Over the years, the popularity of the motorcycle still remains a factor in the etiology of major facial trauma. At the University of Maryland Shock Trauma Unit, the number of ballistic injuries has increased in proportion to the increase in drug trafcking. The character of ballistic injuries has also changed over the years from more destructive weapons to smaller caliber weapons.
Coronal incision
Upper blepharoplasty incisions
Transconjunctival incisions
Transconjunctival incisions Intraoral incisions Extraoral incisions Extraoral incisions
Fig. 3.1 Cutaneous incisions (solid line) available for open reduction and internal xation of facial fractures. The conjunctival approach (dotted line) also gives access to the orbital oor and anterior aspect of the maxilla, and exposure may be extended by a lateral canthotomy. Intraoral incisions (dotted line) are also indicated for the Le Fort I level of the maxilla and the anterior mandible. The lateral limb of an upper blepharoplasty incision is preferred for isolated zygomaticofrontal suture exposure if a coronal incision is not used. A horizontal incision directly across the nasal radix is the one case in which a local incision can be tolerated over the nose. In many instances, a coronal incision is preferable unless the hair is short or the patient is balding.
Neligan_vol_3_Chapter 3_main.indd 49.e1
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Initial assessment
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Fig. 3.2 Palpation of the superior and inferior orbital rims. (A) The superior orbital rims are palpated with the pads of the ngertips. (B) Palpation of the inferior orbital rims. One should feel for discontinuity and level discrepancies in the bone of the rim and evaluate both the anterior and vertical position of the inferior orbital rims, comparing the prominence of the malar eminence of the two sides of the face.
Fig. 3.4 Condylar examination. The mandible is grasped with one hand, and the condyle area is bimanually palpated with one nger in the ear canal and one nger over the head of the condyle. Abnormal movement, or crepitation, indicates a condylar fracture. In the absence of a condylar fracture, a noncrepitant movement of the condylar head should occur synchronously with the anterior mandible. Disruption of the ligaments of the condyle will permit dislocations of the condylar head out of the fossa in the absence of fracture.
Fig. 3.3 An intraoral examination demonstrates a fracture, a gingival laceration, and a gap in the dentition. These alveolar and gingival lacerations sometimes extend along the oor or roof of the mouth for a considerable distance.
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Initial assessment
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Fig. 3.5 With the head securely grasped, the midface is assessed for movement by grasping the dentition. Loose teeth, dentures, or bridgework should not be confused with mobility of the maxilla. Le Fort fractures demonstrate, as a rule, less mobility if they exist as large fragments, and especially if they are a single fragment, than do lower Le Fort fractures. More comminuted Le Fort fractures demonstrate extreme mobility (loose maxillary fractures).
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Orbital fractures
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Fig. 3.10 Endoscopic approach through the maxillary sinus permits direct visualization of the orbital oor and manipulation of the soft tissue and oor repair.
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Midfacial fractures
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Fig. 3.15 Reduction of a nasal fracture. (A) After vasoconstriction of the nasal mucous membrane with oxymetazoline-soaked cotton applicators, the nasal bones are outfractured with the handle of a #3 scalpel without the blade. (B) The septum is then straightened with an Asch forceps. Both the nasal bones and the septum should be able to be freely dislocated in each direction (C) if the fractures have been completed. If the incomplete fractures have been completed properly, the nasal bones may then be molded back into the midline and remain in reduction (D). Care must be taken to avoid placing the reduction instruments into the intracranial space through a fracture or congenital defect in the cribriform plate. The cribriform plate (vertical level) may be detected with a cotton-tipped applicator by light palpation and its position noted and avoided with reduction maneuvers. (E) Steri-Strips and adhesive tape are applied to the nose, and a metal splint is applied over the tape. The tape keeps the edges of the metal splint from damaging the skin. A light packing material is placed inside the nose (such as Adaptic or Xeroform gauze) to minimize clot and hematoma in the distal portion of the nose.
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Fig. 3.21 The zygoma and its articulating bones. (A) The zygoma articulates with the frontal, sphenoid, and temporal bones and the maxilla. The dotted area shows the portion of the zygoma and maxilla occupied by the maxillary sinus. (B) Lateral view of the zygoma. (From Kazanjian VH, Converse J. Surgical Treatment of Facial Injuries, 3rd edn. Baltimore MD: Williams & Wilkins; 1974.)
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Fig. 3.22 (A) A Carroll-Girard screw may be placed through a small incision in the malar eminence into the body of the zygoma and the position of the zygomatic bone manipulated. (B) The screw is placed in position to align the rim.
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Fig. 3.24 (A) Incision marked and checking position of elevator. (B) Elevator placed beneath deep temporal fascia supercial to muscle to reach depressed segment of arch, which is elevated in a smooth maneuver.
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References
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Facial fractures
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Neligan Vol 3 Chapter 03 Main

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SECTION I

Access the Historical Perspective section and Fig. 3.1 online at

2013 Elsevier Ltd, Inc, BV

Clinical examination of the face

Blunt trauma craniofacial injuries

Upper facial fractures

Computerized tomographic scans

Upper facial fractures

Surgical anatomy of the orbit

Orbital physical examination

Blow-out fractures of the oor of the orbit

Blow-out fractures in younger individuals

Radiographic evidence of fracture

Indications for surgical treatment

The timing of surgical intervention

Operative technique for orbital fractures

The forced duction test

Restoration of continuity of the orbital oor

Bone grafts for orbital oor reconstruction

Ocular (globe) injuries and blindness

Complications of orbital fractures

Implant migration, late hemorrhage around implants and implant xation

Ptosis of the upper lid

Lid lamellae and their relation to contracture

Infraorbital nerve anesthesia

Fractures and dislocations of the nasal septum

Treatment of fractures and dislocations of the septum

The treatment of nasal fractures

Open reduction and the use of supporting K wires

Complications of nasal fractures

Traumatic telecanthus and hypertelorism

Nasoethmoidal orbital fractures

Classication of nasoethmoidal orbital fractures

Classication of nasoethmoidal orbital fractures

Treatment of nasoethmoidal orbital fractures

Fractures of the zygoma

The importance of the central fragment in nasoethmoid orbital fractures

Lacrimal system injury

Complications of nasoethmoidal orbital fractures

Fractures of the zygoma

Physical diagnosis and surgical pathology of zygoma fractures

Classication of zygoma fractures

Minimalist approach for fractures without zygomaticofrontal suture diastasis

Endoscopic conrmation of orbital oor integrity

Classication of zygoma fractures

Fractures with Z-F suture diastasis

Posterior approach (coronal incisions)

Treatment of fractures of the zygoma

Buttress articulations and alignment

High energy zygoma fractures

High energy zygoma fractures

Fixation required to achieve stability

The maxillary sinus approach, with and without endoscopic assistance

The intraoral approach

Compound comminuted fractures of the zygoma

Compound comminuted fractures of the zygoma

Delayed treatment of fractures of the zygoma

Complications of zygomatic fractures

Frontal attachment Cranial base Orbital buttress Nasoethmoid region

Nasofrontal buttress Zygomatric buttress Mandibular buttress