Maxillofacial trauma 2

Maxillofacial Trauma
[Type text] Page 1
Maxillofacial
trauma
Dr. Firas kassab

Dr. Firas Kassab Page 2
Outline
 Scope, problems, priorities
 Diagnosis
 Types of Fractures
 Bone Anatomy
 Bone Fracture
 Bone Healing
 Nasal Bone Fractures
 Mandibular Fractures
 Zygomatic and Orbital Fractures
 Maxillary Fractures
 Nasoethmoidal fractures

OBJECTIVES
 Identify the causes of CMF injuries
 Discuss the initial management of CMF trauma
 Discuss the bone and fracture biology
 Discuss the principles of internal fixation
 Discuss the different CMF fractures
INTRODUCTION
 Maxillofacial fractures usually occur as the result of massive facial trauma. There is
extensive facial swelling, midface mobility of the underlying bone on palpation,
malocclusion of the teeth with anterior open bite, and possibly leakage of
cerebrospinal fluid (cerebrospinal rhinorrhea) secondary to fracture of the cribriform
plate of the ethmoid bone. Double vision (diplopia) may be present, owing to orbital
wall damage.
 Involvement of the infraorbital nerve with anesthesia or paresthesia of the skin of
the cheek and upper gum may occur in fractures of the body of the maxilla. Nose
bleeding may also occur in maxillary fractures. Blood enters the maxillary air sinus
and then leaks into the nasal cavity.
SCOPE
For this morning we’re going to talk about maxillofacial trauma. The principles will be the
same probably if you have trauma of the bones in other parts of the body. And of course if
you have trauma you will be learning the same principles as of dealing with other traumas
of the body. We’re going to deal more with the trauma of the facial skeleton which
includes:

 Mandible
 Zygoma
 Orbital
 Maxilla
 Nasal bone
 Naso-orbitoethmoidal
 Craniofacial defects
CAUSES
 Assault
 Motor Vehicle Accidents
 Sports injuries
 Falls especially among elderly patients
 Work-related
 Pathological fractures
 Automobile accidents, fisticuffs, and falls are common causes of facial fractures.
Fortunately, the upper part of the skull is developed from membrane (whereas the
remainder is developed from cartilage); therefore, this part of the skull in children is
relatively flexible and can absorb considerable force without resulting in a fracture.
PROBLEMS
 Airway
o Swelling of the soft tissues
o Hemorrhage
o Fractures

 You will be asked to handle the airway. You will have a lot of swelling, hemorrhage
and fractures which will obstruct the airway such that when confronted with this
situation, you come up with the ABCs.(see below in first aid)
 Shock
 Hypovolemia
 Pain
 Consciousness- associated CNS injuries
 Cervical vertebral injuries
PRIORITIES :
 For the ABCs, number one is airway then breathing and circulation .It is the same for
other types of trauma. If the patient is stable with good airway, breathing and
circulation, then you can address the other problems/injuries.
 First Aid
 Airway
 Breathing
 Circulation
 Resuscitation
 Exclusion of other injuries
DIAGNOSIS :
diagnose your patients with trauma.
History
 For craniomaxillary fractures, this will probably be one of the shortest histories you
will get. Why? Because you’re just going to ask for the following:
 Nature of injury (NOI)

 Place of injury (POI)
 Date of injury (DOI)
 Time of injury (TOI)
 Why do you need these things? Because probably this is a medico-legal case. Aside
from the four, you just get:
 Direction of the force
 Kind of force applied to the patient
Examination
 Then you can now do your PE which focuses on inspection, palpation and
auscultation
 Inspection
 Palpation
 Auscultation
 When you do your physical exam, you also look for these:
 Deformity- changes in the patient’s facial shape
 Bleeding/hematoma
 Trismus- inability of the patient to open his mouth; If you’re able to open your
mouth for 2 cms, you are normal. Anything below that would be abnormal.
 Tenderness- if you palpate and there is pain
 Dental Problems – fractures of the tooth, loosening of the teeth
 Movement of the Face – sometimes you have patients with flattening of the cheeks,
and if you hold on to the cheeks and try to move them, they will have some
crepitation or movement if the face, that is a sign of a fracture
 Ophthalmologic findings especially enophthalmos and exophthalmos
 Enophthalmos- eye goes inward
 Exophthalmos- eye/contents of orbit move out of the orbit
 Hypertelorism- both eyes are beyond the normal horizontal plane; one eye moves
laterally
 Signs of fractures of the facial bones include deformity, ocular displacement, or
abnormal movement accompanied by crepitation and malocclusion of the teeth.

Anesthesia or paresthesia of the facial skin will follow fracture of bones through
which branches of the trigeminal nerve pass to the skin.
 Then you might have to do several or special tests.
Types Of Fractures
 What are types of fractures? This is just an overview.
 Complete- total loss of continuity; Imagine this microphone, if you have cortex on
top, medulla on middle and cortex again on the bottom. In a complete fracture, you
have fracture on all these 3. But for example, you only have fracture on the cortex
and medulla but not on the other cortex, then that is an incomplete fracture.
 Incomplete- with continuity
 Simple- consists of 2 pieces or fragments, overlying mucosa and skin are intact
 Comminuted- consists of 3 or more fragments
 Compound- with an open wound
 Complex- involving a long fracture line; it’s like when you break it on the proximal
side and moves along the longitudinal plane up to the other side.
 Complicated- involves both the maxilla and mandible (Panfacial Fracture); so here
you have two areas involved.
 Greenstick- involves one cortical plate; here, you are mainly talking about pediatric
fractures.

FACIAL BONE
Your facial bone is a
 Dynamic tissue- it constantly undergoes resorption and remodelling
 Structure determined by
 Material properties
 Mechanical and metabolic function
 The shape of the head is spherical and it is made as such that when the skull is hit,
it is hit tangentially.
ANATOMY
Architecture of bone

 Cortex- compact osseous tissue: hard part of the bone
 Medulla- cancellous or spongy bone
Bone Cells
 Osteoblasts- associated with formation of osseous tissue; appears on surface of
bone undergoing development
 Osteocytes- osteoblasts which has become embedded within the bone matrix; are
the ones that produce bone materials
 Osteoclast- multinucleated giant cell; derived from the stromal cells of the bone
marrow; are the ones regulating formation of the bone. If there is more bone in one
area, the osteoclast will try to resorb that bone
 By the action of all these 3 bone cells, your bone becomes dynamic. By dynamic, we
mean that once it becomes fractured, it will heal by itself.
Other Bone Structures
 Haversian Canals - cylindrical, branching and anastomosing canals; Contain blood
vessels with small amount of connective tissues
 Volkmann’s Canals- connect Haversian canals with each other, and external surface
of the bone and bone marrow cavity
 Periosteum at the edge
 Bone Marrow would be in the middle which is a part of your cancellous bone (not
compact with a lot of cells embedded in them)
 Endosteum- thin connective tissue layer lining the walls of the bone cavity, filled with
bone marrow
Haversian System (OSTEON)
 Unit structure of compact bone
 Irregular cylindrical, branching and
anastomosing structure with thick
walls and a narrow lumen
(Haversian Canal) and your
haversian canal forms your haversian system.
 Surrounded by concentrically arranged lamella of bone
 Directed/move along the long axis of the bone

 This is an example of your haversian system. In the middle, it moves longitudinally.
BONE FRACTURE
Now if you have a fracture, imagine a long bone with a discontinuity along that bone and
the force is transmitted along that bone and a break in that bone happens, then there’s
fracture already.
 Continuity is destroyed and normal force transmission is absent
 Leads to rupture of blood vessels with hematoma formation
 Localized avascularity of the fragment ends
 Thrombosis of vessels within haversian and Volkmann’s canals
 No treatment until function is impaired
 Imagine your mandible, if you have a fracture in your mandible but the patient is still
able to chew and chewing is the major function of your mandible then no treatment
is necessary.
 Main aim: Re-establish function
If you are asked in the exam what is the treatment of choice when a mandible is
fractured but the patient is still able to chew, probably the answer is to just leave it as is
because it can still function anyway.
Bone Healing

 The fracture won’t stay as it is, of course you’ll have bone healing. And you have
two types of bone healing:
 Indirect bone-healing
 Aka: secondary osseous and soft tissue healing
 Occurs via pluripotential cells: bone, periosteum and soft tissue
 Direct Bone healing
 Aka: Primary osseous healing
Two types:
 Contact healing
 Gap healing
 Indirect Bone-Healing :
Occurs via pluripotential cells
 bone, periosteum and soft tissue
 Results from mechanical instability of the fracture
 leading to resorption of fracture ends
 Callus formation (which happens later in the process)
 This is one statement that we need to understand. You have indirect bone healing
because there Is mechanical instability of the fracture. If you have a fracture in the
radius and the patient still moves his arm/elbow and there is instability, even if you
splint it or if you put a cast, the arm will still be able to move. Meaning there is still
mechanical instability. And because the fracture ends move against each other, this
will lead to resorption of fracture ends. Healing will still take place and formation of
callus happens.
stages of callus formation
o Deposition of granulation tissue
 Hematoma formation
 Periosteum stripped away from bone surface
 Migration of Neutrophils and Macrophages into hematoma- this is because of the
open blood vessels

 Phagocytosis of hematoma and necrotic debris
 Ingrowth of capillaries and fibroblasts
o Osteoid synthesis.
 Transformation of granulation tissue into interfragmentary connective tissue
 The next stage is the transformation of that granulation tissue into interfragmentary
connective tissue. You have development of new osteoprogenitor cells, production of
osteoid.
 Osteoid synthesis proceeds to produce a connective tissue between the fracture
ends.
 The newly formed osteoid will be arranged in a haphazard manner in a woven-bone
pattern.
o Remodelling into fibrocartilage
 Osteoid is layed in a haphazard manner producing woven bone pattern. This
becomes your fibrocartilage. And this becomes your callus. There are two:
 External Callus- which is found on the side; outside the axis of the bone
 Internal Callus—which is found in the center; in between your bone fragments
o Mineralization
 Once bone ends are closely apposed, ossification between fracture ends occurs.
There is changing into bone already.
 3rd
week: callus well established but mechanically weak (woven bone)
o Haversian remodelling
 Your haversian system/osteons will move from one fracture segment into the other.
You should understand that your osteons are the basic structure of your bone. And
they will have to move from one fracture end to another for that bone to be fully
healed. This happens within the next few months
 Osteoclastic erosion and organized osteoblastic osteoid synthesis takes place
 Replace woven bone with compact, organized lamellar bone
 In the next few months, the Haversian system (osteons) will replace your woven
bone. It will later become a compact, lamellized bone
 This transformation happens after 6 weeks. It will remodel

Direct Bone Healing
 Aka Primary osseous healing
 It happens only if you have perfect anatomic repositioning of fractured segments
back to their normal position and stable fixation
 Lack of callus formation: stage 1,2,3,4 will not undergo callus formation
 Disappearance of the fracture lines: happens immediately after direct bone healing
 So how do we achieve that?
 Synergism between contact and gap healing
 Close apposition of segments provides mechanical stability
 Osteons are in direct contact
 Allowing transverse bridging of the haversian system with no intervening callus
formation
2 types
 Contact healing
 Gap healing
Direct or primary healing only occurs when there is no motion across the fracture line.

Contact Healing
Seen after stable anatomic repositioning
Contact healing only happens when there is perfect anatomic repositioning of your fracture
ends and stable fixation. There is no callus formation. Immediately after direct bone
healing, there is disappearance of suture lines. This happens when there is a synergism
between contact healing and gap healing. There should be close apposition of segments
and there should be mechanical stability. Your osteons/haversian systems are in direct
contact allowing transverse bridging of your haversian system with no callus formation.
o Perfect interfragmentary contact
o No possibility for any cellular or vascular ingrowth
o Cutting cones (haversian system) are able to cross this interface from one
fragment to the other by remodelling the haversion canal..
o Only seen directly beneath the mini plate.
Gap Healing
Takes place in gaps with a width greater than 200 um
Osteoblasts deposit osteoid on the fragment ends. This space is very small such that the
cones will be able to traverse without any problem. Seen on the inner side of the
mandible
Seen on the inner side of the mandible
Undergoes several stages as well
Stages of Haversian remodelling
o Gaps are filled with transversely-oriented lamellar bone completed within 4-6
weeks
o Replacement by axially-oriented osteons. In 10 weeks, you have newly re-
constructed cortical bone.
 Contact healing and gap healing are seen especially when you put your implants.

 It appears that the bridging of a bony gap by bone can only occur in the absence of
motion across that gap. The more motion is present, the greater the amount of
callus will be needed to stabilize the fragments so that healing by bone can
eventually occur. Conversely, the more stable a repair is (and thus less motion is
present), the less callus will form and the greater the likelihood that bone will
directly bridge fracture and heal the injury. It of course follows that when callus is
unable to stabilize a fracture, bone will never form; the fracture remains bridged by
fibrous tissue, thus forming a fibrous union (alternately known as a ―non-union,‖ a
―fibrous non-union,‖ or a ―pseudoarthrosis.‖ To accomplish a stable repair, it is
necessary to understand the biomechanics of the facial skeleton, and even more
important, it is critical to use this understanding when applying fixation. Otherwise,
motion will tend to occur when the repair is loaded in function, and complications
are then more likely to occur.
Delayed Healing
Factors detrimental to bone healing
 Poor blood supply
 Poor general nutritional status
 Poor apposition in the fracture ends
 Foreign bodies in the fractures
 Infection
 Corticosteroid intake
Successful Healing
Minimum Requirements For Successful Bone Healing
 Biological Requirement
o You need functioning cells that participate in the various phases of the
healing process.

 These functioning cells should be able to reach the site of repair
 Adequate nutritional supply is needed
 Good blood supply is a primary prerequisite
 Mechanical Requirement
o Immobilization- You need to immobilize the fractures for that to heal.
o Interfragmentary Motion
 Tissues are continuously torn and squeezed.
 Tolerance
o Connective tissue 100%
o Cartilage 10-15%
o Bone 2%
 Let us look at the different tissues in the body. If you have a break in your skin, that
skin will still heal even if you move the skin. The skin, or any other connective
tissue, will be able to tolerate that 100%. If there is movement in your cartilage,
only 10-15 % will tolerate that and will heal. If there is movement in your bone, the
bone will not be able to tolerate that and will not heal. Such that, if there is still
movement in your bone, you will not achieve bone healing.
OPERATIVE TREATMENT OF FRACTURES
 Aim:
o Rapid recovery of form and function
o Relief of pain
o Avoidance of late complications
o Short hospitalization time
o Early return to work
 Optimal, not maximal, stability is required.

Nasal Bone Fractures
Nasal Bone Anatomy
Anatomy: The two nasal bones form the
bridge of the nose. Their lower borders,
with the maxillae, make the anterior nasal
aperture. The nasal cavity is divided into
two by the bony nasal septum, which is
largely formed by the vomer. The superior
and middle conchae are shelves of bone
that project into the nasal cavity from the
ethmoid on each side; the inferior conchae
are separate bones.
 The nasal bone is the most frequently traumatized bone. It is very prominent in
the face, and would probably be the first to be injured when there is trauma
o It is most predisposed to fractures is at the junction of the thin, broad
and lower portions of the nasal bone
o It is intimately related to the nasal septum
o Nasal septal fracture or dislocation may co-exist with nasal bone fractures.
Fractures of the nasal bones, because of the prominence of the nose, are the most
common facial fractures. Because the bones are
lined with mucoperiosteum, the fracture is
considered open; the overlying skin may also be
lacerated. Although most are simple fractures and
are reduced under local anesthesia, some are
associated with severe injuries to the nasal septum
and require careful treatment under general
anesthesia.
Signs

 Stepdown deformity- If you touch nasal bridge, you feel that there is a sudden
downward deformity.
 Nasal Fracture Stepdown Deformity
o Epistaxis
o Nasal obstruction secondary to fracture
o Septal deviation
o Mucus and blood clots
o Crepitations (sound heard or felt during palpation of the nose)
o All external manifestations may be masked by severe soft tissue edema
especially in a patient seen a few hours after injury. Especially if there is
swelling.
Management
 The most appropriate treatment for a nasal injury is the least invasive one that will
fully correct the deformity without long-term complications or relapse. Non-displaced
fractures that do not result in any defects are best managed with observation alone .
1. Closed reduction
 Indications:
 Fractures which are non-comminuted
 Mild to moderate
 Recent fractures
 Use Ashe forceps/hemostat
 Should be done within 7-10 days in adults,
2-4 days in children
 Closed nasal reduction is best for simple injuries such as an isolated, unilateral nasal
bone fracture with medial displacement.
 One of the most important reasons for failure of closed nasal reduction is concurrent
nasal septal fracture.

Closed reduction We just get the fractured bone and elevate that. Pull that upward
and that will actually replace the bone back to its original anatomic position. Most of the
time, we put the patient into general anesthesia because it is painful. Some of the
indigent patients would prefer to have this done under local anesthesia. We introduce
anesthetics in the infraorbital rim, inside the nose and the lip.
Instruments needed for reduction of simple nasal fractures
o fiber optic headlight
o intranasal specula
o scalpel knife
o Ashe forceps - for displaced septum
o Walsham forceps - for impacted nasal bones
o nasal splint
o tape and bandage
2. Open reduction
 For more severe trauma (e.g. bilateral, depressed fracture with septal and
cartilaginous involvement), an open approach is the best means of producing a
satisfactory outcome.
 Disadvantages of using open reduction for majority of nasal fractures are the higher
treatment costs and the increased risk of surgical complications.
 Open reduction should be limited to those cases in which it would yield significantly
better results than more conservative measures to justify the drawbacks. Indications
include:
o Bilateral fractures with dislocation of the nasal dorsum and significant septal
pathologic changes
o Bilateral fractures with major dislocation with or without significant septal
pathologic states
o Infrastructure of the nasal dorsum
o Fractures of the cartilaginous pyramid without dislocation of the upper lateral
cartilages.
3. Alternative Reduction Methods

 External compression plating
 Percutaneous wire fixation
Complications of Nasal Fractures
o Subperichondrial fibrosis with partial obstruction
o Synechiae
o Obstruction of the nasal vestibule
o Osteitis
o Malunion of the nasal fractures with deviation
MANDIBULAR FRACTURES
Anatomy
The mandible (lower jaw) is a U-shaped structure with several areas:
Symphysis – found in the middle in between middle incisors. Any fracture in this area is
called a symphyseal fracture.
Parasymphysis – Between lateral incisors and canine, make an imaginary line going
down to the inferior border of the mandible. Any fracture there is considered
parasymphyseal.
Body – from lateral incisors to 3rd molar; between angle and parasymphysis.
Angle - junction of ramus and body of mandible.

Alveolar area – tooth bearing portion
Condyle – attached to glenoid fossa
Coronoid process
Ramus- From the angle going up
The mandible or lower jaw is the largest and strongest bone of the face, and it
articulates with the skull at the temporomandibular joint. The mandible consists of a
horseshoe-shaped body and a pair of rami. The body of the mandible meets the ramus
on each side at the angle of the mandible.
Traumatic impact is transmitted around the ring, causing a single fracture or multiple
fractures of the mandible, often far removed from the point of impact.
Signs And Symptoms
 Malocclusion patient is unable to close the mouth and appose the teeth normally.
When the patient has an abnormal bite.
 Hyposthesia of lower lip and gingiva – due to damaged inferior alveolar nerve
 Sublingual hematoma
 Mucosal disruption
 Pain and tenderness over fracture
 Tooth loosening
 Trismus- inability of the mouth to open more than 2 cm
 Facial deformation/Swelling
Investigation Of Mandibular Fractures
 Imaging Studies
o Radiology
 Panorex (Panoramic
X-ray)
 Mandible series
(frontal, lateral,
oblique
 Study models

 Photography- compare it with pretrauma pictures of the patient
 For the mandible, most surgeons prefer plain x-rays, or more commonly panoramic
topography, and often both as the imaging techniques of choice.
Management Of Mandibular Fractures :
 In the dentate mandible, the first priority is reestablishment of the proper occlusal
relationship of teeth.
 As discussed earlier, we require immobilization for the fractures to heal. You may
either use splinting or compression.
Splinting
o Application of a more or less stiff device to the fractured bone.
o But this does not completely abolish fracture mobility.
2 types of Splinting:
External splinting
 Reduce fractures without surgical intervention
 May be fixed to teeth, or applied to mucosal or skin covered surfaces
 In your long bone, the splint will be the cast. You apply that to your skin. Even with
the cast, the patient will still be able to move his hand and move the fracture ends.
So it does not completely abolish fracture mobility
Internal Splinting
o The stabilizing devices are fixed directly to the fracture segments
o Some interfragmentary motion
o Interfragmentary wire sutures and flexible plates. Even if you put these
directly to the bone, you will still have some interfragmentary motion
Compression/ Internal fixation
Excludes interfragmentary motion
Consists of pressing together 2 surfaces, either bone to bone or implant to bone. You
compress the bone together. This is achieved only by using your implants.
Biological advantages:

 When you compress, there is undisturbed healing because it guarantees absolute
stability even under conditions of function. If you compress the mandible, even if the
patient uses his mandible, the fractured ends will not move against each other.
Immobilization is the key to healing.
 Allows load sharing between the bone and the implant.
 Provides maximum strength with minimum fixation material.
 A load-sharing repair depends on the integrity of the
underlying bone, and the fixation appliance is positioned so
as to ensure that the forces in function are borne by bone
itself. A small plate across the tension zone will ensure the
solid bone is pushed together in function so that it shares
the load with the fixation appliance. Miniplate fixation,
compression plate fixation, and lag screw fixation all
represent load-sharing repairs and require adequate bone
contact to succeed.
Closed Reduction
Barton’s Bandage – an internal splint

Intermaxillary fixation (IMF) for 6 weeks
– There are rubber bands applied to the
teeth. The patient will be unable to move the
mouth. There will still be some
interfragmentary motion.
Intermaxillary Fixation. This is another
example of an internal splint. If you have
Barton’s bandage of Intermaxillary fixation,
the fractures will heal but it will take 6 weeks
before it heals. He will not be able to eat for 6 weeks and so he needs an NGT. Imagine
how discomforting this is.
 Eyelet wires
 Arch bars – A good arch bar will re-establish proper occlusal relationship of teeth
and will also provide a good tension band across the alveolar portion of the fracture.
 NGT
 Liquid feedings
Open Reduction
o Direct visual access to the fracture. You open up the skin or the mucosa to
visualize the fracture.
o Anatomical reduction of bone fragments
o Fixation
Wire osteosynthesis The wires are pliable
.They will not be able to totally abolish fracture
mobility. Although they are applied directly to
the bone, this is still considered as internal
splint. Not compression.
Interosseous Wiring :

Screw Fixation- compression/ internal fixation
Plate Fixation- compression/ internal fixation
 Miniplates
 Reconstruction Plates

Plates and Screws. It is only if you have internal fixation, that you can totally abolish
fracture mobility and go through direct bone healing, and achieve healing faster compared
to indirect bone healing.
Post Operative Care
 Airway
o Avoidance of IMF in post op period
o Nasopharyngeal airway
o Tracheostomy
 Analgesia
 Antibiotics
 Fluids and diet

ZYGOMATIC FRACTURES AND ORBITAL FRACTURES
Anatomy
 The zygomatic bones (cheek bones, malar bones), forming the prominences of the
cheeks, lie on the inferolateral sides of the orbits and rest on the maxillae.
 The anterolateral rims, walls, floor, and much of the infraorbital margins of the orbits
are formed by these quadrilateral
bones.
 The zygomatic bones articulate with
the frontal, sphenoid, and temporal
bones and the maxillae. Inferior to
the nasal bones is the pear-shaped
piriform aperture, the anterior nasal
opening in the cranium
 The zygomatic arch is formed by the
union of the temporal process of the
zygomatic bone and the zygomatic
process of the temporal bone
Bones of the Orbit
 Frontal
 Greater wing of sphenoid
 Lesser wing of sphenoid
 Ethmoid
 Lacrimal
 Zygomatic
Superior Orbital Fissure
Located between the greater and lesser wings, it communicates with the orbit and
transmits the ophthalmic veins and nerves (CN III, CN IV, CN V1, CN VI, and sympathetic
fibers) entering the orbit.
Contains:

 Superior and inferior division of oculomotor n.
 Trochlear n.
 ophthalmic n. - lacrimal and nasociliary branches
 superior and inferior divisions of ophthalmic rim (vein)
 sympathetic fibers of cavernous sinus
Inferior Orbital Fissure
Contains:
 zygomatic branch of the maxillary nerve
 ascending branch of pterygopalatine ganglion
 inferior orbital fissure separates the mandible from sphenoids
Signs of Zygomatic/Orbital Fracture:
 Black eye
 Lateral subconjuctival hemorrhage
 Swollen or flattened cheek
 Diplopia/Restricted Eye Movements
 Hypoesthesia of the cheek
 Trismus
 Proptosis
 Enophthalmos: imagine your orbit as a glass of water, and you put a ping pong ball
on top and if you break the glass, the ping pong ball will actually go downward and
that is what we call enophthalmos
Tripod Fracture
 involves the zygomatico-frontal, zygomatico-maxillary and zygomatico-
temporal suture lines (due to inherent weakness)
 tripod fractures they usually begin with pre-injury weakness of the facial bone and
foramen

Principles Of Treatment
 Restore the patient to pre-injury facial configuration
 Prevent cosmetic deformity
 Prevent delayed visual disturbances
 Repair within 5-7 days allows edema to decrease and avoids shortening of
masseter with lateral and inferior rotation
Treatment
1- Closed Reduction
Gillies Temporal Approach
 incise at hairline (temporal area), insert
a metal rod going towards maxilla and
pull out zygoma
 Your tripod fracture will cause a portion
of the cheek to move either medially or
laterally. If t move medially, we make a small incision by the hairline get a piece of
metal rod, insert that rod, then push the cheek out

Cheek Hook
get a hook, pull out the bone so it will return to the normal configuration
Transbuccal hook approach
make a small incision inside oral cavity, insert the hook and pull zygoma out
2- Open Reduction
 Perform a coronal incision and expose the fracture and then plate the fracture
 Frontozygomatic
 Inferior orbital
 Oral
 Bitemporal
Fixation
 Miniplate osteosynthesis
 1 mm thin plate
 Microplate osteosynthesis
 ½ mm thin plate
 Resorbable materials
BLOWOUT FRACTURES
Compression of orbital contents deforms the orbital floor, walls, and roof.
Open door or trap door deformity
Your globe will move inward, X-rays will show a TEARDROP SHAPE SIGN

Types Of Blowout Fracture
Pure Blowout Fracture
 No involvement of the orbital rim, only the floor is involved
 With entrapment of EOMs
 Must be differentiated from simple orbital floor fractures
Impure Blowout Fracture
 Orbital rim involved
 Often associated with malar, NOE, Le Fort and Frontal Sinus fractures
Signs And Symptoms
 Diplopia
 Restricted eye movements
 Enophthalmos
Superior Orbital Fissure Syndrome
 Symptoms of Superior Orbital Fissure Syndrome
 Diplopia
 Paralysis of EOMs
 Exopthalmos
 Ptosis
 Blindness (apex)

 Usual mechanism is a blow to the eye whereby the diameter of the causative force is
usually bigger than the diameter of the orbit
 This forces the orbit downward since the orbital space is limited posteriorly and the
orbital floor has least resistance.
Lamina papyracea: thinnest portion of the
orbital bone
 Usually the orbit herniates through the
fracture
 Presence of continuity between the sinus
and the orbit
Orbital emphysema: air in radiograph
Tear drop sign: represents the herniated orbital contents, periorbital fat and inferior
rectus muscle
 CT scan provides better evaluation since it can detect the fracture and hemorrhage
in different planes

 Treatment
Open Reduction Internal Fixation (ORIF)
Orbital Defect Reconstruction Plates
Silicone implants
Autologous Bone
If the patient cannot afford the titanium implant, we
just get a piece p bone from the
calvarium, one cortical level, then we lay
that on the defect.
Titanium mesh(implants)
MAXILLARY FRACTURES
Buttresses Of The Facial Skeleton
 Nasomaxillary
 Zygomaticomaxillary
 Pterygomaxillary
 What are your buttresses? They are preformed structures in the face which are
stronger than the other areas of the face. These are the structures that hold the
maxilla together. If you have fractures and disruption of the buttresses, these are
the areas you have to compress or plate for you to be able to achieve correct
treatment of your maxillary fractures. You have to manage all of these buttresses
first.
 will not be able to withstand the forces of occlusion
 Reconstruction is made either through wires or plates.

 The buttresses are strong because of your bite; the pressure of biting is transverse
to the buttresses. If the buttresses are fractured, the maxilla and mandible will
collapse.
Imaging
 Radiographs
 Occipitomental
 Lateral
 CT
 MR
 Angiography
 Photography
 Study models
Anatomical Classication
 Le Fort I
 Le Fort II
 Le Fort III
 The Le Fort classification describes various midfacial fracture patterns ranging from
isolated detachment of the alveolar process (Le Fort I) to separation of the midfacial
bones from the anterior skull base (Le Fort III).

Le Fort Type I
(Transverse Maxillary
Fracture)
Le Fort Type II
(Pyramidal Fracture)
Le Fort Type III
(Craniofacial
Dysjunction)
Broken pterygoid plates
+ fracture that runs
horizontally above the
anterior maxillary
alveolar process
Broken pterygoid plates +
fracture that runs along
maxillary sinus, inferior orbital
rim, orbital floor, medial
orbital wall, & nasofrontal
suture
Broken pterygoid plates
+ zygomatic arch
fracture + craniofacial
separation
LE FORT I
 Low level fracture
 Often mobile
 Mild swelling
 Disturbed occlusion
 Deviated midline
 If you have patient with a history of facial trauma, when
you hold the teeth and you pull that out, the alveolus
(tooth-bearing structure) will move anteriorly, that is your
anterior drawer sign. Only the tooth bearing segment
moves, then that is a sign of your Le Fort I fracture.
LE FORT II
 Sub-zygomatic pyramidal
 Gross swelling
 Immobile
 Anterior Open Bite
 Altered Sensation

 Long faced appearance
 CSF rhinorrhea
 When you pull anteriorly, even the nasal bridge will move
anteriorly, the drawer sign will include the whole nasal
bridge. Be careful because the infraorbital may already be
affected hence increased sensation to pain.
LE FORT III
 Suprazygomatic craniofacial dysjunction
 Gross swelling
 Immobile
 Altered occlusion
 Long face
 Flattened cheek
 CSF rhinorrhea
 The whole face is disjoint from the skull. When you pull,
even the cheeks and the inferior orbital rim will move
anteriorly.

Treatment
 Conservative
 Closed Reduction
 Open Reduction
 External Fixation
 Internal Fixation
 Wires: again wires are not internal fixation, just
internal splints
 Suspension
 Osteosynthesis
Summary of Anterior Drawer Sign
Le Fort I Alveolus moves anteriorly
Le Fort II Alveolus and nasal bridge moves anteriorly
Le Fort III Alveolus, nasal bridge, cheeks and inferior orbital rim move anteriorly

 Screws
 Plates
 Internal Fixation
NASOETHMOIDAL INJURIES
 Trauma to central midface
 Traumatic telecanthus or hypertelorism
 Telecanthus – the canthal ligament has moved laterally during traumatic injuries.

 Nasal deformity
 Orbital wall involvement
 Enophthalmos
 Diplopia
 The main structural buttress of the nasoethmoid: Frontal process of the Maxilla
 Contains insertion of the medial canthal ligament
o TYPE I NOE Fracture
 Has a large central fragment
 represent a single noncomminuted central fragment without medial canthal tendon
disruption
o TYPE II NOE Fracture
 Involve comminution of the central fragment, but the medial canthal tendon remains
firmly attached to a definable segment of bone.

o TYPE III NOE Fracture
 Are uncommon and result in severe central fragment comminution with disruption
and detachment of the medial canthal tendon insertion.
TREATMENT
 The objectives of definitive surgical treatment of NOE fractures are reduction and
fixation of unstable fracture segments to stable structures
SUMMARY
 Initial management of craniomaxillaryfacial trauma involves the ABC’s of emergency
 Successful bone healing requires immobilization
 Internal fixation abolishes inter=fragmentary motion

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