Mgt of midface fractures

ALEM H
R-3
 Clinical findings
A-LEFORT I FRACTURE:
Pts with lefort I may have minimal external signs.
However, if the maxilla has been displaced the following can
be described:
- pain
-mobility while clenching
- changes in occlusion due to posterior displacement of
maxilla i.e
anterior open bite
premature contact of molar occlusion
-Areas of acchymosis in maxillary vestibule
-bruising of the palatal tissue. [if palatal split is present]
 Con..
-Tenderness in the region of fracture site i.e maxillary
buttress.
-mobility on demonstration ,unless the fractured maxilla
is firmly impacted .
Note:
mobility is demonstrated by grasping the maxilla
through the mouth and producing lateral movement
while stabilizing the head with the nonexamining hand.
on radiography:
-air emphysema of the facial soft tissue when fracture
communicates antra laterally. But this sign is
inconsistent finding.
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B-LEFORT II FRACTURE:
TPS with lefort II may have more obvious external signs i.e:
-Some degree of external swelling, due to a fracture across
the nasal bridge or around the medial orbital wall.
-Signs of NOE fractures if this complex is involved
-Subconjunctival hemorrhage which is detected if the
periorbital tissues are not too edematous
-Infraorbital acchymosis
-Periorbital acchymosis may also be present occasionally.
-Sign of lefort i.e
anterior open bite, maxillary mobility on demonstration,
areas of acchymosis on maxillary vestibule etc.
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-CSF rhinorrhea if dural tear is involved in cribriform
fracture
Note :
establishing mobility of a pure lefort II fracture is
performed by mobilizing the maxilla through the
mouth while palpating the nasofrontal junction and
the infraorbital rim.
However, palpation of these areas may be complicated
by significant edema, concurrent nasal fracture and
mobility of the overlying soft tissue.
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LEFORT III FRACTURE:
Lefort III fractures may exhibit bilateral periorbital edema and acchymosis, producing the clinical appearance of:
-raccoon eyes bilateral periorbital edema and acchymosis] as a result of craniofacial separation]

Csf rhinorrhea or csf otorrhea if dural tear is involved in cribriform plate or auditory canal roof fracture.

-battles sign [ area of bruise over the mastoid process]

-Malocclusion if fracture is displaced.

-Diplopia due to significant expansion of orbital volume or entrapment of the soft tissues surrounding the globe.

-Orbital Dysplopia with an associated antimongoloid slant due to inferior displacement of the lateral orbit containing
the attachment of the lateral canthus.
-associated NOE fracture.
-mobility on demonstration.
note:
Mobility at a lefort III is confirmed by moving the maxilla while palpating the nasofrontal and zygomaticofrontal
sutures.
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-a significant variation to any lefort fracture
pattern is the presence of the a sagittal
fracture of the palate.
-this injury occurs with a frequency of 15-20%.
-this injury may result in constriction of
maxillary arch, producing lateral crossbites if is
note recognized and addressed during the
reduction and fixation of the midface.
 Con..
NOE COMPLEX INJURY:
A PT with a NOE complex fracture presents
with certain stigmata associated with
displacement of the underlying skeleton and
its soft tissue attached.
these signs vary according to whether a
unilateral or bilateral fracture is present and
the amount of displacement of the segments.
 Con..
A-WHEN FRACTURES ARE CONFIRMED TO THE
MIDDLE OF THE COMPLEX:
- The clinical signs
- may be limited to a depression of nasal bridge
- Or possibly associated with accentuated
nasofrontal angle
- the thin skin overlying the medial canthus may
be drown inward, emphasizing the nasojugal
fold.
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B- IF THE FRACTURES EXTEND LATERALLY AND THE FRONTAL PROCESS OF THE
MAXILLA AND LACRIMAL BONES ARE INVOLVED:
-distortion of medial canthal attachment .
-asymmetry b/n medial canthus of each eye. because the distance b/n the
medial canthus of each eye to the skeletal midline may be altered.
-traumatic telecanthus which refers to increasing of the total inter canthal
distance [from medial canthus to medial canthus] as a result of trauma.
Note:
the normal intercanthal width in
black=33.9mm 3
white =32mm 3
therefore, in post traumatic pt intercanthal width greater than 35mm in
white or 37mm in black is considered abnormal.
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C- IF THE FRACTURES ARE ASSOCITED WITH MIDFACE FRACTURES:
- traumatic hypertelorism
midface injury can produce separation of the two orbits with respect to each other,
known as traumatic hypertelorism which is demonstrated by measurements b/n
the two pupils in central gaze.
Note:
normal inter pupillary distance in
black=633.7
white=633
Therefore, interpupillary distance greater than 66mm in white or 37mm in black are
considered abnormal.
-Rounding of the medial canthal angle
occurs when the attachment of the medial canthus is lost.
furthermore, lose of the medial canthal attachment occurs as a result of detachment
of the canthus from the bon e or disarticulation of the bone containing the
attachment from the remainder of the skeleton.
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D- IF A LACERATION OCCURS OVER THE MEDIAL
CANTHUS:
the clinical signs
epiphora
-which is produced by obstruction to the drainage
of tear.
-the obstruction thus in case, is due to injury of the
nasolacrimal system.
-epiphora can also be seen trauma to nasolacrimal duct
when NOE complex fracture involves maxilla.
Con..
 RADIOGRAPHIC EXAMINATION
CT SCAN:
The scan thicknesses used for the brain imaging, the facial examination and the glob and the orbital soft
tissues are different
-CT examinations are part of the routine preop evaluations in most of major trauma centers.
CT SCAN S OF THE BRAIN:
- are ordered emergently when the intracrania injury is suspected.
are normally obtained with 5mm sections.
CT SCANS OF THE FAIAL SKELETON:
are ordered at an early stage unless the pt is unable or unstable to lie still because of other injuries or
intoxication.
-are ordered in both axial and coronal planes.
Separate bone and soft tissue windows are formatted to aid identification of fractures and soft tissue
injuries.
-facial injuries should ideally be assessed with 3mm sections.
Whereas, the glob and the orbital soft tissues should be taken with 1.5mm sections
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3-D:

-this image is reconstructed in computer software from two dimensional ct scans .

- accuracy of this depends on the quality of the software and how close the individual sections are to each other.
-eg. A Scan performed with 1.5 cuts produces more accurate rendering than with sections 5mm apart.

Although 3D reconstruction may prove useful in appreciating the general morphology of injured facial skeleton and the
degree of displacement , a cautious reliance on these images is recommended.
If a scan performed with 3MM sections, a change in direction or segments smaller than 3mm may not be accurately
depicted.

This point is illustrated by the pictures in the next page ,

where a fractured segment of the supraorbital rim; Which actually lies with in the orbital margins
appears to be superficial to the rim on the 3D reconstruction.
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plain radiographs:
- Before the ct examinations become a part of the routine evaluation of pts with midface injuries, the
plain films were the only means of identifying facial fractures.
- A typical series includes PA, LATERAL VIEWS, OM and submental vertical view.
Experienced examiners are often able to diagnose fractures by examining key sites for steps or diastases
i.e
- zygomatic buttresses, zygomaticofrontal sutures, Infraorbital and Pyriform rim and nasofrontal
junction.
- Additional clues can also be provided by opacification of sinus spaces secondary to the
accumulation of blood.
- Problems
- It is often difficult to completely trace a fractures course because of projection and
superimposition of adjacent structures.
- Soft tissue edema can mask the location of a fracture.
these problems are further compounded when the radiographer is unable to position the pt for
optimal view because of the facial injuries sustained or a possible cervical spine injury i.e
when AP views are substituted for PA or MO views are used in place of OM views distortion of
the skeletal structures makes examination even more difficult.
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MRI:
Is indicated mainly when direct examination of
optic nerve and tract becomes necessary
following the identification of an optic
neuropathy.
- this technology has also been used with some
benefits to distinguish b/n sinus mucosal edema
and herniation of orbital contents in fractures
involving the orbital floor, however this
distinction can usually be made with adequate
soft tissue CT windows
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 Evolution of treatment modalities
Before the development of rigid fixation device
[in the past 20 yrs]:
-closed reduction and indirect stabilization of fracture The mainstay of treatment was.
Indirect intraoral fixation [ maxillomandibular] or craniomandibular form fixation were used.
The indirect fixation technique used suspension of fractured bones from stable superior structures with
internal or external skeletal fixations.
The following modalities were used as a craniomandibular fixation.
indirect extraoral internal skeletal fixations i.e
Circumzygomatic, zygomaticofrontal,infraorbital wires provided superior stabilization.
indirect extraoral external fixation i.e
The plaster of paris head cups

direct external fixation i.e

frontal pins were used as extracranial form of fixations.
Direct internal fixation i.e
transosseous wires were used
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Wiring of the fracture sites or transfixion with pins and kirschner wires directly stabilized the segments.
Disadvantage of the early techniques

1- the direct internal approach was discouraged in comminuted fractures . because

soft tissue dissection was required to pass the transosseous wires
this dissection was believed to compromise the vitality of the fractured bone.

2-fractures fixed with wires is most effective in resisting superior-inferior and lengthwise distraction
and less stable when rotary forces are applied.
therefore, this technique was subject to displacement around the long axis of the wires.

3-even if bone was missing , consideration was rarely given to grafting a recently traumatized site ,for
fear of infection.

4- the early practices were called in to questions because

critical review of postoperative was identified significant number of pts with a lack of projection,
foreshortening of midface, facial asymmetry and nonunion of fracture sites.

In the past 20yrs the approach to the mgt of midface injury has changed, largely as a result of
development of rigid fixation devices.
Con..
 Initial mgt of midface fractures
-if a pt is unable and cannot undergo treatment: emergent care must be deferred as initial mgt.
in this case, when comprehensive treatment is delayed, initial mgt of the pt should consist of:
closure or packing of the laceration, tetanus prophylaxis and temporary immobilization of fractures
with IMF.
The application of IMF for the stabilization midface fractures is some what controversial.
- opponents of this practice suggest that movement of the mandible while it is attached to fractured
midface may distracts the segments further.
-this has not been the experience of the authors who have found IMF useful as a temporary
stabilizer and helpful in reduction of fractures when used in conjunction with elastic traction.

furthermore, if the occlusal rxnsxp is unclear obtaining impression of dentition for study modal is
helpful.
-if there are no contraindications to treatment:
initial mgt should be directed at accurately defining the extent of injury and addressing problems i.e
facial lacerations and persistent csf leakage.
- lacerations that expose fracture sites provide opportunities to address both injuries early and
simultaneously [with in 12hrs after trauma ].
this approach enhances primary soft tissue healing and reduces the need for additional incision.
extensive lacerations that may be contaminated should be managed judiciously. Because
definitive reconstruction may be jeopardized if wounds dehisce or become secondarily infected.
 Con..
Characterization of midface fractures:
-Characterization of the injury is important
non intervention must always be considered as an option in minimally
displaced fractures with little alteration to function or facial aesthetics.
-but In many situations, a full characterization of the injury is not possible
at an early stage.
the true extent of the facial deformity may be masked by soft tissue
edema or subcutaneous emphysema.
A full ophthalmologic examination may be compromised by edema.
this may prove significant if a pt experience visual problem after
surgical manipulation.
thus, in case of such situations comprehensive treatment is postponed .
why?
When treatment is delayed , opportunity exist to gather more diagnostic
informations.
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Different methods to accurately characterize the extent of injury:
1- 3-D reconstructions of axial and coronal CT sections.
offer information concerning the extent and direction of fracture
displacement.
but they are not completely accurate in their representation of fracture
sites.
Additional radiographs may also be required if a full CT examination is not
available.
2- impression of the maxillary and mandibular dentition
when occlusal instability is the result of insufficient interdigitation
defining the occlusal rxnsxp with splint is important. Why?
provides essential information when a preexisting malocclusion,
missing teeth, dentures, extensive dental restorations or active
orthodontic treatments creates poorly defined occlusal rxn sxps
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Mgt of CSF leakage:

introduction:
CSF passage through the nose [ rhinorrhea] or ear[ otorrhea]may be produced by certain types of midface fractures.
Leakage commonly occurs with lefort-II and lefort-III FRACTURES AS A RESULT OF DURAL TEARS in the vicinity of
cribriform plate or temporal bone.

1-elevating the pts head:

Is an initial measure to decrease the flow of csf.
to diminish ICP through promotion of venous drainage. If this failed,

2-reduction and stabilization of midface fracture.

is the most effective method to control csf.
if early definitive treatment can not be undertaken temporary stabilization may be required with mmf.
but this mmf may aggravate the situation in the presence of persistent csf leakage.
here, craniomandibular fixation using hallo frame or steinmann type pins provide stable alternatives .
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3- lumbar puncture
4- ventriculostomy [ insertion of a camino-bolt]
5-diuretics
administration of mannitol and hyperventilation
can decrease ICP. But are rarely used.
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Antibiotic coverage in pts with midface fractures:
Guidelines for antibiotic coverage of midface fractures have not been clearly established.
Closed fractures, uncomplicated by csf leak or subcutaneous emphysema, do not routinely require
antibiotics.
-In the events an antibiotic prophylaxis needed and during intracranial surgery
First generation cephalosporin i.e
cefazolin [ancef] 1g i/v bid
this provides adequate coverage against gram positive skin and oral flora as well as significant gram
negative organisms i.e
klebsiella, haemophilus, and proteus mirabilis
-if staphylococcus aureus and enterobacter contamination are concerns
antibiotic therapy of combined
nafcillin [or oxacillin] 2g I/V every four hours with cefotaxime 2g I/V every 8 hours
And ceftriaxone 2g I/V a day is recommended
- In the presence of methicilin-resistant s. aureus infection
- vancomycin 1g I/V BID SUBSTITUTED FOR nafcillin
- Note:
- Most csf leakage will cease once the midface fractures have been adequately stabilized.
- rare case if persistent leakages are referred to a neurosurgeon, who may elect to close a dura tear
with an autogenous fascia lata graft , pericranial flap, or allogeneic graft such as lyophilized dermis
 Definitive mgt of midface injury
Not all midface injuries require surgical intervention.
therefore definitive mgt includes
1- nonintervention:
un displaced midface fractures with out alteration in respiratory ocular and
masticatory function and not associated with deformity and asymmetry can be
managed by observation effectively with out any definitive intervention.
2-non surgical intervention:
small displacement of fracture segments in the midface which are apparent on
radiographic examination but human eye is unable to discern may produce minor
functional discrepancy in vision, mastication and respiration.
i.e enophthalmos < 2mm
this situation can be managed non surgically using the ff methods.
fabrication of new denture to correct an occlusal discrepancy, onlay grafting ,
bone reduction for localizing deformities , secondary septorhinoplasty.
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3-Surgical intervention:
Considerations in surgical intervention:
-selection of intraoperative air way
-sequence of fracture reduction and fixation
- surgical approaches for midface fractures
- anatomic references for midface fractures
- method of reduction and fixation
-postoperative care
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I-Intraoperative air way mgt:
in the presence of midface or panfacial injuries mgt of intraoperative
air way requires special considered to develop a coordinated
strategy.
discussion with the anesthesia care provider concerning extent of
injury, length of procedure and surgical approaches is essential.
Coordinated plan should address
the route of intubation
the direction of anesthetic tube
the surgeons positions around the field
the use of special operating table attachment i.e the mayfield
head-holding device
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d/t routes of intubation can be use depending on appropriate surgical approach required.
nasal intubation:
indication
isolated midface fractures at lefort-I level
these fractures are approached almost exclusively through transoral route. And thus can be managed effectively
with nasal intubation.
-either Rae tube or standard endotracheal tube with 60 degree connector can be used.
-nasal endotracheal tube should be directed cephalad and secured with adequate forehead support .
pt may be extubated postoperatively without danger of air way compromise unless prolonged intubation is required
for other reasons.
contraindication:
- Nasal injury
- surgical need to manipulate the nose.
-midface injury with the presence of cribriform plate fracture [ according to the ATLS] its risk of introducing the
tube in to the anterior cranial fossa.
however, the potential for inadvertently introducing an endotracheal tube in to the cranial fossa and the incident of
secondary meningitis is a rare occurrence.
In a study of 160 nasal intubation performed on pts with midface injury , misdirecting of the endotracheal tube did nt
occur in a single case.
Similar study performed by Ree and colleagues confirm relative safety of this intubation in midface injury.
 Con..
Lefort I fracture in combination with mandibular fractures
or badly displaced nasal injury, lefort II and lefort III
fractures represent a challenge to intraoperative air
way mgt.
Because nasal intubation may be contraindicated as a
result of the nasal injury or the need to manipulate the
nose surgically.
Whereas, oral intubation may be prevented by the
presence of IMF.
In such situations, several approaches can be adopted
depending on the pts injury and the state of dentition.
The following approaches can be used mainly
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A-oral intubation:
these type of injury in edentulous pt or partially dentate pt with sufficient space b/n
the teeth to accommodate the endotracheal tube can be intubated intraorally.
I- when mmf is applied in an edentulous pt:
the tube is positioned through a portal created in the gunning splints or dentures.
II- In partially dentate pt :
a reinforcing anode tube can be introduced through the space by directing behind the
mandibular second molar.
III-nasal intubation and switching the intubation to an oral route intraoperatively:
Indication
midface fracture the presence of nasal injury.
Nasal intubation followed by rigid fixation to stabilize mandible and maxilla after mmf
application, then switching to oral intubation to surgical manipulation of the nasal
injury.
IV-SURGICAL INTUBATION
INDICATION
When either nasal intubation or tube switch is unfeasible
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Sequencing of rx for midface and NOE complex fractures:
-is developing a plan order in an organized approach to midface architectural
reconstruction.
-enables the surgeon to perceive successfully restore reconstruction of midface
injuries.
-restoration of both pre injury facial aesthetics and function is now the goal.
To establish anterior-posterior and transverse dimension of the midface skeleton
In the absence of mandibular fracture
use of mandibular dentition is an excellent way.
in panfacial fractures involving mandible
when a reasonable dentition is present and posterior ramus height has been
preserved with at least one intact mandibular condyle
the mandible remains suitable reference
 Con..
if accuracy of the mandibular reference is compromised by lack of dentition, dislocated bilateral
condylar fracture and loss of continuity two options of reference can be used
1 - the upper third of the facial skeleton provides one option i.e

alignment of frontozygomatic , zygomaticosphenoid and zygomaticotemporal sutures establishes

midface position
2-mandible can be anatomically reduced as an arbitrary guides to the remaining midface.

if the mandibular fracture is complex and extent

staging the surgical reconstruction of the facial skeleton should be considered.
in this case, surgical reconstruction of facial skeleton are staged in separate, short procedures
avoiding long and exhausting effort to achieve the goal.
this is because when the operator fatigue can lead to less than ideal result.
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The surgical reconstruction stages in the ff way:
1-mandle:
In the first stage mandible is treated paying special attention to vertical,
anterior-posterior and transverse dimension.
2-mandibulomaxillary occlusion and zygomaticomaxillary fracture reduction:
After fixation of mandible maxilla is placed in to occlusion and secured with
IMF. This maneuver reduces fractures below lefort I level.
And then, both ZM complex fracture is reduced by closing the interface b/n
maxilla and zygoma at the zygomatic buttress to proper alignment.
this surgical technique establishes the correct anterior-posterior and
transverse dimension of the midface.

3-frontal sinus injury treatment

Is treated with obliteration of the sinus and the frontonasal duct [if
necessary]
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4-NOE complex
Proper sequencing of NOE complex reconstruction greatly enhances the final
out-come in extensive midface injury.
Ellis proposed a sequence that we have used with some modifications for
several yrs with excellent results.
In this sequencing:
1-bony reconstruction of the central portion of NOE is completed.
exposure and mobilization of NOE complex
bones of nasal vault is fixed to frontal bone
both frontal process of maxilla fixed to frontal bone
2-peripheral bony reconstruction and medial canthus repair
infra orbital rim is plated.
correction of medial orbital wall fractures that expand orbital volume
by reducing fractured segments or inserting graft.
reattachment of the medial canthal tendon to a stable bone.
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5-realignment of nasal septum and reduction of lefort I
-realignment of Displaced nasal septum
-then osteosynthesis of lefort I at the pyri-form and
zygomatic buttress. This restores the anterior and
posterior pillars of the midface.
6-nasal dorsum and orbital floor grafting
The final stage of the treatment of the pan facial trauma
is completed reconstruction of the orbital floor and
nasal dorsum with
bone graft or alloplastic substitutes
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Summary of sequencing:
An organized approach to the facial injuries
generally begins at the maxillary and mandibular
arches with progression to the vertical mandible.
- The naso orbito-ethmoidal complex is stabilized
to the cranium and bone is grafted when
indicated is performed.
- The zygomatic complex is related medially and
orbital reconstruction performed.
- The facial architectural reconstruction is
completed at refort-I level.
 Con..
to the Surgical access midface:
-there are two types of access to the midface injury.
laceration and formal incision
Midface injury can be addressed through laceration that
conveniently expose the underlying fracture i.e
if the laceration is close by to the fracture and doesnt involve much
effort or trouble we can use the laceration it self as a surgical
access.
-there are also systematic approaches to address it.
Three approaches provide full exposure to the midface, with the
exception of the lower and middle third of the nose i.e
maxillary vestibular , lower eye lid and coronal approaches.
- These approaches can be use separately or in combination
depending on the type of injury sustained.
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Maxillary vestibular approach:
Indication:
this incision extending from one zygomatic buttress to the other provides
direct exposure of pyriform rims, zygomatic buttress and maxilla.
The flap can be retracted far enough superiorly to visualize frontal process of
maxilla and infraorbital rims.
however, insufficient relaxation and infraorbital neurovascular bundles
seldom allow proper fixation of these area through the vestibule.
-when extensive comminution of the anterior maxilla is present, the free
pieces should be removed unless they large enough to fixate to prevent
sequestration and the resulting defect is reconstructed by a bone graft if
indicated.
the is because small pieces can be detached during the dissection in the
subperiosteal plane and sequestration sustained.
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Lower eye lid approach:
Surgical access to the frontal process of maxilla, orbital walls, orbital floors and infraorbital rims are obtained through this approach.

Brief review of lower eye anatomy:

The lower eye lid is

lined by conjunctiva
covered with loose skin and palpebral portion of orbicularis oculi.
Supported by fibrous skeleton called septum orbitale [orbital septum].

Orbital septum
Also known as septum orbitale.
in its inferior 2/3 it is directly attached to the anterior lacrimal crest and bony margin of the orbit.

In its medial extent it is thickened to form medial palpebral ligament.

this ligament and the medial canthal tendon [extension of o oculli muscle] are confluent in this area and the tendon tightly anchors to bone.

Laterally the septum

remains thin
fuses with the o oculli , forming raphe which provides connection b/n the o ocilli and orbital rim.

The septum in its superior 1/3 is thickened to form tarsal plate.

the tarsal plate
is more rigid and adapt the lid closely to the corneal surface.
anchored the eyelashes
contains meibomian glands. Secretions of which delay evaporation of the tears.
 Con..
Types of incision:
Incision can be created through the lid skin [
subciliary or infraorbital incision] or through
the conjunctival surface [ transconjunctival
Incision].
1-transconjunctival Incision:
Can be used to expose infraorbital rim, orbital
floor and both medial and lateral orbital walls.
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Technique
-first Incision through the lateral canthal skin with scalpel blade or iris scissor.
this facilitates lid retraction
Detaching of raphe from the insertion to the orbital rim.
this is to distinguish canthal release from canthotomy.
frontal canthotomy [canthal release]
is necessary if a wide dissection the orbit or exposure of lateral rim to fz suture is required.
this Incision is made parallel to the palpebral fissure.
this is b/s it heals very aesthetically , without distorting the lateral canthus.
exposure of the conjunctiva by eversion of the lower lid with skin hook or two traction sutures.
Insertion of corneal protector.
Conjunctival infiltration with LA combined with vasoconstrictor.
Incision
made approximately halfway b/n lid fornix and margin below the tarsal plate level with
electrocautery or scalpel blade.
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Subconjunctival dissection
- to ward the medial canthus:
either electrocautery or iris scissor is inserted through the lateral canthal incision for a subconjunctival dissection
toward the medial canthus.
the conjunctiva is then divided sharply with the scissor.
the medial extent of this dissection must avoid the inferior punctum and canaliculus.
once the conjunctival incision is joined to the canthal release, additional lid retraction is possible.
-transconjunctival dissection to ward the infraorbital rim:
may be continued in pre or postseptal plane.
is performed with electrocautery or a sharp tipped scissors.
frequent palpation of the rim guides the dissection to avoid perforation of the flaps in to the face.
dissection is directed toward intact areas of the rim, avoiding to use displaced segment as a reference.
avoid also orbital fat herniation in to the field in addition to flap perforation in this trans conjunctival dissection.
1-preseptal dissection
is performed b/n the septum and overlying orbicularis oculi muscle avoiding orbital fat herniation.
this dissection is continued approximately 5mm below the rim before incising through the periosteum.
however, adhesions b/n the thin skin-muscle flap to the underlying septum may produce unaesthetic result.
2-postseptal dissection
malleable copper retractor is conformed to the orbit for retraction of the fat from the field.
dissection is performed b/n conjunctiva and septum with lower end close to the rim.
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Subperiosteal dissections:
are completed to fully expose
the fractures
the adjacent areas which are used as
anatomic references for reduction and
stabilization
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Closure of transconjunctival Incision:
begins with periosteal layer, especially if a graft was placed
within the orbit.
the periosteum is sutured with resorbable suture i.e
chromic catgut.
Suturing of the deep tissues:
Do not require approximation, as can distort the alignment of
the lid when performed imprecisely.
however, when orbital fat herniation was sustained.
continuous or judiciously spaced interrupted resorbable 6-o
suture is used to close deep tissues.
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Suturing of the lateral canthal release[the canthotomy]:
-If the raphe was not detached
the canthal tissue is secured to the periosteum with a deep suture
-when canthotomy has been performed and the periosteum elevated
proper reattachment of the lateral canthus requires suturing to a
transosseous hole created at the level of the canthal attachment.
Slow resorbing suture like 5-o vicryl can be used.
the desired effect is approximation of the canthus against the sclera at the
same level as the medial canthal attachment.
technique
-suture is passed through the lower edge of the lateral canthal incision.
then the suture continued passing deep into the incision to engage the
periosteum or transosseous hole at the level of canthal attachment.
finally suture passed through the upper edge of canthal Incision and tied
under a small amount of tension.
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Subciliary Incision:
is alternative incision of lower eye lid approach to expose frontal
process of maxilla, both orbital walls, infraorbital rim and orbital
floor.
Technique
horizontal cutaneous Incision of 2-3mm below the lid margin is
performed.
superficial plane [b/n the orbicularis muscle and lid skin] or deep
plane [ b/n the muscle and the septum] dissection is continued to
5mm below the rim margin.
finally, subperiosteal incision is completed to fully expose the
fractures and adjacent structures for reduction and fixation.
Closure
begins with periosteal layer end with cutaneous layer.
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Complications of lower eyelid approach:
Both alternative incisions are more likely to associate with complications than any other approaches
used in mgt of midface injury.
Many of these complications are related to the scarring.
-ectropion
adhesion of the skin to underlying tarsal plane and septum may produce unsightly dimpling.
If the scar contracts or adheres to the orbital rim, retraction of the lid may create ectropion.
- secondary conjunctivitis:
lid retraction or disruption of the tarsal plane separates the lower eye lid from the cornea.
loss of this important seal produces epiphora or dehydration, resulting in this secondary
inflammation.
Globe asymmetry
increased amount of scleral show accentuates this aesthetic problem.
-Diathesis b/n the lid and the sclera as well as loss of medial-lateral canthal alignment.
due to failure of reattachment of the lateral canthal tissues to the orbital periosteum.
Con..
 Con..
Coronal approaches
Indication
the superior component of the midface including NOE complex,
frontal bone, FZ suture and zygomatic arch.
This technique enables wide exposure of the region while camouflaging
the Incision behind the hairlines.
The coronal flap can be developed centrally or may be extended
laterally depending on the degree of exposure required.
Central flap is enough to access NOE complex, frontal bone and fz
suture. Whereas the flap is extended laterally when exposure to
zygomatic is required.
lateral extension of coronal pap
connects helical facial junction on one side of the face to the other.
in other words, inferior extensions within the preauricular creases
may be required if the zygomatic arches needed exposure.
anterior extension of coronal flap
as the incision crosses the skull adopting an anterior curvature with
the incision facilitates access to the NOE complex.
 Con..
Steps and techniques:
1-fluid dissection
fluid dissection with saline and a vasoconstrictor is performed in the subgaleal plane.
2-INCISION
Incision is performed to the level of subgalea and galea aponeurosis is divided in a short segment with adequate
hemorrhage control before proceeding further
techniques of hemostasis
- using traditional method of securing bleeding margin including
oversewing the edges with 2-o silk sutures.
applying a series of Raney or Michel clips along the Incision

using cautery for coagulation including

colorado tip [ especial cautery tip]
this produces effective hemostasis as the Incision is made, concentrating
heat to a small area.

cautery units with low power settings i.e

a coagulation setting of 1o, a cut setting of 6 blend made of 5 are adequate for both
Incision and hemorrhage control.
 Con..
3-dissection
the flap is developed above the pericranium [suprapericranial flap]
curved mayo scissors is effective in releasing the loose ct attachment b/n
the inferior surface of the galea and the pericranium.
the flap is retracted forward till the superficial temporalis fascia [ a part of
superficial muscloaponeurotic system[SMAS] ] covering the temporalis
muscle becomes apparent.
4-Lateral extension of the flap
when a full lateral extension is required to expose zygomatic arch or to
facilitate anterior release the motor temporal br of the facial nerve must
be protected.
Techniques
Identification of the temporal branch
planning [ marking ] of an angled incision behind the temporal branch
 Con..
-Identification of the motor temporal br of the facial nerve
- the course of this nerve has been described by Bernstein and Nelson and related to several superficial land marks.
after the main leaving the parotid gland
approximately four rami [range 3-5] are formed.
these rami
pass from deep to superficial
cross the zygomatic arch at least 1.8 cm anterior to the helical facial junction and 2cm behind the frontal
process of the zygoma along a horizontal line drown from the lateral canthus of the eye.

alternatively the anterior most ramus has been described as

passing one finger breadth behind the lateral orbital margin.

Then the branches run superficially in the fat pad just below the superficial temporalis fascia [SMAS] to the lateral
margin of the frontalis muscle
in the frontal area
the rami pass beneath the frontalis muscle to innervate it and runs b/n the eye brow and 2cm higher.

Another set of land marks that enclose the course of the temporal branch , developed by Correia and Zani , describes
two diverging lines from the tip of the earlobe to the lateral extent of the highest forehead crease and the
eyebrow.
 Con..
-marking of incision
When lateral extension is required to facilitate the anterior retraction of the
flap
an angled incision is made behind the temporal nerve through the
superficial and deep fascia layers.
the supra flap is elevated just superficial to the temporalis muscle belly
and deep to temporal fat pad, which contains the nerve.
the dissection is connected to the central subgaleal flap more than 2cm
above the eyebrow, to protect the branch to the frontalis muscle.
subperiosteal incision
when the extension is required to expose the zygomatic arch
An incision is made across the root of the zygomatic arch
through the periosteum
1cm in front of the anterior most concavity of the auditory canal
 Con..
When exposure to lower portion of frontal bone or NOE complex is required
periosteal Incision is designed too low across the nasal root .
superiorly base subperiosteal flap is developed.
modification of this subperiosteal flap
sealing defect in the anterior cranial fossa should be taken in to
consideration, while designing periosteal incision and thus, the superior
based subperiosteal flap is too short to cover the cranial defect.
in case the consideration is required
modification periosteal Incision is made i.e
A high periosteal Incision is made on the frontal bone.
inferiorly based subperiosteal flap is developed to expose NOE complex or
the lower portion of frontal bone.
This flap is of sufficient length for rotation through the frontal craniotomy.
 Con..
-placement of a suction drain
a flat suction drain is placed transversely across the
cranium in the subgaleal plane i.e
a 7mm Jackson- pratt drain can be used.
drain is extoriorized through a small incision in the
lateral aspect of the flap just behind the superior helix.
Two drains may also be used, if significant postop
bleeding is anticipated.
-resuspension of facial mimetic or temporalis muscles
this prevents the postop soft tissue ptosis.
 Con..
A- resuspension of facial mimetic muscle
is performed when the soft tissue around the zygoma and arch has
been dissected.
this prevents postop facial soft tissue ptosis.
technique
transosseous holes are drilled in the frontozygomatic regions.
the lateral facial soft tissues are attached with nonresorbable sutures.
B-resuspension of temporalis muscle
If the muscle is elevated to expose the lateral orbital wall,
resuspension of the muscle to a screw or hole in the superior
temporal line is important.
 Con..
-closure of periosteum and galea in layer using resorbable sutures.
-skin closure with surgical staples, which are removed after 7 to 1o
days.
postop complications of coronal flap
-alopecia along the incision line.
-temporal wasting
-potential for temporal nerve injury.
note
development of the temporal wasting is still not fully understood,
but may be secondary to
atrophy of temporal fat
or failure of the temporal muscle to attach it self superiorly
enough to restore its former length and bulk.
 Con..
Midface degloving approach:
also known as sublabial degloving Incision.
the approach combines the maxillary degloving incision with the open
rhinoplasty approach
this approach was originally used as a means to access the nose and the
paranasal sinus for the purpose of tumor resection.
is an excellent method to expose the central midface for reduction and
fixation of fracture with out production of cutaneous scare.
Indication
it provides an excellent exposure of the zygoma, infratemporal fossa,
anterior and posterior maxillary walls, nasal skeleton, orbital floor, and the
inferior portion of medial and lateral orbital walls.
 Con..
Techniques
1-fluid dissection
in this step hemostasis is aided with
infiltration of lidocaine with vasoconstrictor along the maxillary vestibule.
topical application of 4% cocaine to the nasal mucosa.
2-Incision
starting with the nose [open rhinoplasty]
bilateral intercartilaginous incisions are made b/n the upper and the lower lateral
nasal cartilages.
these bilateral incisions are continued laterally along the anterior margins of the
pyriform apertures and through the nasal floor into the maxillary vestibule.
a transfixation Incision
is created medially through the membranous septum, extending from the nasal
tip to the floor and it connected superiorly with the intercartilaginous incisions.
the incision is completed with dissection of the nasal floor.
 Con..
3-dissection
dissection is performed in a supraperichondrial plane over the upper lateral cartilages until the nasal bones are
reached.
the soft tissue is elevated from the dorsum of the nose through the intercartilaginous incision with a freer elevator.

4-periosteal Incision and subperiosteal flap

periosteal incision using a curved joseph blade is performed on the nasal bones and subperiosteal flap extending to
the nasofrontal junction, superiorly and to the nasomaxillary sutures, laterally is developed .
here, care must be taken not to disarticulate the upper lateral cartilages from the nasal bones.

5-maxillary vestibular degloving Incision

a- a standard maxillary vestibular incision is performed from first molar to first molar.
b-completion of the nasal dissection medially i.e
the vestibular nasal floor and transfixation Incision.

6-maxillary vestibular dissection

a single subperiosteal dissection is raised.

then the whole midface degloving dissection exposes the entire midface to the level of orbital floors and nasal roots
Con..
 Con..
7-closure
for the transfixation Incision and vestibular Incision
closure is achieved with 3-o sutures

for the nasal sill, intercartilaginous areas and the floor

with slowly resorbable vicryle 4-o sutures.

note
a careful reapproximation of the transfixation Incision
is very important to position the nasal tip correctly.
 Con..
8-Rhinoplasty dressing
a standard Rhinoplasty dressing done
for the purpose of
reducing edema
adapting the nasal soft tissues to the underlying nasal skeleton.

using
transversely applied surgical tape over the dorsum of the nose, and
protective splint

Complications
the complications related to this procedure
are minimal
relate primarily to adverse scaring in the nasal vestibule.
incorrectly placed transfixation suture may cause

nasal synechiae
increased alar show
 Con..
Surgical approaches to the NOE complex
direct approaches i.e
preexisting laceration over the
vertical incision along the nasal dorsum
transverse Gullwing Incision within the eyebrows
uni /bi lateral nasal Lynch INCISIONS
H-shaped incision across the nasal bridge [open sky exposure]
these approaches offer greater degree of direct exposure.
but produce less aesthetic results in a prominent areas of the face
indirect approaches i.e
coronal incision
lower eyelid incision
Maxillary vestibular incision
 Con..
A- coronal approach
the superior component of NOE
occurring alone or in combination with
other midface fractures
can be accessed through the coronal flap,
provided sufficient anterior release is
achieved.
If the flap is tethered by attachment of supraorbital and supratrochlear
neurovascular bundles
freeing the nerves from the foramen provides additional relaxation.
Technique
inferior margin of the foramen is removed using burs and small osteotomes.
neurovascular bundles are mobilized through the defect created
dissection of these bundles in to the soft tissue flap is done.
 Con..
The problem of coronal approach to access NOE complex
this approach is a limited access to
the medial portion of the infraorbital rim and
the inferior portion of the frontal process of the maxilla.
Therefore additional incision is required to expose the areas,
especially, when plate stabilization necessitates a wide
exposure of the field i.e
Lower eyelid incision
Maxillary vestibular incision
 Con..
B-lower eye lid approach
Indication
infraorbital rim can be entirely exposed through this
approach.
C-maxillary vestibular approach
Indication
frontal process of maxilla
unilateral, incomplete, single-segment injuries with
fractures through the frontal process of maxilla and
infraorbital rims with out involvement of frontonasal
articulation can be treated with this approach alone.
 Con..
D-H shaped incision
also called open sky exposure
is an Incision done across the nasal bridge
 Con..
E- LYNCH incision
Is a curved incision made over the lateral nasal bones anterior to the
attachment of the medial canthus
indication
NOE complex for limited reconstruction
Problem
lynch incision is insufficient approach of NOE complex when the ff
are indicated in this injury
bilateral canthopexies
bone graft reconstruction of NOE complex.
In such cases a wider exposure of the complex is necessary and lynch
incision is insufficient.
Con..
Con..
 Reducing midface fractures
Proper reduction is arguably the most important step in midface injuries.
Because several complications are the result of inadequate or improper reduction of
these segments.
Methods and vectors of reduction depends on the fracture pattern, degree and
direction of displacement.
universal rule mechanics
states that reduction force is applied close to fracture site [articulation of segments].
because this movement results in
-greater movement of the articulation
-more control over the direction of movement
Lefort I is reduced with forceps applied to the nasal floor and palate essentially for
bridging the fracture lines.
Rowe disimpaction forceps is an example of these instruments.
the Rowe forceps grasp the maxilla with lt and rt twin blades
the operator looks his/her wrist and uses coordinated movement to rock the maxilla
in to place.
 Con..
Reduction of midface fractures displaced posteriorly and inferiorly
first disimpact the maxilla in the area of pterygoid plate applying
downward force and sufficient anterior displacement is achieved.
Blunted instrument can also used if the anterior displacement is not
sufficient i.e
seldin retractor is placed in pterygomaxillar junction the maxilla
distracted into anterior position.
finally rowe forceps is used to bridge the fracture line.
IF palatal fracture is present it prevents the application of rowe
forceps.
In such cases Hayton williams maxillary forceps uses twin blades that
engage the lateral surface of the maxilla.
 Con..
Reduction of lefort II and lefort III fractures
These type of fractures can also be reduced with
disimpaction forceps.
However, the further the fracture sites are from the point
of force application, the less efficient the reduction.
therefore when inadequate alignment results,
individual segments are reduced separately.
There are two techniques of reducing individual
segments.
direct reduction technique
indirect reduction technique
 Con..
Direct reduction techniques are achieved with
elevator
bone hook
wire inserted through the fragments.
Indirect reduction techniques employ
bone hook
carroll-girard screws that engages the zygomatic
body and reduces fractures at the
frontozygomatic suture, zygomaticotemporal
articulation, infraorbital rim and buttress.
 Con..
Traction
constitutes another methods for reducing fractures
of the midface.
this method is achieved using elastic bands applied
to maxillary and mandibular arch bars
However, once again, the traction method may not
effectively reduce all midface fractures.
especially If the fracture sites are distant from the
dentition.
 Con..
Systemic complication of Lefort II and Lefort III level reduction
Oculocardiac reflex
may be produced during reduction of the midface fractures at the lefort II and III
level.
This response [afferent limb] is a reactionary bradycardia mediated by the ophthalmic
branch of the trigeminal nerve.
this reaction follows traction on the orbital content, especially the medial rectus
muscle.
Relays b/n the descending spinal trigeminal tract and the visceral motor nucleus of the
vagus nerve with in the reticular formation [efferent limb] produces a slowing of
the heart rate.
mgt
the bradycardial Reflex
can be corrected by releasing reduction forces
Or treated with administration of I/v atropine, if hemodynamic compromise persists.
 Con..
Reduction of impure midface fractures
is achieved using direct reduction technique at
the separate fragments.
eg. Hemi-lefort II fracture with contralateral
zmc component requires
reduction of lefort and zmc separately using
direct technique.
 Con..
Establishment of adequacy of reduction in midface fracture
the complex anatomy of the midface requires examination of all
fracture sites.
especially the problem areas I.e
areas of comminution
circular rings which includes zygomatic body [lateral orbital rin], area
of FZ suture, zygoma part of infraorbital rim.
the later fracture area is a cause for gradually increasing diameters
of the midface.
so a small errors in the alignment of medial structures will result in
progressively larger discrepancies further laterally.
 Con..
Reducing NOE complex fracture
NOE complex is reduced as a separate maneuver fractures from the
alignment of associated midface fractures.
NOE complex has two important features for which special attention must
be paid.
restore the shape of the complex
the complex is wedge shaped and restoring the projection to the
complex requires proper reduction of the base
sequencing of fracture reduction
NOE fracture reduction is sequenced before reduction and fixation of
inferior [pyri form rim] and lateral [medial orbital rim] elements
alignment of the bones is restored making up the central fragments
Con..
 Con..
Techniques of reduction
A-to restore the shape of the complex
This reconstruction of the central fragment is most commonly
achieved transnasal wiring i.e
type I, unilateral [ complete, unilateral-single segment fracture]
is present with lateral displacement of the medial orbital wall.
so transnasal wiring is used to reduce.
type I, bilateral [ bilateral single segment fracture]
is present with the central fragment remaining intact.

therefore, usually do not require transnasal wiring

 Con..
type II [ comminuted NOE complex fractures] and type III
[ comminuted complex fractures with fracture
extension in to the canthal insertion ]
transnasal wiring is required to restore central
fragments and reduce the width of the complex.
Note : wires
used to produce projection of the complex must be
passed as far posteriorly as possible i.e
posterior and superior to the lacrimal fossa .
And when used to attach the medial canthal tendon, a
high to low reduction produces the best restoration of
the medial canthus geometry.
 Con..
B-reduction of lateral nasal bones and frontal process of
maxilla
these fragment structures are also reduced as part of
the maneuver to reconstruct the central fragment.
this reduction is achieved with elevator applied
through the nose or
with a walsham forceps applied externally and through
the nose.
c-alignment of other midline structures
is completed after reconstructing the central fragment
of NOE complex i.e
 Con..
The nasal process of frontal bone
Is usually displaced posteriorly
is reduced with a towel clip applied to the bone.
The perpendicular plate of ethmoid bone
is reduced with an asch septal forceps
small bone fragments that are no longer connected
to the major fracture segments must be reduced
individually.
Con..
 Con..
the medial canthal tendon injury

is fundamental component of successful treatment in NOE complex injury.

Because it serves as medial insertion of the orbicularis oculi muscle.
loss of anchorage of the tendon allows the muscle to contract unopposed, producing a round canthal angle.

possible scenarios encountered in the mgt of these tendon injuries

1-both medial canthal tendon remained attached in type I, bilateral
2-The tendon is attached to a bone fragment that is separated from the complex in type I, unilateral or type IINote

3-the tendon has been avulsed from its bony connection but the bone where the tendon inserts is still present in
type III
4- the bone where the tendon inserts is missing in type III
 Con..
reattachment of the medial canthal tendon
reattachment requires fixation of the tendon to stable segment of bone and
is the fundamental component successful treatment in NOE complex.
Indication
in type I, bilateral complex fracture tendinous attachment is preserved in its
majority and no need of tendon reattachment
the lateral displacement of the complex only mged.
in type I unilateral , type II type III tendon needs reattachment.
technique
identification of the tendon and tendon bearing bone fragment
creation of transnasal channels with 1.5mm wire passing bur or 18 gauge
spinal needle
attachment of the tendon to the opposite portion of the complex with
wire.
 Con..
Biomechanics and healing of the midface:
a-fracture displacement vectors
understanding the physiologic forces exerted on the midface and the
characteristics of fracture healing of midface is important for proper
fixation of it.
the understanding of forces and biological responses of d/t maxillofacial
skeletal structures is confounded by
the non uniform geometry of bones
the number and orientation of attached muscles and ligaments.
therefore, understanding of potentially destabilizing forces is
important in treatment of fracture to restriction of the fracture
fragments in all possible direction of motion.
 Con..
A fractured segment of bone is capable of displacing in six directions along the X[horizontal] Y[vertical]
and Z [sagittal] axes i.e
three translatory movements
three rotational movements
the translation in all direction can be restrained by a plate or wire of adequate tensile and
comprehensive strength.
but the rotary movements require constraint at three separate points lie from one another.
Note
of restricting rotation,
1- plates are more capable than wires
2- wider plates [ fixation points farther apart] are more effective than narrower plates against
rotary movements which is a consideration when microplates are used in fixation of midface
fractures.
3-three plates or several wires oriented at d/t angles from one another provides more rigidity than a
single plate providing one point of fixed.
therefore, a ladder shaped three dimensional bone plate applies some of this reasoning to
stabilize fractures in all six possible dimensions.
Con..
 Con..
B-Screw fixation
rigidity and conformation of plates and its retention against the bone
are also important biomechanics concept in bone fracture
stabilization.
retention of the plate is dependent on
1- the bone screws ability to resist various pull-out forces, that is
provided by the friction.
this pull-out resisting friction force is generated by
-the thread shoulder of a screw
-thread cut into bone
2-the degree of contact b/n the screw thread and bone
i.e the greater the contact, the placement in untapped bone
However, whether the is tapped or untapped microfractures and
crushing of bone are observed, but do not appear to be significant.
 Con..
C-load path:
Is the path a force takes when applied to a structure.
generally a force flows through the stiffest component of an area.
therefore the following biomechanics must be taken in to account in this concept of mechanics.
A-apposition b/n the fractured bone fragments
the apposition of the segments should be good [more stiff] in order the load path to share b/n the
bone and the fixation device.
the stiffest portion of the midface corresponds the vertical and horizontal pillars, constituting thick
cortical plate and scant interposed marrow.
thus, are optimal sites fore stabilization of fracture, provided bony continuity is present.
B-approximation of fracture ends
approximation of the ends b/n fragments should be close resulting in interdigitation.
thus, this interdigitation provides additional stability of fracture, counteracting rotary forces.
 Con.
C-proper fixation device selection
d/t devices must be employed for interdigitated and space separated
fragment ends i.e
microplates or wires are adequate in interdigitation whereas the
devices with multiple screws can absorb the increased force in
space separation with out material failure.
D-adequate number of screws application
screws help distribute the force exerted on a plate.
therefore,
if there is gab b/n fragment ends the load path transfer
predominantly to the plate or wire and thus, multiple screw in
each segment is proper.
this reduces the amount of force to a single portion of plate or
bone.
 Con..
Neuromuscular response to fractures
the force voluntary contraction in muscles associated with fractures is a part
of biomechanics that should be considered in fracture stabilization.
Spontaneous muscular splinting of fractured bones is known to occur.
this muscular splinting appears to be coupled with simultaneous reduction
in force of contraction and this physiologic response is known as
neuromuscular response of fractures.
this phenomenon has been demonstrated in masseter muscle :
1- in the presence of zygomatic complex fractures
2-mandibular angle fractures
in fracture of these two areas bite force appears to be reduced during
initial period of repair or for several weeks following the surgery.
 Con..
Healing of midface fractures :
invocation of the protective response against
aggravation of a fracture site
meaning, what is the demand this response make
on the fracture site?
explains why a number of fixation devices of d/t
strengths have been successful clinically but
failed in vitro testing.
 Con..
Mechanisms of midface bony healing
there are two mechanisms of fracture healings.
1-Intramembraneous
2-endochondral
Several studies have been performed , with conflicting results. Thaller concludes and we agreed that the mechanism of
healing depends on the conditions imposed on a fracture sites.
1-intramembraneous
this mechanism of healing occurs in contact alignment of segments
in the absence of reduced vascularity, mobility and infection bone is formed.
Steps:
enlargement of chondrocytes and form cartilage over a thin bone [primary ossification center]
newly drived osteoblastes cover the cartilage
vascular penetration to the cartilage
thin bone enlarge and replace cartilage
osteoblastes form secondary ossification center
vessels invade the bone

reducing mobility through rigid fixation and using bone graft as a support across a fracture interface are believed to
contribute to bony union even in the most unfavorable midface fractures.
This type of healing is called primary healing.
 Con..
Endochondral ossification
occurs in gab reduction
steps:
-early cartilage center [primary ossification center]
perichondriun and hyaline cartilage formation
-formation of secondary ossification center [enlargement of
chondrocytes ], periosteum and bony collar.
-cartilage is covered with osteoblastes and vascular invasion [primary
marrow formation and secondary ossification center appearance ]
if the fibrocartilageous bridge provide sufficient stability, bone is
formed later.
if the noxious factors [infection, mobility and reduced vascularity]
persist, fibrocartilaginous union may persist. Nonunion.
This type of healing is called secondary healing.
 Con..
Fixation of midface and NOE fractures:
Stabilization of midface fracture
mainstay of treatment during 1980 are:
extracranial device
intermaxillary fixation
transosseous wires
currently the accepted standard of care:
rigid, interfragmentary bone plates and screws.
advantages of bone plates
a-over craniomaxillary and craniomandibular
it provides greater stabilization.
Reason, the effectiveness of fracture reduction increases with the
application of forces close to the fracture sites
 Con..
B-over extracranial techniques
Bone plates provide greater stability
reason plates are applied over the fragments providing three-dimensional stability, whereas
extracranial techniques rely on a sandwich effect.
C-over transosseous wires
Reason plates provide greater three-dimensional stability
transosseous wires are effective in restricting linear distraction of two fracture fragments but
less capable of preventing rotational movements.
transosseous wires require greater soft tissue dissection on both outer and inner surfaces of a
fragment
plates can be placed with exposure of only the outer surfaces of a fragment,
thereby preserving some soft tissue attachments to the bone.
this attachment of soft tissue may be important to the vitality of the bone.
Transosseous wires produce a greater amount of intrafragmentary pressure, especially around the
transosseous holes , when tightened to produce close apposition of fracture margins
this may lead to
bone necrosis
subsequent fractures through the transosseous hole resulting in loss of fixation
 Con..
Wire fixation
still retains a place in the treatment of midface injuries, even with the use of bone
plates
wires are used
in skeletal form of fixation to supplement arch bars
as means of attaching splints to the maxillofacial skeleton
as ligatures to attach important soft tissue structures to their bony insertions
As transosseous fixation forms to provide temporary stabilization of individual
fractures in the staged reconstruction of panfacial fracture.
aim
this helps ensure that proper reduction of all fractures have achieved before bone
plate fixation
while also helping to align fracture segments as plates are being conformed and
applied.
 Con..
Internal rigid fixation techniques:
Since michelet introduced miniplate stabilization of
facial fractures in 1972, plating of midface fractures
has become universal standard for pts with these
injuries.
Multiple systems and devices from different
manufactures offer a wide choice of plates.
Selection of the appropriate plate should be based on
the configuration of the pts actual injuries
a knowledge of midface fracture biomechanics
 Con..
Plate designs:
Plating system varies according to several parameters.
set of plating device
bony plates and bony screws
important features considered in organizing the d/t
devices
rigidity, shape[configuration] and width of the bone
plate
number of stabilizing points, and diameter and size of
screw
 Con..
Rigidity of internal fixation devices

of a particular plate is essentially a function of its thickness

reason
titanium comprises the vast majority of plating devices. Titanium is an alloy of cobalt-chromium and
molybdenum, which replaces both stainless steel and vitallium.
Thicker plates provide greater resistance to deformation than thinner plates.
Functional loads concentrated along the entire plate and underlying bone provide greater stability
against pullout forces.
Types of rigid internal fixation devices
generally there are four types
Miniplates , which range in thickness from 0.6mm to 1mm
Microplates , which range in thickness from 0.5 to 0.6
mesh plate designs
and three-dimensional plate designs
 Con..
Disadvantage of thicker plates
assume a higher profiles
this makes them more palpable, when placed in areas where soft
tissue coverage is thin i.e maxillary vestibule, nasal bridge and
infraorbital rim
higher failure of the fixation device
reason
they are more difficult to adapt closely to the underlying bone, in
which the functional loads will preferentially concentrate at the
plate-screw interface rather than along the entire plate and
underlying bone.
this may result in instability due to loosening of screws and the
ultimate failure of the fixation device.
Miniplates are more rigid, as the are thicker
 Con..
Width of bone plates
wider plates provide greater stabilization
against rotational forces.
miniplates tend to be wider than microplates
both mini and micro plates are linear designs
the altered plates linear design also tend to be
wider than the plates of linear designs,
providing great resistance to rotational forces.
 Con
Shape of bone plates
The alteration of plates in configuration from linear design [shape] to
several d/t designs have been resulted from the effort to increase
the geometric width of d/t devices with out increasing the
thickness.
the d/t designs use the same principle that the wider plate provide
the greater stability against rotational forces and to augment
rotational stability across fracture sites.
altered designs
the alteration of plates from linear designs to X, H, L, T, Y SHAPES
mesh and ladder shaped three-dimensional plates
all of these shape modifications are to augment rotational stability
across the fracture sites.
 Con..
Bone screws
are plating devices used to stabilize a bone plate to the underlying bone
Factors affecting screw stabilization
screw size
screw diameter
anatomic site [amount of intervening bone b/n adjacent screw holes]
fracture pattern
significance of cortical bone
number of stabilization points
Degree or extent of separation b/n stabilization points
Variables encountered with methods to stabilize a bone plate with the underlying
bone
Minimum number of screws in each bone segments to prevent rotation in the x and y
axes
Minimum number of augmented device.
integrity of the screw bone interface
 con
The goal of the stabilization in midface fractures
prevent all the translatory and rotational movements
Methods of stabilization in midface fractures
two-points stabilization
bicortical retention of screws is less a feature in midface plating than mandibular fixation, because
of the absence of a significant cortical plates.
furthermore, screws help distribute the force exerted on a plate, multiple screws in each segment
reduces the amount of force to a single portion of the plate or underlying bone.
a screw with a larger diameter possesses a greater resistance to pull-out forces but require adequate
amount of intervening bone b/n the adjacent screw holes, otherwise large diameter screws placed
to close together may result in the holes becoming confluent and ultimate loss of integrity.
hence as a whole, a minimum of two screws in each bone segment is required to prevent rotation in
x and y axes.
augmented stability of nonlinear device.
as the farther apart the points of fixation the more effective the device in counteracting rotation,
hence the augmented stability of nonlinear device
 Con
Resorbable bone plates screws
Both the plates and the screws are combination of d/t biodegradable polymers i.e
polylactile-polyglycolic copolymer
are developed in an effort to limit stabilization to the period it takes a fracture to heal and remodel.
are thermoplastic plates
Advantages
plate removal is no longer necessary when used in prominent areas or denture bearing areas.
are easily conformed to a fracture site
theoretical advantages
diminished likelihood of growth restriction, when placed over sutures.
promotion of remodeling under functional loads in the absence of stress shielding
Limitations
The size of the plates are longer than miniplates
and use screws 2mm in diameter

screws are difficult to remove

screws are applied with a break-away nipple attachment, which makes removal deffocult
 Con..
d/c in technical consideration
Resorbable plates become malleable after placing the
device b/n specially designed pads that produce heat
following an exothermic chemical reaction.
therefore the techniques are
softening the plates by placing b/n the pads
conforming the plates to the fracture site
tapering holes by drilling
screw insertion
Or if complex multidirectional bend is required molding
the device in a template is recommended.
 Con..
Location of fixation
the precise location and number of plates and screws necessary to provide stabilization of the midface and NOE
complex fractures are often determined by the fracture patterns.
Location of fixation
a position of the plate and screw is determined by two principles
areas that contain the greater amount of cortical bone provide greater retention of screw fixation, being stiffer than
the remainder of the skeleton.
areas that correspond path load through the midface.
remember: load [the force applied over a structure] flows through the stiffest component of an area.
A positioning of midface fixation is determined based on the principle i.e

provided the bone plates are well adapted to the bony segments in these fracture sites, the placement of fixation
devices coincident with load paths helps distribute the forces among the individual components present at a
fracture (bone fragments, plate and screws)

Hence two internal fixations are applied to the Rx midface injuries.

through the vertical and horizontal pillars
have greater amount of cortical bone
are the stiffest areas of midface
in areas not subject to large loads i.e
the anterior and lateral walls of the maxilla and the anterior table of frontal sinus are common sites of applications
 Con..
the number and orientation of plates and
screws
Are determined based on the principle
the use of multiple plates and stabilization
points oriented at d/t angles from one
another enhances the translational and
rotational stability of the fragments
 Con..
Stabilization of the d/t fracture patterns
lefort I
use three- point fixation with miniplates
I.e stabilized by L-shape miniplate or three-dimensional plate alternatively ,
paced at zygomatic buttresses and Curved plate, placed along pyriform
rim.
Lefort II
Use three-point fixation with miniplates i.e
linear or Y-configuration plate placed at the frontonasal junction, curved
plate at the infraorbital junction and l-shape at the zygomatic buttress.
Lefort III
USE three-point fixation
at the frontonasal junction and frontozygomatic regions.
but the zygomatic arches may also be plated, if exposed for the purpose of
reduction, and some additional stability are gained.
Con..
Con..
 Con..
Stabilization of palatal fractures
Lateral and medial fixation of the maxilla with an arch bar in combination
with a palatal splint is sufficient.
However, if internal fixation is required
Use two point fixation with miniplates i.e
one is applied along the anterior surface of maxilla below the nasal spine and
the second at posterior junction of hard palate.
Approaches to the palatal fractures are
Small mucosal incision at the posterior junction of the hard palate in the
presence of labial sub-mucoperiosteal dissection routinely performed to
access midface fractures.
The additional elevation of a palatal flap to expose the midportion of the
palate is hazardous to the vascular supply of the maxilla.
 Con..
Stabilization of NOE complex fractures
Use two point fixation with miniplate
linear or T- or Y-shaped miniplate placed at the frontonasal
junction, whereas long curved plate to suspend frontal
process of the maxilla from the frontal bone.
microplate and mesh can also be used here and are better
reason for use of microplate
fracture segments are small
loading forces are virtually absent
the low profile of microplates also make them ideally
suitable to this area, which is covered with relatively thin
tissues.
 Midface fracture in pediatric
outlines
the differences in
prevalence
etiology
injury type
dx
mgt
 Con..
Prevalence
pediatric midface fractures are rare, if nasal bone fractures are discounted they are almost absent.
this is due to anatomic factors ie
the relative prominence of the cranium
incomplete pneumatization of sinuses.
elasticity of an immature facial skeleton with nonossified sutures.
Reduced classic area of weakness
Etiology
in cities
motor vehicle incidents are the first prevalent causes
firearm related injuries are the second most common causes

in rural environment
motor vehicle incident are the prevalent causes and no in injuries secondary to firearm

the potential of child abuse must always be considered in pediatric pts when the etiology is poorly
verified
 Con..
Dx
in the infant population is complicated by an inability to communicate reliably with pt.
Hx
symptoms may not be accurately conveyed.
Physical examination
reactions to examination may be the result of apprehension rather than pain.

analysis of occlusal relationships is complicated by

a mixed dentition with missing or partially erupted teeth

investigations
radiographs
is the principal means for diagnosis
CT
is the standard, using multiple thin cuts to image the facial skeleton
sedation may be necessary to prevent motion artifact.
the helical scanning techniques have considerably shortened the time required for a study
 Con..
Treatment of pediatric injuries
surgical mgt of pediatric midface injuries generally follows the same
principles as for adults, with some modifications related to the actual age
of the pt.
airway control
in pediatric population is complicated by incomplete development of the
laryngeal cartilaginous frame-work.
in pts younger than 10 years age the cricoid cartilage provides the only
circumferential support to the air way.
therefore, cricothyroidotomies are contraindicated.
endotracheal intubation is the best airway mgt than surgical
use of fibroptic larngeoscopy improves difficult air way mgt.
But cricothyroidotomy is an emergency mgt of air way in pediatric pts
( our teachers)
 Con..
Fracture mgt in pediatric pts
Can be mged by both open and closed techniques.
Closed technique
when this technique is adopted, the ability the dentition to establish an occlusal rxnsxp and support
fixation must be considered.
If the maxillary and mandibular arches interdigitate precisely
minimally displaced fractures
fractures that maintain a stable position after reduction
These type of fractures can be mged with IMF.
Children tolerate a period of IMF much better than might be expected.
Period of IMF
can generally be reduced from 6 months to 2months.
Because fracture healing in the young proceeds very rapidly
if arches do not interdigitate precisely
fabrication of acrylic splint is necessary and additional skeletal support is provided with
circummandibular and pyriform aperture wires to prevent subluxation of teeth with shortened
roots.
 Con..
Open reduction technique
Indication
Fractures that can not be reduced adequately in closed technique.
employed the same access incision, sites, number and type of fixation as used for adults and produce
excellent results.
Sutural growth in the midface is active until approximately age of 7 years.
Before this, plates bridging zygomaticomaxillary, midpalatal and zygomaticotemporal sutures may
inhibit facial growth.
here fixation devices applied need removal or resorbable plates should be used.
If these areas are avoided or fixation is used in pts order than 7 years no need of removal

Whenever fixation devices are applied to the mandible and maxilla, developing tooth buds that may be
present high in the alveolus must be avoided.

Involvement of the parent

they should be assured about treatment and outcome i.e

if growth or functional disturbances are possibilities, parents should be advised early about the
necessity for long-term review and the potential for further corrective surgery.
 Geriatric midface fractures
Prevalence
fractures of the upper midface are the most
prevalent of all craniomaxillofacial fractures in
older people.
Motor vehicle and fall incidents are the leading
causes.
 Con..
Mgt
factors that decrease the necessity for surgery
Significant medical hx
The frequent use of denture as prosthetic
appliances can be remade to overcome small
discrepancies in skeletal alignment.
reduced concerns over aesthetics
 Con..
Techniques of reduction
Are similar to those used in the treatment of adult.
However
access
fracture sites are commonly accessed directly .
both skin laxity and deep furrows hide the sites of cutaneous
incision well, providing a greater opportunity to such access
rigid fixations with possible encroachment in to denture-bearing sites
require
removal of devices or use of resorbable plate and screws.
in the absence of natural dentition, the establishment of an occlusal
guide requires incorporation of arch bars in to denture or
fabrication of gunning splints.
these are retained using skeletal suspension.
 Complications and morbidity
associated with midface injuries
The complexity of the midface and its associated structures provide
ample opportunity for the development of adverse outcomes.
Incident
It Is hard to derive an accurate incidence of each problem, owing to a
number of reports variation in study design, definition of
complications and operator experience levels.
For the purpose of this presentation
adverse sequelae to the mgt of midface are divided in to two groups
-amenable:
sequelae that may be corrected a secondary surgery
-not amenable:
Not amenable to further surgical mgt
 Con..
Non amenable complications:
nerves affected
olfactory, optic, oculomotor, trochlear, infraorbital and abducents nerves.
Infraorbital nerve injury
hypoesthesia the clinical finding.
In the infraorbital nerve hypoesthesia some recovery of function can be expected to occur, although the extent can not
be corrected either by the severity of injury or by the type of surgery performed.
persistent hypoesthesia several years after injury may or may not be concern to the pt.
Anosmia
Occurs in 50% fractures involving the cribriform plate.
But also caused by damage to the olfactory nerves, disruption of the olfactory epithelium lining the nose and lesion of
the olfactory bulb and tract
Supraorbital or supratrochlear nerve hypoesthesia
associated with the use of coronal flaps.
this complication is probably secondary to stretching and manipulation of these nerves.
these deficits appear to be transient i.e
In most cases sensation is returned one month later and continued with time in some cases.
Traumatic paresis of the temporal branch of facial nerve
this complication is also associated with the use of this coronal flaps in immediate postop period.
and more that half of the problems are persistent at least six months following surgery.
 Con..
Amenable complications:
A-secondary nasal deformity
major deformities
asymmetry of the bony-cartilaginous frame work
Septal deviation or fibrosis
Collapse of the nasal valve
And synechia
cause
This complication represents
Inadequate reduction of fractures
Insufficient stabilization
failure to repair a damaged structures
Nasal deformity secondary to midface injuries is the most common problem
and is diverse
 Con..
Secondary corrective surgery
Assessment and timing are delayed for a minimum of 6 months to allow
edema to subside and scars to mature.
When intervention is undertaken early
failure to correctly diagnose all the problems, unstable skeletal components
and active reparative process may lead to
incorrect procedures
poorly controlled osteotomies
excessive bleeding
posttraumatic rhinoplasty
procedures to the deformities of correct osteo-cartilaginous vault
repositioning osteotomies
removal of bony irregularities
Realignment of nasal and septal cartilages
camouflage augmentation procedures
 Con..
Procedure to remove webbing within the nose
excision followed by Z- plasty or local soft
tissue flaps.
Reconstruction of nasal valve
is difficult
may involve augmented support of the alar
cartilage with grafts.
 Con..
Malocclusion:
Is a common problem
Results from inadequate reduction or in
sufficient stabilization
Incidence varies with the type of fixation used.
rigid plating techniques tend to be less forgiving than closed or wire
stabilization of fractures.
in this case
postfixation adjustments with elastic traction can correct the small
discrepancies(occlusal equilibrium). But whether the correction
occurs through movement of skeletal segments or dental
compensation is unknown.
orthodentics
 Con..
significant malocclusions present in pts treated with IMF
are corrected by
orthognathic surgery at lefort I level, whatever the level
of the original injury.
associated malpositionig of nasal bones, NOE
complex or zygomatico-orbital complex are addressed
as separate procedures.
mandibular osteotomies may be added to reduce the
total distance moved by the maxilla to correct the
discrepancy.
 Con..
Timing of corrective surgery
Is based more on intuition than science i.e
If secondary procedure is performed with in 3weeks of
injury, it is usually possible to separate the malunited
segments along the existing fracture lines
However, if comminution is present or surgery is delayed
beyond this initial healing period, allowing the
fractured midface to heal completely and to regain its
previous form through remodeling facilitates
orthognatic surgery.
 Con..
ARF and sigma:
The summation of the processes that occur during homeostatic remodeling is known
as activation-resorption-formation(ARF).
completion of ARF in humans take approximately 3 to 6 months.
the period is referred to as sigma.
Therefore, fractured bones will not regain their prefracture strength and form at least
6 months following injury.
in contrast to mandibular ramus surgery, which relies on controlled fractures along
prescribed lines of weakness, midface surgery for the correction of malocclusion
utilizes full of osteotomies to mobilizes the maxilla.
Therefore surgery can be performed before the completion of sigma, if it is confined
to the maxilla.
Orthognatic surgery is performed in a similar manner to a surgery performed for the
correction of developmental abnormalities
Adjustments in technique must made for fixation devices and post injury scaring.
if bone plates become incorporated with in the healing bone matrix, it is often
possible to perform the osteotomies directly through the plates
 Con..
NON UNION OF MIDFACE FRACTURES:
are less common than malocclusions
usually related to mobility of a fracture sites, significant bone loss, or
postoperative infection.ie
any of these processes can compromise normal bone healing.
Treatment of non union
control of infection with suitable antibiotics
removal of soft tissues interposed b/n segments
adequate debridement of fracture sites
Positioning of the skeletal fragments in proper relationship to one
another.
Bone grafting defects at the bony interface
Rigid fixation stabilize both the fracture fragments and the bony grafts
 Con..
FACIAL ASYMMETRY
is related to improper reduction of skeletal components involved in
midface fractures.
These can occur despite wide exposure of the d/t fracture sites
through multiple accesses
are the result of a complex three dimension relationship among the
various pieces.
segments most commonly associated with noticeable deformities are
zygomatic complex and orbit.
Deformity of these segments result in
Asymmetries of facial width
overcontouring of the arches
orbital dystopia
enophthalmos
 Con..
Inadequate or improper reduction of midface fractures can occur for a variety of
reasons.
failure to align the zygomaticosphenoid suture because of its relatively hidden
location.
edema that obscures the facial contours
comminution of fracture sites increase the chance of error.
The coronal flap that drapes over the face for most of the procedures can contribute
to mistakes by preventing simultaneous visualization of the face and fracture sites.
small discrepancies in alignment of medial structures produce large error laterally.
Treatments of asymmetries
for small zygomatic deformities or if orbital surgery is not required
Camouflage procedure with onlay bone grafts or alloplasts are usually sufficient to
correct asymmetries
when large movements or concurrent orbital surgery is contemplated
Zygomatico-orbital osteotomy is preferred.
 Con..
Planning of zygomatico-orbital osteotomy
planning the amount and direction of movement is complicated by a
lack of defined land marks and repeatable reference points.
attempt at using anthropometric techniques
have not been successful because of the difficulty in translating
clinical references in to corresponding surgical land marks.
Once the zygoma has osteotomized, positioning the bone with respect
to its opposite member is usually achieved by eye.
the imprecision of this technique is evident by the number of tertiary
reconstruction (50%) needed to achieve adequate result following
initial revisional surgery.
 Con..
The recent development of stereolithography and stereotactic
image-guided surgery may offer some real advantages.
Three-dimensional models fabricated from laser polymerized
resins may be used to accurately plan the necessary
movement and amount of bone removal at the d/t
osteotomy sites.
the intraoperative stereotactic navigations through three-
dimensional electrical sensors attached to the facial
skeleton allows the operator to display the amount and
direction of movement produced in an osteotomized bone
in real time.
these movements are transferred to radiographs or
planning models to gauge the adequacy of reduction.
Con..
 conclusion
The mgt of midface fracture is complicated by complex three-dimensional
arrangements of structures making up this region of the face.
Although significant advancement have been made in the development of
fixation devices. Proper reduction of fractured fragments remains the
most vital component of the adequate treatment.
to this end, wide exposure through various incisions and an appreciation of
both occlusal and anatomical references provide the necessary guides for
alignment.
timing of surgery is also important.
early treatment is considered to produce the best aesthetic results.
because the restoration of bony frameworks before scarring and
contracture of the soft tissue envelope is possible.
Immediate bone grafting of midface defects has been shown to be well
tolerated, provided adequate soft tissue coverage is present and
secondary infection is not expected.
 Con..
Reference
fonseca 3 trauma