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MAXILLARY FRACTURES
ANATOMY
Buttress System
-vertical buttresses:
-nasamaxillary
-zygomaticomaxillary
-pterygomaxillary
-horizontal buttresses:
-frontal bar: superior orbital rims and glabellar area
-inferior: inferior orbital rims, maxillary alveolus
and palate, zygomatic processes, serrated edges of
greater wings of sphenoid bone
LeFort Classification
-LeFort I
-low maxillary; transverse maxillary fracture
-upper alveolus becomes separated from upper maxillary
-typically caused by a low anterior-to-posterior force
-involves anterior lateral maxillary wall, medial maxillary wall, pterygoid plates, septum at floor
of nose
-LeFort II
-pyramidal
-caused typically from a superiorly directed force against the maxilla or an anterior to posterior
blow along the Frankfort plane
-involves nasofrontal suture; orbital foramen, rim and floor; frontal process of lacrimal bone,
zygomaxillary suture; lamina papyracea of ethmoid, pterygoid plate; and high septum
-LeFort III
-craniofacial dysjunction
-separates facial skeleton from base of skull, typically caused by high velocity impacts, moto
vehicle accidents, oblique forces
-involves nasofrontal sure; medial and lateral orbital wall and floor; zygomaticofrontal suture;
zygoma and zygomatic arch; pterygoid plates and nasal septum
PATIENT EVALUATION
Computed Tomography
-critical areas in CT evaluation:
-vertical buttresses
-zygomatic arch
-orbital walls
-bony palate
-mandibular condyles
-orbital injuries likely to produce exophthalmos are those in which disruption of orbital floor exceeds at
total area of 2 cm2, bone volume changes exceed 1.5 cm3, or considerable fat and soft tissue displacement
occur
Ophthalmologic Evaluation
-testing of visual acuity, pupillary function, ocular motility
-inspection for hyphema
-inspection of fundus for gross disruption
MANAGEMENT PHILOSOPHY
Immediate Reconstruction
-usually within 24-48 hours
-immediate reconstruction is usually less difficult and more successful than delayed reconstruction
-delayed reconstruction:
-risk of cicatricial contraction of facial soft tissues, scarring, bone resorption
-can allow up to 2 weeks for delayed repair
SURGICAL TECHNIQUES
Zygoma
-four sutures involved in zygomaticomaxillary complex fractures (“tripod fracture”)
-zygomaticofrontal
-zygomaticomaxillary
-zygomaticotemporal
-zygomaticosphenoid
-stabilization requires minimum of two point fixation:
-zygomaticofrontal suture
-inferior orbital rim
-lateral antral wall
-zygomatic arch
-procedures usually delayed 5-7 days to allow resolution of edema
-closed reduction:
-used if no comminution Gilles operation +/- transzygomatic Steinmann pin fixation
-open reduction:
-used if comminution of lateral antral wall sublabial incision with plating at
zygomaticomaxillary buttress
-tripod fracture add transconjuntival incision to access medial orbital rim and lateral brow
incision for zygomaticofrontal suture
-centrally displaced zygomatic arch approached via coronal, hemicoronal, or extended pretragal
incision
-lid damage
-meticulous closure of transconjunctival incision required to prevent ectropion
-lip distortion
-caused by sublabial approach
-hollowing of soft-tissue contours over canine fossa
-superior deviation of corner of mouth and lateral aspect of upper lip
-caused by collapse and contracture of buccal soft tissues into large anterior and anterolateral
antral wall defects
-vision loss
-from trauma
-occasionally an oversized implant causes acute increase in IOP and must be removed
-implant visibility
-malocclusion
-can be caused by plates that are not correctly adapted to bone tightening of screws can produce
torque causing movement of fragments
-malunion, nonunion
-plate exposure
-forehead/cheek hypesthesia
-osteomyelitis
-dental injury
ORBITAL FRACTURES
ANATOMY
CLINICAL PRESENTATION
SSx: enophthalmos (? 2-3 mm pathologic), hypopthalmos, exophthalmos, proptosis, entrapment diplopia,
hypesthesia of infraorbital nerve, psedoptosis
MANAGEMENT
-postoperative blindness
-CSF leak
-persistent enophthalmos and diplopia
-ectropion
-ectropion
-epiphora
-cheek hypesthesia
-extrusion of grafts
-osteomyelitis
-palpable or observable plates