Midface Trauma

MIDFACE TRAUMA
Tabitha Galloway, MD
Gregory Renner, MD
November 6, 2012
OUTLINE
 Facial Anatomy and Biomechanics
 Fracture Classifications
 When to Operate
 Surgical Approaches for Exposure
 Fracture Fixation
 Complications
FACIAL ANATOMY AND
BIOMECHANICS
FACIAL SUBUNITS 7
FACIAL SUBUNITS 7
BIOMECHANICS
 Function of facial bones
 Sustain masticatory forces and provide normo-occlusion
 Provide support for soft tissue envelope with complex facial expressions
 Basis for aesthetics in facial height and width
 Protect vital organ systems and their function
FACIAL BUTTRESS SYSTEM- VERTICAL
1
FACIAL BUTTRESS SYSTEM- VERTICAL
2
FACIAL BUTTRESS SYSTEM- HORIZONTAL
1
FACIAL BUTTRESS SYSTEM- HORIZONTAL
3
BETWEEN THE BUTTRESSES- CRUMPLE ZONES
http://reviews.cnet.com/8301-13746_7-10311507-48.html
ANGLE’S CLASSIFICATION OF
OCCLUSION
When treating fractures occuring in tooth bearing bones important to
understand normal and abnormal dental occlusive relationships.
What is angle’s Class I occlusion?
 Mesiobuccal cusp of maxillary first molar is within the mesiobuccal
groove of mandibular first molar
http://medical-dictionary.thefreedictionary.com/malocclusion
NORMAL DENTAL ANATOMY
2
http://www.toothmingle.com/information/what-is-tooth-numbering/
FRACTURE CLASSIFICATIONS
WITHIN THE MIDFACE
ORBITAL FRACTURES
 While considered part of the
midface, will defer to the
dedicated orbital trauma lecture
 Tend to occur in conjunction
with a number of fractures we
will discuss today
 Surigcal exposures discussed can
similarly be used for orbital
fracture repair
http://www.motifake.com/75463
NOE -- BRIEFLY
 Consider it a separate, single unit….
 Is a part of the medial vertical buttress
 High force trauma to the nasal bones typically
transmits to NOE
 Part of the crumple zone effect
 Significant cosmetic and functional deformities
 Telecanthus
 Epiphora
 Nasofrontal duct damage
 Cribiform plate injury
 Ocular damage
2
NOE: MARKOWITZ CLASSIFICATION
4
WHICH MARKOWITZ CLASSIFICATION? 4
WHICH MARKOWITZ CLASSIFICATION? 4
ZYGOMATICOMAXILLARY COMPLEX
ZYGOMATICOMAXILLARY COMPLEX 4
 Malar eminence
 Most anterior point of facial projection of lateral face
 Strength varies between central and articulating
points
 What are the articulating points of the zygoma?
 Classically called “Tripod” or “Quadrapod”
 Can see up to 5 fractures
 Lat. Orbital wall, orbital floor, anterior maxillary wall,
lateral maxillary wall, zygomatic arch
 Number and severity vary based on mechanism
 Mildest on spectrum isolated zygomatic arch
7
ZYGOMATICOMAXILLARY COMPLEX 4
ZYGOMATICOMAXILLARY COMPLEX 4
RENÉ LE FORT (1869-1951) 5
 Father, brother and uncle (Leon Le Fort) all physicians
 Youngest person in France to earn a medical degree-
age 21
 Calling for teaching after battlefield physician career
 Experimental Study of Fractures of the Upper Jaw
 Parts 1-III published in February, March and April1901 in Revue
de Chirurgie
 Experiments on intact or decapitated mostly fresh
cadavers
 Majority of trauma inflicted by wooden club or block or
throwing
 Remove crainal vault and dura, boil skull to remove soft tissues
LE FORT FRACTURES
Which facial bone must be fractured in order to classify the fracture as a
Le Fort fracture?
A.
Temporal
B.
Sphenoid
C.
Palatine
D.
Ethmoid
Clipart ETC. (n.d.). Retrieved February 10, 2011, from Online service of Florida's Educational
Technology Clearinghouse:
http://www.bing.com/images/search?q=clip+art+Medical+sphenoid+bone+free&view=detail&id=B69060
4E8E87030C7240880AEE5A545043289A3D&first=1&FORM=IDFRIR
LE FORT FRACTURES
1
LE FORT I
2
 Horizontal Maxillary Fracture
 Separates alveolus from craniofacial
skeleton
 Above level of dentition
 Crosses nasal septum
 Posterior through maxillary sinus
walls
 Pterygoid plates
http://radiographics.rsna.org/content/26/3/783/F21.expansion.html
LE FORT II
2
 Pyramidal Fracture
 Crosses face in superiomedial
direction
 Inferior orbital rim
 Orbital floor
 Medial orbit
 Nasal root or through nasal bones
 Nasal septum
 Posterior maxillary walls
 Pterygoid plates
http://radiographics.rsna.org/content/26/3/783/F21.expansion.html
LE FORT III
2
 Craniofacial Separation
 Separates zygoma from temporal
bone and frontal bone
 Lateral and medial orbits
 Nasofrontal junction at midline
 Nasal seputm
 Pterygoid plates
http://radiographics.rsna.org/content/26/3/783/F21.expansion.html
LE FORT FRACTURES 4
HOW TO DETERMINE LE FORT4
 Examine pterygoid plates first
 If fractured, likely a Le Fort fracture
 Only Le Fort I

involves lateral aspect of piriform aperature
 Only Le Fort II
 involves inferior orbital rim and zygomaticomaxillary suture line
 Only Le Fort III
 involves zygomatic arch and lateral orbital wall
LE FORT FRACTURES 4
 May be more than one Le Fort level on same side
 May be asymmetrical
 Common for other facial fractures to occur in conjunction with Le Fort
 Be sure to look for fractures which will affect occlusal repair
 Mandible
 Maxillary dentoalveolar
 Palate
PALATE FRACTURES
 Split palate (saggital fracture)




important to identify
Palatal mucosa tear good sign
of underlying fracture
Re-establish appropriate width
to the palate
Dentition rotates lingual or
buccal around fracture
Options
 Arch bars
 Palatal splint
 ORIF
2
WHEN TO OPERATE?
WHEN TO OPERATE
 No consensus on management plan
 Consider overall stabilization of patient and concomitant injuries
 Airway, expanding hematomas, brain injuries, vision testing
 Delay until resolution of swelling to better appreciate native contour
 May not be as important with radiologic advances in imaging
 Should we be fixing earlier?
 Avoid further damage to the soft tissue envelope
 Less pliable, less resilient, less satisfactory healing
2
SURGICAL EXPOSURE
INTRAOPERATIVE AIRWAY ACCESS
 Intubation vs. tracheostomy
 Nasal vs. oral tube
 How to secure the tube
 Use of MMF intraoperatively or post-operatively
EXTENSION OF TRAUMATIC INJURIES
 Commonly traumatic injuries can be extended and utilized for fixation
 Advancement in minimal exposure for maximum benefit in fixation of
traumatic injuries
 Midface is not forgiving area to place an incision directly over fracture
line
CORONAL INCISION
 Offers great exposure of the upper face
 Pre-auricular extension of incision
 More attractive alternative to gull-wing or butterfly incisions
6
CORONAL INCISION 6
 Skin, subcutaneous connective tissue,
galea, loose areolar tissue
 Subgaleal dissection
 Incise peri-osteum 2-3 cm posterior to
skin flap
 At superior temporal line inferiorly
through superficial layer of deep
temporal fascia to protect temporal
branch of facial n.
 Frontal branch facial n. lies superficial to
deep temporal fascia 1-2.5 cm from tragus
along zygomatic arch
 Closure- be sure to re-suspend fascial
layers
6
ACCESSING THE ZYGOMATIC ARCH 7
 Keen
 Trans-oral
 Gillies
 Deep to temporalis fascia
 Muscle passes deep to the arch
https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDR
wN3Q1dDA08XN59Qz8AAQwMDA_2CbEdFAONltfE!/?showPage=redfix&bone=CMF&segment=Midfac
e&classification=92Zygoma,+Isolated+zygomatic+arch+fracture&treatment=&method=Open+treatment&implantstype=With
out+fixation+(reduction+only)&redfix_url=1285234140361
ACCESSING THE ZYGOMA 7
 Caroll-Girard Screw
 Tool for reduction
 Can be used via incision or
percutaneously for ZMC
reductions
 Once reduced variety of incisions
used for access of fractures for
stabilizations
ZMC FRACTURE LINES EXPOSURE
 Upper lid blepharoplasty incision
 Lateral brow incision
 Lower lid conjunctival incision with lateral canthotomy
7
6
ACCESS TO THE LOWER MIDFACE
 Transoral access via gingivobuccal sulcus incisions
 Midface degloving approach
 Risk of nasal stenosis
 Palate access – usually via traumatic lacerations
7
http://emedicine.medscape.com/article/867687-treatment#a1128
7
FRACTURE FIXATION
BASICS
 Keep in mind goals of fixation
 Regain/reapproximate pre-morbid
occlusion
 Establishing facial height, width, and
projection
 Plate along the buttresses
 Ideal to get 2 screws on either side of
fracture line
 May need to consider bone grafting if
> 5mm bone loss along buttress
1
PANFACIAL FRACTURES - SEQUENCE
 Mandible – as landmark for maxillary reconstruction
 Placement of arch bars and MMF to establish normal occlusion
 Address saggital palate fractures here, avoid rotation or widening
 Ensure mandibular height
 Subcondylar fractures, dislocations from glenoid fossa, intracapsular hematoma
 Midface
 Frontal bar needs to be intact first for midface suspension
 Top to bottom fixation of fractures… may want to start with ZF line
 Reduction along zygomaticiomaxillary buttresses
 Lefort I last to be reduced
PANFACIAL FRACTURES – SEQUENCE
7
COMPLICATIONS
COMPLICATIONS
 There is significant difficulty in reoperation in these areas
 Malocclusion
 Malunion
 Globe malpositioning
 Telecanthus
 Shortened midface
 Flattened and widened midface – “dish face”
 Elongated face – “faces equina”
 Hollowing of infraorbital area
 Soft tissue descent and diasthesis
REFERENCES
1.
2.
3.
4.
5.
6.
7.
Linnau KF, Stanley RB, Hallam DK, Gross JA, Mann FA. Imaging of high-energy
midfacial trauma: what the surgeon needs to know. Eur J Rad 2003;48: 17-32.
Kellman RM. Maxillofacial Trauma. In: Cummings W Jr., Haughey BH, Thomas JR,
et. al. Cumming’s Otolaryngology Head and Neck Surgery. 4th edition. St. Louis:
Mosby, 2005.
McRae M, Frodel J. Midface Fractures. Facial Plastic Surgery 2000; 16(2): 107-113.
Fraioli RE, Branstetter BF IV, Deleyiannis FW-B. Facial Fractures: Beyond Le Fort.
Otolaryngol Clin N Am 2008; 41: 51-76.
Noffze MJ, Tubbs RS. Rene Le Fort. Clinical Anatomy 2011; 24: 278-281.
Ochs MW. Fractures of the upper facial skeleton and midfacial skeleton. In:
Myers EN et. al. Operative Otolaryngology Head and Neck Surgery. 2nd edition.
Philadelphia: Saunders Elsevier, 2008.
AO Foundation. www.aofoundation.org.