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GITAM DENTAL COLLEGE & HOSPITAL
DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY
SEMINAR ON
Midfacial fractures
Presented By:
Dr. Sambhav K Vora
III MDS

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CONTENTS
I. INTRODUCTION
II. DEFINITION
III. HISTORY
IV. MIDDLE THIRD BONES
V. PHYSICAL CHARACTERISTICS
VI. ARTICULATION WITH BASE OF SKULL
VII. BIOMECHANICS
VIII. CLASSIFICATIONS
IX. LE-FORT I,II,III FRACTURES
X. PALATAL FRACTURES
XI. EXAMINATION
XII. MANAGEMENT
XIII. VIEWING OF IMAGES
XIV. CLASSIFICATION OF METHODS OF MAX.FRACTURE
FIXATION
XV. USE OF DIFFERENT TYPES OF INTERNAL WIRE SUSPENSION
XVI. FIXATION TECHNIQUES
XVII. SURGICAL APPROACHES TO EXPOSURE OF MAXILLA
XVIII. COMPLICATIONS
XIX. CONCLUSION
XX. REFERENCES

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INTRODUCTION
Fractures of the maxilla and associated bones were commonly referred to as
fracture of the middle third of the facial skeleton.
The reconstruction of the midface following trauma demands
uncompromising care. The phase is intimately related to self image. It is the
region responsible for our sense of smell,vision & for providing our voice &
its resonance through the presence of air sinuses.
DEFINITION OF MIDDLE ONE THIRD OF THE FACE:
The middle third of facial skeleton is defined as an area bounded superiorly
by a line drawn across the skull from zygomaticofrontal suture across the
frontonasal and frontomaxillary sutures to zygomaticofrontal sutures on the
opposite side and inferiorly by the occlusal plane of the upper teeth. It also
extends backwards as far as the frontal bone above and the body of sphenoid
below and pterygoid plates of the sphenoid below
MIDDLE THIRD OF FACIAL SKELETON IS MADE OF:
Maxillae
Zygomatic bones
Zygomatic process of temporal bones Paired bones

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Palatine bones
Nasal bones
Lacrimal bones
Vomer
Ethmoid and its attached conchae
Two inferior conchae
Pterygoid plates of sphenoid
The relative fragility of the mid-facial skeleton acts as a cushion for trauma
directed towards the cranium from an anterior or anterolateral direction.
ARTICULATION WITH THE BASE OF THE SKULL:
It is known that the frontal bone and body of sphenoid form an inclined
plane which slopes downwards and backwards from the frontal bone at an
angle of about 45° to occlusal plane of upper teeth. The bones of the middle
third of facial skeleton articulate with these strong foundation bones and
when fracture occurs there is backward and downward displacement causing
the posterior teeth and maxillae to push open the mandible producing a
gagging of occlusion posteriorly. In extreme cases the soft palate may be
pushed down upon the dorsum of the tongue causing embarrassment to the
airway. The fractures usually follow the lines of weakness within the face
described classically Guerin (1866) and Lefort (1901).

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CLASSIFICATION:
A. FRACTURES NOT INVOLVING OCCLUSION:
I. Central Region:
a. Fractures of the nasal bones/nasal septum.
Lateral nasal injuries
Anterior nasal injuries
b. Fractures of frontal process of maxilla
c. Nasoethmoidal fractures
d. Fractures of type (a), (b) and (c) extending into the frontal bone
(frontoorbitonasal dislocation).
II. Lateral region:
Fractures involving the zygomatic bone, arch and maxilla excluding
dentoalveolar component.
B. Fractures involving the occlusion :
Dentoalveolar
Subzygomatic
- Lefort I (low level or Guerin)
- Lefort II (Pyramidal Fracture)
Suprazygomatic
- Lefort III (High level or craniofacial dysfunction)

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MODIFIED LEFORT FRACTURE CLASSIFICATION :
LeFort Level Description
I Low maxillary fracture
la Low maxillary fracture with multiple segments
II Pyramidal fracture and nasal fracture
IIb Pyramidal and NOE fracture
III Craniofacial dysjunction
IIIa Craniofacial dysjunction and nasal fracture
IIIb Craniofacial dysjunction and NOE
IV Lefort II or III fracture& cranial base fracture
IV a + supra orbital rim fracture
IV b + anterior cranial fossa and supra orbital rim
fracture
IV c + anterior cranial fossa and orbital wall fracture
FRACTURE PATTERNS
Rene Lefort -1901 gave a classification based on his study of the lines of
weakness present on the human skull.
LeFort I: A horizontal fracture above the level of the nasal floor. The
fracture line extends backwards from the lateral margin of the anterior nasal

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aperture below the zygomatic buttress to cross the lower third of the
pterygoid laminae. The fracture also passes along the lateral wall of the nose
and the lower third of the nasal septum to join the lateral fracture behind the
tuberosity.
LeFort II: Fracture runs from the middle area of the nasal bones down either
side, crossing the frontal process of the maxillae into the medial wall of each
orbit. Within each orbit the fracture line crosses the lacrimal bone behind
the lacrimal sac before turning forward to cross the infraorbital margin
slightly medial to or through the infraorbital foramen. The fracture now

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extends downwards and backwards across the lateral wall of the antrum
below the zygomatico maxillary suture and divides the pterygoid laminae
about half way up.
Lefort III: The fracture runs from near the frontonasal suture transversely
backwards, parallel with the base of the skull and involves the full depth of
the ethmoid bone, including the cribriform plate within the orbit the fracture
passes along below the optic foramen into the posterior limit of the inferior
orbital fissure. From the base of the inferior orbital fissure the fracture line
extends in two direction; backwards across the pterygomaxillary fissure to
fracture the roots of the pterygoid laminae and laterally across the lateral
wall of the orbit separating the zygomatic bone from the frontal bone.

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Stanley and Nowak (1985) in a cephalometric study of cadaver facial
impacts stressed the importance of the angle of impact in relation to the
horizontal buttresses of the facial skeleton.
Impacts on the nasion at 30°-60° above the horizontal are likely to cause a
Lefort III fracture.
A horizontal impact whose vector is in the horizontal orbitomental plane
tends to cause LeFort II fracture.
Impacts below the anterior nasal spine tends to detach the hard palate and
maxillary alveoli from the nest of the midface.
This time honored classification does not provide full description of the
degrees of comminution and displacement, nor does it mention two

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commonly associated and very important lesions the parasaggital fracture of
the upper jaw. Furthermore the severity of maxillary fracture to other areas
of the craniofacial skeleton.

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Cooter S.David (1989) classified the fracture of the facial skeleton.
Main bones of the skull was classed as (Major zones) and the sutures,
various bone parts are classed as (Minor Zones).
In case of maxilla.
Major Zone : Maxillary bone as a whole.
Major code of maxilla : MX.
Minor zone : Anterior wall of maxilla, buttresses, palate, dentoalveolar and
pterygoid.
Minor code : MxA, MxB, MxP, MxD, MxT.
Severity of Fracture:
No fracture : 0
Undisplaced fracture : I
Obviously displaced fracture : 2
Comminuted/Compound fracture : 3

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BIOMECHANICS
Buttresses form basic vertical and horizontal framework for
facial skeleton
Imp. Facial structures – orbit and paranasal sinuses are
surrounded by buttresses
Manson et.al
4 vertical – 3 bilateral. Peripheral
1 central
3 horizontal
Withstand vertically directed forces
Poorly suited – horizontally or ventrally directed forces

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VERTICAL BUTTRESSES
3 Bil peripheral :
Nasofrontal buttress
Frontal process of maxilla
Nasal bones
Nasofrontal suture
Med.wall of max.sinus & orbits
Forms a bridge between anterior hard palate and frontal
bone
zygomatic buttress
body of zygoma and its frontal process
transmit forces from mid-maxilla to frontal bone
pterygomaxillary buttress
pterygoid process & plates of sphenoid bone
posterolateral & posteromedial walls of
adjacent maxillary sinus
transmit forces from posterior hard palate and
alveolar ridges to the base of skull

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1 Central :
Nasoethmoid Buttress
Ethmoid
Vomer Bone
Forms an important osseous bridge between
lower facial skeleton and the cranium

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• Inferior buttress
alveolar ridge
hard palate
acts as important stabilizing bridge between the two maxillary bones
HORIZONTAL BUTTRESS
• Superior buttress
orbital plate of frontal bone
cribriform plate of ethmoid bone
• Middle buttress
zygomatic process of temporal bone
body & temporal process of zygoma
infraorbital process of zygoma
orbital surface of maxilla
segments of frontal process of maxilla
provides lateral stability to facial skeleton
protects central facial skeleton from horizontally directed
forces

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CLINICAL FEATURES OF INDIVIDUAL FRACTURE :
LEFORT I, LOW LEVEL OR GUERIN TYPE FRACTURE :
May occur as a single entity or in association with Lefort II and III fractures.
A Lefort I fracture which often escapes diagnosis is the impacted type which
results from violence transmitted via a blow to the lower jaw and is often
therefore associated with a fracture of the mandible. It is possible to see the

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condition unilaterally when it involves only one maxilla, the tooth bearing
portion being split along the median palatal suture.
Clinical Features:
Upper lip laceration, loose or fracture maxillary incisors.
Airway obstruction - (+/-)
Edema of the upper lip and (laceration +/-)
Lengthening of the face - may or may not be present depending whether the
fracture is impacted or not.
Epistaxis-(+ve)
Nasal septal deformity may or may not be present
Impacted type of fracture may almost be immobile but implication will be
present, usually caused from trauma transmitted via a blow to lower jaw
where lower teeth come and hit against the maxillary teeth.
Occlusion is disturbed and a variable amount of mobility may be found in
tooth bearing segment of maxilla due to dentoalveolar fracture if present.
Echymosis will be present in buccal vestibule.
On percussion of the upper teeth there will be distinctive cracked pot sound.
ln case of a fracture coursing through the palatal suture line or adjacent to it
a palatal echymotic area is usually noted.
SYMPTOMS:
Initial hemorrhage from nose or mouth.
Teeth meet abnormally.
Pain on mastication.
Maxillary mobility with swallowing.
Trismus
Nasal obstruction, upper airway obstruction

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Dysphagia
SIGNS:
Lip laceration, lose or fractured maxillary incisors.
Lower maxillary asymmetry, malocclusion
Gingivobuccal sulcus echymosis of tenderness
Septal tear or dislocation
Facial elongation, cracked pot sound
Subcutaneous emphysema and crepitus
Oropharyngeal edema and hematoma
Opaque antrum on transillumination
Radiographs:
OPT, PA skull. Lateral skull, PNS.
LeFort II or Pyramidal Fracture :
Referred to as a pyramidal fracture with the apex of the pyramid being the
nasofrontal suture. Classic manifestation of this fracture is bilateral
periorbital edema at times accompanied by echymosis giving rise to
Racoon's sign.
Clinical Features: Gross oedema of the middle third of facial keleton.
1) Airway obstruction : ±
2) Cerebrospinal fluid leak : ±
3) Crepitus : ±
4) Decreased extraocular muscle function : ±
5) Diplopia : ±
6) Echymosis, buccal vestibule : +
7) Periorbital echymosis : +

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8) Subconjuctival echymosis : +
9) Enopthalmoid : ±
10) Bilateral epistaxis : +
11) Infra orbital rim defect : +
12) Lengthening of the face with disk face deformity : + (Moon face)
13) Malocclusion : +
14) Medial canthal defomuty : ±
15) Nasal septal defoimity : ±
16) Pupil height, unequal : ±
17) Lateral orbital rim defect : (-)
18) Anaesthesia/Parasthesia of tile cheek : ±
19) Posterior gagging of occlusion due to retropositioning of maxilla: +
Radiographs : PA skull, Submentovertex, Labial skull. Water view, CT
Scan.
LE FORT III :
Also called as the craniofacial dysfimction. The symptoms are classic dish
face and the mobility of2ygomaticomaxiUary complex.
Gross oedema of the soft tissues over the middle third of the facial skeleton
(+)
Airway obstruction (±)
Cerebrospinal fluid leak (±)
Crepitus (+)
Decreased extraocular function (±)
Diplopia(±)
Periorbital echymosis(+)

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Subconjunctival echymosis (+)
Endopthalmos(±)
Bilateral epistaxis (+)
Labial orbital rim defect (+)
lengthening of face (±)
Trismus (±)
Malocclusion (+)
Medial canthal deformity (±)
Nasal septal deformity (±)
Parasthesia of anterior cheek (+)
Pupil height unequal (±)
Epiphora (±)
Telecanthus (±)
Radiographs : PA skull, Submentovertex, Lateral skull. Water's view, CT
scan.
Airway obstruction with stridor or dysphagia may arise from either sagging
of the soft palate against the tongue or posterior oropharyngeal wall edema
or hematoma caused by sudden impact of the posterior margin of the hard
palate against the cervical spine, also it may be due to presence of clots and
debris like bone or tooth fragments.
In some cases the direction of the traumatizing force and subsequent pull of
both gravity, pterygoid muscle action and superior constrictor muscle
combine to produce a degree of posterior displacement and inferior tipping
of the fragments.
Lengthening of the face can be then if fracture fragments is free floating and
percussion of teeth will have cracked pot sound.

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In LeFort III fracture due to bilateral separation of frontozygomatic sutures
causing lengthening of the face and lowering of the fracture fragment
bilaterally and lowering of the occular level due to fracture passing above
the withnall's tubercle removing the support given to the eye by suspensory
ligament oflockwood.
A para saggital split usually occurs in 10% of LeFort fracture. The fracture
line is usually within I cm of but not within the midline. The vomer
strengthens the midline of the palate and the alveolar process provides the
bulk laterally. Therefore the fracture is through the thin bone just off the
saggital plane. Therefore a linear echymosis of the overlying mucosa
fracture line may be palpable and two side can be moved independently.
CSF RHINORRHEA :
CSF rhinorrhea results from a breakdown of the dura and supporting
structures of the skull base resulting in a connection between the
subarachnoid space and the nose. It may be a complication of trauma, tumor
ablation, paranasal sinus disease, or surgery. Regardless of etiology, the
mechanism is essentially the same. There is a disruption of the arachnoid
and the dura, coupled with an osseous defect, and a CSF pressure gradient
that is either continuously or intermittently greater than the healing tensile
strength of the disrupted tissue. This causes separation of the dural fibers and
CSF leakage.
CSF rhinorrhea may occur directly through the anterior cranial fossa or
indirectly from the middle or posterior fossa via the Eustachian tube. More
specifically, these portals of entry may take place across the frontal sinus,

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cribriform plate of the ethmoid, the sphenoid sinus, the sella, or via the
temporal bone from the middle ear and through the Eustachian tube.
C.S.F. OTORRHEA:
If an intact tympanic membrane ruptures (CSF) fluid will leak out of the ear
resulting in (CSF) otorrhea. Loss of hearing is frequently associated with
collection of fluid in the middle ear cleft. Anosmia is associated with tear in
the area of the cribriform plate. If this symptom can be localized to one side
of the nasal fossa or the other it can sometimes be of value in localizing the
leak problem.
If (CSF) rhinorrhea is straight forward if the fluid is not mixed with blood,
nasal secretions or lacrimal secretions it should be collected in a vial and if
glucose level analysis of 45 mg/dl confirms (C.S.F.).
CSF Nasal Secretions Serum
Glucose (mmoles/lit) 2.5-3.9 0.6-1.4 3.5-52
Protein (g/lit) <0.5 >2 60-85
K (Mmoles/Lit) 2.5-3.5 12-26 3.3-4.8
C.S.F. will not stiffen a hand kerchief, while nasal secretion will do so.
C.S.F. will also form characteristic concentric rings when poured on linen or
tissue paper. Patient should be questions about any salty taste.
It should be noted that absence of leakage does not imply the absence of
leakage does not imply the absence of a tear of dura. Meningitis is the
inherent risk is a basal skull fracture with a concomitant dural tear. Mulec
reported a case of cerebrospinal fluid rhinorrhea 12 years following injury.

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The presence of a basilar skull fracture with a dural tear is not a
contraindication to the reduction of midface fractures. On contrary a mobile
midface often creates a pumping action that results in increased CSF
leakage. Early reduction and immobilization are therefore indicated.
Epiphora :
Post-Traumatic Enopthalmos :
Diplopia :
Hooding of the Eye :
The suspensory ligament of Lockwood which is a fascial sling posses from
medial attachment in the region of the lacrimal bone to be inserted laterally
into whitnall tubercle on the lateral wall of the orbit just below the
frontozygomatic suture. If fracture posses above the Whitnalis tubercle the
zygomatic bone is displayed downwards and the upper eyelid follows it
causing a characteristic hoarding of the eye.
Anaesthesia/Parasthesia :
Of the anterior cheek can be can be due to trauma to the
infraorbital nerve. Subsequent oedema of the middle 3nl of the face also
contributes to parasthesia of that region.
POST-TRAUMATIC TELECANTHUS :
Medial canthal ligament is attached to the anterior and posterior lacrimal
crest. Any injury due to trauma to the nasoethmoidal area causing fracture
of the bones with comminution the fracture fragments will spread laterally
into the orbital space. Comminution of the lacrimal bone or avulsion of
ligaments from the lacrimal crest or direct laceration of die medial canthus
would cause displacement of medial canthal ligament laterally. The tension
exerted by the orbicularis oculi muscle, now unchecked due to displacement

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of (M.C.L.) well result in rounding of the medical canthus and a shortening
of the horizontal palpebral fissure. Lateral migration of the canthus will than
obscure the camucnie and alter the angle set by the lids at the medial
canthus, detachment of Homer's muscles which maintains the backward pull
of the lid will cause a laxity and excessive scleral show. Measuring the
interpupillary distance and dividing it by half will give us the approximate
intercanthal distance. Telecanthus thus is the term applied for widening of
the medial canthus.

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HYPERTELORISM :
Is the term applied for bony displacement of the whole orbit (usually
observed with a congenital bone deformity). Normal intraorbital distance i.e.
distance between medial walls of the orbit) is usually less than 25 mm in the
adult female and 28 mm in adult male.
VIEWING THE IMAGES
Mc gregor and Campbell (1950) described rgstem for examining the OM
view by following four lines :
1. the first line: run across the zygomatic frontal sutures ,the frontal
sinuses and the superior margins of the orbit.
2. the second line: runs along the zygomatic arches,the inferior margins
of the orbits and the nasal bones
3. the third line: crosses the mandibular condyles and coronoid process
and the maxillary sinus
4. the fourth line runs along the occlusal plane of the teeth and crosses
the mandibular rami.
5. Trapnell (1985) added a fifth line which runs along the inferior border
of the mandible.
DOLAN’S LINES FOR THE MODIFIED CAUD WELL
PROJECTION:
the first extends along the outer margin of the orbital process of the
frontal and zygomatic bones

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the second line is the innominate line or oblique orbital line
the third extends along the inner margin of the orbit down to break
into 2 roughly parallel lines meeting at the inferior orbital fissure . the
line then continues along the orbital margin inferiorly ,internally and
superiorly
the fourth runs along the occlusal plane of the teeth and crosses the
mandibular rami.
Dolans lines for the OM projection:
1. the ―orbital line‖: extends along the inner margins of the lateral,
inferior & medial walls of the orbit ,passing over the nasal arch to
follow same structure on the opposite side.
2. the zygomatic line: extends along the superior margin of the arch and
body of the zygoma passing along the lateral margin of the frontal
process of the zygoma to the zygomatic frontal suture
3. the maxillary line: extends along the inferior margin of the zygomatic
arch, the inferior margin of the body and buttress of the zygome and
the lateral wall of the maxillary sinus.

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30. 30

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PALATAL FRACTURES:
Fractures of the palate present a unique challenge to the surgeon skilled
in conventional management of mid fractures. These unstable fractures are
an Infrequent finding in the maxillotacial trauma patient. Most often palatal
fractures are associated with other fractures of the midrace. They are found
8% of Le Fort fractures, and rarely are they found as an isolated fracture.To
ensure proper postoperative stability and restoration of preinjury occlusion, a
staged surgical approach is required for each class or palatal fracture.
DIAGNOSIS
Today with many trauma centers equipped with highly accurate CT
scanners, few palatal fractures go undiagnoscd. This imaging modality is
especially important in diagnosing those palatal fractures that are not
associated with any clinical signs indicative of this type of fracture.
Most patients having palatal fracture will demonstrate clear signs and
symptoms. In up to 65% of palatal fractures, the patient will demonstrate a
laceration of the lip, with 45% concurrently possessing both palatal and
gingival mucosal disruption.15
A change in the maxillomandibular occlusal

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relationship is also a reliable indicator. Segments of a fractured palate arc
most often found to be displaced in both an anterior and a lateral direction.l6
The surgeon should be cautioned against using occlusion as an indicator of
the presence of a palatal fracture, because the fracture may be masked by a
concurrent mandible fracture, which itself produces marked rotation and
displacement of its fractured fragments.
CLASSIFICATION
Six patterns of palatal fractures have been dccribedls
based on their
relationship with the maxillary alveolus, teeth, and palatal midlinc
Type I—Alveolar fracture (2 types)
Type la—Anterior alveolus—contains only the incisor teeth and alveolus in
that region
Type Ib—Posterolateral—contains premolars, molars, and alveolus in that
region
Type II—Sagittal fracture
Type II fractures occur as a midline split of the palate. These types are found
with the most frequency in the second to third decade because of a lack of an
ossified midline palatal suture.
Type III—Parasagittal fracture
Most common fracture found in adults (63%) because of the thinner palatal
bone located parasagittally.These fractures are differentiated from type Ib
fractures because they contain the canine in addition to the premolars and
molars.
Type IV—Paraalveolar fracture
Found directly palatal to the maxillary alveolus and also contains the incisor
dentition.
Type V—Complex/comminuted fracture

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Multiple large, obliquely oriented fracture segments or gross comminution
Type VI--—Transverse
The rarest palatal fracture found, ir divides the maxilla
in a coronal plane.
TREATMENT
The approach to surgical treatment of palatal fractures begins with the
identification of the specific type of fracture, state of the dentition, and
associated maxil-larv or mandibular fractures. Predictable treatment is
performed when using the combination of rigid internal fixation, application
of arch bars, and a palatal acrylic splint in complex fractures.

34. 34
MANAGEMENT :
Once the (ABC) of primary trauma management has been satisfied
and after a history has been noted the initial clinical examination is done,
starting with a brief visual inspection of the facial structure followed by
palpation to locate any evidence of fractures. Radiology plays a critical role
in the precise diagnosis of fractures. Additional information can be
obtained with (CT) scanning. Bleeding from laceration must be controlled
by pressure or placing sutures at the site. Bleeding from the ear can be due
to associated condylar fractures causing laceration along the anterior wall of
the canal. A perforation or bluging of the tympanic membrane usually
indicates a basillar skull fracture. Subconjunctival haemorrhage reflects an
orbital or periorbital injury. Of similar importance is the evaluation of the
nose particularly the septum which may have septal haematoma if present
haematoma should be trained to avoid septal necrosis and ultimately
development of septal perforation. Even watchout for CSF rhinorrhea
which results from the fracture involving the base of the skull and escape of
CSF to either the ethmoid, sphenoid, frontal sinus or cribriform plate areas.
Bilateral periorbital echymosis is commonly seen as a result of fracture of
the base of the anterior cranial fossa and also is known as the racoons sign.
Echymosis in the buccal fold frequency indicates a fracture of the maxilla of
the zygoma or in an isolated fracture of the lateral wall of the maxillary
sinus. Crackling sound in the subcutaneous tissue indicates subcutaneous
emphysema which may be due to the passage of air throughout the fractured
wall of maxillary sinus. Test for infraorbital nerve anesthesia as the nerve
can be damage in case of Lefort II or as a result of orbital blow out fractures.

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Anosmia as a result of midfacial fracture involving the cribriform plate may
occur , this may be due to the transsection of olfactory nerves and can be
permanent. Injury to the intracranial course of occulomotor nerve resulting
in compression of the nerve may lead to dilated peoples indicating the
cranial nerve III dysfunction. Lateral rectus muscle dysfunction or lateral
gaze dysfunction usually indicates involvement of abducent nerve. Fracture
of bones surrounding the optic foramen results in compression of optic
nerve. In unconscious patient optic and occulomotor nerve function can be
evaluated by using the consensual light reflex. Echymosis in the maxillary
buccal fold and a class III open bite malocclusion are indicative of maxillary
fracture. A direction and force of injury usually drives the maxilla
posteriorly and inferiorly resulting in this occlusal deformity. Nasofrontal
suture region should be palpated firmly when the maxilla is manipulated to
exclude Lefrot II and Lefort III maxillary fractures. The thumb and index
finger can be used for palpation in the buccal fold region as the maxillary is
manipulated by placing one hand on the forehead while manipulating the
maxilla with other. Lack of maxillary mobility does not exclude a maxillary
fracture always depending on the direction and force of injury a maxillary
fracture may be significantly impacted and mobilization may be possible
only after the patient has been anesthetized and disimpaction forceps has
been used. Significant displacement of lateral orbital rim may result in
diplopia secondary to displacement of the lateral canthal ligament. Patient's
visual acquity and extraocular movements must be reevaluated as a part of
periorbital examination. Intraoral palpation of the buttress may disclose a
step deformity. Intracanthal width normal 30 to 30 mm although slight
racial variation exists, measurement beyond 32 mm generally indicates the
presence of traumatic telecanthus. Although traumatic telecanthus is not

36. 36
associated with diplopia or other regional changes it would result in
cosmetic deformity. The triad of a flattened nasal bridge, and obtuse medial
canthal angle and increased intercanthal angle should alert the clinician to
tile presence of deformity. Palpation of nasofrontal suture will reveal
repetition and pulling the soft tissue laterally into the lateral canthal angle
region results in rounded or semi lunar crease rather than a sharp canthal
angle. Traumatic telecanthus is easily differentiated from hypertelorism in
which the interpupillary distance is increased normally 60 to 65 mm.
Hypertelorism is generally seen in congenital deformities such as Crouzon's
disease and Apert's syndrome and rarely is a result of trauma. Large number
of muscles attached to the walls of the maxilla but these insert only into the
skin and do not contribute to the deformity of the fracture. Perigoid muscles
in case of Lefort fractures usually act on die fracture fragments and pull
them posteriorly and laterally. Intraorally after checking for mucosal
lacerations, subrnucosal echymosis, status of teeth, integrity of palate and
upper alveolus should be evaluated. A split palate may be often be
associated with laceration and separation of alveolar rim. Premature contact
of molar teeth and an openbite deformity is due to displacement of the whole
maxilla backward and 2< downwards. Whereas crossbites are apparent with
lateral displacement of the maxilla in case of a split palate.
The examination is usually carried out with a gloved finger which is passed
on to the hard palate exerting an upward and rocking force which may
elicited pain, crepitus and abnormal mobility. Further examination of other
sites using bimanual palpation at pyriform base and nasofrontal and fronto-
zygomatic suture areas in turn while applying upward rocking force to the
hard palate. In some cases of patients with gross midface instability can be
demonstrated by asking the patient to bite upwards with his mandible

37. 37
resulting in upward movement of the upper jaw.
Preoperative planning of whether open or closed method one to be
employed, following this decision the type of fixations selected following
which the necessity for and type of intermaxillary fixation depending upon
the condition of the teeth, presence of alveolar or palatal fractures will
influence the choice between interdental eyelet wires, arch bars, gunning
type of splints.
Usually the surgery may be delayed until the patient's condition has been
stabilized and the swelling has largely settled though many controversies are
present regarding early or late management.
TREATMENT :
As in the treatment of any other fracture the objective with a fracture of the
middle of the face is to achieve reduction followed by an adequate period of
fixation to ensure stable union.
Facial skeleton can be broadly divided into three concentric rings. The outer
ring or framework of the face is reconstructed first by reducing the frontal
bone and orbital roof, zygomatic complex on each side and establishing a
mandibular platform below. Now the central block can be reduced and
mixed within it utilizing the occlusion below and direct fixation to the
cranium above. The most control ring comprises of the nasal complex on
each side.
After using the mandible as a guide to accurate reduction, the middle third
must be immobilized by attaching it to a fixed point on the vault of the skull.
Treatment of Unilateral Maxillary Fracture :
If fracture fragment is mobile digital pressure may be utilized to reduce the

38. 38
fracture. The teeth in fracture segment are first loosely wired to the
maxillary arch bar. The teeth in the unfractured segment are securely ligated
(I.M.F.) is carried out on the unfractured site and completed on the fractured
side after reduction and lightening of interdental wires of that fragment
(IMF) is released after 4 weeks by which time satisfactory stabilization will
have observed.
Occlusal splints can also be used. Arch bars are placed on both
maxillary arches. The maxillary bar is cut at the line of fracture. The
interdental splint is wired first to stable fragment and the fracture portion of
arch is manually reduced into the splint and secured with a 24 gauge wire.
The mandible is then positively guided into the splint and (IMF) is
completed. Reduction is usually attamed with minimal difficulty especially
if carried out soon after the injury. On occasional, impacted fracture are
encountered which may not be responsive to digital manipulation. Here
Rowe's disimpaction forceps is an excellent tool for achieving reduction. An
open reduction may be utilized if fracture fragment appears to be unstable
following attempted reduction. An open reduction may be utilized if
fracture fragment appears to be unstable following attempted reduction. In
this case application of arch bans and an occlusal splint is necessary prior to
the placement of interossoeus wiring or bone plates. With rigid fixation in
place there is no need for the patient endure (I.M.F.). Teeth in the line of
fracture are lefr in place unless there is excessive mobility or unless the
fracture has occurred through the coronal 2/3'd of the tooth. An edentulous
minimally fracture hemimaxilla demands only digital reduction of the
garments. However when the fractured fragment contains teeth and the
unfractured one is edentulous, therapy comprises an open reduction and the
use of interosseous wiring or semirigid plate fixation.

39. 39
An early reduction of fracture as a rule presents minimal difficulty. Beyond
7 to 10 days increasing force has to be applied to complete a reduction. A
minimally displaced fracture is reduced and immobilized by intermaxillary
wire fixation. One month of immobilization is usually sufficient for healing
to occur. In the case of severe commination it may be necessary to extend
the period I to 6 weeks. An impacted fracture one not easily reduced because
of early fibrous union should treated by die use of either a Rowes or Hayton
Williams disimpactions forceps the beaks of the Rowes forceps are placed
along the nasal floor and against the palate. They are used a pair or singly.
To protect the nasal mucosa and the palatal mucoperiosteum, it is wise to
place rubber tips on the beaks. By means of a rocking and rotating motion
will usually recalcitrant maxilla. An open reduction has to be used when a
delayed reduction or severe impaction resists closed reduction methods. The
site of fracture is surgically exposed and the fracture liens are again followed
using a chisel. Use of a Rowe or a Hayton Williams forceps can be used
after that to complete the last of reduction. After that fixation can be done.
In cases of Lefort II and III fracture reduction of fracture is done in the
above mentioned ways. On occasion the superior aspect of the complex is
unstable owing to comminution of adjacent nasal bones, orbital floor and
medial orbital wall. The signs of entrapment of the orbital contents are noted
and the appropriate wall should be explored to free the entrapment.
Fractures should be mobilized and fixation done small defects are connected
by placement of a homologues graft. Large defects are treated by an
autogenous tip bone graft.
If the defect is so large that the bone graft has no shelf on which to set a
graft than a Steinmann pin is driven through the infraorbital rim and into the
medial and lateral walls forming a base on which to set the graft.

40. 40
Antral packings can be carried out in case of orbital floor fracture via a
Caldwell-Luc approach which provides an useful method for treatment of
comminuted body rim fracture also. A '/2 inch iodoform gauze preferably
run through antibiotic ointment is packed into the antrum and left for 3
weeks and then removed. The sinus is irrigated copiously for another I week
and then closed.
SAGITTAL MAXILLARY FRACTURES:
In reconstruction of the maxillary arch it can be difficult to restore the
correct width and projection in sagittal maxillary fractures. Prior
stabilization of the zygomatic arches creates another outer facial frame and
establishes the correct buttress figuration, so that the displaced sagittal
fractured maxilla an be put into its proper position. When the mandible is
made intact by intermaxillary immobilization the maxillary arch can be
positioned anatomically. Atransversal lag screw under the nasal anterior
spine, or miniplates horizontally across the sagittal fracture, can be helpful.
The palatal fracture can then be exposed and plated.
In the edentulous patients it is important that correct vertical posterior facial
height be established so that dentures can be fitted in the future. If possible
a gunning split is made from the patient's denture, if not available then a
splint made from models cast from dental impression of edentulous jaw
should be used. These splints are wired to the upper and lower jaws and then
to each other during surgery for a close reduction of fracture in both anterio-
posterior and vertical planes.
CLASSIFICATION OF METHODS OF MAXILLARY FRACTURE
FIXATION:

41. 41
I. Internal fixation :
a) Direct osteosynthesis
i Miniplates and screws Preferred methods of treatment
ii Wires
b) Suspension wires
i Frontal central or laterally placed (Kufiler)
ii Circumzygomatic (Cubero)
iii. Zygomatic Ancillary methods
iv. Cirumpalatal/ Palatal screw of treatment
v Infraorbital
vi Piriform aperture (Adams)
vii Peralveolar
II. External Fixation :
a) Cramomandibular
b) Craniomaxillaly
i) Supra orbital pens
ii) Zygomatic pins Less frequently use
iii) Hala frame
iv) Levant frame
Use of different types of internal wire suspensions.
1. Frontal
a. Central - used for Lefort II and III (Mandible is unstable).
b. Lateral - used for LeFort II and III where mandibular stable.
II Circumzygomatic - Lefort II and I
III Zygomatic - LeFort I
IV Infraorbital, Pyreform aperture - LeFort I

42. 42
Pyreform Aperture.
V Transnasal : Gunning splint
VI Per-alveolar : Gunning Splint
FIXATION TECHNIQUES :
EXTERNAL FIXATION APPLIANCE ON A HEAD CAP :
When internal fixation of the maxilla is not possible, external fixation
can be applied on a head cap using a Kingsiey splint or Wassmund
Hirschgeweih (antlers).
Metal side bars, fitted into square tubes on the maxillary splint or maxillary
denture, are directed outward through the angle of the mouth and parallel to
the buccal surface in the dorsal direction and attached to a plaster head cap
by means of elastic bands or rigid plaster connecting bars. The plaster cap
can be combined with an extension bar for continuous fraction on the
fractured parts by way of rigid or spring supported auxiliary elements. These
methods are really only of historical significance.

43. 43
EXTERNAL FIXATION BY A HALO FRAME :
The halo frame is a steel or titanium ring which is screwed to the skull for
fixation. The apparatus is constructed on the principle of the head frame
used in neurosurgeiy for stereotactic operations. Traction and fixation
elements can be attached to the ring, which surrounds the entire skull in the
manner of a halo. In principle, he halo frame can be used wherever the
plastic head cap is appropriate, especially in multiple fractures of the
midface. In contrast to the combination of splint side bars, elastics, plaster
connecting bars and a head cap, with its many possibilities for fracture and
maxillary displacement during healing, the halo frame is safe and more
comfortable for the patient. Its advantages are stability and variability. With

44. 44
a halo frame specific regions can be extended without interfering through the
mandible and adjustment is easy. The disadvantage is the clumsiness of the
apparatus and its marital appearance. However, it is very surprising that
patients are not seriously incon nienced by this device, and it is more
comfortable than a head cap.
The halo frame may be fixed to the skull under local anesthesia. For
hygienic reasons the hair should be cut as short as possible. In general 4 to 5
screws are used to fix the frame, 2 in the occipital region and 2 or 3 in the
anterior part of the skull. The screws placed through the frame must be
inserted directly into the bone.
The halo frame is indicated for repositioning the maxilla when no treatment
is possible immediately after injury, so that the maxilla is springly fixed after
2 or 3 weelcs and is not mobile enough for surgical replacement and bony
fixation. Using elastic and springs applied on intraoral splints or
transbuccally by ire traction, the maxilla can be slowly repositioned and held
in position either for healing or for surgical treatment by intraosseous
wiring, suspension wiring or plating.
A similar result can be obtained using a Le Vant frame. However, this relies
on two supraorbital pins to locate the cranial fixation. Although this is very
rigid, it is not always possible to use it in severe craniofacial trauma. These
systems can only control the fractures at an occlusal level, and are rarely
indicated.

45. 45
INTERNAL FIXATION BY WIRE SUSPENSION :
Internal wiring suspends the maxilla from the mobile part to a fixed point of
the non-fractured skull from stable skeletal points into the oral cavity; these
are fixed on both sides on the arch bars under traction (craniofacial
suspension). The following suspension techniques are common frontomalar
suspension, suspension on the glabella, pirifonn aperture wiring, infraorbital
wiring, and circumzygomatic wiring. The limitations of wire suspension are
the incomplete exposure and the use of compression with suspension wires,
which carries the possibility of shortening the midface by compression in
cases with multiple fragments. Suspension wires provide only a single point

46. 46
one 29 dimensional force of application. Three dimensional stabilization is
only achieved by multiple fixation points per fragment, or by use of the plate
and screw technique. For suspension wiring to be successful there must be
effective integrity of the upper jaw buttresses when this is not so suspension
wires and IMF will not prevent upward movement of jaw complex along an
arc centered at the TMJ leading to open bite anteriorly as well as posterior
gagging of occlusion.
Except for circumzygomatic wire suspension, all craniofacial wire
suspensions require exposure of the suspension point on the front, on the
zygomatic frontal suture, on the infraorbital rim and on the piriform
aperture. A hole is drilled at the suspending point nd the wire inserted into it.
Both ends of the wire are now fixed in an awl which, with the wire loop, is
placed in the oral cavity for frontomalar suspension, suspension of the
glabella and infraorbital wiring. Circuimygomatic wiring requires only a
loop from the oral cavity circumfe ntial to the zygomatic arch and returning
into the oral cavity. Piriform aperture wiring is carried out by exposure of
the piriform aperture using a vestibulary incision. The wire ends, brought
into the oral cavity, are fixed laterally to the splint either in square tubes or
in small wire loops; however, they an also be conducted around the arch bar.
Tightening of the wire suspension is done after the occlusion has been
established and intermaxillary fixation applied. Suspension wires are
normally removed after 6 weeks using an intraoral approach, except or the
craniofacial suspension wire at the frontal bone. This must be removed by
exposure through a small incision on the wire loop transected here.

47. 47

48. 48

49. 49
OPEN REDUCTION AND INTERNAL FIXATION BY
INTEROSSEOUS WIRING :
The limitations of internal fixation by wire suspension relate to incomplete
fixation of fracture fragments, closed reduction of the lower midface, and
compression as a mean of fixation. Closed reduction of ten does not
anatomically reconstruct the buttresses of the midface, and three
dimensional stability is not obtained. Midface shortening and retrusion
between the orbits and maxillary alveolus are common complications of
internal wire suspension. More accurate restoration of midface height and
projection can be achieved by open reduction in the lower maxilla (LeFort I
level). Anteriorly at this level the nasomaxiUary and zygomaticomaxillary
buttresses are stabilized with open reduction. Reconstruction of thin sinus
wall fragments between the two anterior pillars is omitted and the pterygoid
buttress is not operated upon. The posterior height of the midface is
restored by utilizing the ramus height of he mandible combined with
intermaxillary fixation.
Midface projection is restored in the Le Fort I level by open reduction of the
nasomaxillary and the 2ygomatico-maxillary buttresses. In the upper
midface open reduction of zygomatic and nasoethmoidal fractures is carried.
In edentulous patients intermaxillary fixation is omitted following open
reduction. Primary bon grafting replaces unusual or absent critical structural
supports.
In associated fractures of the mandible it is important to reconstruct the
mandible both horizontally and vertically to provide a stable base for
intermaxillary fixation and prevent the mandible and maxilla drifting
posteriorly and superiorly, thereby producing a disk face. Stabilization of

50. 50
ramus height by open reduction of subcondylar fractures prevents such
displacement. Midface fractures managed by extended open reduction
sometimes require 2-3 extra weeks of intermaxillary fixation.
OPEN REDUCTION AND INTERNAL FIXATION BY
MINIMICROPLATES AND SCREWS:
The classic treatment of midfacial fractures used to be intermaxillary
fixation combined with craniofacial wire suspension or open reduction and
external fixation by interosseous wiring, which is unpleasant for the patient
who is in many cases affected with multiple traumas.
Breathing is difficult, especially when the nose is tamponed and a nasal tube
is inserted for feeding. In some cases a tracheotomy is necessary and
feeding is only possible with liquids. Oral hygiene is limited, especially for
sedated patients in intensive care.
To prevent these disadvantages early and open surgical management of
midface fractures has become established, using miniplates, microplates and
screws. The procedure is based on exact repositioning of the minimum
possible number of fragments, and stabilization eventually in combination
with bone grafts. In addition to the advantages of exact fragment
repositioning, the maxillary height is stabilized and intermaxillary fixation is
no longer necessary.
Maxime Champy in 1975 developed the technique used by Francois
Michelet in the early 1970s to describe a method of inserting monocortical
miniaturized plates on the mandible, and by Harle in 1975 and Luhr in 1979
on the midface. The technical advantages of miniplate osteosynthesis are the
use of small and easily adapted plates, monocortical application, functional
stability and biomechanical suitability. Indications for use of the miniplate

51. 51
system have been found in orthognathic surgery, in craniofacial surgery, in
the treatment of midface fractures, in reconstructive bone surgery, and in
preprosthetic and dental implant surgery. The microplate system, a network
system using a number of different types and screws, h been developed in
different countries.
It is well known that today, except for mandibular reconstruction, mini and
microplates and screw osteosynthesis are the treatment of choice for
craniomaxillofacial bone surgery, but that there are significant differences in
design, materials, mechanical properties and cots between the commercially
available systems. For this reason they should not be considered
interchangeable. The surgeon must decide which system he prefers, and
selection should be based on the unit cost, the instruments and implants
available, their biocompatability and the compatibility of the implant.
SURGICAL APPROACHES TO EXPOSURE OF THE MAXILLA:
INTRAORAL APPROACH BY GINGIVOBUCCAL SULCUS
(SUBLABIAL) INCISION OR BY MARGINAL RIM INCISION :
The typical intraoral incision lines for exposure of the maxilla are placed
within the unattached mucosa 4-5 mm beyond the level of the attached
gingiva. In order to reduce scar tissue formation and minimize the risk of
infection, the marginal rim incision can be used as an alternative. For the
edentulous patient the incision line or exposure of the maxilla is usually on
the crest of the alveolar ridge.
The lower half of the midface can be exposed using these approaches, as
well as the infraorbital rim and the lateral buttress of the maxilla. A common
complication of the vestibulary approach is wound dehiscence, which is

52. 52
never seen after a marginal rim incision. The reason for this is the
immunological defense mechanism of the periodontium.
LOWER EYELID APPROACH:
The lower orbital rim and orbital floor can be exposed
transcutaneously through a subciliary, lower eyelid or infraorbital incision.
In the transconjunctival approach the incision is limited by the fornix. For
more extensive exposure a lateral canthotomy and cantolysis is necessary.
The lower eyelid incision shows the best results, with a lower complication
rate than the other approaches. The incision is placed parallel to the ciliary
margin just caudal to the tarsus. The orbicularis muscle is exposed and blunt
dissected in the direction of the muscle fibers. The skin muscle flap is turned
down and the orbital septum exposed as far as the infraorbital rim. After
this has been identified an incision is made from the facial side of the rim
above the infraorbital nerve through the periosteum. Using subperiosteal
dissection the orbital floor and the infraorbital rim are exposed above the
infraorbital nerve. After osteosynthesis the periosteum is approximated and
the skin closed without subcutaneous sutures.
TRANSCONJUNCTIVAL LATERAL CANTHOTOMY APPROACH :
The transconjunctival lateral canthotomy approach provides wide exposure
to the orbital floor, lateral orbital wall, infraorbital rim and lateral orbital rim
upto approximately I cm above the frontozygomatic suture. This approach
is indicated in addressing fractures in these areas. The complication rate is
low ; however, blunting of the lateral canthus and entropion may occur.
These problems are eliminated during closure by approximating the cut edge
of the tarsal plate to the lateral canthus with a semipermanent suture. The

53. 53
periorbital area is prepared in the usual fashion, with precautions to avoid
getting the preparation solution into the eye. A corneal shield may be used at
the surgeon's discretion.
UPPER LID BLEPHAROPLASTY APPROACH :
The upper lid blepharoplasty approach gives excellent access to the
frontozygomatic suture, with very good esthetic results, and is becoming
more and more popular. The incision is placed in an upper lid skin crease,
from midpupil to the lateral orbital rim. As usual in the orbital region
homeostasis is performed with bipolar cautery. Monopolar cautery can
damage the underlying sclera because of thermal conduction. The incision is
continued on the layer of the orbital septum towards the frontozygomatic
suture. The periosteum is incised and the fracture is exposed. After bone
surgery the periosteum is approximated and the skin incision closed by
running, intracutaneous or mattress sutures with no subcutaneous sutures.
BROW INCISION:
The brow incision for exposure of the frontozygomatic suture is the most
common technique, and has an extremely low complication rate. An incision
is made through the skin parallel to the hair shafts the superior border of the
lateral brow overlying the frontozygomatic suture. The muscle fibers must
be blunt dissected down to the periosteum, which is cut and sharply
detached. After the application of osteosynthesis material the periosteum is
approximated subcutaneously and skin sutures placed. After surgery scars
are sometimes visible and localized hair loss can occur.

54. 54
CORONAL APPROACH:
The coronal approach gives excellent exposure of the cranium and
upper craniofacial skeleton, but widening of the scar on the top of the head,
paraesthesias posterior to the incision and weakness of the temporal branch
of the facial nerve are documented complications. Shaving the head is not
necessary if dural exposure is not intended. The incision is made through the
scalp, the subcutaneous tissue and the galea until the loose layer of the scalp
between the galea and pericranium is reached. Hemostasis can be obtained
with cautery, scalp clips or running silk locking sutures. The dissection in
the layer over the pericranium down to the supraorbital rim is relatively
bloodless. Care must be taken below the fusion of the temporal lines because
of the temporal branch of the facial nerve, which passes over the zygomatic
arch 2 cm superior to the supra orbital rim. The pericranium is incised and
the dissection continued over the bone to the supraorbital rim. When the
neurovascular bundle of the frontal nerve is enclosed in a foramen the bone
bridge is excised. To preserve the temporal branch of the facial nerve, the
fusion of temporal line and of the superficial and deep layers of the deep
temporal fascia must be identified. If the dissection continues superficial to
the fascia, the frontal branch of the facial nerve will be transected. Inferior to
this line effusion a fit pad is seen which is exposed by an incision in the
superficial layer of the deep temporal fascia. The dissection continues
through the fat pad, leading to the zygomatic arch.
After incision a subperiosteal detachment on the superior border of the
zygomatic arch is performed. The temporal branch of the facial nerve is now
retracted laterally with the periosteum of the arch and the superficial layer of
the deep temporal fascia. To prevent facial nerve injury sharp instruments
should never be used because penetration by a sharp instrument could cause

55. 55
nerve damage. When the nerve has been protected the dissection can
proceed in the subperiosteal layer to the lateral orbital rim. If the medial wall
must be exposed the anterior and the posterior limbus of the medial canthal
ligaments and the lacrimal sac are identified. Caution must be taken to avoid
the anterior
ethmoidal artery. If dissection must proceed further the artery must be
clipped and divided to reduce the chance of an orbital hematoma.
If the canthal ligaments require reattachment they should be secured. Also,
the temporal fascia should be sutured for proper soft tissue configuration.
Wound closure is with either staples or sutures.
POST-OPERATIVE MANAGEMENT:
At the conclusion of the operative period a nasopharyngeal airway is
inserted and it is kept patent by occasional aspiration with a length of 3 mm
bore polythene tubing attached to a sucker nozzle. If craniomaxillary
fixation has been employed, it is possible to defer IMF until the patient has
fully recovered consciousness to enable him to breath through the mouth. If
IMF a tongue suture brought out of the mouth through the fixation to enable
the tongue to be controlled while the patient is unconscious. Suction
apparatus, oxygen, tracheostomy set, wire cutters should be available along
with emergency drugs by the bed side in case an emergency should occur.
Nasopharyngeal airways should be kept in position until the patient should
be fully conscious and has an adequate airway and maintains vital signs. If
patient is cerebrally irritated and restless, IV diazepam is one suitable
sedative which may be administered. When patient is conscious and
following removal of nasopharyngeal airway respiration may be helped by

56. 56
occasional suction and clearing of blood and mucous from the teeth and
coating the lips with petroleum jelly. Prophylactic antibiotics for the first
week should be mandatory. Adequate fluids by mouth are required. Vital
signs to be recorded and maintenance of oral hygiene. In cases necessary a
nasogastric tube should be placed. In later post-operative period early
ambulation of the patient is desirable and until this is possible the patient
should have regular breathing and leg exercises. Fractured are untied in 3 to
4 weeks and fixation can be removed at this time.
COMPLICATIONS
– Failure to restore anatomic contour leads to septal deviation
– Malocclusion
– Infraorbital nerve paresthesia
– Enophthalmos
– Infected hardware
– Altered vision
– Sinusitis
– Anosmia
– Non-union
– Csf leak

57. 57
CONCLUSION:
• Midface fractures occur in a wide variety of patterns
• The various extended access approaches can be tailored to these
fracture patterns
• Restoration of the facial buttresses is crucial in reestablishing the
pretruamatic aesthetic structure and function of the facial skeleton

58. 58
REFERENCES:
Maxillofacial Injuries - Rowe and Williams.
Oral and Maxillofacial Trauma - Raymond J.Fonseca.
Maxillofacial Surgery - Peter Ward Booth.
Killey's fracture of middle third of facial skeleton.
Maxillofacial trauma by Robert H.Mathog.
Pediatric Maxillofacial Surgery- Kaban
Management Of Midfacial Fractures – Joms (1993)51;960-968
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