3. Overview
• Classic tripod, orbital floor, LeFort fractures
better thought of as
orbitozygomaticomaxillary fractures
• Precise anatomic reduction is key
• Goal is functional
and cosmetic rehabilitation
http://entbgh.blogspot.com/
4. Epidemiology
• Males : Females -- 4:1
• Predominantly in 20’s or 30’s
• Cause
– MVA > altercation > fall
• Site
– Nasal > Zygoma > other
• In altercations left zygoma fractured more often
http://entbgh.blogspot.com/
16. Facial
Buttress
system
From :Stanley RB. Maxillary
and Periorbital Fractures. In
:Bailey BJ ed., Head and Neck
Surgery-Otolaryngology, third
edition, Philadelphia, Lippincott
Williams & Wilkins 2001, pg
777. http://entbgh.blogspot.com/
18. Facial
Buttress
system
From: Celin SE. Fractures of
the Upper Facial and
Midfacial Skeleton. In: Myers
EN ed., Operative
Otolaryngology Head and
Neck Surgery, Philadelphia,
WB Saunders Company
1997:1143-1192.
http://entbgh.blogspot.com/
20. Facial Buttress system
From: Celin SE. Fractures of the Upper Facial and Midfacial Skeleton. In: Myers EN ed., Operative
Otolaryngology Head and Neck Surgery, Philadelphia, WB Saunders Company 1997:1143-1192.
http://entbgh.blogspot.com/
21. Facial
buttress
system
From: Rowe NL, Williams JL.
Maxillofacial Injuries. Edinburgh,
Churchill Livingstone,1985, pg
19.
http://entbgh.blogspot.com/
22. LeFort fractures
• Rene LeFort 1901 in cadaver skulls
• Based on the most superior level
• Frequently different levels on either side
• LeFort I
• LeFort II
• LeFort III
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23. From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian
Publishing Company 1988, pg76.
http://entbgh.blogspot.com/
24. Modified LeFort Classification
From: Marciani RD.
Management of Midface
Fractures: fifty years
later. J Oral Maxillofac
Surg 1993;51:962.
http://entbgh.blogspot.com/
27. Maxillary Fractures LeFort I
• Clinical findings:
– Facial edema
– Malocclusion of the
teeth
– Motion of the
maxilla while the
nasal bridge
remains stable
http://entbgh.blogspot.com/
29. Maxillary Fractures
LeFort II
• Clinical findings:
– Marked facial edema
– Nasal flattening
– Traumatic telecanthus
– Epistaxis or CSF
rhinorrhea
– Movement of the
upper jaw and the
nose.
http://entbgh.blogspot.com/
35. Zygoma Tripod Fractures
Clinical Features
• Clinical features:
– Periorbital edema and
ecchymosis
– Hypesthesia of the
infraorbital nerve
– Palpation may reveal
step off
– Concomitant globe
injuries are common
http://entbgh.blogspot.com/
40. Orbital Blowout Injury
• Usually inferior
and/or medial wall
• Cone will become
more spherical
• Leads to
enophthalmos,
inferior
displacement
• Muscle entrapment
causes diplopia
http://entbgh.blogspot.com/
46. Physical Exam
• Often edema,
swelling, or patient’s
mental status make
physical exam
difficult
• CT is modality of
choice -- axial and
coronal
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47. CT areas to evaluate
• Vertical buttresses
• Zygomatic arch
• Orbital walls
• Bony palate
• Mandibular condyles
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57. Treatment of maxillary fractures
• Early repair
• Single-stage
• Extended access
approaches
• Rigid fixation
• Immediate bone grafting
• Re-suspension of soft
tissues
http://entbgh.blogspot.com/
58. Maxillary fractures
• Steps of reconstruction-Rohrich and Shewmake
• Reestablish facial height and width
• IMF with ORIF of mandible
• Zygomatic arch reconstruction restores facial width
and projection
• Reconstruction continues from stable bone to
unstable and from lateral to medial
http://entbgh.blogspot.com/
59. Internal fixation vs. traditional
methods
• Klotch et al 1987
• 43 patients
• 22 treated with ORIF using AO miniplates
• 21 treated with combination of
intermaxillary fixation, and/or
interosseous wiring, and/or primary bone
grafting
http://entbgh.blogspot.com/
60. • Most severe injuries in
rigid internal fixation
group
• Shorter IMF, early return
to diet, lower percentage
of tracheotomy
• No plate infections
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61. • Haug et al 1995
• 134 patients
treated by
maxillomandibula
r fixation or rigid
internal fixation
• Postoperative
problems in 60%
vs 64%
http://entbgh.blogspot.com/
62. • Complication rates
similar
• Rigid fixation has
benefits:
– Airway protection
– Enhanced nutrition
– More rapid return to
pretraumatic
function
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64. Order of
Repairs
• Work from stable
to unstable
• Use occlusion as
guide
• Generally stabilize
mandible, zygoma
and palate before
midface before
orbit and NOE
http://entbgh.blogspot.com/
65. Zygoma
• Ideally done
between 5-7 days for
resolution of edema
• Pre- or intra-
operative steroids
can help with edema
• After 10 days
masseter begins to
shorten
http://entbgh.blogspot.com/
66. Zygoma
• Minimally displaced, non comminuted can
be treated with reduction only
• Increasing amounts of displacement and
comminution may require plating of lateral
antrum, orbital rim, ZF suture, and even the
zygomatic arch
• One can wire the ZF suture first to assist
with reduction, then plate it after other
areas stabilized
http://entbgh.blogspot.com/
77. Midface
• “Rigid” fixation misnomer with small plates
and thin bones
• Semirigid fixation (wire) sometimes preferable
• Early function can be achieved with soft diet
only
http://entbgh.blogspot.com/
89. Orbital Roof
• Uncommon due to high levels of force needed
to fracture orbital roof
• Commonly with intracranial problems
http://entbgh.blogspot.com/
93. Conclusion
• Goal is functional and cosmetic rehabilitation
• Precise anatomic restoration key
• Treatment tailored to each individual
• Knowledge of anatomy and techniques will
lead to superior results
http://entbgh.blogspot.com/