MAXILLARY AND PERIORBITAL FRACTURES

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

LeFort I LeFort II LeFort III

F.Ling - Maxillary and Periorbital Fractures (1)

PATHOPHYSIOLOGY

Buttress System Loading

-disruption of a single buttress can weaken entire lattice and cause its collapse
-random collapse under anterior or lateral impact usually prevented by strength of horizontal buttresses
combined with their relation to base of skull

Anterior Impact Forces

-causes LeFort type fractures
-maxillary retrusion or rotation, midfacial elongation and malocclusion

Lateral Impact Forces

-zygomatic process of frontal bone almost always spared clean separation of zygomaticofrontal suture
-zygomatic arch sustains single fracture near its midpoint
-“tripod” fracture

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

Extended Access Approaches

-bicoronal, sublabial and transconjunctival incisions, subciliary, brow incisions, pretragal incisions
-closed reduction and maxillomandibular fixation are adequate management of less complex, minimally
displaced maxillary fractures
-maxillary fractures found to be displaced on CT are best managed by extended access approaches that
allow direct visualization

F.Ling - Maxillary and Periorbital Fractures (2)

Stable Internal Fixation
-rigid internal fixation devices can obviate the need for IMF used to stabilize maxillary fractures
-pts still need to be on soft diet to reduce mechanical loading of buttresses

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

F.Ling - Maxillary and Periorbital Fractures (3)

Maxilla
-restoration requires reestablishment of proper occlusion and stabilization of midfacial buttress system
-must first ensure proper alignment of mandibular condyles
-usually IMF done first then midfacial vertical dimension stabilized by ORIF
-if condylar height cannot be maintained, then midfacial buttress system reconstructed first to
establish vertical and horizontal positioning of the occlusal plane
-restoration of zygoma required
-palatal fractures:
-parasagittal splits reduced anteriorly at inferior rim of piriform (plates) aperture and posteriorly
(interossous wire)
-maxillary reduction usually starts with reattachment of zygomaticomaxillary buttress (usually has less
severe injury) to obtain vertical height
-panfacial fractures:
-work from stable base
-begin with MMF and associated mandibular fractures
-work lateral (zygoma and ZM buttress) to establish anterior projection
-work medial to restore buttress system

F.Ling - Maxillary and Periorbital Fractures (4)

COMPLICATIONS

-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

-seven orbital bones:

1. frontal
2. zygomatic
3. maxillary
4. lacrimal
5. ethmoid
6a. greater wing of sphenoid
6b. lesser wing of sphenoid
7. palatine
-optic canal contents:
-optic nerve
-ophthalmic artery
-superior orbital fissure contents:
-CN III, IV, V1 (lacrimal, frontal, nasociliary
divisions), VI
-supraorbital vein
-inferior orbital fissure contents:
-zygomaticofacial and zygomaticotemporal divisions of V2
-inferior ophthalmic vein

CLINICAL PRESENTATION
SSx: enophthalmos (? 2-3 mm pathologic), hypopthalmos, exophthalmos, proptosis, entrapment diplopia,
hypesthesia of infraorbital nerve, psedoptosis

F.Ling - Maxillary and Periorbital Fractures (5)

Theories of Orbital Floor Injury
-Hydraulic Theory:
-force to orbital region increases intraocular pressure fractures floor
-Buckling Theory:
-force on inferior rim directly fractures floor

Traumatic Optic Neuropathy

-injury to optic canal and superior orbital fissure results in compressive injury to involved nerves
-SSx: ophthalmoplegia (optic nerve), ptosis (V1), pupillary dilation (CN III), anaesthesia of upper eyelid
and forehead (V1)
-tx: -for progressive loss consider high-dose corticosteroids and osmotic diuresis, if no improvement
may consider orbital or optic nerve decompression
-if CT reveals bony impingement may undergo decompression urgently

MANAGEMENT

-indications for surgical intervention:

-enophthalmos (>2-3 mm)
-mechanical entrapment
-diplopia
-dehiscence of intraorbital tissue
-high risk of enophthalmos and/or hypophthalmos (large floor defects)
-contraindications for surgical intervention:
-hyphema
-retinal tear
-globe perforation
-only seeing eye
-sinusitis
-frozen globe
-timing ideally should be completed 7-10 days after swelling has subsided
-delayed repair may reveal bone resorption and scar contracture
-approaches:
-subciliary incision:
-placed 2-3 mm below cilia of lower eyelid (may extend into crow’s feet for better
exposure)
-transconjunctival incision
-Lynch incision:
-allows exposre to medial wall
-brow incision:
-allows exposure to posterolateral wall
-subtarsal incision:
-incision placed 5-7 mm below cilia of lower eyelid in a crease line
-Caldwell-Luc (transantral) approach:
-indicated for severely comminuted and posterior fractures
-reconstruction of orbital floor:
-reconstruction of orbital floor positioned higher than pretrauma level to prevent inferior
displacement of orbit
-medial orbital floor (orbital plate of maxilla) reconstructed with alloplastic implant
-options:
-polyethylene (Marlex)
-gelflim
-bone

F.Ling - Maxillary and Periorbital Fractures (6)

COMPLICATIONS

-postoperative blindness
-CSF leak
-persistent enophthalmos and diplopia
-ectropion
-ectropion
-epiphora
-cheek hypesthesia
-extrusion of grafts
-osteomyelitis
-palpable or observable plates

F.Ling - Maxillary and Periorbital Fractures (7)