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									Management of Maxillofacial Trauma




Zygomatic complex fractures

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                Contents
Fracture of the zygomatic complex and arch

Orbital floor fractures

Traumatic injury to the frontal sinus

Naso-ethmoial orbital fracture (NEO)

Nasal fractures

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      Zygomatic bone complex
  Anatomy
Star-shape like with four processes
  Frontal process
  Temporal process
  Buttress
  Orbital floor (Maxilla and GWSB)

Temporal fascia and muscle

Masseter muscle

                                      3
     Zygomatic complex and arch
              fracture
The malar bone represent
  a strong bone on fragile
    supports, and it is for
  this reason that, though
   the body of the bone is
   rarely broken, the four
     processes- frontal,
    orbital, maxillary and
   zygomatic are frequent
      sites of fracture.
                                     Zygomatic bone fractured as a
                                     block near its principle three suture
HD Gillies, TP Kilner and D Stone,   lines and often displaces inwards to
                              1927
                                     a greater or lesser extent.
                                                                      4
                   Occurrence
              •As isolated fracture
•In combination with other middle third fracture
    •With internal orbital fracture (blow out)


  Observed in (>50%) of middle third
  fracture (in developed countries due to assaults)
  The zygomatic arch fracture can be
  isolated in most of the cases
                                                      5
           Signs and symptoms
Periorbital ecchymosis and edema

Flattening of the malar prominence

Flattening over the zygomatic arch

Pain and tenderness on palpation

Ecchymosis of the maxillary buccal sulcus

Deformity at the zygomatic buttress of the
maxilla

Deformity at the orbital margin
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Trismus
Abnormal nerve sensibility
Epistaxis
Subconjunctival ecchymosis
Crepitation from air
emphysema
Displacement of palpebral
fissure (pseudoptosis)
Unequal pupillary levels
Diplopia
enophthalmos

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Clinical examination

 Inspection

 Palpation

 Visual examination
     Eye movement
     Diplopia
     Pupil reaction




                       8
  Radiographical evaluation


Nothing is more valuable to the surgeon in
  determining the extent of injury and the
 position of the fragments-both before and
   after operation- than a good skiagram
                (radiograph)



           HD Gillies, TP Kilner and D Stone, 1927

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  Occipitomental view

(Posterioanterior oblique)


  (water’s view)




                             10
   submentovertex




Recommended for isolated
zygomatic arch fracture

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CT scan
 Coronal sections
 Axial sections




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                     Treatment
Timing:
  As early as possible unless there are ophthalmic,
  cranial or medical complications

  Preiorbital edema and ecchymosis obscure the
  fine details of the fracture, intervention can be
  postponed but not more than a week


                      Indications:

                         •Diplopia
          •Restriction of mandibular movement
              •Restoration of normal contour
   •Restoration of normal skeletal protection for the eye
                                                            13
             Classifications
Displacement

Rotation along the axis of FZ processes
   Anterio-posterior displacement
Rotation along the prominence of the bone
   Medio-lateral displacement

Extension of the fracture along processes

      points of fractures

Combination with other injuries
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                Treatment
   The methods of treating a fractured malar bone
   recommended by the various writers who have
 reported cases include simple digital manipulation
 under genre real anesthesia, external manipulation
by means of a cow-horn dental forceps grasping the
 edges of the bone, traction and elevation by means
   of wire or heavy bone elevators passed through
   small local external incisions, and elevation via
incision in the mucosa of the ginigival sulcus at the
  canine fossa. Our technique, which has now been
used successfully in a number of cases, differs from
                  those mentioned.

             HD Gillies, TP Kilner and D Stone, 1927

                                                    15
         Methods of reduction
Temporal approach (Gillies et al
1927)




Suitable for isolated
zygomatic fracture with
good stability afterwards
                                   16
Methods of reduction



  Percutaneous approach (malar hook,
  Carroll-Girard bone screw)




 Suitable for displaced zygomatic
 fracture with high
 Stability after reduction

                                       17
Methods of reduction


  Buccal sulcus
  approach (Keen
  1909)




  Elevation from
  eyebrow approach
 (the same principle of Gillies
           approach)


                                  18
 Open reduction and fixation
Transosseous wiring at
      –Frontozygomatic suture
      –Infraorbial rim



 Surgery:

 •Lateral eyebrow incision

 •Infraorbital approach
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Open reduction and fixation



  Rigid fixation using plate and screws at
         Frontozygomatic suture
         Infraorbial rim
         Inferior buttress of the zygoma

    Surgery:

    •Lateral eyebrow incision
    •Infraorbial approach
    •Subciliary (blepharoplasty) incision
    •Mid-lower lid incision
    •Transconjunctival approach
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Points of fixation:




 Lateral              Buttress of   Infraorbital
 orbital rim          zygoma        rim and
                                    buttress 21
   Other methods of fixation

Kirschener wire

Pin fixation

Antral pack



                               22
    Internal orbital fractures
In conjunction with other
facial fractures

As isolated type (Blow out
fracture)




                                 23
Anatomy
 The floor is made of:
 Maxillary bone and
 part of zygoma
 bounded laterally by
 the inferior orbital
 fissure and small
 part of the ethmoid
 bone


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Clinical and radiographical presentation

 Subconjunctival ecchymosis

 Crepitation from air emphysema

 Displacement of palpebral fissure

 Unequal pupillary levels

 Diplopia
 enophthalmos

                                       25
Diplopia and
enophthalmous
Superior orbital
fissure syndrome




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             Treatment
Rational for intervention:

Small defect with no clinical consequence
may not warrant the surgical intervention.



Large defect with handicapping symptoms
should be operated.
                                             27
   Method of reconstruction
Intra-sinus approach
to the orbital floor




External approach to
the internal orbital
floor


                              28
Materials in orbital reconstruction

Autologous graft
   Bone (cranial, rib, iliac)
   Cartilage
Allogenic materials
   Lyophilized dura
Alloplastic materials
   Siliastic and proplast
     implants
   Teflon
   hydroxyapatite
   Titanium mish

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Nasal-orbital ethmoid injuries
They represent a wide spectrum of injuries

    Simple nasal fracture with involvement
              Of orbital bones




     Grossly comminuted and compound
naso-orbital ethmoid fracture involving the base
     of skull with significant displacement

                                                   30
                 Diagnosis
Clinical examination:
Obliterating swelling
Canthus detachment
Lacrimal apparatus damage
Deformity of nasal bridge
CSF leak

Radiographical examination:
Occipitomental views
Lateral skull views
CT and 3D CT


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           Fracture classification
             Nasal-orbital ethmoid fractures

  Type I
Unilateral or bilateral, involves only one portion of the
  medial orbital rim with the attached canthal tendon
  Type II
Unilateral or bilateral, may be large segments of
  comminuted type and the canthus remains attached
  to the large central segment
  Type III
Unilateral or bilateral, comminution involves the central
  segment of the attached tendon results in avulsion
  of medial canthus

                                                            32
   Management of nasal-orbital
       ethmoid fractures
Examination for
determination of the extent
of the injury (surgical
exploration)
      Nasal bone
      Orbital and ethmoidal
      Frontal bone


Debridement and closure of
open wounds


Reduction and stabilization
of bone fracture


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      Principles of treatment
Good surgical exposure via:
     Existing laceration
     Coronal flap
     Open sky approach

Reduction and stabilization using:
     Transnasal wiring
     Osteosynthesis

Prompt treatment as an aid to good
reduction

Immediate bone grafting if this is
indicated
                                     34
            Detached canthus
                Traumatic telecanthus


Increase in inter-canthal distance
          secondary to
   canthus displacement or
           detachment



Seen in association to:
   Nasal bone
   NEO
   Le Forts fractures


                                        35
Surgical management of detached
            canthus
Transnasal wiring
technique (unilateral
type)



Canthopexy
 – Identification of the
   ligament
 – Liberation of the
   periorbital tissue
 – Liberation of the lacrimal
   pathway
 – Nasal transfixation
 – Contralateral fixation
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   Lacrimal duct system injury

 The lacrimal sac can be torn by
 fragments of a comminuted fracture
                   Or
 Compressed by a mass of callus
 which may block the nasolacrimal canal



EPIPHORA               Dacryocystitis


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    Reconstitution of the lacrimal passages

  Done at the same time of canthopexy via
           – The original scars
           – Lateral nasal incision (Lynch)
           – Bi-coronal incision


  Dacryocystorhinostomy
If the sac remains intact, drainage of lacrimal fluid by probing
    or removing of surrounded bone to allow drainage into the
                                nose


  Conjunctivo-rhinostomy
implantation of a duct-like polythene tube or glass in case of
  duct damage

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         Frontal sinus fracture
  Frontal sinus

       An air filled cavity lined by ciliated respiratory
           epithelium encased in the frontal bone


Drains into nasal cavity via fronto-nasal duct




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Extent of the injury:
 Anterior table

 Posterior table

 Associated injuries:
 mid-face or head
 injuries e.g.
     Le Fort II, III
     NOE
     Neuralgic insults
     Ocular injuries

                         40
                Diagnosis
Clinical examination




Radiographical
evaluation
    Occipitomental views
    Lateral skull view
    CT scan



                            41
   Classification of fractures
Anterior table fracture
      – Linear
      – Displaced


Posterior table fracture
      – Linear
      – Displaced


Outflow tract injury (naso-lacrimal duct)
                                            42
        Surgical management
Intranasal cannulation

Frontal sinus
trephination

Osteoplastic flap

     Sinus ablation
     (obliteration)

     Cranialization

     Reduction and fixation

                              43
     Reduction and fixation
Surgical approaches:

– Site of penetrating injury




– Coronal approach



                               44
Sinus ablation
(obliteration)
        – Bone
        – Fat
        – Muscle and
          fascia
        – Alloplastic
          materials




                        45
Fixation
      – Wires
      – Plating




                  46
               Nasal fractures
Anatomy
 Midline central facial
 structure that fulfills
 both cosmetic and
 functional purposes

 Formed by union of
 rigid and flexible struts

          2 rectangle-shaped
               nasal bone
            ULCs, LLCs and
              midline septal
                 cartilage

                                 47
           Classification of injuries
  Low energy injuries
Simple injury caused by low velocity trauma (simple
  noncomminuted)

  High energy injuries
Severe injury with comminution of nasal facial Skelton due to
  higher amount of energy


    Patterns of injury

           •Lateral injury (from the side)
           •Sagittal injury (from the front)
           •Inferior injury (from below)

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                 Treatment

Low energy injuries
Reduction (close
manipulation, open
reduction) and stabilization

Nasal packing

External nasal splint

Adjunct septoplasty

Postoperative care
                               49
Complex injuries
Immediate measures:
    Extra and intranasal examination
    Identification of extra and intranasal
    lacerations
    Identification and control of site
    bleeding
Surgical procedures:
    Open septal procedures
    Open nasal procedures
    Open rhinoplasty
    Open-sky “H” technique

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