Midface Fractures

1. Midface Fractures E.RAZMPA M.D OTOLARYNGOLOGIST HEAD & NEACK SURGEON ASSOCIATE PROFESSOR TEHRAN UNIVERSITY OF MEDICAL SCIENCES Evaluation and Management www.razmpa .com

2. Midface Fractures Etiology • Motor Vehicle Accidents • Assault • Sport • Falls • Work • Pathological

3. Midface Fractures • Osteology of the midface • 2 maxillae • 2 zygomata • 2 zygomatic proceses of temporal bone • 2 palatine bones • 2 nasal bones • 2 inferior conchae • 2 pterygoid plates of sphenoid bone

4. Midface Fractures • Three buttresses allow face to absorb force • Nasomaxillary (medial) buttress • Zymaticomaxillary (lateral) buttress • Pyterigomaxillary (posterior) buttress

5. Midface Fractures Classification • Anatomical • Lefort • I • II • III • Unilateral • Sagittal • Wassmund • Severity • Cooter and David • MFISS

6. Midface Fractures Lefort Classification • Weakest areas of midfacial complex when assaulted from a frontal direction at different levels (Rene’ Lefort, 1901) • Lefort I: above the level of teeth • Lefort II: at level of nasal bones • Lefort III: at orbital level

7. Midface Fractures Lefort Classification • Provides uniform method to describe the level of major fracture lines • Allows references regarding the probable points of stability for surgical treatment • Does not incorporate vertical or segmental fractures, comminution or bone loss

8. LeFort I : Transverse Maxillary Lefort II : Pyramidal Lefort III : Craniofacial Disjunction Zygomatic Complex Orbital Floor Nasal Fractures Naso-orbital/Ethmoid Midface Fractures

9. LeFort - AP view Midface Fractures

10. Le Fort I Midface Fractures • Low level • Often mobile • Mild swelling • Disturbed occlusion • Deviated midline

11. Midface Fractures Lefort I FractureTransverse Maxillary

12. Le Fort II Midface Fractures • Subzygomatic pyramidal • Gross swelling • Immobile • Anterior open bite • Altered sensation • Long faced appearance • CSF rhinorrhoea

13. Lefort II FracturePyramidal Midface Fractures

14. Le Fort III Midface Fractures • Suprazygomatic craniofacial disjunction • Gross swelling • Immobile • Altered occlusion with AOB • Long faced appearance • Flattened cheek prominence • CSF rhinorrhoea

15. Midface Fractures Lefort III FractureCraniofacial Disjunction

16. Midface Fractures Blow Out Fractures • Compression of orbital contents deforms the orbital • Floor • Walls • Roof • May result in • Diplopia • Restricted eye movements • Enophthalmos • Superior orbital fissure syndrome

17. Midface Fractures Nasoethmoidal Injuries • Central midface • Traumatic telecanthus or hyperteleorism • Nasal deformity • Orbital wall involvement • Enophthalmos • Diplopia

18. Diagnosis of Maxillofacial Injuries Midface Fractures • Inspection • Palpation • Diagnostic Imaging • Plain films • CT • Stereolithography (where available)

19. Midface Fractures

20. Midface Fractures Inspection Sublingual ecchymosis Step defects, ridge discontinuity, malocclusion

21. Midface Fractures Diagnosis of Maxillofacial Injuries • PALPATION • “Step” Defect • Crepitus • Bony segments • Subcutaneous emphysema • Mobility

22. Midface Fractures Facial ExaminationPalpation of Midface/bridge of nose

23. Facial ExaminationOrbits Evaluation Midface Fractures

24. Facial Examination Midface Fractures • Orbits evaluated • Periorbital edema and ecchymosis • Gross visual acuity determined • Diplopia • Pupillary size & shape • Subconjunctival hemorrhage • Funduscopic evaluation

25. Facial Examination Midface Fractures • Orbits evaluated • Lid lacerations • Attachment of medial canthal tendon • Rounding of lacrimal lake • Increased intercanthal distance • Epiphora • Prompt Ophthamology consult

26. Midface Fractures Facial Examination • Evaluate mandibular opening • Palpation of buccal vestibule Crepitus of lateral antral wall • Occlusion evaluated Absence and quality of dentition noted • Ecchymosis common finding • Pharynx evaluated for laceration & bleeding

27. Diagnosis of Lefort I Fractures Midface Fractures • Direction of force • Maxilla displaced posteriorly and inferiorly • Open bite deformity • Hypoesthesia of infraorbital nerve • Malocclusion • Mobility of maxilla • Noted by grasping maxillary incisors

28. Lefort I Fractures Signs and Symptoms Midface Fractures • Damaged teeth and soft tissues • Swelling and bruising • Deformity of alveolus • Malocclusion • Independent movement of fragments • Altered sensation

29. Diagnosis Lefort II and III Midface Fractures • Bilateral periorbital edema & ecchymosis • Step deformity palpated infraorbital & nasofrontal area • CSF rhinorrhea • Epistaxis

30. Diagnosis of Lefort II and III Midface Fractures • Clinical evaluation provides only a rough impression since swelling hides the underlying bony structures • Plain film radiographs and axial and coronal CT images are the basis for precise diagnosis & treatment plan

31. Diagnosis of Maxillofacial Injuries Midface Fractures • DIAGNOSTIC IMAGING • Panorex • Plain films • CT • Stereolithography

32. Radiographic Evaluation Midface Fractures • Plain Films • Lateral Skull • Waters View • Posteroanterior view of skull • Submental vertex • CT Scan • 1.5 mm cuts • axial and coronal views

33. Radiographic Evaluation Midface Fractures Lateral skull Water’s View

34. Radiographic Evaluation Midface Fractures CT Scan 3D CT

35. Lateral C-Spine Film Midface Fractures

36. C-spine CTs Midface Fractures

37. 3D CT Midface Fractures

38. Stereolithography Midface Fractures

39. Midface Fractures Radiographic Evaluation Stereolithography allows actual model of defect. A nice reconstruction tool to use if available

40. Maxillofacial Injuries Midface Fractures • Treatment divided into following phases • Emergency or initial care • Early care • Definitive care • Secondary care or revision

41. Principles Midface Fractures • First Aid • Airway • Breathing • Circulation • Resuscitation • Exclusion of other injury

42. Emergency Care Midface Fractures • Evaluate the airway • Existence & identification of obstruction • Manually clear of fractured teeth, blood clots, dentures • Endotracheal intubation & packing of oronasal airway

43. Emergency Care Midface Fractures • Preserve the airway • Control of hemorrhage • Prevent or control shock • C-Spine stabilization • Control of life-threatening injuries • head injuries, chest injuries, compound limb fractures, intra-abdominal bleeding

44. Airway Management Midface Fractures • Chin lift to open intact airway • Intubation • Oral: C-spine injury absent on X ray • Nasotracheal intubation: C-spine injury suspected • Surgical Airway • Cricothyroidotomy • Tracheosotomy

45. Emergency Care Midface Fractures • Extensive vascularity of head & neck may lead to massive blood loss • Monitor vital signs closely • Intravenous infusion • Penetrating injuries need to be explored • Arteriogram • Esophagram

46. Treatment of Blood Loss & Shock Midface Fractures • Hemorrhage most common cause of shock after injury • Multiple injury patients have hypovolemia • Goal is to restore organ perfusion

47. Treatment of Blood Loss & Shock Midface Fractures • External bleeding controlled by direct pressure over bleeding site • Gain prompt access to vascular system with IV catheters • Fluid replacement • Ringer’s Lactate • Normal saline • Transfusion

48. Soft tissue injury Midface Fractures • Facial lacerations not complicated by associated injury can be managed in an ER setting • Large extensive facial and scalp lacerations are preferably closed in an operating room environment

49. Facial lacerations Midface Fractures

50. Soft tissue injury Midface Fractures • Hemostasis • Debridement • Approximate wound edges • Sutures • Steristrips • Dressings • Antibiotics/Tetanus