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Comprehensive Understanding of Maxillary and Periorbital Fractures

Learn about the epidemiology, anatomy, fracture patterns, patient evaluation, ophthalmologic considerations, treatment, and order of repairs for maxillary and periorbital fractures. This article emphasizes the importance of precise anatomic reduction for functional and cosmetic restoration.

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Comprehensive Understanding of Maxillary and Periorbital Fractures

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  1. Maxillary and Periorbital Fractures Michael E. Decherd, MD Shawn D. Newlands, MD, PhD January 26, 2000

  2. Overview • Classic tripod, orbital floor, LeFort fractures better thought of as orbitozygomaticomaxillary fractures • Precise anatomic reduction is key • Goal is functional and cosmetic rehabilitation

  3. 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

  4. Anatomy

  5. Anatomy

  6. Anatomy of the Orbit • Bones: Frontal, Zygomatic, Ethmoid, Lacrimal, Maxilla, Palatal, Sphenoid

  7. Anatomy of the Orbit • Four-sided pyramid or cone

  8. Anatomy of the Orbit • Maximum vertical dimension 1.5 cm behind rim • Floor is concave and then convex

  9. Anatomy of the Orbit • Floor slopes into medial wall • Optic nerve superomedial to true apex

  10. Anatomy of Zygoma • Four superficial and two deep articulations • Intersection of arcs define malar prominence

  11. Anatomy of the Maxilla • Paired embryologically • Functionally acts with palatine bone

  12. Anatomy of the Maxilla

  13. Vertical Buttresses • Resist occlusal load

  14. Horizontal Buttresses

  15. Fracture Patterns

  16. LeFort Fractures • Experimentally determined weak points • Can be in combinations bilaterally • Useful descriptor • Results from anterior forces

  17. Le Fort I

  18. Le Fort II

  19. Le Fort III

  20. Zygoma Fractures • Results from lateral forces

  21. Zygoma Fractures • Impacted zygoma may mask orbital floor defect

  22. Orbital Blowout Injury

  23. Orbital Blowout Injury

  24. Orbital Blowout Injury • Usually inferior and/or medial wall • Cone will become more spherical • Leads to enophthalmos, inferior displacement • Muscle entrapment causes diplopia

  25. Patient Evaluation

  26. Physical Exam • Can be very difficult in traumatized patient • Don’t forget trauma ABC’s (ATLS) • Look for occlusion, trismus, stability, asymmetry, extraocular movements, V2 anesthesia, stepoffs, bowstring test, lacerations and ecchymosis

  27. Physical Exam • Midface asymmetry may indicate zygoma fracture

  28. Physical Exam • Palpate for midface instability

  29. Physical Exam -- Ophthalmologic Considerations • Ophthalmologic Minimums • Visual acuities (subjective and objective) • Pupillary function • Ocular motility • Anterior chamber for hyphema • Fundoscopic exam • If in question ophthalmologic consultation is indicated

  30. Eye Algorithm • If obtunded, afferent pupillary defect may indicate visual loss

  31. Afferent Pupillary Defect

  32. Ophthalmologic Exam

  33. Ophthalmologic Exam • Hyphema is blood in anterior chamber • Hx - vision worse supine, clears upright • Can cause increased IOP

  34. Ophthalmologic Exam • Tonometer measures IOP • Greatly increased IOP causes pulsatile optic disk

  35. Ophthalmologic Exam • Retinal detachment requires ophthalmologic attention

  36. Ophthalmologic Exam • Iridodialysis (torn iris • Opacified cornea

  37. Ophthalmologic Exam • Fluorescsein reveals corneal abrasion • Dislocated lens

  38. Ophthalmologic Exam • Subconjunctival ecchymosis may indicate orbital fracture

  39. Forced Duction Testing

  40. Physical Exam • Often edema, swelling, or patient’s mental status make physical exam difficult • CT is modality of choice -- axial and coronal

  41. CT areas to evaluate • Vertical buttresses • Zygomatic arch • Orbital walls • Bony palate • Mandibular condyles

  42. Treatment

  43. Goal is functional and cosmetic restoration Treatment must be individualized Various factors can affect management strategies Multi-trauma Concomitant mandible injury Only-seeing eye Treatment

  44. Work from stable to unstable Use occlusion as guide Generally stabilize mandible, zygoma and palate before midface before orbit and NOE Order of Repairs

  45. Order of Repairs

  46. 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

  47. 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

  48. Zygoma Algorithm

  49. ORIF of Lateral Antral Wall

  50. Gillies Reduction

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