Facial Injury

SECTION I • Craniofacial Trauma
3
Facial injuries
Eduardo D. Rodriguez, Amir H. Dorafshar, and Paul N. Manson
injury, but primary and secondary enforcement of the laws

SYNOPSIS
vary in effectiveness with ethnicity, education, and geographic
location.5–7
■ Facial injuries often involve bone and soft tissue, and each must be
A unique aspect of facial injury treatment is that the aes-
managed precisely in a timely fashion.
■ Soft tissue injuries include contusions, lacerations, hematomas, and
thetic result may be the chief indication for treatment. In other
cases, injuries may require surgery to restore function, but
avulsions.
commonly, both goals are necessary. Although there are
■ Bone injuries are fractures, and they are classified by anatomic area
few facial emergencies, the literature has underemphasized
and are characterized by displacement and comminution.
the advantages of prompt definitive reconstruction and
■ Bone injuries are treated with open or closed reductions, and typically
early operative intervention in achieving superior aesthetic
rigid fixation is used for stabilization. The thick areas and edges where
and functional results. Economic, sociologic, and psychologic
bones articulate are called “buttresses”; these areas guide application
factors in a competitive society make it imperative that an
of fixation devices. Fracture stabilization is conducted through aesthetic
expedient and well-planned surgical correction be executed
incisions, which provide access to buttress articulations. The
sequence of reduction and the need for exposure of a specific buttress in order to return the patient to an active and productive life
articulation depend upon the level of comminution, displacement, and while minimizing disability.
the presence of adjacent fractures.
■ Anatomic closure of incisions, reattaching the soft tissue to its proper Access the Historical Perspective section, including
location on the bone, provides the soft tissue “reduction” necessary to Fig. 3.1, online at
obtain aesthetic results.
■ Finally, a specific sequence of immediate injury management for both
http://www.expertconsult.com
the bone and soft tissue is necessary in ballistic or high-energy
injuries where bone and soft tissue are badly contused, avulsed and/or
missing.
Initial assessment
Management begins with an initial physical examination and
Introduction is followed by a radiologic evaluation accomplished with
computerized tomographic (CT) scanning. CT scans visualize
Over ten million people are injured in automobile accidents soft tissue and bone.9 It is no longer feasible or economically
in the US yearly.1 Statistics on the number of facial injuries justifiable to obtain plain radiographs with certain exceptions,
vary widely based on social, economic, and geographic dif- such as the panorex mandible examination or dental films.
ferences. The causes of facial injuries in the US include motor The availability of regional Level I and II trauma centers has
vehicle collisions, assaults, altercations, bicycle and motorcycle provided earlier, safer, and improved trauma care for poly-
accidents, home and industrial accidents, domestic violence, trauma, severely injured patients.
athletic injuries, and falls, particularly in the elderly.2 The
automobile is frequently responsible for some of the most
devastating facial injuries, and injuries to the head, face, and
Clinical examination of the face
cervical spine occur in over 50% of all victims.3,4 Seat belts and A careful history and thorough clinical examination forms the
airbags have reduced the severity and incidence of facial basis for the diagnosis of almost all facial injuries. Thorough
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Historical perspective 47.e1
Historical perspective Coronal incision Upper

blepharoplasty
incisions
In the 1980s, the application of craniofacial exposures
improved the ability to restore the pre-injury facial appear-
ance by providing access to the entire facial skeleton (Fig.
3.1). These techniques had their adverse sequela of soft tissue
and nerve damage and displacement of soft tissue position on
the facial skeleton. Current facial injury treatment minimizes Transcon-
potentially morbid exposures. The techniques of extended junctival
open reduction, immediate bone grafts, and microvascular incisions
tissue transfer have made impossible injuries manageable.
The principle of immediate skeletal stabilization in anatomic
position has been enhanced by the use of rigid fixation. Soft Peri-
tissue position and volume over this expanded skeleton are Transcon- auricular
maintained, preventing soft tissue shrinkage, displacement, junctival incisions
incisions
and contracture. These techniques improve the functional
and aesthetic results of facial fracture treatment. In the last Intraoral
thirty years, the improvements in automobile construction, incisions
restraints, and traffic regulation have offered much protection
from facial injury. The use of restraints, airbags and padded Extraoral
Extraoral
incisions
surfaces, the multi-laminated windshield, and the improved incisions
design of rearview mirrors and steering wheels have all
reduced the frequency and severity of facial injuries.8 Over the
years, the popularity of the motorcycle still remains a factor
in the etiology of major facial trauma. At the University of
Maryland Shock Trauma Unit, the number of ballistic injuries
has increased in proportion to the increase in drug traffic. The
character of ballistic injuries has also changed over the years
from more destructive weapons to smaller caliber weapons. Fig. 3.1 Cutaneous incisions (solid line) available for open reduction and internal
fixation of facial fractures. The conjunctival approach (dotted line) also gives access
to the orbital floor and anterior aspect of the maxilla, and exposure may be
extended by a lateral canthotomy. Intraoral incisions (dotted line) are also indicated
for the Le Fort I level of the maxilla and the anterior mandible. The lateral limb of an
upper blepharoplasty incision is preferred for isolated zygomaticofrontal suture
exposure if a coronal incision is not used. A horizontal incision directly across the
nasal radix or vertical incision along the glabellar fold is the one case in which a
local incision can be tolerated over the nose. In many instances, a coronal incision
is preferable unless the hair is short or the patient is balding.
48 SECTION I CHAPTER 3 • Facial injuries
Fig. 3.2 Palpation of the superior and inferior orbital rims. (A) The superior orbital
rims are palpated with the pads of the fingertips. (B) Palpation of the inferior orbital
rims. One should feel for discontinuity and level discrepancies in the bone of the
rim and evaluate both the anterior and vertical position of the inferior orbital rims,
comparing the prominence of the malar eminence of the two sides of the face.
examination of the face is indicated even if the patient has

only minor wounds or abrasions.
The clinical examination should begin with the evaluation Fig. 3.4 Condylar examination. The mandible is grasped with one hand, and the
for symmetry and deformity, inspecting the face and compar- condyle area is bimanually palpated with one finger in the ear canal and one finger
over the head of the condyle. Abnormal movement, or crepitation, indicates a
ing one side with the other. Palpation of all bony surfaces condylar fracture. In the absence of a condylar fracture, a noncrepitant movement of
follows in an orderly manner. The forehead, orbital rims, nose, the condylar head should occur synchronously with the anterior mandible.
brows; zygomatic arches; malar eminence; and border of the Disruption of the ligaments of the condyle will permit dislocations of the condylar
mandible should be evaluated (Fig. 3.2). Careful inspection of head out of the fossa in the absence of fracture.
the intra-nasal areas should be made using a nasal speculum
to detect lacerations or hematomas. A thorough inspection of
the intra-oral area should be made to detect lacerations, bleed-
ing, loose teeth, or abnormalities of the dentition (Fig. 3.3).
Palpation of the dental arches follows the inspection, noting
mobility of dental–alveolar arch segments. The maxillary and
mandibular dental arches are carefully visualized and pal-
pated to detect any irregularity of the bone, loose teeth, intra-
oral lacerations, bruising, hematoma, swelling, movement,
tenderness, or crepitus. Mobility of the midface and mandible
should be methodically assessed (Figs. 3.4 & 3.5).
Fig. 3.5 With the head securely grasped, the midface is assessed for movement
by grasping the dentition. Loose teeth, dentures, or bridgework should not be
confused with mobility of the maxilla. Le Fort fractures demonstrate, as a rule, less
Fig. 3.3 An intraoral examination demonstrates a fracture, a gingival laceration, mobility if they exist as large fragments, and especially if they are a “single
and a gap in the dentition. These alveolar and gingival lacerations sometimes fragment”, than do lower Le Fort fractures. More comminuted Le Fort fractures
extend along the floor or roof of the mouth for a considerable distance. demonstrate extreme mobility (“loose” maxillary fractures).
Upper facial fractures 49
An evaluation of sensory and motor nerve function in the

facial area is performed. The presence of hypesthesia or Upper facial fractures
anesthesia in the distribution of the supraorbital, infraorbital,
or mental nerves suggests a fracture along the bony path of Frontal bone and sinus injury patterns
these sensory nerves (cranial nerve V). Cutaneous branches
of these nerves may also have been interrupted by a facial The frontal sinuses are paired structures that have only an
laceration. ethmoidal anlage at birth. They have no frontal bone compo-
Extraocular movements (cranial nerves III, IV, and VI) nent initially. They begin to be detected at 3 years of age, but
and the muscles of facial expression (cranial nerve VII) significant pneumatic expansion does not begin to occur until
are examined in the conscious, cooperative patient. Pupil- approximately age 7 years. The full development of the frontal
lary size and symmetry, speed of pupillary reaction, globe sinuses is complete by the age of 18 to 20. The frontal sinuses
turgor, globe excursion, eyelid excursion, double vision, are lined with respiratory epithelium, which consists of a cili-
and visual acuity and visual loss are noted. A funduscopic ated membrane with mucus secreting glands. A blanket of
examination and measurements of globe pressure should be mucin is essential for normal function, and the cilia beat this
performed. The presence of a hyphema, corneal abrasion, mucin in the direction of the nasofrontal outflow tracts
visual field defect, visual loss, diplopia, decreased vision, or (NFOT). The exact function of the paranasal sinuses is still
absent vision should be noted and appropriate consultation unclear. When injured and obstructed, they serve as a focus
requested. for infection, especially when NFOT function is impaired. The
nature of the open frontal sinuses and the multiple layers of
Computerized tomographic scans the skull protect the intracranial contents from injury by
absorbing energy.
The definitive radiographic evaluation is the craniofacial CT The predominant form of frontal sinus injury is fracture.
scan with axial, coronal, and sagittal sections of bone and soft Fracture involvement of the frontal sinus has been estimated
tissue windows.10,11 CT evaluation of the face can define bone to occur in 2% to 12% of all cranial fractures, and severe
fractures, whereas the soft tissue views allow for soft tissue fractures occur in 0.7% to 2% of patients with cranial or
definition of the area of the fracture. 3D CT scans12 allow for cerebral trauma.
comparison of symmetry and volume of the facial bones Approximately one-third of fractures involve the anterior
bilaterally. Specialized views, such as those of the orbital apex, table alone, and 60% involve the anterior table and posterior
provide a special magnified visualization. table and/or ducts. The remainder (7%) involve the posterior
wall alone. Some 40% of frontal sinus fractures have an
accompanying dural laceration.
Timing of treatment
Timing is important in optimizing the management of facial
injuries. Bone and soft tissue injuries in the facial area should
Clinical examination
be managed as soon as the patient’s general condition permits. Lacerations, bruises, hematomas, and contusions constitute
Time and time again it has been the authors’ impression that the most frequent signs of frontal bone or sinus fractures. The
early facial injury management decreases permanent facial “spectacle hematoma” is a sign of an anterior cranial base
disfigurement and limits serious functional disturbances.13,14 fracture, and frontal sinus and skull fractures must be sus-
This does not mean that one can be cavalier about deciding pected if any of these signs are present. Anesthesia of the
who might tolerate early operative intervention. Indeed, the supraorbital nerve may be present. Cerebrospinal fluid rhi-
facial surgeon must have a complete knowledge of the norrhea may occur. There may or may not be subconjunctival
patient’s ancillary injuries as well as those of the face. Classi- or periorbital ecchymoses with or without air in the orbit or
cally, facial soft tissue and bone injuries are not acute surgical intracranial cavity. In some cases, a depression may be
emergencies, but both the ease of obtaining a good result and observed over the frontal sinus, but swelling is usually pre-
the quality of the result are better with early or immediate dominant in the first few days after the injury, which may
management. Less soft tissue stripping is required, bones are obscure the depression.
more easily replaced into their anatomic position, and easier Small fractures of the frontal sinus may be difficult to
fracture repairs are performed. There are some patients, detect, especially if they are nondisplaced. Therefore, the first
however, whose injuries cannot be definitively managed presentation of a frontal sinus fracture may be an infection
early. Exceptions to acute treatment include patients with or symptom of frontal sinus obstruction, such as mucocele
ongoing or significant blood loss (i.e. pelvic fractures), elevated or abscess formation.17 Infection in the frontal sinus may
intracranial pressures, coagulation problems, and abnormal produce quite serious complications because of its location
pulmonary ventilation pressures.15 Under local anesthesia, near the brain and meninges. Infections include meningitis,
however, lacerations are debrided and closed, interdental fixa- extradural or intradural abscess, intracranial abscess, osteo-
tion applied, and grossly displaced fractures reduced. Many myelitis of the frontal bone, or osteitis in devitalized bone
patients with mild brain injuries or multi-system traumas do fragments.18–22
not have criteria preventing operative management.16 These
patients may receive facial injury management at the time that
other injuries are being stabilized. It is not uncommon,
Nasofrontal outflow tract
however, in the University of Maryland Shock Trauma Unit The development of a frontal sinus mucocele is linked to
for several teams to operate on a patient at the same time in obstruction of the NFOT, which is involved with fractures in
several anatomic areas. up to 50% of cases of frontal sinus injury. The NFOT passes
through the anterior ethmoidal air cells to exit adjacent to the thoroughly stripped, even into the recesses of the sinus, and
ethmoidal infundibulum. Blockage of the NFOT prevents the NFOT occluded with well-designed “formed-to-fit” cal-
adequate drainage of the normal mucosal secretions and varial bone plugs or calvarial bone particulate grafting mate-
predisposes to the development of obstructive epithelial lined rial (Fig. 3.6). If most of the posterior bony wall is intact, the
cysts or mucoceles. Mucoceles may also develop when islands entire frontal sinus cavity may be filled with cancellous bone.
of mucosa are trapped by scar tissue within fracture lines and The iliac crest provides a generous source of rich cancellous
attempt to grow after the injury, producing a mucus mem- bone.32 Formerly, the cavity was left vacant to heal by a slow
brane lined obstructed cystic structure.23 process called “osteoneogenesis”, filling slowly with a combi-
The sinus is completely obliterated only when it is deprived nation of bone and fibrous tissue. However, the incidence of
of its lining and when the bone is burred, eliminating the infection is higher by comparison to filling the empty cavity
foramina of Breschet24 where mucosal ingrowth occurs along with cancellous bone graft.33
veins in the walls of the sinuses. Regrowth of mucosa can also If the posterior table is missing, grafting may be performed
occur from any portion of the frontal sinus, especially if for localized defects, but it is always emphasized that the floor
incompletely debrided. The reported average interval between of the anterior cranial fossa should be reconstructed with
the primary injury and development of frontal sinus mucocele bone. For large defects, a process called cranialization is
is 7.5 years. selected, where the posterior wall of the frontal sinus is
removed, effectively making the frontal sinus a part of the
intracranial cavity. The “dead space” may be filled with can-
Radiography cellous bone or left open. Any communication with the nose
Frontal bone and sinus fractures are best demonstrated using by the NFOT or with the ethmoid sinuses should be sealed
CT Scans.25 Hematomas or air fluid levels in the frontal sinus with carefully designed bone grafts or bone graft particulate
may be visualized as well as potential injuries to the NFOT. material after debridement. The orbital roof should be recon-
Persisting air-fluid levels imply the absence of NFOT function structed primarily by thin bone grafts placed external to the
as do displaced fractures in the medial floor of the frontal orbital cavity. An intracranial exposure is often preferred for
sinus. large defect orbital roof reconstruction.
The use of a galeal flap in the treatment of extensive frontal
bone defects designed with a pedicle of the supraorbital and
Surgical treatment supratrochlear artery or with the superficial temporal artery
The best technique of exposure in major fractures involving is recommended for vascularized soft tissue obliteration of
the frontal bone is the coronal incision. This allows a combined “dead space”.
intracranial and extracranial approach to the anterior cranial
fossa which provides visualization of all areas, including Complications
repair of dural tears, debridement of any necrotic sections of
frontal lobe, and repair of the bone structures. Complications of frontal bone and sinus fractures include:
Frontal sinus fractures should be characterized by describ- 1. CSF fluid rhinorrhea
ing both the anatomic location of the fractures and displace- 2. Pneumocephalus and orbital emphysema
ment. The indications for surgical intervention in frontal sinus 3. Absence of orbital roof and pulsating exophthalmos
fractures include depression of the anterior table, radiographic 4. Carotid–cavernous sinus fistula
demonstration of involvement of the NFOT with presumed
future non-function, obstruction of the NFOT with persistent
air-fluid levels, mucocele formation, and fractures of the
posterior table which may have lacerated the dura.26,27 Some Orbital fractures
authors recommend exploration of any posterior table fracture Orbital fractures may occur as isolated fractures of the
or any fracture in which an air-fluid level is visible. Others internal orbit (also called “pure”) or may involve both the
have a more selective approach, exploring posterior wall internal orbit and the orbital rim (also called “impure”)34,35
fractures only if their displacement exceeds the width of the (Fig. 3.7).
posterior table, a distance suggesting simultaneous dural
laceration.28,29 Simple linear fractures of the anterior and
posterior sinus walls which are undisplaced are safely
Surgical anatomy of the orbit
observed. The orbits are conceptualized in thirds progressing from
Any depressed frontal sinus fracture of the anterior wall anterior to posterior. Anteriorly, the orbital rims consist of
potentially requires exploration and wall replacement to thick bone. The middle third of the orbit consists of thin bone,
prevent contour deformity. Most of these patients have no and the bone structure thickens again in the posterior portion
compromise of NFOT function; however, those that do will of the orbit. The orbital bone structure is thus analogous to a
have fractures of the medial floor of the sinus. If sinus drain- “shock-absorbing” device in which the middle portion of the
age is compromised, the sinus should be defunctionalized. orbit breaks first, followed by the rim, both absorbing energy
The anterior wall of the sinus may be explored by an appro- and protecting the poster third from displacement and the
priate local laceration or a coronal incision, or more recently globe from rupturing.
endoscopic drainage and elevation have been recommended The optic foramen is situated at the junction of the lateral
for simpler fractures. Anterior wall fragments are elevated and medial walls of the orbit posteriorly and is well above the
and plated into position. If it is desired that the NFOT30,31 and horizontal plane of the orbital floor. The foramen is located
sinus be obliterated because of involvement, the mucosa is 40–45 mm behind the inferior orbital rim.
Orbital fractures 51
A B C
D E
Fig. 3.6 (A) Nasofrontal outflow tract (NFOT). (B) Bone plug for NFOT. (C) Bone obliteration of frontal sinus.
(D) “Back table” surgery for bone replacement. (E) Bone reconstruction and cranialization of the frontal sinus; F
intracranial neurosurgery. (F) Postoperative result.
Orbital physical examination Radiographic evidence of fracture

The most important component of the physical examination CT scans performed in the axial, coronal, and sagittal planes,
is to check the visual acuity in each eye: the patient’s ability using both bone and soft tissue windows, are essential to
to read newsprint or an ophthalmic examination card such as define the anatomy of the orbital walls and soft tissue
the Rosenbaum Pocket card. Visual field examinations should contents, and the relation of the extraocular muscles to the
be performed to detect edema, corneal abrasion, globe lacera- fracture.
tion, contusion, and hematoma. The simultaneous presence of
a subconjunctival hematoma and a periorbital hematoma
confined to the distribution of the orbital septum (so called Indications for surgical treatment
“spectacle hematoma”) is evidence of a facial fracture involv-
The indications for surgical treatment include:
ing the orbit until proven by radiographs (Fig. 3.8). Extraocular
movements should identify double vision or restricted globe 1. Double vision caused by incarceration of muscle or the
movement. All patients with orbital injuries must be frequently fine ligament system, documented by forced duction
checked for light perception and pupillary afferent defects examination and suggested by CT scans.
post-injury, preoperatively and postoperatively. Globe pres- 2. Radiographic evidence of extensive fracture, such that
sure may be assessed by tonometry and should be less than enophthalmos would occur.
15 mm. The results of a fundus examination should be 3. Enophthalmos or exophthalmos (significant globe
recorded. The presence of no light perception generally indi- positional change) produced by an orbital volume
cates optic nerve damage or globe rupture.36 Light perception change.
without usable vision usually indicates optic nerve damage, 4. Visual acuity deficit, increasing and not responsive to
retinal detachment, hyphema, vitreous hemorrhage, or ante- medical dose steroids, implying that optic canal
rior or posterior chamber injuries. Globe and eye injuries decompression may be indicated, although this has
require expert ophthalmologic consultation. become more controversial.36
5. “Blow-in” orbital fractures that involve the medial or

lateral walls of the orbit and severely constrict orbital
volume, creating increased intraorbital and globe
pressure.
Blow-out fractures of the floor of the orbit

A blow-out fracture is caused by the application of a traumatic
force to the rim, globe, or soft tissues of the orbit. Blow-out
fractures are accompanied by a sudden increase in intraorbital
pressure.37
Medial orbital wall fractures

Medial orbital wall fractures may be isolated or combined
with fractures of the floor.38 With the loss of the infero-medial
orbital strut (connected to the middle turbinate) located
between the medial wall and floor, there is increased difficulty
achieving the proper shape and volume of the orbital contents.
This is an indication for repair with either anatomically con-
toured calvarial bone grafts or alloplastic implants to repro-
duce the normal inwardly contoured shape of the orbit. The
exposure for reduction of a medial orbital fracture include
A
trans- or retrocaruncular approaches, which can be used in
combination with a transconjunctival incision to provide wide
exposure to the floor and medial orbit for repair.39 A coronal
incision provides the broadest exposure of the medial orbital
wall.
Blow-out fractures in younger individuals

In children, the mechanism of entrapment is more frequently
trapdoor than the “blow-out or punched out” fracture seen in
adults. As opposed to incarceration of fat adjacent to the
Fig. 3.7 (A) Mechanism of blow-out fracture from displacement of the globe itself
into the orbital walls. The globe is displaced posteriorly, striking the orbital walls
and forcing them outward, causing a “punched out” fracture the size of the globe.
(B) “Force transmission” fracture of orbital floor.
Fig. 3.8 The combination of a palpebral and subconjunctival hematoma is

suggestive of a fracture somewhere within the orbit. There is frequently a zygomatic
or orbital floor fracture present when these signs are confirmed.
Operative technique for orbital fractures

Endoscopic approaches for orbital floor fractures
Recently, endoscopic approaches through the maxillary sinus
have permitted direct visualization of the orbital floor and
manipulation of the soft tissue and floor repair with this
approach, which avoids an eyelid incision.44–46
Cutaneous exposures
A number of incisions have been employed to approach the
Fig. 3.9 Blow-out fracture in a child produced by a snowball. Note the nearly orbital floor:
complete immobility of the ocular globe and the enophthalmos. Such severe loss of 1. Inferior lower eyelid incision. These have the least
motion implies actual muscle incarceration, an injury that is more frequent in incidence of lower eyelid ectropion of any lid incision
children than in adults. This fracture deserves immediate operation with release of location but tend to generate the most noticeable scar
the incarcerated extraocular muscle system. It is often accompanied by pain on
attempted rotation of the globe and sometimes nausea and vomiting. These
and are prone to lymphedema.47–49
symptoms are unusual in orbital floor fractures without true muscle incarceration. 2. Subciliary skin muscle flap incision. This incision near
the upper margin of the lid leaves the least conspicuous
scar of any cutaneous incision.50,51 However, they are
inferior rectus muscle, children more frequently “scissor” or prone to have the highest incidence of lid retraction
capture the muscle directly in the fracture site, as the springy (scleral show and ectropion). The mid-lid variation has
bone of children recoils faster than the entrapped soft tissue, less ectropion but more obvious scar if taken lateral to
pinning the muscle. This may be suggested on physical the pupil, and more edema.
examination with near immobility of the eye when upgaze is 3. Transconjunctival incision. A preseptal or retroseptal
attempted on the affected side, pain with attempted eye dissection plane can be established. There is no
motion, as well as nausea, vomiting, and presence of an cutaneous lid scar unless a lateral canthotomy is
oculocardiac reflex, which consists of nausea, bradycardia, utilized.
and hypotension (Fig. 3.9). Trapdoor fractures with actual
muscle incarceration is an urgent situation that demands
immediate release of the incarcerated muscle to preserve its Surgical technique
perfusion.40–42 Most practitioners emphasize that a better Generally, a corneal protector is placed over the eye to protect
prognosis occurs if the muscle is released early, although more the globe and cornea from instruments, retractors, or rotating
recently it has been suggested that appropriate surgical tech- drills. The inferior rectus muscle, the orbital fat, and any
nique is more important than the timing of release per se.43 orbital soft tissue structures should be carefully dissected free
from the areas of the blow-out fracture. Intact orbital floor
Surgical treatment must be located around all the edges of the fracture, and any
The surgical treatment of orbital fractures has three goals: displaced “blow-out” soft tissue gently released from the
fracture.
1. Disengage entrapped structures and restore ocular The fracture may be made larger permitting easier removal
rotatory function. of incarcerated soft tissue. The floor must be explored suffi-
2. Replace orbital contents into the usual confines of the ciently posteriorly that intact orbital floor beyond the defect
normal bony orbital cavity, including restoration of both is confirmed. This “ledge” is frequently the orbital process of
orbital volume and shape. the palatine bone, 35–38 mm posterior to the rim. Placing a
3. Restore orbital cavity walls, which in effect replaces the freer into the maxillary sinus, one may locate the back of the
tissues into their proper position and dictates the shape sinus and move it superiorly to verify the position of the
into which the soft tissue can scar. “ledge” which will be felt as a projection from the back wall
of the sinus. The “ledge” may be verified on sagittal CT scan
The timing of surgical intervention images.52,53 The “ledges” in fracture treatment are landmarks
with which implant material should be aligned to re-establish
In isolated blow-out fractures, it is not necessary to operate an anatomic orbital shape and volume.
immediately unless true muscle incarceration is present. In
the presence of significant edema, retrobulbar hemorrhage,
optic nerve injury, retinal detachment, or other significant
The forced duction test
globe injuries, such as hyphema, it is advisable to wait a Limitation of forced rotation of the eyeball (the “forced
number of days until stability of ocular condition is duction” test or the “eyeball traction” test) (Fig. 3.10) provides
confirmed. a means of differentiating entrapment of the extraocular
Significant orbital fractures are best treated by early surgi- muscles from muscle weakness, paralysis, or contusion. The
cal intervention. The authors firmly believe that the earlier forced duction test should be performed for initial diagnosis,
significant orbital volume change or functional muscle and then 1) before dissection; 2) after dissection; 3) after the
derangement can be corrected, the better the final aesthetic insertion of each material used to reconstruct the orbital wall;
and functional result. 4) just prior to closure of the incisions. It is crucial that these
preoperative results. Both double vision and blindness have

sometimes occurred after day 1 either in orbital fractures
or in postoperative treatment, but these conditions are
usually present at the time of injury or acutely following
the surgery.
Complications of orbital fractures

Diplopia
Extraocular muscle imbalance and subjective diplopia are
usually the result of muscle injury or contusion but can be the
result of incarceration of either the muscle or the soft tissue
adjacent to the muscles, or the result of nerve damage to the
third, fourth, and sixth cranial nerves.55–59 Traumatic surgical
dissection is also a mechanism as is forceful removal of
Fig. 3.10 The forced duction test. Forceps grasp the ocular globe at the insertion
of the inferior rectus muscle, which is approximately 7–10 mm from the limbus. A
drop of local anesthetic instilled into the conjunctival sac precedes the procedure.
measurements all be compared to detect what is causing

interference. Reconstructive material must not interfere with
globe movement, and a full range of oculo-rotatory move-
ments must accompany restoration of proper eye position.
Restoration of continuity of the orbital floor

The purpose of the orbital floor replacement, whether a bone
graft or an inorganic implant, is to re-establish the size and
the shape of the orbital cavity. This replaces the orbital soft
tissue contents and allows scar tissue remodeling to occur in
an anatomic position and proper shape (Fig. 3.11).
Bone grafts for orbital floor reconstruction

Split calvarial, iliac, or split rib bone grafts provide the ideal A
bone substitute for reconstruction of the internal orbital
fractures.54 It is not known whether bone grafts resist bacterial
colonization better than inorganic implants, but that is the
presumption. Bone grafts are presumed to survive at the
50–80% level.
Inorganic implants
The inorganic implant offers the reconstruction of the orbital
floor without an additional operation for bone graft harvest.
Titanium mesh alone or titanium mesh with polyethylene
may be easily utilized for larger defects.
The incidence of late infection with any technique is less
than two percent, and displacement should not occur if the
material has been properly anchored. Rarely, artificial or bone
graft materials exposed to the sinus may not re-mucosalize,
and may be responsible for recurrent cellulitis.
Postoperative care B
Light perception must be confirmed preoperatively and fre-

Fig. 3.11 Medial orbital wall fracture. (A) Coronal CT scan image illustrating
quently postoperatively. Pupillary reactivity must be assessed medial orbital wall fracture. (B) Postoperative three-dimensional CT scan
before and at least twice daily for the first several days after demonstrating repair of medial orbital wall repair using titanium alloplastic mesh
surgery. Double vision should be noted and compared with implant.
incarcerated orbital contents from a fracture, where tearing of the globe position has been stabilized by enophthalmos
the muscle occurs. correction.
Enophthalmos Scleral show, ectropion, and entropion – vertical

Enophthalmos 60,61
is the second major complication of a blow- shortening of the lower eyelid
out fracture, and the major cause is enlargement of the bony Vertical shortening of the lower eyelid with exposure of the
orbit with herniation of the orbital soft tissue structures into sclera below the limbus of the iris in the primary position
a larger space with remodeling of the shape of the soft tissue (scleral show) may result from downward and backward
into a spherical configuration. Displacement of intramuscular displacement of the fractured inferior orbital rim. The septum
cone fat into the extramuscular compartment is another and lower lid are “fixed length” structures and are therefore
mechanism, initiating a loss of globe position, as is retention dragged downward by their tendency to adhere to the abnor-
of the ocular globe in a backward position by scar tissue. A mally positioned inferior orbital rim. This can result in scleral
popular theory was fat atrophy, but computerized volume show or ectropion if occurring in the “anterior lid lamellae”
studies prove that fat atrophy makes a significant contribution (skin or orbicularis) or entropion if occurring in the “posterior
in only 10% of orbital fractures. lid lamellae” (septum, lower lid retractors, and conjunctiva).
Only in the actual performance of the operation can the
Retrobulbar hematoma surgeon define the true nature of the problem, release the
adhesions, correct the lid shortening, and stabilize the lid
In severe trauma, retrobulbar hematoma may displace the
position with appropriate grafts into the proper location.66
ocular globe. Retrobulbar hematoma is signaled by globe
Correction procedures generally do not elevate the lower lid
proptosis and exophthalmos, congestion and prolapse of the
by more than 3 mm.
edematous conjunctiva. Diagnosis is confirmed by a CT scan
image with soft tissue windows. Drainage is not possible as
retrobulbar hematomas usually are diffuse. Orbital fracture Infraorbital nerve anesthesia
treatment in the setting of retrobulbar hematoma has increased Infraorbital nerve anesthesia is extremely disconcerting to
risk, as volume increase and vascular spasm may affect globe patients who experience it, especially initially. The area of
circulation. The reconstruction is best performed when hem- sensory loss usually extends from the lower lid to involve the
orrhage, swelling and congestion have subsided, and vision medial cheek; the lateral portion of the nose, including the ala;
is stabilized. and the ipsilateral upper lip. The anterior maxillary teeth may
be involved if the branch of the infraorbital nerve in the
Ocular (globe) injuries and blindness anterior maxillary wall is involved. Decompression of the
The incidence of ocular injuries following orbital fractures is infraorbital nerve from pressure of the bony fragments within
14–30%. The incidence depends on the scrutiny of the exami- the infraorbital canal may be indicated either acutely or late
nation and the recognition of minor injuries, such as corneal after fracture treatment especially if the zygoma demonstrates
abrasion. Ocular globe injury may vary in severity from a medial displacement impinging the infraorbital canal with
corneal abrasion to loss of vision to globe rupture, retinal impaction into the nerve.
detachment, vitreous hemorrhage, or a fracture involving the
optic canal.62 Blindness, or loss of an eye, is remarkably infre- The “superior orbital fissure” syndrome and
quent despite the severity of some of the injuries sustained the “orbital apex” syndrome
because of the “shock absorber” type construction of the orbit.
The incidence of acute visual loss following facial fractures Significant fractures of the orbit extend posteriorly to involve
is on average 1.7%,63 and blindness following facial fracture the superior orbital fissure and optic foramen. Involvement
repair has been estimated to be about 0.2%.64 of the structures of the superior orbital fissure produces a
symptom complex known as the superior orbital fissure
syndrome. This consists of partial or complete involvement
Implant migration, late hemorrhage around of the following structures: the two divisions of the cranial
implants, and implant fixation nerve III, superior and inferior, producing paralysis of the
Migration of an implant anteriorly may occur with extrusion levator, superior rectus, inferior rectus, and inferior oblique
if the implant is not secured to the orbital floor or to a plate muscles; cranial nerve IV causing paralysis of the superior
that attaches to the rim. Spontaneous late proptosis can be oblique muscle; cranial nerve VI producing paralysis of the
caused by hemorrhage from longstanding low-grade infec- lateral rectus muscle; and the ophthalmic division of the
tion around orbital implants or from chronic sinus or lacrimal trigeminal nerve (V) causing anesthesia in the brow, medial
system infection.65 portion of the upper lid, medial upper nose, and ipsilateral
forehead. Symptoms of the superior orbital fissure syndrome
may be partial or complete in each of the nerves.67 When
Ptosis of the upper lid accompanied by visual acuity change or blindness, the injury
True ptosis of the upper lid should be differentiated from implies concomitant involvement of the combined superior
“pseudoptosis” resulting from the downward displacement orbital fissure (CN III, IV, V & VI) and optic foramen (CN II).
of the eyeball in enophthalmos. True ptosis results from If involvement of both the optic nerve and superior orbital
loss of action of the levator palpebrae superioris. Ptosis in fissure occur, this symptom complex is called the orbital
the presence of enophthalmos should not be treated until apex syndrome.
Anteroposterior blows result in posterior displacement of

Midfacial fractures the nose into the nasal cavity and may occur with or without
lateral impact. They also occur in three degrees of severity:
Nasal fractures plane I, where the distal portion of the nasal bones are
involved; plane II, where the entire nasal bones and dorsal
septum are involved; and Plane III, where the comminution
Types and locations of nasal fractures extends beyond the nose into the frontal processes of the
Lateral forces68 account for the majority of nasal fractures and maxilla; again, the latter injuries are true nasoethmoidal–
produce a wide variation of deformities, depending on the orbital fractures. With any nasal fracture of significance, the
age of the patient, intensity and vector of force. Younger septum “telescopes”, losing height, and the nasal bridge
patients tend to have fracture dislocations of larger segments, drops. Violent blows result in multiple fractures of the nasal
whereas older patients with more dense, brittle bone often bones, frontal processes of the maxilla, lacrimal bones, septal
exhibit comminution. A direct force of moderate intensity cartilages, and the ethmoidal areas (i.e. the true nasoethmoidal
from the lateral side may fracture only one nasal bone with orbital fracture).
displacement into the nasal cavity (plane I lateral impact).
When forces are of increased intensity, some displacement of
the contralateral nasal bone occurs and the fracture may be
Fractures and dislocations of the nasal septum
incomplete or greensticked requiring completion of the Fractures and dislocations of the septum may occur indepen-
contralateral fracture to centralize the nasal processes (plane dently or concomitantly with fractures of the distal nasal bone
II lateral impact). In more severe (plane III lateral impact) framework. Most commonly, the two injuries occur together,
frontal impact injuries, the frontal process of the maxilla may but frontal impact nasal fractures carry the worst prognosis
begin to fracture and may be depressed posteriorly on one regarding preservation of nasal height with closed reduction
side. This depression first arises at the pyriform aperture techniques (Fig. 3.13). Because of the intimate association of
inferiorly and then involves the entire structure of the frontal the bones of the nose with the nasal cartilages and bony nasal
process of the maxilla, and is in effect the first stage of a septum, it is unusual to observe fractures of either structure
hemi-nasoethmoidal fracture, displaced inferiorly and poste- without damage to the other. In particular, the caudal or
riorly (plane III “lateral impact” nasal fractures are identical cartilaginous portion of the septum is almost always injured
to “type I” hemi-nasoethmoidal fractures) (Fig. 3.12A–C). in nasal fractures.
These fractures are “greensticked” or almost undisplaced at The caudal portion of the septum has a degree of flexibility
the internal angular process of the frontal bone. The sidewall and bends to absorb moderate impact. The first stage of nasal
of the nose drops on one side, the septum telescopes and septal injury is fracturing and bending, and the next stage
displaces, and the nasal airway is effectively closed on the involves overlap between fragments, which reduces nasal
ipsilateral side by the sidewall and turbinate impacting height. In mid-level severity injuries, the septum fractures,
toward the septum blocking the airway. In stronger blows, the often initially with a C-shaped or double transverse compo-
septum begins to collapse from an anteroposterior perspec- nent in which the septum is fractured and dislocated out of
tive as the comminution increases. the vomerine groove with or without involvement of the
A B C
Fig. 3.12 Frontal impact nasal fractures are classified by degrees of displacement, as are lateral fractures. (A) Plane I frontal impact nasal fracture. Only the distal ends of
the nasal bones and the septum are injured. (B) Plane II frontal impact nasal fracture. The injury is more extensive, involving the entire distal portion of the nasal bones and
the frontal process of the maxilla at the piriform aperture. The septum is comminuted and begins to lose height. (C) Plane III frontal impact nasal fractures involve one or
both frontal processes of the maxilla, and the fracture extends to the frontal bone. These fractures are in reality nasoethmoidal orbital fractures because they involve the
lower two-thirds of the medial orbital rim (central fragment of the nasoethmoidal orbital fracture), as well as the bones of the nose.
Midfacial fractures 57
cartilage support and preventing soft tissue contracture70

(Fig. 3.15).
Open reduction and the use of supporting k wires

In severe nasal injury (i.e. plane II nasal injury), open reduc-
tion with bone or cartilage grafting to restore nasal height may
be required. Semi-closed reductions71 with limited incisions
using K wires to attempt to stabilize the nasal bones are less
effective and accurate.72 Internal splinting of the septum
should be part of the treatment plan (Doyle splints). Some
nasal fractures are sufficiently dislocated that they can only
be stabilized with an open rhinoplasty reduction and bone or
cartilage grafts.73
A closed reduction may be best performed before edema
prevents accurate palpation and visual inspection to confirm
the reduction, and before partial healing or fibrosis limits
A the effectiveness of reduction. In practice, closed reduction
of most nasal fractures is frequently deferred 5–7 days until
the edema has partially subsided and the accuracy of the
reduction may again be confirmed by visual inspection
and palpation. After two weeks, it becomes more difficult
to reduce a nasal fracture, as partial healing in malalign-
ment has occurred. The soft tissue shrinks to accommodate
the reduced skeletal volume, making anatomic reduction
more difficult.
Treatment of fractures and dislocations of the septum

The nasal septum should be straightened and repositioned as
soon after the injury as possible. Fractures of the nasal bones
and septum frequently occur simultaneously, and it is impor-
tant to ensure that at the time of reduction the nasal bones
and septum fragments can be freely deviated in both lateral
directions to ensure completion of partial or “greensticked”
fractures. Incomplete fractures create early recurrence of dis-
placement by causing the nasal bones and septum to “spring”
B back toward their original deviated position. When nasal
bones are reduced, their intimate relationship with the upper
Fig. 3.13 Palpation of the columella (A) and dorsum (B) detects superior rotation and lower lateral cartilages tends to reduce the upper septal
of the septum and lack of dorsal support. There is an absence of columellar support cartilage as well unless the cartilages are torn or avulsed from
and dorsal septal support.
their attachments. Displacement of the cartilaginous septum
out of the vomerine groove will not be reduced with nasal
bone reduction alone and must be done manually with an
vomer and anterior nasal spine, where displacement of the Asch forcep, and the septal fragments maintained in position
fractured segments cause partial obstruction of the nasal with an intranasal (Doyle) splint (see Fig. 3.14). In cases where
airway. Severe fractures of the septum are associated with the septum has been dislocated from the anterior nasal spine,
“telescoping” or overlapping type of displacements, with a the septum should be reunited by suture or wire fixation to
“Z-shaped” characteristic deformity,69 where the septum loses the spine;74 septal hematomas should be aspirated and mini-
considerable length, obstructing both airways. The septum is mized by transfixation sutures through and through the
severely shortened, giving rise to a retruded appearance in mucosa.
lateral profile: the distal dorsum of the nose slumps posteri- When nasal fractures are treated late after the injury, it may
orly, and the columella and tip are retruded and upturned. not be possible to obtain the desired result with a closed
reduction or with a single operation. Healing may make the
reduction of the displaced or overlapped fragments impos-
The treatment of nasal fractures sible without osteotomy at each area of previous fracture by
Most nasal fractures are reduced by closed reduction (Fig. open rhinoplasty, septal resection and repositioning, and/or
3.14A–E). In moderate or severe frontal impact fractures bone or cartilage grafting. Some advocate acute septal open
where loss of nasal height and length occur (plane II or plane reductions, where telescoped portions of the septum are
III nasoethmoidal orbital fractures), open reduction and resected creating additional mucosal and cartilage injury and
primary bone or cartilage grafting may be the only way to causing further loss of nasal height. Septal reconstruction
restore the support of the nose and return it to its original procedures are generally best performed secondarily. All
volume and shape, filling the soft tissue envelope with new patients with nasal fractures should be warned that a late
A B C
Fig. 3.14 Reduction of a nasal fracture. (A) After

vasoconstriction of the nasal mucous membrane with
pseudoephedrine-soaked pledgets the nasal bones are
“outfractured” with a Boies nasal elevator. (B) The
septum is then straightened with an Asch forceps. Both
the nasal bones and the septum should be able to be
freely dislocated in each direction (C) if the fractures
have been completed. If the incomplete fractures have
been completed properly, the nasal bones may then be
molded back into the midline and remain in reduction
(D). Care must be taken to avoid placing the reduction
instruments into the intracranial space through a
fracture or congenital defect in the cribriform plate.
(E) Steri-Strips and adhesive tape are applied to the
nose, and a splint is applied over the tape. Intranasal
D E Doyle splints are placed inside the nose to minimize
clot and hematoma in the distal portion of the nose.
rhinoplasty is expected for correcting deviation, irregularity, may be required, and in many patients turbinate outfracture,
loss of nasal height, or nasal airway obstruction. or partial resection of enlarged turbinates, may simultane-
ously be advisable.
Synechiae may form between the septum and the turbinates
Complications of nasal fractures in areas where soft tissue lacerations occur and the tissues are
Hematomas of the nasal septum, while uncommon, may in contact. These may be treated by division and placement
result in subperichondrial fibrosis and thickening with partial of a Doyle splint between the cut surfaces for a period of 10–14
nasal airway obstruction. The septum in these cases may be days.
as thick as 1 cm in areas and may require trimming. In the Obstruction of the nasal vestibule may occur as a result
case of repeated trauma, the cartilages of the septum may be of malunited fractures of the pyriform margin, especially if
largely replaced with calcified or chondrified material. Sub- displaced and telescoped medially, or from overlap or lateral
mucous resection of thickened portions of the nasal septum displacement of the nasal septum into the ipsilateral airway.
presence of closed splinting may not prevent recurrent devia-

tion owing to the release of “interlocked stresses” in carti-
lage.76,77 Any external or internal deformity of significance
may require a corrective rhinoplasty.
Nasoethmoidal orbital fractures

Nasoethmoidal orbital fractures are severe fractures of the
central one-third of the upper midfacial skeleton. They com-
minute the nose, the medial orbital rims, and the pyriform
aperture. Nasoethmoidal fractures are isolated in one-third
and extended in two-thirds of cases to involve either the
frontal bone, zygoma, or maxilla. One-third are unilateral and
two-thirds are bilateral.
The central feature characterizing nasoethmoidal orbital
fractures is the displacement of the lower two-thirds of the
medial orbital rim, which provides the attachment of the
medial canthal ligament. Any fractures that separate this part
of the frontal process of the maxilla with its canthal-bearing
A tendon potentially allow canthal displacement.
Surgical pathology
The bones that form the skeletal framework of the nose
are projected backward between the orbits when subjected
to strong traumatic forces. These bones form the junction
between the cranial, orbital, and nasal cavities. A typical cause
of a nasoethmoidal orbital fracture is a blunt impact applied
over the upper portion of the bridge of the nose producing a
crush in the upper central midface. The severity of the impact
or penetrating injuries may burst the soft tissues, producing
an open, compound, comminuted injury. When displacement
of the upper nose and anterior frontal sinus occur, no further
resistance is offered by the delicate “matchbox-like” structures
of the interorbital space; indeed, these structures “collapse
and splinter”.
Interorbital space
The term “interorbital space” designates an area between the
orbits and below the floor of the anterior cranial fossa. The
“interorbital space” contains two ethmoidal labyrinths, one
B on each side, and consists of the ethmoidal cells, the superior
and middle turbinates, and a median thick plate of septal
Fig. 3.15 (A) Preoperative and (B) postoperative images of a 20-year-old male
bone and the perpendicular plate of the ethmoid.
who sustained a nasoethmoidal orbital fracture during a wrestling match.
Traumatic telecanthus and hypertelorism

Traumatic telecanthus is an increase in the distance between
Osteotomy of the bone fragments can correct displaced frac- the medial canthal ligaments. The patient has a characteristic
tures; however, contracture due to shrinkage or loss of soft appearance of telecanthus, where the medial canthal liga-
tissue lining may require excision of the scar and replacement ments are further apart than normal. The eyes may appear to
with mucosal or composite grafts within the nasal vestibule be further apart, simulating orbital hypertelorism.78,79 Trau-
or in some cases flap reconstruction. matic orbital hypertelorism80 (as opposed to telecanthus) is a
Residual osteitis or infection of the bone or cartilage is deformity characterized by an increase in the distance between
occasionally seen in compound fractures of the nose. These the orbits and the ocular globe81 and requires bilateral laterally
conditions are usually treated by repeated conservative displaced zygoma fractures in addition to bilateral nasoeth-
debridements until the infected focus is completely removed. moidal orbital fractures.
Secondary soft tissue grafting may restore absent tissue.
Chronic pain is infrequent and usually affects the external
nasal branches of the trigeminal nerve.75
Malunion of nasal fractures is common after closed reduc- The appearance of patients who suffer nasoethmoidal orbital
tions, since the exact anatomic position of the bone fragments fractures is typical. A significant frontal impact nasal fracture
is difficult to confirm or achieve by palpation alone, and the is generally present, with the nose flattened and appearing to
have been pushed between the eyes. There is a loss of dorsal

nasal prominence, and an obtuse angle is noted between the
lip and columella. Finger pressure on the nose may document
inadequate distal septal or proximal bony support. The medial
canthal areas are swollen and distorted with palpebral and
subconjunctival hematomas. Ecchymosis and subconjunctival
hemorrhage are the usual findings. Crepitus or movement
may be palpated when external pressure is deeply applied
directly over the canthal ligament. A “bimanual examination”
of the medial orbital rim is helpful if the diagnosis is uncertain:
it is performed by placing a palpating finger deeply over one
medial canthal ligament and placing a clamp inside the nose
with its tip directly opposite the pad of the finger. The frontal
process of the maxilla may then, if fractured, be moved
between the index finger and the clamp, indicating instability
and confirming both the diagnosis and the need for an open
reduction. The clamp, if placed under the nasal bones too A
anteriorly (and not at the medial orbital rim to medial canthal
ligament attachment), erroneously identifies a nasal fracture
as canthal instability.
Radiographs
CT scans are essential to document the injury. The diagnosis
of a nasoethmoidal orbital fracture on radiographs requires at
a minimum four fractures that isolate the frontal process of
the maxilla from adjacent bones. These include (1) fractures
of the nose, (2) fractures of the junction of the frontal process
of the maxilla with the frontal bone, (3) fractures of the medial
orbit (ethmoidal area), and (4) fractures of the inferior orbital
rim extending to involve the pyriform aperture and orbital
floor. These fracture lines, therefore, define the “central frag-
ment” of bone bearing the medial canthal ligament as “free”
and, depending on periosteal integrity, may displace the
medial orbital rim. B
Fig. 3.16 (A,B) Lateral image of 3D craniofacial computer tomography scan of a

Classification of nasoethmoidal orbital fractures type 1 nasoethmoidal orbital fracture injury pattern pre- and post-open reduction
and internal fixation of midface fractures using the inferior alone approach.
Nasoethmoidal fractures are classified according to a pattern
established by Markowitz and Manson82 types I–III, according
to the bimanual examination and the CT scan.83
Type I is an incomplete fracture, mostly unilateral but bone reduction. Therefore, canthal ligament reattachment is
occasionally bilateral, which is displaced only inferiorly at the required as a separate step, accomplished with its own set of
infraorbital rim and piriform margin. Inferior alone approaches transnasal wires for each of the bone of the medial orbital rim
(gingival buccal sulcus +/− inferior orbit) are necessary and then the canthus. In general, the bony reduction of the
(Fig. 3.16). intercanthal distance should be 5–7 mm per side less than the
Type II nasoethmoidal orbital fractures are comminuted desired soft tissue distance (Fig. 3.18).
nasoethmoidal fractures with the fractures remaining outside
the area of the canthal ligament insertion. The central frag-
ment may be managed as a sizable bony fragment and
Treatment of nasoethmoidal orbital fractures
united to the canthal ligament-bearing fragment of the other Treatment consists of a thorough exposure of the nasal orbital
side with a transnasal wire reduction. The remainder of the region by, at most, three incisions: a coronal (or an appropriate
pieces of the nasoethmoidal orbital skeleton are reduced and laceration or local upper nasal incision (midline or transverse
then stabilized by junctional plate and screw fixation to the radix), a lower eyelid incision, and a gingival buccal sulcus
frontal bone, the infraorbital rim, and the Le Fort I level of incision.84 Nasal and forehead lacerations are common but
the maxilla. Type II fractures may be unilateral or bilateral should not be extended, as the scar deformity from extension
(Fig. 3.17). is frequently worse than making a separate incision.
Type III nasoethmoidal orbital fractures either have avul- The primary principle underlying open treatment of naso-
sion of the canthal ligament (uncommon) or the fractures ethmoidal orbital fractures involves the preservation of all
extend underneath the canthal ligament insertion. The frac- fragments of bone and their accurate reassembly. Despite
ture fragments are small enough that a reduction would even anatomic reassembly of the nasal bone fragments,
require that the canthus be detached to accomplish the primary bone grafting is usually necessary to improve the
A B C
Fig. 3.17 (A) Frontal 3D craniofacial computer tomography scan of a type II nasoethmoidal orbital fracture injury pattern in a 23-year-old female who sustained craniofacial
injuries following being struck by a motor vehicle as a pedestrian. (B) Pre- and post-open reduction and internal fixation of midface fractures. (C) Postoperative frontal
photograph view of patient approximately 12 months from surgery.
nasal height and to provide smooth dorsal contour. The bone laterally and brought clearly into the surgeon’s view laterally
onto which the canthal ligament is attached (if comminuted) and next to the nasal bones, where its superficial position
may require replacement with a bone graft. allows turning of the fragment; in this position, drilling and
wire pass through the “central” fragment. Nasal bone frag-
ments can be temporarily dislocated or removed to permit
The importance of the “central fragment” in better exposure of the medial orbital rim segments. Removing
nasoethmoidal orbital fractures the nasal bones is especially helpful in passing a transnasal
First, identify and classify what is happening to the bone of wire from the posterior and superior aspect of one “central”
the medial orbital rim which bears the medial canthal liga- fragment (medial orbital rim canthal bearing bone fragment)
ment as there is a direct relationship between surgical tech- to the other. The medial orbital rims are then replaced in
niques, simplicity of surgery, and outcome of the treatment. anatomic position and then linked with fine wires to adjacent
The most essential feature of a nasoethmoidal reduction is nasal and frontal bone fragments. Following the placement of
the transnasal reduction of the medial orbital rims by a wire two transnasal wires, one should pass one extra wire per side,
placed posterior and superior through the bone of the canthal for soft tissue reapproximation to bone. Junctional plate and
ligament insertion. The medial orbital rim with its attached screw fixation at the periphery of these reassembled frag-
canthal-bearing segment is first dislocated anteriorly and ments is employed after the initial interfragment wiring is
A B C
Fig. 3.18 (A) Frontal 3D craniofacial computer tomography scan of type III nasoethmoidal orbital and a Le Fort II type injury pattern in a 33-year-old who sustained
craniofacial injuries following being thrown off a motorcycle without a helmet. (B) Pre- and post-open reduction and internal fixation of midface and mandibular fractures.
(C) Postoperative frontal photograph view of patient 6 months from surgery.
tightened. It should be emphasized that the transnasal reduc- zygomatic bone has a quadrilateral shape with several pro-
tion wires must be passed posterior and superior to the lacri- cesses that extend to reach the frontal bone, the maxilla, the
mal fossa in order to provide the proper direction of draping temporal bone (zygomatic arch), and orbital processes.
force necessary to create the preinjury bony position and
shape of the canthal ligaments. The transnasal reduction is not Physical diagnosis and surgical pathology of
a “transnasal canthopexy”, as it does not involve the canthal
ligament per se. It is a reduction only of the “central bony
zygoma fractures
fragment” of the nasoethmoidal orbital fracture. Although the zygoma is a sturdy bone, it is frequently injured
because of its prominent location. Moderately severe blows
Canthal reattachment are absorbed at the malar eminence and transferred to its
If the canthal ligament requires reattachment (the canthal buttresses. Severe blows may cause separation of the zygo-
tendon is rarely stripped from bone), the canthal tendon85 may matic body at its articulating surfaces; these high-energy
be grasped by one or two passes of 2-0 nonabsorbable suture injuries dramatically increase the width of the midface. As the
adjacent to the medial commissure of the eyelids through a zygoma is disrupted, it is usually displaced in a downward,
2–3 mm horizontal incision in the skin directly over the medial, and posterior direction, whereas high-energy injuries
canthal ligament.86 The 2-0 nonabsorbable suture is then displace the zygoma in a posterior and lateral direction
passed into the internal aspect of the coronal incision, and the because of disruption of the ligaments in addition to the
suture is then connected to a separate set of #28 transnasal fractures. The direction of displacement varies with the direc-
wires per side that have been passed transnasally superiorly tion of the injuring force and with the pull of the muscles,
and posteriorly to the expected position of the medial canthus. such as that of the masseter.
The transnasal canthal ligament wires are tightened only as Periorbital and subconjunctival hematomas are the
the last step after the bone reduction, and after medial orbital most accurate physical signs of the orbital fracture always
and nasal bone grafting are completed. Each set of canthal associated with a complete zygoma fracture. Numbness of
wires is tightened gently after a manual reduction of the the infraorbital nerve is a common symptom as well. The
canthus to the bone with forceps is performed, to reduce stress infraorbital nerve runs in a groove in the posterior portion
on the ligament by the canthal sutures. Each canthal reduction of the orbit and enters a canal in the anterior third of the
wire pair is then separately twisted over a screw in the frontal orbit, behind the infraorbital rim.90 It may be crushed in a rim
bone. fracture with medial displacement, as the fracture occurs in
the weak area of bone penetrated by the infraorbital foramen.
Direct force to the lateral face may result in isolated frac-
Lacrimal system injury tures of the temporal extension of the zygoma (zygomatic
Interruption of the continuity of the lacrimal apparatus arch) and the zygomatic process of the temporal bone in the
demands specific action. Most lacrimal system obstruction absence of a fracture of the remainder of the zygoma and its
occurs from bony malposition or damage to the lacrimal articulations.
sac or duct.87 The most effective treatment involves initial Medial displacement of an isolated arch fracture is usually
satisfactory precise repositioning of fracture segments to observed and may impinge against the temporalis muscle and
the bony part of the lacrimal system. If transection of the coronoid process of the mandible resulting in restricted man-
soft tissue portion of the canalicular lacrimal system has dibular motion. Fractures in the posterior portion of the
occurred, it should be repaired over fine silicone tubes with zygomatic arch may enter the glenoid fossa and produce
magnification.88 stiffness or a change in occlusion because of the swelling in
the joint or muscles. In high-energy injuries or gunshots, frag-
Complications of nasoethmoidal orbital fractures ments of bone can be driven through the temporal muscle and
The early diagnosis and adequate treatment of nasoethmoidal make contact with the coronoid process and precipitate the
orbital fractures achieves optimal aesthetic results with the formation of a fibrous or bony ankylosis, necessitating exci-
lowest number of late complications. Depending on the sion of the bone of the coronoid process and scar tissue as a
quality of initial treatment and the results of healing, further secondary procedure.
reconstructive surgery may be required in some cases. Late Fracture dislocation of the zygomatic body with sufficient
complications, such as frontal sinus obstruction, occur in less displacement to impinge on the coronoid process requires
than 5% of isolated nasoethmoidal orbital fractures where considerable backward dislocation of the malar eminence.
damage to the anterior frontal sinus walls has not occurred. Level discrepancies or step deformities at the infraorbital
Deformities and nasal functional impairment are late compli- margin can usually be palpated in the presence of inferior
cations, which can be minimized by early diagnosis and orbital rim displacement. The lateral and superior walls of the
proper early open reduction. The presence of a nasoethmoidal maxillary sinuses are involved in fractures of the zygoma, and
orbital fracture may be obscured by the swelling and escape torn maxillary sinus lining results in bleeding within the sinus
detection. After several weeks, nasal deformity and enoph- with unilateral epistaxis. The lateral canthal attachment is
thalmos are evident.89 directed towards Whitnall’s tubercle, located approximately
10 mm below the zygomaticofrontal suture, which is a shallow
eminence on the internal aspect of the frontal process of the
Fractures of the zygoma zygoma. When the zygoma is displaced inferiorly, the lateral
The zygoma is a major buttress of the midfacial skeleton. It attachment of the eyelids via the lateral canthal ligament
forms the malar eminence, giving prominence to the cheek, is also displaced inferiorly giving rise to an antimongoloid
and forms the lateral and inferior portions of the orbit. The slant of the palpebral fissure. The globe follows the inferior
displacement of the zygoma with a lower (inferior and lateral) entry of elevators into the orbit as the maxilla and zygoma are
position after fracture dislocation. Double vision is usually dissected. The infraorbital nerve is protected by the dissection
transient in uncomplicated fractures of the zygoma, which and is immediately seen after detaching the levator anguli
always involve the orbital floor. Diplopia may persist when oris muscle. The zygoma may often be reduced by placing the
the fracture is more extensive, especially if a fracture com- tip of an elevator in the lateral aspect of the maxillary sinus
minutes the inferior orbital floor. Diplopia may result from directly behind the malar eminence and levering the body of
muscle contusion, incarceration of perimuscular soft tissue or the zygoma first outward and then forward. Alternately, a
actual muscle incarceration (rare in zygoma fractures), or Carrol–Girard screw (Walter Lorenz Co., Jacksonville, FL) can
simply drooping of the muscular sling. be placed in the malar eminence through a percutaneous inci-
sion and manipulated. In gingival buccal sulcus approaches,
Anterior approaches after the reduction maneuver has been completed, zygomatic
stability depends upon an incomplete fracture at the zygo-
The anterior approach may be partial or complete and poten- maticofrontal suture. The floor of the orbit can be inspected
tially involves up to three incisions: (1) access to the zygomati- with an endoscope through the maxillary sinus. It is also
cofrontal suture; (2) access to the inferior orbital rim; and (3) possible to tell from a preoperative CT the degree of orbital
access to the zygomaticomaxillary buttress, anterior maxilla, floor comminution. Fractures with orbital floor comminution
and malar prominence. and significant displacement require an additional inferior
Twenty-five percent of complete fractures of the zygoma orbital approach.
are undisplaced or have such subtle displacement that they
do not benefit from an open reduction. Thirty-five percent of Fractures with zygomaticofrontal (Z-F) suture diastasis
fracture dislocations of the zygoma result in greensticked
fractures at the zygomaticofrontal suture, and these may be If the Z-F suture demonstrates diastasis, direct exposure of the
reduced with a gingivobuccal sulcus incision alone without suture permits stabilization through the lateral portion of an
exposure of the suture. Forty percent of fracture dislocations upper blepharoplasty incision (<1 cm) which is made directly
of the zygoma result in complete separation at the zygomati- over the Z-F suture 8–10 mm above the lateral canthus. Pal-
cofrontal suture, which may be palpable through the skin over pating the frontal process of the zygoma between the thumb
the upper lateral margin of the orbit. The latter fractures and index finger, the junction of the zygoma with the frontal
require exposure through an incision directly over the suture, bone can be marked precisely in eyelid skin. The incision
i.e., the lateral limb alone of an upper lid blepharoplasty. should be short and never progress laterally out of the eyelid
Orbital rim and orbital floor exposures may be necessary skin, as it will scar noticeably. Alternately, the Z-F suture may
based on the fracture patterns visualized on preoperative CT be approached through a laceration or by superior dissection
scans.91 from a subciliary or conjunctival lower lid incision by canthal
detachment. The inferior portion of the orbit may be
approached through a midtarsal, subciliary, or conjunctival
“Minimalist” approaches for fractures without incision. The conjunctival fornix incision produces the least
zygomaticofrontal suture diastasis cutaneous scarring, but the exposure may be restricted by fat
In this approach, the gingivobuccal sulcus is opened and the prolapse. The treatment of a zygoma fracture has recently
anterior face of the maxilla and zygoma are degloved. The become quite specific and directed only at areas that require
infraorbital rim and infraorbital nerve are visualized from an open reduction for confirmation of alignment or for fixation
inferior direction. Palpation with a finger on the rim avoids (Fig. 3.19).
A B C
Fig. 3.19 (A,B) Frontal 3D craniofacial computer tomography scan of a right zygomaticomaxillary fracture in a 22-year-old male who sustained craniofacial injuries
following a sports-related injury, pre- and post-open reduction and internal fixation of the right zygomaticomaxillary complex and orbital floor fractures. (C) Postoperative
frontal photograph view of patient 3 months following surgery.
Coronal incisions (posterior approach) include medial displaced isolated arch fractures and simple
large segment or single piece zygoma fractures in which the
Fractures with extreme posterior displacement and those with displacement is medial and posterior, without comminution
lateral displacement of the zygomatic arch often benefit from at the buttresses, and where the fracture at the Z-F suture is
the addition of a coronal incision. These represent 5% of iso- incomplete and nondisplaced. An elevator placed beneath the
lated zygoma fractures. The coronal incision allows exposure malar eminence allows the zygoma to be “popped” back into
of the entire zygomatic arch, roof of the glenoid fossa, the Z-F position. Palpation is the guide to reduction, such as the
suture, and the lateral orbital wall, which is the area that inferior orbital rim. The stability of closed reduction depends
confirms proper alignment and medial position of the zygo- on the integrity of periosteal attachments and principally
matic arch (Fig. 3.20). “greensticking” at the Z-F suture. The force of contraction
of the masseter muscle may act to create postoperative
displacement.92
Treatment of fractures of the zygoma Displacement at the Z-F suture93 comminution of the infe-
rior orbital rim or Z-M buttress and lateral displacement of
Closed reduction
the zygomatic arch and body are characteristics that were
Remotely, closed reduction techniques were employed for found to predict a poor result from closed reduction.
most zygomatic fractures. In practice, many fractures can be
treated reasonably with closed reduction, and especially
where cost is an issue, this treatment would have to be con- Buttress articulations and alignment for complete
sidered. Those fractures still amenable to closed reduction open reduction
Six points of alignment with adjacent bone may be confirmed
with complete craniofacial exposures: Z-F suture, infraorbital
rim, zygomaticomaxillary buttress, greater wing of the sphe-
noid, orbital floor, and zygomatic arch. The orbital floor may
require reconstruction with bone or artificial materials such
as Medpor or titanium mesh.
Methods of reduction
The first step that should be considered in complete open
reductions is passing an osteotome through the Z-F suture
after exposing it, mobilizing and thoroughly completing all
fractures. This step is the most neglected step in open reduc-
tion internal fixation (ORIF) of zygomas and routinely simpli-
fies the rest of the reduction.
Reduction through the maxillary sinus

Next, the body of the zygoma is mobilized by displacing it
laterally, completing fractures and achieving free displace-
A
ment and mobility. A Carroll–Girard screw (Walter Lorenzo,
Jacksonville, FL) may be utilized percutaneously or from an
intraoral approach providing leverage to manipulate the
zygoma. This approach is used by persons who do not com-
plete the fractures.
Temporal approach
A temporal approach for the reduction of zygomatic fractures
was described by Gilles. An elevator is slipped along the
muscle behind the zygomatic arch or under the malar emi-
nence, depending on the areas of reduction required. A small,
2-cm incision placed vertically within the temporal hair heals
with an inconspicuous scar. The elevator must be placed deep
to the deep temporal fascia, visualizing the temporalis muscle.
The bone may be palpated with one hand to document the
accuracy of reduction, while the other hand guides the eleva-
tor into position and corrects the displacement by force
B application. Gentle elevation often “clicks” the arch into posi-
tion. Moving the elevator back and forth with repeated eleva-
Fig. 3.20 (A) Frontal 3D craniofacial computer tomography scan of a high energy
tion movements may disrupt the periosteum holding arch
orbito-zygomaticomaxillary complex injury in a 33-year-old who sustained
craniofacial injuries following a high speed motor vehicle collision. (B) Pre- and fragments together, and an open reduction is then required.
post-open reduction and internal fixation of the left orbital and zygomaticomaxillary The approach can also be used for reduction of the zygomatic
complex through anterior and posterior (coronal) approaches. body.
Fixation required to achieve stability Plate and screw fixation then unites the segments. In fractures
Several individuals have examined zygomatic stability fol- treated late, the masseter muscle may require division or
lowing open reduction. Rinehart and Marsh94 studied cadaver mobilization from the inferior surface of the malar eminence
heads and used 1, 2, or 3 miniplates and accessed stability of and arch in order to allow the bone to be repositioned supe-
non-comminuted zygoma fractures submitted to static and riorly. The masseter muscle contracts in the case of the malre-
oscillating loads to simulate the effect of the masticatory duced fracture and may block reduction. Fractures treated
apparatus on postoperative displacement. Neither single with delay are more safely treated with osteotomy than force-
miniplate nor triple wire fixation was enough to stabilize the ful mobilization by blunt forces, which may result in new
zygoma against simulated masseter forces; however, 3 mini- undesirable fracture lines radiating into the apex of the orbit,
plates were sufficient, which stabilized the Z-F, Z-M, and with cranial nerve injury (blindness).
infraorbital rim areas.
Del Santo and Ellis felt that Rinehart and Marsh overesti- Complications of zygomatic fractures
mated the postoperative forces that could be generated by the Bleeding and maxillary sinusitis
masseter muscle and suggested that stability with less than 3
plates would be possible, based upon actual human measure- Bleeding into the maxillary sinus is usually of short duration.
ments of bite forces after zygomatic fracture treatment.92 It is always prudent to irrigate blood clots from the antrum
and to remove bone fragments, which drop from the orbital
floor and sequester. Rarely, the ostea of the maxillary sinus
Surgical techniques for fixation following reduction
will be occluded by the fractures and require endoscopic sinus
The authors’ approach varies depending on the complexity of surgery. In those patients with pre-existing sinus disease,
zygoma fracture pattern and the extent of involvement of the acute exacerbation may be a complicating factor.
orbital floor, which can be assessed using preoperative CT
scan.95 Late complications
If there is minimal involvement of the orbital floor and
no diastasis at the Z- suture, the zygoma is approached Late complications of zygomatic fractures include nonunion,
intraorally at the zygomaticomaxillary buttress. It is reduced malunion, double vision, infraorbital nerve anesthesia or
using one of the techniques described above, and one plate hypesthesia, and chronic maxillary sinusitis. Scarring may
fixation technique is sufficient using an L-shaped plate at result from laceration or malpositioned incisions. Generally,
the zygomaticomaxillary buttress. If there is diastasis at the ectropion and scleral show are mild and resolve spontane-
Z-F fracture line, then a short (1 cm) upper blepharoplasty ously. Gross downward dislocation of the zygoma results in
incision exposes the Z-F fracture line, a portion of the lateral diplopia and orbital dystopia. Usually, more than 5 mm of
orbital wall, and the zygomaticosphenoid suture line. Here, inferior globe dystopia is required to produce diplopia. Treat-
the zygoma has its broadest articulation with the greater wing ment97 involves zygomatic mobilization by osteotomy with
of the sphenoid, and therefore direct visualization may be bone grafting to augment the malar eminence when malar
helpful in confirming anatomical reduction of the zygoma. projection is deficient. The position of the eye must be restored
Since one can only look through one incision at a time, the with intraorbital bone grafts or alloplastic material. Infection
use of temporary interfragment wire positioning at the Z-F is not common, and usually responds to antibiotics and sinus
fracture line while holding the zygoma into correct anatomi- or lacrimal drainage.
cal reduction at the zygomatic–sphenoid fracture line, inferior Impacted fractures of the zygomatic arch which abut the
orbital rim, and zygomaticomaxillary buttress allows relative coronoid process may result in ankylosis. A gunshot wound
positioning of the zygoma fracture. The zygomaticomaxillary is especially prone to this problem. If the zygomatic arch
buttress followed by the Z-F fracture line may then be plated cannot be repositioned, coronoidectomy through an intraoral
sequentially. route usually frees the mandible from the ankylosis and
In the authors’ experience, the judgment of whether to permits normal function. It is important that the patient vigor-
open the lower lid rests upon whether (1) there is a large ously exercise to preserve and improve the range of motion
orbital floor fracture component of the zygoma fracture that obtained, which may take 6 months.
requires replacement, or (2) there remains a significant step-
off at a comminuted inferior orbital rim following fracture Orbital complications
reduction. A lower eyelid transconjunctival incision without Orbital complications consist of diplopia, visual loss, globe
lateral canthoplasty allows reduction and fixation with a low injury, enophthalmos or exophthalmos, and lid position
profile inferior orbital rim plate +/− an orbital floor plate. abnormalities.
Periosteal resuspension of the lower eyelid and cheek is criti-
cally important should eyelid exposure be utilized.96 Numbness
Persistent anesthesia or hypesthesia in the distribution of the
Delayed treatment of fractures of the zygoma infraorbital nerve usually lasts only a short time. If total
Repositioning after two weeks frequently requires osteotomy anesthesia exists for over six months, it is likely that the nerve
of the fracture sites to mobilize the zygoma for reduction. is severely damaged or perhaps transected. If the nerve is
After the bone has been mobilized, an inspection of each impinged by bone fragments, especially in a medially and
fracture site should be conducted to remove any area of posteriorly impacted zygoma fracture, reduction or decom-
fibrous ankylosis or any proliferative bone, which was not pression of the infraorbital canal and neurolysis are sometimes
present originally, as its presence may prevent proper align- indicated. Bone spurs or constricting portions of the canal
ment. Rarely, resorption has occurred requiring bone grafting. should be removed so that the nerve has an adequate
opportunity for regeneration and relief of pressure. The nerve

must be explored throughout the floor of the orbit so that it
is free from any compression by bone fragments, scar tissue,
or callus. The functional results of this surgery in terms of
pain relief remain unclear.
Anesthesia can be annoying for patients, especially
immediately after the injury. Patients generally partially
accommodate to the neurological deficit. Some spontaneous Frontal
attachment
reinnervation may occur from adjacent facial regions as well
as regrowth of axons through the infraorbital nerve. Usually Cranial
base Orbital
some vague sensation is then present. buttress
Nasoethmoid
Oral–antral fistula region
An oral–antral fistula requires debridement of bone or mucosa,
confirmation of maxillary sinus drainage into the nose, and
closure with a transposition mucosal flap for cover. A 2-layer Nasofrontal
closure is required. A bone graft may be placed in between buttress
the layers of soft tissue. The buccal fat pad can be mobilized
Zygomatic
and sewn into the defect prior to the mucosa being closed over
buttress
it. Rarely, a distant flap is required for difficult persistent
Mandibular
fistulae. buttress
Plate complications
Complications include screw loosening or extrusion, plate Pterygomaxillary
exposure requiring removal, and tooth root penetration by buttress
screws. Prominent plates over the zygomatic arch are directly Fig. 3.21 The vertical buttresses of the midfacial skeleton. Anteriorly, the
due to associated soft tissue atrophy (temporalis) and to nasofrontal buttress skirts the piriform aperture inferiorly and composes the bone of
malreduction of the zygomatic arch laterally. Probably 10% of the medial orbital rim superiorly to reach the frontal bone at its internal angular
plates placed at the LeFort I level need to be removed for process. Laterally the zygomaticomaxillary buttress extends from the zygomatic
process of the frontal bone through the lateral aspect of the zygoma to reach the
exposure, non-healing wound, or cold sensitivity. Plate maxillary alveolus. A component of the zygomaticomaxillary buttress extends
prominence at the Z-F suture are due to inadequate soft tissue laterally through the zygomatic arch to reach the temporal bone. Posteriorly, the
closure and poor plate selection.98 pterygomaxillary buttress is seen. It extends from the posterior portion of the maxilla
and the pterygoid fossa to reach the cranial base structures. The mandibular
buttress forms a strong structural support for the lower midface in fracture
Midface buttresses treatment. This support for maxillary fracture reduction must conceptually be
achieved by placement of both jaws in intermaxillary fixation. The other “transverse”
The midface is a system of sinus cavities where certain thicker maxillary buttresses include the palate, the superior orbital rims, and the inferior
areas (or buttresses) provide considerable structural support. orbital rims. The superior orbital rims and the lower sections of the frontal sinus are
The important midface supporting skeleton consists of hori- also known in the supraorbital regions as the frontal bar and are technically frontal
zontal and vertical structural supports connected by thin bone and not part of the maxilla. (From Manson PN, Hoopes JE, Su CT. Structural
plates of bone. In fracture treatment, the thicker pillars are pillars of the facial skeleton: an approach to the management of Le Fort fractures.
anatomically reconstructed and repositioned to re-establish Plast Reconstr Surg. 1980;66:54.)
the preinjury facial bone architecture. The vertical supports
consist of the nasal septum in the midline and the nasomaxil-
lary, zygomaticomaxillary, and pterygoid buttresses (Fig. gestive of fractures involving the maxillary bone. The swell-
3.21). The nasomaxillary buttress extends along the pyriform ing is usually moderate to severe indicating the severity of the
aperture through the frontal process of the maxilla superiorly fracture. Malocclusion with an anterior open bite and rotation
to the internal angular process of the frontal bone. The zygo- of the maxilla suggest a fracture of the maxilla. The maxillary
maticomaxillary buttress extends through the bony mass of segment is frequently displaced downward and posteriorly,
the body of the zygoma and through the frontal process of the resulting in a class III malocclusion and premature occlusion
zygoma to the external angular process of the frontal bone. in the posterior dentition with an anterior open bite. On inter-
Posteriorly, the pterygoid plates provide posterior stabiliza- nal examination, there may be tearing of the soft tissues in the
tion of the vertical height of the midface to the skull base.99 labial vestibule of the lip or the palate, findings that indicate
The horizontal buttresses of the midface consist of the inferior the possibility of an alveolar or palate fracture. Hematomas
orbital rims and the associated orbital floor, the zygomatic may be present in the buccal or palatal mucosa. The face, after
arch and the palate at the level of the maxillary alveolus.100 several days, may have an elongated, retruded appearance,
the so-called “donkey-like faces” suggestive of a craniofacial
disjunction. An increase in midfacial length is seen.
Inspection Palpation
Epistaxis, bilateral ecchymosis (periorbital, subconjunctival, The bone should be palpated with the tips of the fingers both
scleral), facial edema, and subcutaneous hematoma are sug- externally through the skin and internally intraorally. Bilateral
Le Fort classification of facial fractures 67
palpation may reveal step deformities of the zygomaticomax- these teeth. The position of the teeth may be maintained by
illary suture, indicating fractures of the inferior orbital rims. ligating the teeth in the fractured segment to adjacent teeth
These findings suggest a pyramidal fracture of the maxilla with the use of an arch bar and interdental wiring technique.
and confirm the zygomatic component of a more complicated Fixation of the alveolar segment should be maintained for at
injury, such as a Le Fort III fracture. Intraoral palpation may least six to twelve weeks, until clinical immobility has been
reveal fractures of the anterior portion of the maxilla or frac- achieved.105
tured segments of the alveolar bone.
Digital manipulation Le Fort classification of facial fractures

Manipulation of the maxilla may confirm movement in the Le Fort (1901) completed experiments that determined the
entire middle third of the face, including the bridge of the areas of structural weakness of the maxilla which he desig-
nose. This movement is appreciated by holding the head nated “lines of weakness” where fractures occurred. Between
securely with one hand and moving the maxilla with the other the lines of weakness were “areas of strength”. This classifica-
hand (see Fig. 3.5). Crepitation may be heard when the maxilla tion led to the Le Fort classification of maxillary fractures,
is manipulated in loose fractures. The manipulation test for which identifies the patterns of midfacial fractures (Fig.
maxillary mobility is not entirely diagnostic because impacted 3.22).106 It should be emphasized that the usual Le Fort fracture
or greenstick fractures may exhibit no movement but still consists of combinations of these patterns in that pure bilateral
possess bone displacement and malocclusion. Le Fort I, Le Fort II, or Le Fort III fractures are less common
than combination patterns.107 The level of fracture is frequently
Malocclusion of the teeth higher on one side than the other, and usually the fracture is
If the mandible is intact, malocclusion of the teeth is highly more comminuted and extensive on the side of the direct
suggestive of a maxillary fracture. It is possible, however, that injury.
malocclusion relates to a preinjury condition. A thorough
study of the patient’s dentition and dental models and refer- Goals of Le Fort fracture treatment
ence to previous dental records and pictures are helpful.
Goals in the treatment of Le Fort fractures include:
Cerebral spinal rhinorrhea or otorrhea 1. Restoration of midfacial height and projection.
2. Achieve proper occlusion.
Cerebral spinal fluid may leak from the anterior or middle
3. Restore the integrity of the nose and orbit.
cranial fossa in high Le Fort fractures and is then apparent in
the nose or ear canal. A fluid leak signifies the presence of a The structural supports between the areas of the buttresses
dural fistula extending from the intracranial subarachnoid and maxillary alveolus are restored to provide proper soft
space through the skull and into the nose, pharynx or ear.101 tissue contour.
Frequently the drainage is obscured by bloody secretions in
the immediate postinjury period.102,103 Transverse (Guerin) fractures or Le Fort I
level fractures
Radiological examination
Fractures which traverse the maxilla horizontally above the
Maxillary fractures are easily demonstrated in craniofacial CT level of the apices of the maxillary teeth section the entire
scans, with the exception that fracture lines in minimally alveolar process of the maxilla, vault of the palate and the
displaced fractures are more difficult to image. The presence inferior ends of the pterygoid processes in a single block from
of bilateral maxillary sinus fluid should always suggest the the upper craniofacial skeleton. This type of injury is known
possibility of a maxillary fracture. as the transverse, Le Fort I, or Guerin fracture. This horizontal
fracture extends transversely across the base of the maxillary
Treatment of maxillary fractures sinuses and is usually bilateral. The fracture level varies from
Treatment of maxillary fractures is initially oriented toward just beneath the orbital rim of the zygoma to just above the
the establishment of an airway, control of hemorrhage, closure floor of the maxillary sinus and the inferior margin of the
of soft tissue lacerations, and placement of the patient in pyriform aperture (Fig. 3.23).
intermaxillary fixation. The latter manually reduces the frac-
ture, reduces movement and bleeding, and is the single most Pyramidal fractures or Le Fort II
important step in the treatment of a maxillary fracture. Post- level fractures
operative intermaxillary fixation may not be necessary after
open reduction of large segment maxillary fractures but is Blows to the central maxilla, especially those involving frontal
increasingly useful for several weeks after comminuted frac- impact, frequently result in fractures with a pyramidally
ture treatment and in panfacial fractures or palatal fractures, shaped central maxillary segment. This is a Le Fort II “central
where rigid stability is difficult to obtain.104 maxillary segment”, and the fracture begins above the level
of the apices of the maxillary teeth laterally and posteriorly in
the zygomaticomaxillary buttress and extends through the
Alveolar fractures pterygoid plates in the same fashion as the Le Fort I fracture.
Simple fractures of the portions of the maxilla involving the Fracture lines travel medially and superiorly to pass through
alveolar process and the teeth can usually be digitally reposi- the medial portion of the inferior orbital rim and extend
tioned and held in reduction while an arch bar is applied to across the nose to separate a pyramidally shaped central
A B
Fig. 3.22 The Le Fort classification of midfacial fractures. (A) The Le Fort I (horizontal or transverse) fracture of
the maxilla, also known as Guerin fracture. (B) The Le Fort II (or pyramidal) fracture of the maxilla. In this
fracture, the central maxilla is separated from the zygomatic areas. The fracture line may cross the nose through
its cartilages or through the middle nasal bone area, or it may separate the nasal bones from the frontal bone
through the junction of the nose and frontal sinus. (C) The Le Fort III fracture (or craniofacial disjunction). In this
fracture, the entire facial bone mass is separated from the frontal bone by fracture lines traversing the zygoma
nasoethmoid, and nasofrontal bone junctions. (From Kazanjian VH, Converse J. Surgical Treatment of Facial
Injuries, 3rd edn. Baltimore MD: Williams & Wilkins; 1974.) C
maxillary segment from the superior cranial and midfacial eyes” and with a subtle malocclusion. The Le Fort III segment
structures. The fracture line centrally may traverse the nose may or may not be separated through the nasal structures. In
high through the upper nasal bones or low through the nasal these fractures the entire midfacial skeleton is incompletely
cartilages to separate superior cranial from midfacial struc- detached from the base of the skull (a “greensticked” fracture)
tures (Fig. 3.24). (Fig. 3.25).108 Treatment may be successful with arch bars and
elastic traction without open reduction.
Craniofacial dysjunction or Le Fort
III fractures Surgical technique
Craniofacial dysjunction may occur when the fracture extends
through the zygomaticofrontal suture and the nasal frontal Le Fort I level fractures
suture and across the floor of the orbits to effectively separate
all midfacial structures from the cranium. In these fractures, In fractures of the Le Fort I type, placing the patient in inter-
the maxilla is usually separated from the zygoma, but occa- maxillary fixation may occasionally be all that is necessary in
sionally (5% of Le Fort III fractures) the entire midface may the case of a minimally mobile and undisplaced fracture. In
be a large single fragment, which is often only minimally most cases, however, the Le Fort I level should be opened
displaced and immobile. These fractures present with “black through a bilateral gingival buccal sulcus incision and the
Fig. 3.23 Frontal 3D craniofacial computer

tomography scan of a Le Fort I type injury
A B pre- and post-open reduction and internal
fixation.
Surgical technique 69
cannot be explained by other sources, especially if air-fluid

levels are present. Any foul odor in the nose or on the breath
necessitates inspection, cleaning and return to the operating
room for drainage and irrigation, and a thorough nasal and
oral examination.
Complications of maxillary fractures

Airway
In almost all cases of extensive fractures, the airway is partially
compromised by posterior displacement of the fracture frag-
ments and by edema and swelling of the soft tissues in the
nose, mouth, throat, and floor of the mouth. In some patients,
a nasopharyngeal airway may assist in establishing a route
for ventilation. In other patients, intubation or tracheostomy
may be indicated.
Bleeding
Fig. 3.24 Frontal 3D craniofacial computer tomography scan of a Le Fort II type
injury pre- and post-open reduction and internal fixation. Hemorrhage may be managed by carefully identifying and
ligating vessels in cutaneous lacerations, and by tamponade
fractures reduced and stabilized with plate and screw fixation

at the bilateral nasomaxillary and zygomaticomaxillary
buttresses. The primary consideration in Le Fort I fracture
treatment is to re-establish normal dental occlusion. Proper
lower midfacial height and projection are achieved by open
reduction.
Le Fort II level fractures

In the case of a simple Le Fort II level fracture, the patient is
first placed in intermaxillary fixation. The fracture should be
opened at the Le Fort I level through a gingival buccal sulcus
incision and through both lower eyelids to provide reduction
and fixation at the orbit, zygomaticomaxillary and nasomaxil-
lary buttresses, and at the inferior orbital rims. The need for
opening fractures crossing the nose must be assessed by the
CT scan and the displacement at the nasofrontal junction.
Lower nasal fractures often do not need this exposure. A
Le Fort III fractures

Open reduction of Le Fort III fractures generally involves
combining procedures at the Le Fort I, Le Fort II, and zygo-
matic levels simultaneously for open reduction and fixation
in a single operation.
Postoperative care of maxillary fractures

The postoperative management of fractures of the maxilla
consists of three times daily dental and oral hygiene, lip
lubrication, mouthwashes, skin care (abrasion and laceration
cleansing), and lubrication with soaps and antibiotic oint-
ments. Provision of adequate nutrition may be accomplished
by a liquid or pureed diet, nasogastric tube, or percutaneous
gastrostomy. The liquid or pureed diet is generally possible
with intermaxillary fixation (IMF) and a soft diet after the IMF
is released. B
Cleansing and aspiration of both the nose and mouth is
very important. The presence of a fever in patients with facial Fig. 3.25 Frontal 3D craniofacial computer tomography scan of a Le Fort III type
fractures should always prompt a sinus evaluation if the fever injury pre- and post-open reduction and internal fixation.
in closed midface injuries with anterior–posterior nasopha- Malunion

ryngeal packing, manual reduction of the displaced maxilla In multiple (complex) panfacial fractures, malunion may
and placing the teeth in intermaxillary fixation. Angiographic result from inadequate diagnosis, inadequate reduction, or
embolization and the combination of external carotid and inadequate fixation. The period of intermaxillary fixation and
superficial temporal artery ligation are rarely necessary. observation may need to be longer when the injury is more
comminuted.
Infection
Maxillary fracture wounds are less complicated by infection Malocclusion
than are mandibular fractures. However, they are contami- If malocclusion is detected, it may respond to elastic traction.
nated at the time of the injury by entry into adjacent sinuses, Once partial healing has occurred, attempts to re-establish
fractures of the teeth, and open intraoral wounds. Fractures occlusion with elastics may simply extrude or loosen the
passing through the sinuses do not usually result in infection teeth. Revision of the reduction after removal of the internal
unless there has been pre-existing nasal or sinus disease, or in fixation devices or a new osteotomy may be necessary. When
the case of persistent obstruction of the sinus orifice by dis- new (secondary) osteotomies are necessary, generally a Le
placed bone fractures or blood clot. If the maxillary sinuses Fort I osteotomy for repositioning of the tooth-bearing
are obstructed, a nasal–antral window or endoscopic drainage segment of the maxilla is preferred as opposed to a higher
of the maxillary sinus by enlarging the orifice may be required. level osteotomy. Occasionally, segmental osteotomies of the
maxillary arch may be necessary to achieve optimal dental
Cerebrospinal fluid rhinorrhea relationships.
High Le Fort (II & III) level fractures may be associated with
fractures of the cranial base or cribriform area, which produce Nasolacrimal duct injury
cerebrospinal fluid (CSF) rhinorrhea and/or pneumocephalus The nasolacrimal duct may be transected or obstructed by the
and may be associated with death.109 Antibiotic therapy may fractures extending across the middle third of the facial skel-
be utilized in these fractures at the discretion of the attending eton between the Le Fort I and Le Fort III levels. Anatomic
surgeon. Although antibiotic prophylaxis in CSF rhinorrhea repositioning of the fracture fragments of the medial portion
has been quite widely employed, it is difficult to prove that of the maxilla and nasoethmoidal orbital area provides the
antibiotics have substantially reduced the incidence of men- best protection against obstruction. Obstruction of the lacrimal
ingitis accompanying cerebrospinal fluid rhinorrhea when system produces dacryocystitis and may require external
administered over a prolonged period. Blowing of the nose drainage.
and placement of obstructing nasal packing should be
avoided, and placement of intranasal tubes should avoid the
superior nose. Lower facial fractures
Blindness Mandible fractures
Blindness is a rare complication of any fracture of the orbit The prominence, position, and anatomic configuration of the
and may complicate fractures of the Le Fort II and III levels. mandible are such that it is one of the most frequently injured
It is rare for the optic nerve to be severed by bone fragments. facial bones. Following automobile accidents, the mandible
The most common etiology is a traumatic shock to the nerve is the most commonly encountered fracture seen at many
or swelling of the nerve within the tight portion of the optic major trauma centers. The mandible is a movable, predomi-
canal or interference with the capillary blood supply of the nantly U-shaped bone, consisting of horizontal and vertical
retrobulbar optic nerve by swelling and edema. segments. The horizontal segments consist of the body and
the symphysis centrally. The vertical segments consist of the
Late complications angles and rami, which articulate with the skull through
the condyles and temporomandibular joints. The mandible
Specific complications referable to the maxilla include non- is attached to other facial bones by muscles and ligaments
union, malunion, plate exposure, lacrimal system obstruction, and articulates with the maxilla through the occlusion
infraorbital and lip hypesthesia or anesthesia, and devitaliza- of teeth.
tion of teeth. There may be changes in facial appearance due The mandible is a strong bone but has several weak areas
to differences in midfacial height and projection, or the trans- that are prone to fracture. The body of the mandible is com-
verse width of the face, and malocclusion.110 posed principally of dense cortical bone with a small substan-
tia spongiosa through which blood vessels, lymphatics, and
Nonunion and bone grafting nerves pass. The mandible is thin at the angles where the body
True nonunion of the maxilla is rare and usually follows joins with the ramus and can be further weakened by the
failure to provide even the most elementary type of intermax- presence of an unerupted third molar or a previous dental
illary fixation or open reduction. If nonunion occurs, the extraction.111
treatment consists of exposure of the fracture site, resection of The mandible is also weak at the condylar neck, cuspid root
the fibrous tissue in the fracture site, reduction of the displaced (the longest root), and mental foramen through which the
segments, removal of any proliferative bone edges, placement mental nerve and vessels extend into the soft tissues of the
of bone grafts in all the existing bone gaps, and stabilization lower lip. The weak areas for fractures are the subcondylar
by plate and screw fixation. area, angle, distal body, and the mental foramen.112–114
Lower facial fractures 71
Mandibular movements are determined by the action of

reciprocally placed muscles attached to the bone. When frac-
tures occur, displacement of the segments is influenced by the Condyle
pull of the muscles attaching to the segments. The direction Coronoid
of the fracture line may oppose forces created by these muscles.
Dental wiring and fixation techniques Third

molar Ramus
Arch bars
Prefabricated arch bars are ligated to the external surface of
the dental arch by passing 24- or 26-gauge steel wires around
the arch bar and around the necks of the teeth. The wires are
twisted tightly to individual teeth to hold the arch bars in the Alveolar process
form of the dental arch. If segments of the teeth are missing, Angle
or if anterior support of the arch bar is needed to balance the Canine root
forces generated by elastic traction anteriorly, the arch bar Mental foramen Body
may be stabilized by additional wires passed from the arch Parasymphysis
bar to the skeleton (skeletal wires). Suspension wires may be
Fig. 3.26 Classification of mandibular fractures.
passed through drill holes at the piriform margin or around
screws. This is particularly applicable in children where the
structure of the teeth tends to render arch bars less stable. The
the mouth or bring the teeth into proper occlusion (trismus).
mandibular arch bar may also be stabilized by wires passed
The patient may refuse to eat or to brush their teeth, which
to a screw at the lower mandibular border or by circum-
then causes discomfort and an abnormal, foul-smelling odor
mandibular wiring. It cannot be overemphasized that the
(fetor oris). Excessive saliva is often produced as a result of
stability and alignment of a fracture reduction depends greatly
local irritation (drooling). Small gingival or mucosal lacerations
on the alignment of the teeth achieved by this initial applica-
or bleeding between teeth indicate the possibility of a fracture.
tion of arch bars.
These gaps make the fracture compound into the mouth.
Newer types of arch bars exist, which utilize fewer points
Bimanual manipulation of the mandible causes mobility or
of contact and fixation, or screws passed into the bone as
distraction at the fracture site, especially when the fracture
anchor for intermaxillary fixation. They are never better than
occurs in the body or parasymphyseal area. One hand should
full arch bars, and commonly achieve less accurate positioning/
stabilize the ramus, while the other manipulates the symphy-
control of fracture fragments. Postoperatively, IMF may be
sis or the body area. The fracture will be demonstrated by
released if the fracture is stable, and the patient is able to
abnormal movement, and the condition and the symptom
achieve normal occlusion. Our follow-up is at least once a
reinforced by the presence of discomfort. The mandible may
week until complete healing has occurred (6–8 weeks),
be pulled forward with one hand while the other hand is
observing occlusion encouraging range of motion and absence
placed one finger in the ear canal and one finger over the
of infection.
condylar process (see Fig. 3.4). Abnormal mobility or crepitus
indicates a fracture in the condylar/subcondylar area or liga-
IMF screws ment laxity, indicating a temporal mandibular joint injury. The
This is a rapid method of immobilizing the teeth in occlusion, most reliable finding in the fractures of the mandible, in
given good dentition and uncomplicated fracture types.115 The dentulous patients, is the presence of a malocclusion. Often, the
number and position of the IMF screws is based on the frac- most minute malocclusion caused by the fracture is quite
ture type, fracture location, and surgeon preference. Screws obvious to the patient. The patient may be unable to move the
must be positioned superior to the maxillary tooth roots and jaw (dysfunction) and may request liquid foods that require
inferior to the mandibular tooth roots, otherwise transfixation minimal jaw movement and mastication. Speech is difficult
of teeth may occur.116 because of pain on motion of the mandible. Crepitation may
be noticeable by manipulation at the fracture site. Often, the
Classification necessary manipulation produces such discomfort that it is
not wise to demonstrate this physical sign. Swelling is usually
Mandibular fractures are classified according to location (Fig. quite obvious and frequently associated with ecchymosis and
3.26), condition of teeth, direction of fracture and favorability a hematoma. Often, an intraoral laceration is present over
for treatment, presence of compound injury through the skin fractures in the horizontal portion of the mandible. There is
or mucosa, and anatomical fracture pattern. frequently deviation to one side or the other, a finding that
supports the diagnosis of a fracture. Tenderness over the frac-
Clinical examination and diagnosis ture site is present, especially in the region of the temporo-
Pain and tenderness are usually present upon motion over the mandibular joint. Such localized tenderness is highly
fracture and may be noted immediately as a result of injury. suggestive of a fracture.
Fractures occurring along the course of the inferior alveolar
nerve may produce numbness in the distribution of the nerve, Direction and angulation of the fracture line
which represents numbness of the ipsilateral lower lip (mental Kelsey Frye117 described fractures as “favorable” or “unfavor-
nerve) and ipsilateral teeth. The patient may be unable to open able” according to their direction and bevel of displacement
A B C D
Fig. 3.27 (A,C) The direction and bevel of the fracture line does not resist displacement due to muscle action. The arrows indicate the direction of muscle pull. (B,D) The
bevel and direction of the fracture line resist displacement and oppose muscle action. The direction of the muscle pull in fractures beveled in this direction would tend to
impact the fractured bone ends. (After Fry WK, Shepherd PR, McLeod AC, et al. The Dental Treatment of Maxillofacial Injuries. Oxford: Blackwell Scientific; 1942.)
(Fig. 3.27). The muscular forces on some fracture fragments displacement and permits light function. ORIF is especially
are opposed by the direction and bevel of the fracture line. appealing to patients because the teeth do not need to remain
Thus, in some fractures, the muscular force would pull the wired, which permits intake of soft foods, oral hygiene, and
fragments into a position favorable for healing, whereas an early return to work. These desirable aspects might not
in other fractures, the muscular pull is unfavorable and justify open treatment if external incisions are required which
separation of the fracture fragments occurs by action of would produce permanent scars.122
the muscular forces. Mandibular fractures that are directed
downward and forward are classified as horizontally favor- General principles of reduction and fixation
able (HF) because the posterior group of muscles and the The basic principle underlying all mandibular fracture treat-
anterior group of muscles pull in antagonistic directions, ment is superior and inferior border stabilization. The general
favoring stability at the fracture site. Fractures running from method of fracture fixation involves arch bar placement and
above, downward, and posteriorly are classified as horizon- the use of a superior border unicortical non-compression mini
tally unfavorable (HU). The bevel of the fracture may also plate. The inferior border is aligned and approximated by a
influence a displacement medially. If a fracture runs from stabilization plate. Comminuted fractures (Fig. 3.28) require
posteriorly forward and medially, displacement would take larger fixation plates and include fractures with “bone loss”
place in a medial direction because of the medial pull of and multiple fragments, where the plate itself bears the entire
the elevator muscles of mastication (vertically unfavorable, load of fixation across the fracture or missing bone (load
or VU). The fracture that passes posteriorly forward and bearing).
laterally is a favorable fracture because the muscle-pull tends
to prevent displacement. It is called a vertically favorable
fracture (VF).
Treatment of class II fractures
In class II fractures, teeth are present on only one side of the
Indications for ORIF of mandibular fractures fracture site, and these fractures require open reduction. This
type of fracture may occur in any portion of the horizontal
1. Favorable or unfavorable class I fractures where stability mandible but frequently is at the angle. The type and strength
is desired. of plate needed to control the non-toothbearing fragment and
2. Class II and class III fractures. displacement of the fracture will vary according to the direc-
3. Comminuted fractures. tion and bevel of the fracture and the position of the teeth,
4. Displaced fractures and those subject to rotation. surrounding muscles, and the absence of comminution.
5. Edentulous fractures.
6. The desire to avoid IMF in the postoperative period.
7. Combined fractures of the upper and lower jaws.
8. Uncooperative (head injured) patients.
Treatment of class I fractures

Class I fractures are those in which there are teeth on each
side of the fracture. Although many of these fractures can be
managed by intermaxillary fixation (IMF) alone in “favor-
able” fractures, if function is desired and post-treatment dis-
placement is to be prevented, internal fixation is also preferred.
If IMF alone is to be used, the period of fixation is six
weeks.118,119 Many mandibular fractures, even if favorable, are
best managed by ORIF. Miniplates may be used for non-
comminuted, non-bone gap fractures where impaction of the
bone ends bears a significant portion of the load of fracture Fig. 3.28 Large reconstruction plate spans fractures of the entire body. (Courtesy
stabilization (load sharing).120,121 This technique prevents of Synthes Maxillofacial, Paoli, PA.)
Fractures at the mandibular angle can be treated using a Extraoral approach to open reduction
variety of techniques depending on the complexity of the
fracture pattern.123,124 For simple fractures at the mandibular The position of an external mandibular incision should always
angle, the authors’ preferred approach is with a Champy plate respect the location of the marginal mandibular branch of the
placed monocortically on the oblique ridge or superior border facial nerve (Fig. 3.29). The subperiosteal dissection technique
of the mandible. also respects neurovascular structures such as the mental
nerve. Careful subperiosteal dissection establishes the extent
and pattern of the fracture, confirming the impression given
Comminuted fractures from the CT. The fragments at the inferior border of the
Comminution negatively influences stability and generally fracture are aligned with clamps. The occlusal reduction
increases the degree of fracture displacement. Three to four should be checked at this point, and loose arch bar wires on
screws are utilized for fracture stabilization placed in non- the minor segment are tightened. IMF is then confirmed or
fractured bone on each side of the entire fracture defect. Upper established. Usually, a superior border plate is now utilized
and lower border plates are preferred in the horizontal man- at the upper border of the mandible and fixated with unicorti-
dible and two plates also in the vertical mandible where cal screws. The occlusion is again checked, alignment of the
possible. fractures re-confirmed, and a lower border plate and screws
applied. A larger plate may be utilized. Generally, a large plate
is initially “overbent” so that it stands 2–3 mm off the central
Class III fractures fracture site. Screw length may be determined by a depth
Class III fractures have no teeth on either side of the fracture. gauge, and bicortical placement is preferred. If a larger plate
Non-displaced, immobile fractures conceptually may be is used, as the bicortical screws are tightened, the overbent
treated by a soft diet with close follow-up. The majority of plate flattens itself against the outer border of the mandible
class III fractures, however, should be managed with rigid and reduces the lingual cortex properly. After the fixation is
fixation with superior and inferior border fixation. secure, any initial positioning wires are removed and the
A B
Fig. 3.29 (A,B) Intraoperative photograph of comminuted mandibular fracture in a 23-year-old male
following attempted homicidal gunshot wound to the face pre- and post-open reduction and internal fixation
C via the extraoral approach using multiple miniplates. (C) Lateral 3D craniofacial computer tomography
postoperative scan following open reduction and internal fixation of comminuted mandibular fractures.
musculature repaired. Care must be taken in suture placement bone ends. Load-sharing fixation relies on the impaction of
to avoid the marginal mandibular branch of the facial nerve, the bone on each side of the fracture to bear the majority of
which is located up to 1–2 cm below the inferior edge of the the functional load with the small plate holding the bone ends
mandible.125 The platysma muscle and the skin are closed in together with force.
layers, and a dependent drain placed. The cutaneous wound Locking plate and screw systems function as “internal
is closed in layers with subcuticular sutures to avoid suture external fixators”, achieving stability by locking the screw to
marks. the plate.128 The potential advantages of these fixation devices
are that precise adaptation of the plate to the underlying bone
Intraoral approach to open reduction is not necessary. As the screws are tightened they “lock” to
the plate, thus stabilizing the segments without the need to
Any fracture in the horizontal or vertical mandible is usually compress the bone to the plate. This makes it impossible for
amenable to an intraoral approach.126 the screw insertion to alter the reduction. This theoretically
This is the preferred exposure for any symphysis or para- makes it less important to have good plate bending, as non-
symphysis fracture and for non-comminuted angle fractures. locking, large plates must be perfectly adapted to the contour
The body region is also able to be reduced but may require a of the bone. Theoretically this hardware should be less prone
percutaneous trocar approach for drilling and screw place- to inflammatory complications from loosening of hardware
ment. In the intraoral approach, the fracture site is exposed since loose hardware propagates an inflammatory response,
through an appropriately placed mucosal incision. The inci- permits motion, and promotes infection.
sion is generally brought about a centimeter out of the sulcus
on the buccal aspect of the mucosa, and mucosal and muscular
layers separately incised. Champy or miniplate system
Mandibular fixation by the use of smaller “mini plates”, as
Selection of internal fixation devices for mandibular advocated by Champy, speeded exposure and was more toler-
ant for mandibular shape and occlusion versus more rigid
fractures: how much fixation is enough plate adaption as the screws were tightened.129,130 The mal-
Edward Ellis III123,127 clarified the issues regarding selection of leable plates minimized malreductions from “plate bending
internal fixation devices for mandibular fractures. Normal errors” common to stiff larger plates. This technique did not
bite forces must be initially countered by fixation devices; result in maximum rigidity achieved with the large plates but
however, patients who have sustained mandible fractures do was generally sufficient for required immobilization for many
not generate normal bite forces for months after the injury. fractures.
Rigid fixation is defined as internal fixation that is stable Small plates are more “user friendly” than more rigid
enough to prevent motion of the bony fragments under systems and rose in popularity to surpass the use of rigid
normal function. It has been recognized that absolute rigidity plate systems. Champy recommended two plates (upper and
of the bone fragments is not necessary for healing of the lower border) in the anterior (symphysis and parasymphysis)
fracture to occur under functional loading. Ellis believes portion of the mandible and a single plate along the superior
“functionally stable fixation” is not “rigid” but satisfies the border in the angle and upper border of the distal ramus (Fig.
goals of maintaining fragment alignment and permits healing 3.30). The need for additional fixation must be assessed care-
during limited active use of the bone. Ellis describes “load- fully, and this technique should be avoided in comminuted
bearing” fixation as sufficient strength and rigidity that the fractures and in the multiply fractured mandible. The tech-
device bears the entire loads applied to the mandible seg- nique can only be used where the bone at the fracture site is
ments during functional activities without impaction of the broad enough to be compressed by the plate to bear the
A B C
Fig. 3.30 (A) Three-quarter view of 3D craniofacial computer tomography preoperative scan on 16-year-old male who sustained a left mandibular angle fracture and right
mandibular parasymphyseal fracture following an altercation. (B) Intraoperative photograph of open reduction and internal fixation of left mandibular angle fracture using the
Champy technique. (C) Three-quarter view of 3D craniofacial computer tomography postoperative scan.
between the bone and the direction of the screw should bisect
a 90-degree angle from the bone in a plane parallel to the bone.
Third molars in mandibular angle fractures

Extraction of an impacted third molar must be carefully
considered. In some circumstances, where the third molar is
partially erupted and inflamed, it should be removed at the
time of fracture treatment to avoid potential complications
(Fig. 3.32).111
Otherwise, it makes little sense to remove bone to extract
a fully impacted third molar, as this weakens the bone and
damages mucosa in the area of the fracture. This can expose
the fracture to the intraoral environment, contributing to bone
A
instability and infection and a less stable fracture by third
molar removal. The fracture site is less vascularized following
third molar removal by virtue of periosteal stripping. Fully
impacted third molars which do not prevent fracture reduc-
tion by minimal displacement of the tooth can be electively
removed when fracture healing is completed.133–135
Antibiotic use
Intravenous administration of antibiotics perioperatively is
recommended especially in patients undergoing delayed
treatment, patients having long operations, patients with
badly contused soft tissue, where the fracture treatment is
delayed and where the tissues are heavily contaminated, and
where multiple intraoral lacerations are present.136,137 It benefits
patients who are medically compromised, have poor nutri-
tional status or systemic illness, or where local conditions of
poor dental hygiene, periodontal, or dental infections increase
B the chance of bacterial complications.
Fig. 3.31 (A) Placement of two horizontal lag screws to reduce and stabilize a Treatment principles of mandibular fractures
parasymphysis fracture using a trocar device. (B) Intraoperative photograph of open
reduction and internal fixation of mandibular symphyseal fracture using lag screws. 1. Establish proper occlusion.
(A, Courtesy of Synthes Maxillofacial, Paoli, PA.) 2. Anatomically reduce the fractured bones into their
normal position.
majority of the “load” of the fracture. The use of a brief initial
period of rest in IMF (1 week) is used by some practitioners
for soft tissue “rest” and provides an initial period of occlu-
sion where less stress is placed on the fracture and importantly
intraoral wounds and the soft tissue.
Lag screw technique

This technique is indicated in non-comminuted parasymphy-
sis or symphysis fractures,131,132 where a long length of screw
can be tolerated (Fig. 3.31). Generally, these screw lengths
require 35–45 mm anteriorly. A specific technique is utilized
where the first cortex in the bone is over-drilled to the major
diameter (thread width) of the screw. The second segment of
the screw path is drilled to the minor diameter (core width
not including treads) of the screw. Only the screw head will
engage bone in the first section of the path, and therefore, as
the screw is tightened into the second section of the fracture,
the screw head impacts the cortex toward the fracture site.
Generally, two lag screws are recommended for each fracture
to be stable, for if one becomes loose, the fracture would be
unstable by rotation. A sleeve or drill guide is used to protect Fig. 3.32 Three-quarter view of 3D craniofacial computer tomography
soft tissue. Oblique body or angle fractures may be lag screwed demonstrating malunion and continuity defect of left mandibular angle fracture with
with 2–3 screws for stability. In screw placement, the angle tooth in line of fracture.
3. Utilize fixation techniques that hold the fractured bone exposed must be debrided. Loose or infected teeth should be
segments in occlusion and normal position until healing removed. Fracture stability must be provided by removal of
has occurred. Open reduction internal fixation (ORIF) current fixation devices and reapplication of longer, stronger
can often permit limited function while healing is reconstruction plates, whose screw fixation of 3–4 screws in
occurring. healthy uninvolved bone outside the fracture area can be
4. Control infection. achieved. In the uncommon persistent infection, the surgeon
may wish to convert to external fixation removing all internal
fixation devices, but most cases may be stabilized with the
Complications after fracture treatment debridement and application of a long reconstruction plate.
Malocclusion No screws should be placed in an area of questionable bone.
Malocclusion is commonly the result of insufficient or inac- Serial debridement of devitalized bone and soft tissue may
curate initial alignment. Poorly applied or loose IMF is the be required to confirm the absence of infection and adequacy
commonest cause, and inadequate reduction, inadequate plate of debridement. Primary or secondary bone grafting is con-
size, length or strength, contour, or failure (loosening) of fixa- ducted when the soft tissue and local area have been cleared of
tion. The most common cause of screw loosening is overheat- infection by debridement, drainage, antibiotics, and mucosal
ing of the bone while drilling. Although subtle malocclusions closure.144
may sometimes be corrected by elastic traction, grinding the
occlusal facets of the teeth or orthodontics, any significant Condylar and subcondylar fractures
malocclusion requires refracture and/or osteotomy.
One must consider dislocation, angulation between the frac-
tured fragments, fracture override (which translates to ramus
Hardware infection and screw migration vertical length shortening), fracture angulation, and bone
Loose hardware generally creates soft tissue irritation, pro- gaps between the fragments. In children, growth consider-
ducing a foreign body response and infection requiring ations145 create a capacity for both regeneration and remodel-
hardware removal. Many times the fracture has healed and a ing which is not present in later years.146,147 Adults are capable
repeat osteosynthesis is not necessary. Migration of loose only of partial restitutional remodeling.
hardware into soft tissue away from the fracture site occasion- High condylar (intracapsular) fractures (head and upper
ally occurs.138 neck) are generally treated with closed reduction with a limited
(2 week) period of postoperative IMF, followed by early
Increased facial width and rotation of the mandible “controlled” mobilization utilizing elastics for re-establishing
Broadening of the distance between mandibular angles is occlusion in a rest position. Most neck and low subcondylar
produced by rotation of the lateral mandibular segments fractures with good alignment, reasonable contact of the bone
lingually at the occlusal surface of the teeth.139 The distance ends, and preservation of ramus vertical height without condy-
between the mandibular angles increases as the mandible lar head dislocation may be treated by IMF for 4–6 weeks, with
rotates, and the lower face widens. This rotation (aggravated weekly observation of the occlusion for at least 4 additional
by tight IMF and the presence of subcondylar fractures) pro- weeks after release of fixation in light function or guiding
duces a malocclusion (open bite) of the palatal and lingual elastics.148,149 Some shortening of the ramus height is almost
cusps of the molar dentition (which may only be visible from inevitable with a closed approach to condylar/subcondylar
a lingual location). A characteristic broadening and rounding fracture treatment,150–152 which may lead to a premature contact
of the face occurs, which is aesthetically and functionally in the ipsilateral molar occlusion and a subtle open bite in
undesirable. It cannot be treated by orthodontics and requires the contralateral anterior occlusion. Angulation between the
refracture.140 The use of a long, strong reconstruction (10–12 fractured fragments in excess of 30 degrees and fracture gap
hole) plate to keep the mandibular angles unrotated and the between the bone ends exceeding 4–5 mm, lateral override,
width of the mandible at the angles narrow is required. and lack of contact of the ends of the fractured fragments
should be a consideration for open reduction in mid or low
Non-union subcondylar fractures types (Fig. 3.33).153–157
Non-union and pseudoarthrosis are uncommon after plate
and screw fixation.141–143 Their presence may be masked in Edentulous mandible fractures
presence of rigid fixation. Plate removal may unmask a poor These fractures represent less than 5% of the mandibular
union, which requires re-fixation of the fracture after thorough fractures.158–160 Fractures commonly occur through the most
debridement at the site of poor fracture healing and possible atrophic portions where the bone is thin and weak. The body
bone grafting of the defect. is a common site for fracture, as compared to the angle and
subcondylar region in dentulous patients.161 Many fractures
Osteomyelitis are bilateral or multiple, and displacement of a bilateral
Soft tissue infection is common after mandibular fracture edentulous body fracture is often severe and a challenging
treatment, but true bone infection, osteomyelitis, is not. Local condition to treat. The fractures in the horizontal mandible
infection may almost always be managed with drainage may be closed or open to the oral cavity. Closed fractures
and antibiotics. The fixation must be confirmed as adequate demonstrating no displacement may be treated with a soft
and intraoral closure inspected, and any instability in the diet and avoidance of dentures; however, in these cases
fracture fixation noted and corrected. Less commonly, observation is critical to be sure that healing occurs within
devitalized soft tissue and bone fragments that are dead or several weeks without further displacement. In practice most
Panfacial injuries 77
A B C
Fig. 3.33 (A,B) Lateral view of 3D craniofacial computer tomography on a 20-year-old female involved in a motor vehicle collision who sustained craniofacial injuries,
pre- and post-open reduction and internal fixation of a right mandibular subcondylar fracture via a retromandibular extraoral approach. Note that the patient also had a Le
Fort II type fracture that was treated with closed reduction and interdental fixation. (C) Lateral profile view photograph of patient 1 year postoperatively.
fractures are better treated with a load-bearing plate. The massive edema and soft tissue contamination and rigidity that
edentulous mandible is characterized by the loss of the alveo- follow these injuries. Early treatment is possible when other
lar ridge and the teeth.162 The bone atrophy may be minimal systems are not injured or are evaluated to exclude significant
if there is sufficient height (over 20 mm) of the mandibular instability. However, no matter how severely the patient is
body to ensure good bone healing. In cases with moderate injured, cutaneous wounds can be cleansed and closed, devi-
atrophy, the height of the mandibular body ranges from talized tissue removed, and the patient placed in intermaxil-
10–20 mm, and healing is usually satisfactory but not as lary fixation. This is the minimum urgent treatment of a
certain as if the height were greater than 20 mm. Small plates significant maxillary or mandibular injury and may always be
with few screws often fail, as there is insufficient bone to accomplished, despite the condition of the patient.
provide buttressing support for “load-sharing” fracture treat- Presently, a one-stage restoration of the architecture of the
ment. The plate must bear the entire load of the fracture, and craniofacial skeleton is the preferred method of treatment for
a large reconstruction (“locking”) plate with 3–4 screws per
side in healthy bone is recommended (Fig. 3.34). In cases
where the mandibular height is less than 10 mm (severe
atrophy) one can assume that the patient has a disease of
“poor bone healing”. Complications following edentulous
mandible fractures directly parallel the extent of mandibular
atrophy. Obwegeser and Sailer163 in 1973 documented that
20% of the complications in edentulous mandible fractures
were seen in the 10–20 mm mandibular height group, and
80% of the complications (i.e. poor or unsatisfactory bone
union) were experienced in cases demonstrating a mandibular
height less than 10 mm. Virtually no complications were seen
in fractures exceeding 20 mm in height. This experience
caused some authors164,165 to recommend primary bone graft-
ing for the severely atrophic edentulous mandible (less than
10 mm in height).
Panfacial injuries
Conceptually, panfacial fractures involve all three areas of the
face: frontal bone, midface, and mandible. In practice, when
two out of these three areas are involved, the term “panfacial
fracture” has been applied.
Fig. 3.34 Lateral view of 3D craniofacial computer tomography on a 64-year-old
Treatment of panfacial fractures edentulous female, with a history of osteogenesis imperfecta, who was referred for
treatment of a malunion of a left mandibular fracture. Postoperative open reduction
The optimal time and the easiest treatment of these injuries is and internal fixation using a load-bearing mandibular plate and iliac bone grafting
within hours of the accident, before the development of via an extra-oral approach.
Order of the procedure

Various sequences have been suggested such as “top to
bottom”, “bottom to top”, “outside to inside”, or “inside to
outside”. In reality, it does not make any difference what the
order is as long as the order and sequence make logical sense
and lead to a reproducible, anatomically accurate bone recon-
struction. In our experience, it is more predictable to stabilize
the occlusion in comminuted fractures by relating the ana-
tomically aligned maxilla to the mandible than by relating the
inferior maxilla to the superior maxilla. The frontal bone is
managed first with any brain injury, then the upper midface
beginning with the central nasoethmoid area and progressing
to the zygoma, emphasizing control of facial width. The
mandible is managed next, linking all segments through
required exposures with wires temporarily, then achieving
mandibular width by relating it to an anatomically reduced
and stabilized maxillary dental arch.
Complications of panfacial fractures

Complications of panfacial fractures include complications
referable to the bone and the soft tissue. The most common
Fig. 3.35 Lack of restoration of the preinjury appearance, even if the underlying
bone is finally replaced into its proper anatomic position, is the result of scarring
bony facial deformities following midface fracture treatment
within soft tissue. Examples of soft tissue rigidity accompanying malreduced relate to lack of projection, enophthalmos, malocclusion, and
fractures include the conditions of enophthalmos, medial canthal ligament increased facial width (Fig. 3.35).
malposition, short palpebral fissure, rounded canthus, and inferiorly displaced The most common soft tissue deformities are descent,
malar soft tissue pad. The lower lip has a disrupted mentalis attachment. Secondary diastasis, fat atrophy, ectropion, thickening, and rigidity. Lack
management of any of these conditions is more challenging and less effective than of periosteal closure over the zygomaticofrontal suture pro-
primary reconstruction. A unique opportunity thus exists in immediate fracture
duces the appearance of temporal wasting because of the gap
management to maintain expansion shape and position of the soft tissue envelope
and to determine the geometry of soft tissue fibrosis by providing an anatomically in the temporal aponeurosis with skeletalization of the frontal
aligned facial skeleton as support. Excellent restoration of appearance results from process of the zygoma (Fig. 3.36). High incisions for arch
primary soft tissue positioning. exposure made higher in the deep temporal fascia require
dissection through fat to reach the zygomatic arch and cause
fat atrophy by direct fat damage (interference with the middle
temporal blood supply).
panfacial injuries, where severe comminution and multiply
fractured facial bones characterize the injury.
Open reduction of all fracture sites is performed with plate
and screw fixation, adding bone grafts to bone defects.
Although local incisions may be useful in selected cases,
regional incisions such as the coronal, transconjunctival, and
upper and lower gingival buccal sulcus provide complete
exposure. An exposure may be avoided when a suitable lac-
eration already exists.
In each subunit of the face, the important dimension to be
considered first is facial width. In less severe fractures, correc-
tion of facial width is not challenging and an “anterior”
approach is sufficient. Control of facial width in more severe
injuries requires more complete dissection and alignment of
each fracture component utilizing all the peripheral and
cranial base landmarks. Reconstructions which emphasize
control of facial width are in fact the principle which recipro-
cally restores facial projection.
The timing and technique of soft tissue reduction are criti-
cal. Repositioning of the bone and replacement of the soft
tissue onto the bone at its correct anatomical location must be
accomplished before the soft tissue has developed significant
memory (internal scarring) in the pattern of the unreduced
bone configuration. Soft tissue replacement requires (1)
layered closure of the soft tissues and (2) reattachment of the
closed soft tissue to the facial skeleton precisely at several Fig. 3.36 “Skeletonization” of the frontal process of the zygoma from failure to
points on the anatomically assembled craniofacial skeleton. close the temporal fascia to the orbital periosteum over the frontal process.
Gunshot wounds of the face 79
Postoperative care Intermediate and high velocity ballistic

Patients with large segment fractures may be adequately injuries to the face
stabilized by plate and screw fixation and permit early release Shotgun pellets have a large mass and are considered inter-
of intermaxillary fixation. Patients with comminuted midface mediate energy deposit projectiles. They travel at speeds of
or panfacial fractures are best served by varying periods of approximately 1200 feet per second and when grouped in a
postoperative intermaxillary fixation of three to four weeks in close distribution, at close range, are capable of causing
addition to plate and screw fixation. massive injury. In civilian practice, many of these injuries
represent shotgun wounds or high-energy rifle injuries, and
they often result from suicide attempts and assaults. Close
Gunshot wounds of the face range shotgun wounds are characterized by extensive soft
tissue and bone destruction.
While some authors advocate delayed reconstruction of Intermediate and high velocity ballistic injuries to the face
gunshot and shotgun wounds of the face, immediate recon- must be managed with a specific treatment plan that involves
struction166,167 and immediate soft tissue closure with serial stabilization of existing bone and soft tissue in anatomic posi-
“second-look” procedures is the current standard of care.168 tion, and maintenance of this bone and soft tissue stabilization
Recent experience documents the safety and efficacy of imme- throughout the period of soft tissue contracture and bone and
diate soft tissue closure and bone reconstruction in an ana- soft tissue reconstruction. Wounds from intermediate and
tomically correct position. These two principles prevent soft high-energy missiles usually demonstrate areas of both soft
tissue shrinkage and loss of soft tissue position and provide tissue and bone loss, as well as areas of soft tissue and bone
improved functional and aesthetic results with shorter periods injury. It is important to reassemble the existing bone and soft
of disability and an improved potential for rehabilitation both tissue as completely as possible, and then serial surgical
functionally and aesthetically. The philosophy of delayed debridement ”second-look” procedures, re-open the soft
closure of these difficult wounds is no longer appropriate, tissue to define additional areas of soft tissue necrosis, drain
creates additional soft tissue deformity, and delays effective hematoma and/or developing fluid collections or infection,
rehabilitation of the affected individuals, some of whom and assure bone integrity. These “second-look” procedures
represent suicide attempts. are imperative if primary reconstruction is attempted. Thus,
Ballistic injuries are classified into low, medium, and high- the emphasis is on primary soft tissue, “skin to skin” or “skin
energy injuries.169 In formulating a treatment plan for ballistic to mucosa” closures, with stabilization of existing bone frag-
injuries, it is helpful to identify the entrance and exit wounds ments in anatomical position. Re-exploration for additional
and the presumed path of the bullet and to appreciate the debridements occur at 48-hour intervals, or at an interval
mass and velocity of the projectile so that the extent of internal determined until soft tissue loss ceases and wound hematoma
areas of tissue injury can be predicted. Conceptually, the areas and fluid collections are controlled. Then, reconstruction
of soft tissue and bone injury and areas of soft tissue loss and proceeds immediately.
bone loss must be individually assessed and noted (four sepa- In cases where composite tissue loss of bone and soft tissue
rate components) for each injury. The areas of injury and the occur, techniques utilizing free tissue transfer of bone and
areas of loss are each precisely outlined, which allows a treat- soft tissue are preferred (Fig. 3.37A–F).170,171 The use of local
ment plan to be developed for early and intermediate treat- tissue advanced over the mismatched cutaneous segment of
ment for the lower, middle, and upper face. the free flap ultimately provides the best cutaneous aesthetic
result.172
Low velocity gunshot wounds

Low energy deposit ballistic weapons usually involve projec-
tiles that have a limited mass and travel at speeds of less than
1000 feet per second. In general, low velocity gunshot wounds Bonus images for this chapter can be found online at
involve little soft tissue and bone loss and have limited associ- http://www.expertconsult.com
ated soft tissue injury outside the exact path of the bullet. It
is thus appropriate that they be treated with immediate defini- Fig. 3.1 Cutaneous incisions (solid line) available for open reduction and
tive stabilization of bone and primary soft tissue closure. internal fixation of facial fractures. The conjunctival approach (dotted line) also
gives access to the orbital floor and anterior aspect of the maxilla, and exposure
Limited debridement of bone and soft tissue are necessary.
may be extended by a lateral canthotomy. Intraoral incisions (dotted line) are
Small amounts of bone may need to be debrided and replaced also indicated for the Le Fort I level of the maxilla and the anterior mandible.
with a primary bone graft, which can be performed primarily The lateral limb of an upper blepharoplasty incision is preferred for isolated
in the upper face. Because of the lack of significant associated zygomaticofrontal suture exposure if a coronal incision is not used. A horizontal
soft tissue injury, little potential for progressive death or incision directly across the nasal radix or vertical incision along the glabellar
progressive necrosis of soft tissue exists, and these injuries fold is the one case in which a local incision can be tolerated over the nose. In
may be treated as “facial fractures with overlying lacerations” many instances, a coronal incision is preferable unless the hair is short or the
patient is balding.
both conceptually and practically.
C
A B
D E F
Fig. 3.37 (A,B) Frontal photographs of a 34-year-old male following a self-inflicted gunshot wound injury to the face demonstrating severe midfacial and mandibular
fractures. (C) Intraoperative photographs following open reduction and internal fixation of mandibular fractures using a load-bearing mandibular plate and a monocortical
miniplate fixation via an extraoral approach. (D,E) Frontal 3D craniofacial computer tomography scan of the patient pre- and post-open reduction and internal fixation of
midfacial and mandibular fractures. (F) Postoperative photograph 1 year following surgery.
Access the complete reference list online at http://www.expertconsult.com

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SECTION I • Craniofacial Trauma

injury, but primary and secondary enforcement of the laws

Historical perspective Coronal incision Upper

examination of the face is indicated even if the patient has

An evaluation of sensory and motor nerve function in the

Orbital physical examination Radiographic evidence of fracture

5. “Blow-in” orbital fractures that involve the medial or

Blow-out fractures of the floor of the orbit

Medial orbital wall fractures

Blow-out fractures in younger individuals

Fig. 3.8 The combination of a palpebral and subconjunctival hematoma is

Operative technique for orbital fractures

preoperative results. Both double vision and blindness have

Complications of orbital fractures

measurements all be compared to detect what is causing

Restoration of continuity of the orbital floor

Bone grafts for orbital floor reconstruction

Light perception must be confirmed preoperatively and fre-

Enophthalmos Scleral show, ectropion, and entropion – vertical

Anteroposterior blows result in posterior displacement of

cartilage support and preventing soft tissue contracture70

Open reduction and the use of supporting k wires

Treatment of fractures and dislocations of the septum

Fig. 3.14 Reduction of a nasal fracture. (A) After

presence of closed splinting may not prevent recurrent devia-

Nasoethmoidal orbital fractures

Traumatic telecanthus and hypertelorism

have been pushed between the eyes. There is a loss of dorsal

Fig. 3.16 (A,B) Lateral image of 3D craniofacial computer tomography scan of a

Reduction through the maxillary sinus

opportunity for regeneration and relief of pressure. The nerve

Digital manipulation Le Fort classification of facial fractures

Fig. 3.23 Frontal 3D craniofacial computer

cannot be explained by other sources, especially if air-fluid

Complications of maxillary fractures

fractures reduced and stabilized with plate and screw fixation

Le Fort II level fractures

Le Fort III fractures

Postoperative care of maxillary fractures

in closed midface injuries with anterior–posterior nasopha- Malunion

Mandibular movements are determined by the action of

Dental wiring and fixation techniques Third

Treatment of class I fractures

Third molars in mandibular angle fractures

Lag screw technique

Order of the procedure

Complications of panfacial fractures

Postoperative care Intermediate and high velocity ballistic

Low velocity gunshot wounds

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