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 Midface Fractures
PART II
Moderator: Dr. Rajay A. D.
Kamath
Presenter: Dr. Jomi Porinchu
MANAGEMENT OF A TRAUMA
PATIENT
 Management

1. Emergency care and stabilization.

2. Examination.
3. Definitive treatment
Rehabilitation
Continuing care
EMERGENCY CARE

Airway Management

Breathing

Circulation

C-Spine injury addressed

SAMPLE HISTORY
 Examination

Preliminary Detailed Examination

Examination
Local
Head Injury
Extraoral
Eyes Inspection
Spine Palpation
Limbs Intraoral
Abdomen and Inspection
Chest Palpation
Soft tissue Radiographic
lacerations
Clinical Examination
Extraocular
Movements
Video
 Radiograhic examination

Plain Films
Lateral Skull
Waters View
Submentovertex (jug-handle)
Occlusal view

CT Scan
Axial and Coronal views
McGrigor & Campbells and Trapnells Lines
Lines of Dolan and the Elephants of Rogers
C T ( Axial)
CT (coronal)
3 D CT
DEFINITIVE TREATMENT
GOALS .

Re-establish midfacial height, width and projection

Establish occlusal relationship

Maintain integrity of nose and orbits

Provide structural support for proper soft tissue contour

Re-establish midfacial vertical buttress

Timing Of Surgical Intervention

Timing still remains controversial

 Treatment Options .

1. Closed reduction & mandibulo-maxillary fixation.

2. Closed reduction & fixation by external appliances.

3. Wire suspension with closed or open reduction.

4. Open reduction & internal fixation by inter-osseous wiring.

5. Open reduction & internal fixation by miniplates, microplates

& screws.
 Closed Reduction & Fixation By External
Appliances
Historical relevance
Can be used in emergency situation.

WASSMUNDS MAXILLARY SPLINT HALO FRAME

Internal suspension
 4. Open Reduction & Internal Fixation By
Interosseous Wiring
Adams(1942) ,Manson et al
ORIF by wires accurate restoration of height & projection

Disadvantages:
Not a functionally stable form of osteosynthesis.
Requires 2-3 additional weeks of IMF.
 5. Open Reduction & Internal Fixation By
Miniplates, Microplates & Screws

Current method of treatment.

Advantages-
1. Functional stability Postop. IMF avoided.
 Approaches
1. Intraoral
G-B sulcus (Sublabial)
Marginal gingival (Sulcular)
2. Lower eyelid Sub-ciliary
3. Transconjunctival
4.Upper Lid blepheroplasty
5. Lateral Brow
6. Coronal approach
VESTIBULAR INCISION
Sub-ciliary
Alternative technique : Extended lower eyelid
approach
TRANS-CONJUNCTIVAL
LATERAL EYE BROW
UPPER EYE LID
CORONAL
Mid-face Disimpaction.

Rowes disimpaction forceps (1966)

Rowes Disimpaction Forceps
Hayton- Williams forceps
Reduction Hook/Stromeyer Hook
Carroll Girard Technique
 Immobilization
Internal fixation:
Le-Fort I
The 4 cardinal bends of the zygomatico- maxillary buttress:
technical note

J Oral maxillofac surg 67:1149-1151,2009

Le-Fort II
 Le-Fort III
Naso-ethmoidal & FZ fixation in combination with orbital rim
& zygoma reconstruction.
 Palatal Fractures

ORIF/Epimucosal plating and later removal

Reduce fracture and use a splint

Combination of first two options

 Complications

Peri-operative and postoperative airway

obstruction
Acute / Chronic sinusitis Ethmoid, sphenoid,
frontal and maxillary sinuses
Postoperative hemorrhage / epistaxis
 Complications
Palpable Hardware

Non-Union / Malunion / Malocclusion

Plate Exposure

Lacrimal System Obstruction / diplopia / enopthalmos

Infraorbital nerve Anesthesia / Paraesthesia

Devitalized Teeth
 References.

Grants Atlas of anatomy 12th edition

Surgical approaches to facial skeleton Ellis

Maxillofacial Surgery , vol.1, 2nd edition. Peter Ward Booth

Oral & Maxillofacial Trauma, vol.2, 3rd edition.- Fonseca

Rowe & Williams Maxillofacial Injuries, vol.1

Killeys Fractures of Middle 3rd of Facial skeleton

Petersons principles of oral and maxillofacial surgery Vol 1

Manual of internal fixation in the cranio-facial skeleton. Techniques recommended

by the AO/ASIF maxillofacial group. Joachim Prein
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