Shinta Fitri Boesoirie

DEPARTMENT OF OTORHINOLARYNGOLOGY - HEAD&NECK

SURGERY
UNIVERSITAS PADJADJARAN / HASAN SADIKIN
GENERAL HOSPITAL
B AN D U N G
2OO5

CLASSIFICATION
FACIAL TRAUMA
- SOFT TISSUES (INCLUDED EYES AND
NERVES ):

CONTUSIO
ABERATION
LACERATION
STAB WOUND, etc

- MAXILLOFACIAL SKELETON Open / close

fracture,
displaced, comminuted,
greenstick

SOFT TISSUES

SKIN

N. FACIALIS

MUSCLES

SENSORIC NERVES

FRACTURE LINES
SKULLBASE

ZYGOMA

CRANIUM

FRONTAL
ORBITA
MAXILLA

Facial Skeleton

FACIAL BUTTRESSES
2.
3.

1.

1. NASOMAXILLAR/FRONTO
NASAL
2. ZYGOMATICOMAXILLAR
3. PTERYGOMAXILLAR

Superior : Orbital Floor

Posterior : Pterygoid plates
of the sphenoid bone
Medial : Nasal Cavity
Inferior : Proceccus
alveolaris

Orbita wall sections

Anterior Orbital rim
Posterior Lateral walls, roof and floor

THE GOAL OF RECONSTRUCTION

TO RECONSTRUCT THE BUTTRESSES

1. NASOMAXILLAR/FRONTO
NASAL
2. ZYGOMATICOMAXILLAR
3. PTERYGOMAXILLAR
REHABILITATION OF :
MASTICATORY FUNCTION
FACIAL AND EYE BALL MOVEMENT
COSMETIC

Type impact
Low Velocity Impact Forces Sport injuries, fistfights
High Velocity Impact Forces Vehicle accident, gunshot
wound, blunt trauma, falls, industrial accident

Mechanism
Anterior Impact Forces
Lateral Impact Forces
Orbital Forces

Mechanism
Anterior Impact Forces
Lateral Impact Forces
Orbital Forces

Pounds Of Forces

DIAGNOSIS
INSPECTION
PALPATION
X-RAY
INSPECTION
LOCAL DEFECTS
ASIMETRY
EYES & NOSE DISORDERS
MAL OCCLUTION, TRISMUS
FACIAL PARALYSIS, etc

FRAKTUR OF THE MAXILLA

- TYPES : LE FORT I, II, III.
GENERALLY IN COMBINATION
- SYMPTOMS : INFRAORBITAL SWELLING

INFRAORBITAL HYPESTESIA
MALOCCLUTION
EPISTAXIS ( LF II-III )
LIQUORRHEA (LF III), etc.

Le Fort I Transverse Fracture

Le Fort II Pyramidal Fracture
Le Fort III Craniofacial Dysjunction

LE FORT

LE FORT I

LE FORT III
LE FORT II
LE FORT II

LE FORT III

CT 3 DIMENTION

FRACTURE

LE-FORT
FRACTURE

FRACTURE

ZYGOMATIC
FRACTURE

FRACTURES OF THE MAXILLA

MULTIPLE FRACTURES OF THE

MAXILLA
CT TRANSVERSAL

Transverse (Guerins) Fracture

Hypoesthesia of the
infraorbital nerve
Buccal echymosis
Epistaxis
Crepitasi

Pyramidal Fracture

Crepitasi, Periorbital ecchymosis

Medial canthal deformity
Hypoesthesia of the infraorbital nerve
Epistaxis, Nasal septal deformity,
Cerebrospinal fluid rhinorrhea

Craniofacial
Dysjunction

Hypoesthesia of the infraorbital nerve, Diplopia, Crepitasi,

Periorbital ecchymosis, Enophtalmos, Epistaxis, Lightening
face, Lateral orbital rim defect, Medial canthal deformity,
Paresthesia cheeck

FRACTURE OF THE ZYGOMA

DIAGNOSIS : - PERIORBITAL ECCHYMOSIS
- BONE DEPRESSED.
DIPLOPIA
- N. INFRAORBITALIS
HYPESTHESIA
X-RAY : WATERS
NOTICE : HEMATOSINUS
TREATMENT : GENERALLY OPEN REDUCTION

FRACTURE OF
THE ZYGOMA

WATERS

ZYGOMATIC
FRACTURE

FRACTURE OF THE ZYGOMA

CT TRANSVERSAL

ZYGOMA

ZYGOMA

DEPRESSED ZYGOMA

DEPRESSED ZYGOMA

PERIORBITAL ECCHYMOSIS

Lateral forces impact

Disruption frontozygomatic
suture, inferior orbital
rim, zygomatic arc
displaced and rotate
malar bone
3 common fracture
Isolated arc fracture
Tripod fracture
# associated with more
extensive midfacial
injury

Sign and Symptom

Periorbital ecchymosis and edema
Flattening of the malar prominence
Flattening over the zygomatic arch
Ecchymosis of the maxillary bucal sulcus
Deformity of zygomatic buttress
Deformity of orbital margin
Trismus and pain
Abnormal nerve sensibility
Subconjuctival ecchymosis
Diplopia
Enophtalmos

The external arcs

contour of the
zygoma have
been disrupted
with comminution
of the inferior
orbital rim and
lateral antral wall

Coronal
Hemicoronal
Lateral / Medial
Eyebrow
Medial Canthus
Temporal
Transconjungtiva
l
Subciliary
Subtarsal
Orbital Rim
Percutaneous
Gingivobuccal

Goal Restoration relationships of the tooth-bearing

segments of the maxilla to the mandible and
stabilization of the midfacial buttress system
Patient with an impaction special disimpaction forceps
Fixation Plating, wiring, screws
Defect Free bone graft

Landmarks And Hazards

Important landmarks root apices of the teeth, nasal floor,
antrum, infraorbital nerve, orbital floor ethmoid refion,
lacrimal bone and lacrimal sac
Hazards related to :
Unfavorable position of the retromaxillary venous plaxus and
maxillary artery
Damage the infraorbital nerve
Entrapment the infraorbital tissue
Bleeding to antral cavity
Scar formation
Metallic implant foreign body
Infection

Palatal fracture
Dental arc stabilized by
arch bars /
maxillomandibular
fixation
Acrylic palatal split

Reduction of the posterior

gap of a displaced parasgittal
fracture of the palate with a
transosseous wire

Need early reduction 7 10

days
Ideally Open reduction and
fixation by plating devices
Impacted fracture Rowe /
Hayton Williams
Reduced by maxilomandibular
fixation with arch bars / Ivy loops

ROWE FORCEPS

Hayton Williams Forceps

Most requires open

reduction and fixation
at the
zygomaticomaxillary,
infraorbital and/or
frontonasal buttresses

Immobilization minimum for 4 weeks

Expose to infraorbital rim and orbital floor
4 basic incision

It almost require exploration, open reduction and

direct fixation
Minimum of fixation one or two buttresses with ivy
loops, wiring or plating
Incision : gingivolabial
Optimal exposure coronal incision
frontozygomatic and frontonasal,
zygomaticotemporal projection

Requires immobilization of the fragments with

restriction of masticatory activity
Splint ussualy removed at 4 10 weeks
Wire removed after few months
Plate, screw are ussualy lefty in place
Antiseptic solution on the wire
Antibiotic for few days
Decongestan nasal drops
Test for vitality of the teeth and meticulous oral
hygiene to prevent caries and gingivitis
Consistent ophtalmologic follow - up

Steps for surgical treatment

Clinical examination and forced duction test
Protection of the globe
Reduction of the fracture
Assesment of the fracture
Determination of necessity for fixation
Application of fixation device
Internal orbital fixation
Bone graft for the defect
Soft tissue resuspension
Post surgical ocular examination

FRACTURE OF THE ZYGOMATIC ARC

X-RAY : SUBMENTOVERTEX
REDUCTION : GILLIES TECHNIQUE

Gillies Reduction
Temporal Approach

Keen Technique
Bucal Sulcus Approach

Elevation From
Eyebrow Approach

Percutaneous Approach

ZYGOMATIC FRACTURE REPAIR

NOSE
ZYGOMATICO FRONTALIS
FRACTURE LINE

ORBITAL RIM INFERIOR

WATERS POST OPERATIVE

MINI PLATE
MINI PLATE

OLD FRACTURE ZYGOMA

CT 3 DIMENTION

RECONSTRUCTION PROCESS

FRACTURE

CORONAL INCITION APPROACH

HIGHLIGHT

This structurally strong bone at midface

protect the vital organ
The Le Fort classifications define the weakest
areas of the midfacial complex when it is
assaulted from a frontal direction at different
levels
The point of impact and the degree and direction
of the forces determines the type and extent of
the fracture
Goal treatment is functional and cosmetic
rehabilitation
Knowledge of anatomy and techniques will lead
to better results