Mid-Face Fracture Types, Diagnosis and Management

• This chapter presents mid-face fracture types, diagnosis, and management.
• The mid-face consists of vertical, horizontal, and sagittal pillars also known as Buttresses.
• Mid-face fractures are common in different populations.
• Facial fractures are detected in 5-10% of trauma patients.
• Diagnosis of mid-face fractures is difficult.
• Treatment of mid-face fractures is complex due to anatomy of midfacial subunits.
• Quality of life is impacted following the unsuccessful management of mid-face fractures.
• Motor vehicle accidents are the primary cause of midface fractures.
• Other causes are assaults, falls, sport injuries, and animal attacks.

Examination of Trauma Patients

• Airway obstruction should be evaluated.
• Removal of fractured teeth, clots, and loose crowns is required to keep the airway open.
• Airway obstruction is due to the displacement of bones or severe bleeding and secretions.
• Cervical spine stabilization by a rigid collar is necessary until spinal injury is ruled out in facial trauma patients.
• Securing the airway using an Advanced Trauma Life Support (ATLS) protocol ensures, a stable patient, and facial examination is performed.

Le Fort Fractures

• Le Fort fractures are classified into three types.
• Le Fort I: Transverse Maxillary
• Le Fort II: Pyramidal
• Le Fort III: Craniofacial Disjunction

Le Fort I Injury

• Le fort I injury is defined as separation of the maxilla from the mid-face.
• The nasal septum, lateral nasal walls, lateral maxillary sinus wall, and pterygoid plates are involved in the Le Fort I injury.

LE FORT II Fracture

• The Le Fort II fracture is also called the pyramidal fracture.
• Separation of the nasomaxillary complex occurs in a Le Fort II fracture.
• The nasofrontal suture, nasal and lacrimal bones, infraorbital rims, zygomaticomaxillary sutures, and pterygoid plates are affected in Le fort II fractures.

LE FORT III

• The Le Fort III fracture is also known as craniofacial dissociation.
• Le Fort III is identified by separation of the whole mid-face from the skull.
• This fracture involves the nasofrontal and zygomaticofrontal sutures, zygomatic arch, and pterygoid plates.

Clinical Signs and Symptoms found in Le Fort Fractures

• Malocclusion is an important indicator.
• Lateral and medial pterygoid muscles pull the fracture segment posteriorly and inferiorly, leading to an anterior open bite.
• Epistaxis is a common sign in all three Le Fort fracture patterns.
• Hypoesthesia of the infraorbital nerve appears in types I and II.
• Bilateral periorbital ecchymosis, also called raccoon eyes, is a classic sign of Le Fort II and III fractures.
• Clinicians must be aware of cerebrospinal fluid (CSF) leak possibilities during Le Fort II and III fractures.

Management of Le Fort Fractures

• Open or closed techniques for Le Fort fracture management are dependent on the mobility of the maxilla.
• Minor maxillary displacement and malocclusion are indications for closed treatment.
• A closed technique is performed by maxillomandibular fixation (MMF) or skeletal suspension.
• Mobile maxilla with severe malocclusion is treated with open reduction and internal fixation (ORIF).
• Lateral nasal walls and zygomatic buttresses are used to provide stability with four plates to manage a Le Fort I fracture.
• Displaced Le Fort II fractures are treated by ORIF of bilateral infraorbital rims and zygomatic buttresses using a miniplate to fix the nasofrontal suture.
• Esthetic problems following Le Fort III fracture, dish-face deformity, are the primary indications of ORIF treatment.

Palatal Fractures

• Hendrickson et al. classified palatal fractures into six anatomical patterns.
• Type I is categorized into anterior and posterolateral fractures.
• Type 1a (Anterior): Palatal fracture involves the incisor teeth.
• Type 1b: Palatal fracture involves the posterior teeth.
• Type II is defined as a sagittal fracture, less common in adults.
• Type III: Para-sagittal fracture occurs in the palate lateral to the vomer attachment.
• The anterior limit of Type III is between the canine teeth extending to the pyriform aperture.
• Type III extends posteriorly to the tuberosity or the midline.
• Type IV: Para-alveolar fracture is a variant of Type III, with the fracture line tracking medial to the alveolar bone of maxilla.
• complex fracture with comminution fragments
• Type V: Complex fracture with comminution fragments.
• Type VI: Is a transverse palatal fracture.
• Type VI fractures are the least common type of palatal fracture.

Signs And Symptoms of Palatal Fractures

• Mobility of alveolar segments results in malocclusion.
• Ecchymosis of the palate indicates the line of fracture.

Management of Palatal Fractures

• Follow-up and no intervention is applied when the occlusion is good, and the fractured segment is minimally displaced.
• MMF is the treatment of choice for moderately displaced palatal fractures unless MMF is contraindicated.
• Gunning use and palatal splints are alternative methods for closed treatment of palatal fractures.
• ORIF is suggested for severely mobile and displaced patterns to prevent splaying of the fragments.

Orbital Fractures

• These are classified into various categories.
• The most common is the Orbital floor fracture which is often detected as a blow-out fracture.
• Orbital roof fractures are the most common in pediatric populations.
• Medial or lateral wall involvement are less common orbital fractures.
• Combined orbital fractures involve all four orbital walls.
• Combined orbital fractures are the least common.
• These lead to both functional and esthetic problems.

Orbital Fractures: Signs and Symptoms

• Subconjunctival hemorrhage and periorbital ecchymosis are signs.
• Infraorbital nerve hypoesthesia is a common symptom.
• Enophthalmus may occur.
• Diplopia has been reported.
• Entrapment of extraocular muscles can occur.
• Forced duction tests are helpful in differentiating between muscle entrapment and neurologic disturbance.
• The forced duction test is sometimes falsely positive due to post-injury edema.
• Diplopia is a common symptom, especially with medial fracture patterns.
• Infraorbital nerve hypoesthesia is a finding when the infraorbital rim is involved.
• Subconjunctival hemorrhage and periorbital ecchymosis has been observed.
• Enophthalmus is usually a result of increased orbital volume or loss of orbital content, specifically orbital fat.

Management of Orbital Fractures

• Non- or minimally displaced fractures require observation.
• No intervention is needed when there are no ocular problems, including diplopia or enophthalmos.
• Fracture size, timing of the reconstruction, and biomaterials for reconstruction are crucial issues in orbital fracture repair.
• Defects over 50% of the orbital wall or 2 cm in length should be treated.
• Enophthalmos and positive-forced duction tests are indications for management of orbital wall fractures.
• Immediate orbital fracture repair is done within 24 hours; early is between 1-14 days; delayed is two weeks after the injury.
• Immediate repair is used when there is muscle entrapment.
• Early orbital reconstruction is used if there is early enophthalmos, diplopia with a positive forced duction test, and large orbital defects (over 50%).
• Delayed orbital reconstructions include diplopia with a negative forced duction test and late-onset enophthalmos.

Naso-Orbital-Ethmoid (NOE) Fractures

• These are classified into three.
• Type I NOE fracture includes the medial tendon being attached to the fractured segment.
• Type II NOE fracture: has comminuted fragments external to the medial canthal tendon insertion.
• Type III NOE fracture: the fracture extends into the medial canthal insertion segment, and the medial canthal tendon is not attached to the central.

Signs and Symptoms of Naso-Orbital-Ethmoid (NOE) fractures

• Epistaxis
• Splayed nasal complex and widened nasal bridge.
• Traumatic telecanthus: in the case of medial canthal tendon detachment
• The intercanthal distance is usually half the interpupillary distance (average of 28-35 mm in white adults).
• Traumatic telecanthus is defined when that measure is more than 40 mm, or half the interpupillary distance.
• A bimanual test detects instability.

Management of (NOE) fractures.

• Stabilization of the fractured segment is the intervention for type I NOE.
• Stabilizing the central fragment, in which the medial canthal tendon is inserted, is the treatment of choice in a type II fracture.
• Transnasal wiring performed simultaneously with orbital medial wall reconstruction in type III cases

Surgical Approaches in the Treatment of Midface Fractures

• Intraoral approaches
• Intraoral approach and vestibular incision are the most common techniques.
• Circum-vestibular incision mesial to the second premolar reaches the nasal lateral walls and zygomatic buttresses.
• Extraoral approaches, bicoronal flaps are the common approach.
• A good approach in repairing NOE fracture.
• Incisions are made several centimeters behind the hair from one superior temporal line over to the other.
• Dissection of the flaps is performed in the subgaleal plane up to 2 cm above the superior orbital rims.
• The periosteum is incised at this level and subperiosteal dissection continues to expose the zygomaticofrontal and nasofrontal sutures
• If there is no displacement of the nasofrontal suture, fixation of zygomaticofrontal sutures is applicable by the lateral brow approach.
• The advantages of the technique are a less noticeable scar and no adjacent anatomical disturbance.

Periorbital Approaches

• Used for orbital and Le Fort II fracture reconstructions.
• Classified based on the distance from the gray line on the lower eye lid.
• Subciliary incision applies when the distance is about 2–3 mm.
• mid-lower lid or subtarsal approach is used, and distance is almost 3–4 mm to the gray line
• Start a few millimeters subcutaneously, followed by orbicularis oculi muscle dissection to best avoid the possibility of ectropion.
• In the Transconjunctival technique the incision is made parallel to the gray line through the conjunctive.
• Because of its invisible scar use of lateral canthotomy and inferior cantholysis are used when the surgeon needs to provide access to the orbit.

Conclusions

• The mid-face is of esthetic and functiona, repairs of facial deformities are difficult
• Accurate diagnosis injuries on the facial bones is important for treatment planning
• The surgeon should have knowledge of facial anatomy and physiology to reconstruct the fractured segments; deformity following facial trauma becomes hard to repair with any second surgeries.
• The goal of the 1st surgery is to address all problems.