Mid- face fractures

Management
 Algorithm for management
1. Airway & Breathing Related to nasal
2. Control of hemorrhage and oral cavities

3. Types of fracture: Simple, compound,

complex, comminuted, greenstick,
pathological

4. Management of soft tissue injuries &

associated dentoalveolar fractures
5. Basic aims of treatment protocol-
a) Restoring function
b) Restoring esthetics
c) Relieving injury to important anatomic
structures

6. Decision of open/ closed reduction

7. Steps in management- Reduction

Fixation
Immobilization
8. Methods of inducing general anesthesia
a) Nasotracheal intubation
b) Orotracheal intubation
c) Submental/ sublingual intubation

9. Hardware used
a) For reduction- forceps, elevators
b) For fixation- wires, arch bars, bone plates &
screws, pins
c) For immobilization- suspension wiring, pins
& frames
10. Access incisions: Intra oral/ extra oral

11. Areas/ ridges used for fixation

Management of soft tissue injuries
• Lacerations
• Steps:
1. Cleaning and debridement
2. Removal of foreign bodies, necrotic tissue
3. Irrigation
4. Freshening of wound margins
5. Approximation and suturing
6. Dressing
• Abrasions
• Steps:
1. Cleaning and debridement
2. Occlusive dressing
Management of dentoalveolar fractures
• Use of self cure acrylic resin
1. Cap splint
Management of dentoalveolar fractures
• Use of self cure acrylic resin
2. Lateral compression splints
Management of dentoalveolar fractures
• Use of self cure acrylic resin
3. Palatal splint
Management of dentoalveolar fractures
• Use of self cure acrylic resin
4. Gunning splint
Fabrication of Gunning splint
Management of dentoalveolar fractures

• Use of patient’s existing dentures

Management of dentoalveolar fractures
• Composite splinting
Use of a wire and composite
Management of dentoalveolar fractures

• Wiring:
1. Bridle wiring
Gilmer’s Wiring Ivy Loops
• Colonel Stout’s wiring
Ernst wiring
• Arch bars
1. Erich arch bars
2. Jelenko 3. Krupp
• Orthodontic brackets
 Aims of Treatment
1. Restoration of function
• Occlusion  achieving a stable occlusion by
correcting open bite, cross bites

• Oral opening  relieving hindrance to oral

opening

• Vision  correction of diplopia and other

visual abnormalities
 Aims of Treatment
2. Restoration of esthtics:
• Correction of dystopia (orbital fractures)
• Restoring the zygomatic contour of face (ZMC
fractures)
• Restoring the intercanthal width (NOE
fractures)
• Correction of facial height (LeFort II and III
fractures)
 Aims of Treatment
3. Relieving injury to important anatomic
structures

• Extra ocular muscles in orbital fractures

• Infraorbital nerve in ZMC fractures
• Pressure on coronoid process due to
impingement of fractures zygomatic arch
 Open v/s Closed Reduction
OPEN CLOSED

1. Displaced fractures 1. Simple, undisplaced

2. Old/ malunited/ fractures
impacted fractures 2. Greenstick fractures
3. Unstable 3. Pediatric patients
fracture/unfavorable 4. Medically compromised
muscle pull patients
4. Multiple fractures
5. Mentally compromised
patient
 FIXATION

Indirect Direct

External Internal Internal

 Fixation
• Indirect- external
1. Facial frames
2. Plaster of Paris head cap
3. Pin fixation
• Advantage:
Extremely rigid fixation

• Disadvantages:
1. Cumbersome to fix
2. External scars at fixation site
3. Infection
4. Cleaning of face/ shaving is impossible
5. Increased hospital stay
 Fixation
• Indirect: Internal
1. Suspensory wiring
a) Frontozygomatic
b) Glabella
c) Circumzygomatic
d) Pyriform Aperture
e) Circumandibular
f) Infraorbital rim
2. Wiring techniques – Gilmer’s, Ivy loops, Col.
Stout multiloop, Ernst

3. Arch bars

4. Lateral compression splints

5. Cap splints
• Advantages:
1. Minimal access & cosmetic disturbance
2. Not visible externally

• Disadvantages:
1. Non rigid
2. Longer treatment duration
 Fixation
• Direct- Internal
1. Intra-osseous wires
2. Bone plates and screws

Miniplates- Semi rigid fixation

 DCP

(RIGID FIXATION)

Recon plate
• Bio degradable plates
• Advantages:
1. Early return to function
2. Precise alignment possible
3. Early discharge from hospital
4. Better patient compliance

• Disadvantages:
1. Stripping of tissues
2. Compromised blood supply
3. Infection
4. Rejection of hardware
2. Bone plates and screws

Miniplates- Semi rigid fixation

 Armamentarium

Rowe’s Disimpaction Forceps

Hayton William Forceps
Asche’s septum forceps
Walsham’s forceps
Bristow’s Elevator
Rowe’s Zygomatic Elevator
 Approaches to the Mid Face

• Various incisions used to gain access to the

fracture site
• May be extra oral or intra oral
• Esthetic considerations
 Intubation methods

1. Naso-endotracheal intubation
2. Oro- tracheal intubation
3. Submental/ sublingual intubation
Nasotracheal
Orotracheal
Submental intubation
Facial Buttresses
• Approach to the maxilla- Buccal vestibule
approach
 Treatment of LeFort I Fractures
• Incision : Buccal vestibular incision
 Treatment of LeFort I Fractures
• Reduction
 Treatment of LeFort I Fractures
• Fixation: Four-point fixation- stabilization of
the midfacial buttresses.
• Areas of fixation
 Treatment of LeFort II Fractures
• Incision:

1. Nasofrontal suture area is intact  bilateral intraoral

exposure

2. Orbital floor, inferior orbital rim, or nasofrontal

region requires exploration and repair 
infraorbital, subciliary, subtarsal, and
transconjunctival incisions
• Approach to the maxilla- Buccal vestibule
approach
• Approaches to the orbital floor and infra
orbital rim Subciliary (A, synonym: lower
blepharoplasty)

Subtarsal (B, synonym: lower or

mideyelid)

Infraorbital (C, synonym:

inferior orbital rim)

The subciliary approach can be

extended laterally to gain access
to the lateral orbital rim (D).
 Treatment of LeFort II Fractures
• Incisions:
1. Infraorbital
 4.5 mm inferior to grey line
 Advantage: Ease of access
 Disadvantages- Potential poor healing, distortion of lower lid

2. Subciliary
 2-3 mm inferior to grey line
 Advantage: Esthetic
 Disadvntage Potential for ectropion
 Treatment of LeFort II Fractures
3. Subtarsal
 3-4 mm below grey line
 Limits lower lid distortion and ectropion

4. Transconjunctival
 Through the conjunctiva, parallel to grey line
 Excellent esthetics
• Fixation for LeFort II
• Fixation
 Treatment of LeFort III Fractures
• Incision: Coronal flap
Reduction for LeFort III Fractures
• Fixation
 ZYGOMA & ZYGOMATIC ARCH #
• Rationale for active Intervention
1.) Functional - Hampered mandibular movements
- Disturbed Occlusion
- Altered Vision
2.) Cosmetics - Flattening of Malar eminence
- Stepping at Infra orbital rim
3.) Entrapment of Soft tissue structures
- Infra Orbital Nerve
- Peri orbital tissues
 Treatment of ZMC Fractures
• Rationale for treatment:
1. Function
a) Diplopia
b) Reduced mouth opening
 Treatment of ZMC Fractures
• Rationale for treatment:
2. Esthetics: Depression of malar prominence
 Treatment of ZMC Fractures
3. Impingement of soft tissues: Entrapment of
infraorbital nerve leading to paresthesia/ anesthesia
 Treatment of ZMC Fractures
• Incisions:
1. Keen’s Approach (intraoral)
2. Dingman’s approach
 Treatment of ZMC Fractures
3. Hemicoronal/ coronal approach
 Treatment of ZMC Fractures
4. Supraorbital eyebrow approach
Used for access to the frontozygomatic suture
 Treatment of ZMC Fractures
Management of arch fractures
5. Gillie’s temporal approach
 Placed 2.5 cm above and anterior to the helix of the ear
 Incision is 2.5 cm angled anterosuperior to posterosuperior
 Incision should be above the point of division of the fascia
 Treatment of ZMC Fractures
• Gillie’s temporal approach
 Treatment of ZMC Fractures
6. Lower lid approaches:
 Infraorbital approach
 Subtarsal approach
 Subciliary approach
 Transconjunctival approach
7. Pre- auricular approach
 Treatment of ZMC Fractures
• Reduction
1. Bristow’s elevator
2. Rowe’s Zygomatic Elevator
Use of Bristow’s elevator through Keen’s approach
Instruments used for reduction of ZMC complex; Straight elevator,
handle of extraction forceps or a flat tipped instrument
Percutaneous approach
using a bone hook
Reduction of zygoma using a Carroll- Girard bone screw
• Circumzygomatic wiring
 Treatment of ZMC Fractures

• Fixation of the fracture

 One point fixation

Vestibular approach
Three point fixation
Four point fixation
 Treatment of Orbital Fractures
• Structure of the bony orbit
• Extra ocular muscles
 Treatment of Orbital Fractures
• Rationale for open reduction
1. Function: Diplopia
a) Entrapment of extra ocular muscles
b) Dystopia
c) Oedema
2. Esthetics
a) Dystopia
b) Enophthlamos
 Diplopia

Monocular Binocular

1. Detachment of lens 1. Physical interference

(oedema, muscle
2. Traumatic injury to entrapment
globe
2. Functional interference
(displacement of globe)
3. Neurological causes
 Treatment of Orbital Fractures
• Incisions:
1. Lower lid incisions
 Infraorbital approach
 Subtarsal approach
 Subciliary approach
 Transconjunctival approach
• Approaches to the orbital floor and infra
orbital rim Subciliary (A, synonym: lower
blepharoplasty)

Subtarsal (B, synonym: lower or

mideyelid)

Infraorbital (C, synonym:

inferior orbital rim)

The subciliary approach can be

extended laterally to gain access
to the lateral orbital rim (D).
• Approaches to the orbital floor and infra
orbital rim

Transconjunctival Approach
Ectropion and Intropion
Ectropion

Entropion
• Reduction of the displaced contents
• Reconstruction of the orbital floor
• Plating of the infraorbital margin through
intraoral approach
• Supporting the orbital floor with an antral
balloon
• Packing the maxillary sinus with a ribbon
gauze
 Treatment of Nasal Fractures
• Rationale for open reduction
1. Function
a) Airway obstruction
b) Anosmia

2. Esthetics
 Treatment of Nasal Fractures
• Armamentarium
1. Asche’s septum forceps
 Treatment of Nasal Fractures
2. Walsham’s forceps
 Treatment of Nasal Fractures
3. Periosteal elevator: used in case of pediatric
nasal fractures
 Treatment of Nasal Fractures
• Stabilization: Intranasal packing may be done
and the external nose is supported with a splint
Plaster of Paris splint
Thermoplastic splint may be used
 Post Operative Care
• Appropriate antibiotic and analgesic cover

• Steroids to be used where necessary

• Nutritional and calcium supplements

 Post Operative Care
• Avoid pressure on the fracture site
 Post Operative Care
• Packing the sinus to support the orbital floor
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