Chẩn Đoán Và Điều Trị Phẫu Thuật Tái Tạo Hiện Đại (CURRENT Reconstructive Surgery)

22
Orbital Fractures and Deformities
Joshua Fosnot, MD / Joseph M. Serletti, MD, FACS
INTRODUCTION
The orbit is a complex union of multiple bones of the
facial skeleton that together provide structure for and
house one of the most important sensory organs of the
human body: the eye. Although this space provides
ample support for normal function and protects against
minor trauma, it is prone to fracture in major facial
trauma and the resultant deformities can create either
an ophthalmologic emergency, poor cosmetic defect, or
both. The management of orbital fractures and defor-
mities has advanced signifi cantly owing to an improved
understanding of the complex anatomy, traumatic
mechanisms, refi ned imaging, and the advancement of
implantable materials for reconstruction. Although
facial trauma often is not isolated to the orbit alone, this
chapter will focus on the identifi cation and management
of the orbital component of facial trauma and resultant
deformities; whereas, other chapters will focus on frac-
tures including the naso-orbitoethmoid (NOE), zygoma-
ticomaxillary complex (ZMC), panfacial fractures, and
soft tissue injuries.
Orbital Anatomy
A thorough understanding of orbital anatomy is para-
mount to the overall appreciation of pathologic pro-
cesses and resultant management of orbital trauma. The
bony orbit is composed of the seven separate bones of
the membranous facial skeleton. These include the fron-
tal, sphenoid, zygomatic, maxillary, ethmoid, lacrimal,
and palatine bones ( Figure 22-1 ). The overall space cre-
ated by this arrangement is roughly pyramidal in shape,
with the base anteriorly and apex posteriorly oriented,
respectively. The anterior rim bony margin is fairly dense
bone giving the outer edge strength for resistance to frac-
ture. The same is true for the posterior apex, as this area
is composed primarily of the cranial fl oor. The bone of
the middle third of the orbit is weak and thin walled by
comparison; thus, it is here that the effects of traumatic
insult are usually seen. This is particularly true for the
inferior wall or fl oor of the orbit. Composed of the max-
illa, the fl oor separates the orbit from the maxillary sinus.
Laterally, the orbit is a bit hardier. Through this wall,
made up of the greater wing of the sphenoid and the
zygoma, lies the temporal fossa. Also fairly resilient, the
superior orbital wall lies under the frontal sinus and ante-
rior cranial fossa and is created by the lesser wing of the
sphenoid and the frontal bone. The orbits are separated
in the midline by the interorbital space—defi ned by the
nasal cavity and the ethmoid and sphenoid sinuses. The
largest portion of the ethmoid, the lamina papyracea,
is the weakest portion of the medial wall and is prone
to fracture. Also contributing to this wall are the lacri-
mal bone and portions of the frontal, maxilla, and lesser
sphenoid.
The optic nerve passes through the optic foramen at the
junction of the sphenoid and ethmoid bones along with the
ophthalmic artery. Between the lesser and greater wings of
the sphenoid bone lies the superior orbital fi ssure. Through
this cleft pass the motor nerves to the extraocular mus-
cles and the ophthalmic division of the trigeminal nerve.
The inferior orbital fi ssure allows passage of the maxillary
division of the trigeminal nerve, the infraorbital artery,
zygomatic nerve, autonomic nerve fi bers, and branches of
the ophthalmic vein ( Figure 22-2 ).
The periorbita (periosteum) lines the orbit and is con-
tinuous with the dura of the cranial vault. The soft tissue
of the orbit consists of the globe itself, extraocular mus-
cles, lacrimal system, fat, nerves, and vessels. The bulbar
fascia (Tenon capsule) surrounds the globe and is inter-
connected to a series of intermuscular and muscle sheath
fascia to ensure that all of the intraorbital contents move
in unison. Due to this interconnection, entrapment of
even orbital fat may lead to signifi cant visual disturbance.
c h a p t e r

234 • CHAPTER 22
All of the extraocular muscles, except for the inferior
oblique, originate from a common periosteal thickening
around the optic nerve called the annulus of Zinn. These
muscles work in concert to move the globes in unison.
The anterior orbit of course is bounded by the eyelids.
The canthal tendons are attached to the maxilla medially
and the zygoma laterally.
PATIENT EVALUATION
As previously stated, isolated orbital trauma is quite rare.
The impact energy necessary to impart a fracture usually
results in additional traumatic injury. This may result in
concomitant facial fractures, or trauma throughout the
body. As most facial trauma is not life-threatening, it is
FIGURE 22-1. (A) Anterior view of bones of right orbit. (B) Medial view of bony wall
of left orbit. (Reprinted with permission from Riordan-Eva P, Whitcher JP. Vaughan & Asbury’s
General Ophthalmology. 17th ed. New York: McGraw-Hill; 2008.)
Orbital plate of frontal bone
Superior orbital fissure
Inferior orbital fissure
Greater wing of sphenoid
Orbital surface of
zygomatic bone
Orbital surface of maxilla
Infraorbital groove
Supraorbital notch
Lesser wing of sphenoid
Optic foramen
Ethmoid bone
Lacrimal groove
Lacrimal bone
Infraorbital foramen
A
Lacrimal fossa
Lacrimal bone
Orbital part of frontal bone
Orbital process
of palatine bone
Ethmoid bone
Sphenoid bone
Anterior ethmoidal foramen
Posterior ethmoidal foramen
Optic foramen
Sphenopalatine foramen
Infraorbital groove in
orbital surface of maxilla
B

ORBITAL FRACTURES AND DEFORMITIES • 235
important to recognize and treat major injuries fi rst, with
proper timing of evaluation and treatment of orbital injury
decided through open dialogue with the trauma surgeon.
Orbital trauma is most frequent in the young adult and
adolescent male patient population. The most frequent
mechanisms of injury are assault and motor vehicle col-
lision. In children, orbital injury is more common in boys
who are older in age. The common mechanisms are most
frequently related to sports or play. The mechanism of iso-
lated orbital fractures typically involves an object (fi st, bat,
etc.) compressing the soft tissue and globe in an anterior
projection, effectively creating a hydraulic press, which
leads to volume expansion and “blow out” of the thin walls
of the orbit.
When a patient presents for evaluation, a detailed his-
tory and physical are an essential starting point. The mech-
anistic details are important; however, the most prudent
information is related to the visual axis. Patients should be
asked about specifi c changes in vision either immediately
after or delayed following traumatic insult. Floaters and
fl ashes may indicate additional pathology such as a retinal
detachment. One should specifi cally ask about diplopia
which may indicate entrapment. Also pertinent however,
is the prior ocular/visual history such as use of glasses, his-
tory of amblyopia, or prior ocular trauma. If the patient is
unconscious or unable to participate, one should take the
time to ask family or friends if they are available.
General Exam
The plastic surgeon should be familiar with a basic visual
examination, although a formal examination including
dilated funduscopic exam is generally warranted by an oph-
thalmologist as well. Contact lenses should be removed to
prevent possible corneal injury. Old photographs are useful
for comparison, especially in patients with severe complex
facial injuries. The physical examination generally begins
with inspection for any obvious trauma and palpation of
the periorbital bone and soft tissue. The bony orbital rims
are palpated for irregularities or tenderness and this is fol-
lowed by evaluation of eyelid movement, including proper
opening and closure. Exophthalmos (anterior malposition
FIGURE 22-2. (A) Anterior view of apex of right orbit.
Trochlear nerve
Frontal nerve
Lacrimal nerve
Superior
ophthalmic vein
Superior orbital
fissure
Lateral rectus
muscle
Inferior rectus
muscle
Inferior orbital fissure
Inferior ophthalmic vein
Abducens nerve
Oculomotor nerve:
superior and
inferior divisions
Nasociliary nerve
Ophthalmic artery
Medial
rectus
muscle
Superior
oblique
muscle
Optic nerve
Levator muscle
Superior rectus muscle
A

236 • CHAPTER 22
FIGURE 22-2. (continued)
(B) Vascular supply to the eye. All
arterial branches originate with the
ophthalmic artery. Venous drainage
is through the cavernous sinus and
the pterygoid plexus. (C) Venous
drainage system of the eye.
Angular vein
Inferior ophthalmic vein
Pterygoid plexus
Anterior facial vein
Submental vein
Superior sagittal sinus
Inferior sagittal sinus
Posterior facial vein
Internal jugular vein
Occipital vein
Superficial temporal vein
Posterior auricular vein
Occipital diploid vein
Cavernous sinus
Superior ophthalmic vein
Frontal vein
Nasofrontal vein
External jugular vein
Vessels of
ciliary body
Minor arterial
circle of iris
Major arterial
circle of iris
Conjunctival vessels
Anterior ciliary vessels
Episcleral vessels
Vortex vein
Choroidal vessels
Retinal vessels
Long posterior ciliary artery
Short posterior ciliary arteries
Dural vessels
Central vessels
of retina
Pial vessels
B
C

ORBITAL FRACTURES AND DEFORMITIES • 237
FIGURE 22-2. (continued) (D) Internal structures of the human eye. (E) Fascia
about muscles and eyeball (Tenon capsule). (F) Check ligaments of medial and lateral
rectus muscles, right eye (diagrammatic). (Reprinted with permission from Riordan-Eva P,
Whitcher JP. Vaughan & Asbury’s General Ophthalmology. 17th ed. New York: McGraw-Hill; 2008.)
Lens
Lens
Lens
Cornea
Pupil
Iris
Anterior chamber angle
Episcleral veins
Posterior chamber
Ciliary body
Pars plana
Pars plicata
Lens capsule
Medial rectus
muscle
Ora serrata
Retina
Choroid
Sclera
Vitreous
Retinal pigment
epithelium
Retinal arterioles and veins
Lamina cribrosa
Arachnoid
Optic nerve
Pia
Central retinal artery and vein
Dura
Optic disk
Long posterior ciliary artery
and long ciliary nerve
Macula
Vortex vein
Sclera
Canal of Schlemm
Conjunctiva
Lateral rectus
muscle
Choroid
Zonule
Retina
Retina
Retina
D
Superior oblique muscle
Inferior oblique muscle
Superior rectus muscle
Inferior rectus muscle
Tenon capsule
E
Check ligament of
medial rectus muscle
Ethmoid
bone
Check ligament of
lateral rectus muscle
F

238 • CHAPTER 22
of the globe) or enophthalmos (posterior malposition of
the globe) are best documented by looking down over the
patient from above the forehead, or by looking up from
below the chin.
Mobility
The patient should be asked to move his eyes in all direc-
tions with specifi c attention to disconjugate gaze or a com-
plaint of diplopia. This can be done quickly by asking the
patient to follow the examiner’s fi nger; however, use of a
penlight is a more sensitive test for documenting a discon-
jugate state. If there is concern for a mechanical restriction,
a forced duction test may be performed in which the con-
junctiva is anesthetized with a topical agent placed into
the lower fornix and the globe is manually manipulated by
grasping the muscle in question with forceps.
Visual Acuity
The standard approach to documenting visual acuity
remains the Snellen eye chart, in which a patient reads char-
acters of varying sizes from a 20-foot distance. In trauma
patients, often this test is not possible due to the inabil-
ity to stand and/or participate. In this case, a Rosenbaum
pocket chart may be used in which a patient holds a card
at a reading distance. In any test of visual acuity, glasses or
contact lenses should be used for examination. Changes
in visual acuity are particularly alarming for either nerve
or intrinsic structural problems with the visual axis, all of
which are ophthalmologic emergencies.
Pupil Exam
The pupil size and shape should be documented at base-
line prior to light examination. Anisocoria (asymmetric
pupil size) can be normal; however, it is more likely to
be an indication of a more sinister process. An abnor-
mally shaped pupil may be indicative of a ruptured globe
or displaced lens. The light is next shone in each eye and
removed individually. Both eyes should constrict and relax
in unison and equally. A relative afferent pupillary defect
or Marcus Gunn pupil is present when the eyes constrict
equally relative to one another; however, when light is
shone in the affected side, the response is less intense bilat-
erally. This may be indicative of a receptive neurologic
defect, vitreal hemorrhage, or retinal injury.
Imaging
While historically, plain x-ray fi lms were obtained to guide
diagnosis and treatment, this has largely been replaced by
faster and more powerful CT scanning with computer-
aided reconstruction and/or modeling. Although plain
fi lms may be helpful to screen patients at low risk for frac-
ture in an effort to avoid the radiation dose of a CT, if a CT
is to be obtained, plain fi lms can be avoided.
CT scanning is the gold standard for diagnosis and clar-
ifi cation of the extent of orbital injury in trauma. Facial
protocol CT scanning with 1 to 3 mm sections in axial
acquisition with sagittal and coronal reformatting is stan-
dard to evaluate the face thoroughly. CT is very sensitive
for picking up fractures and can also clarify soft tissue
involvement, hematoma, and entrapment or herniation
( Figure 22-3 ). In fact, studies have shown decent accuracy
in predicting eventual enophthalmos through the use of
CT imaging and computer modeling. 1
While ultrasound is incredibly useful for evaluating the
extent of injury within the globe itself, its use in diagnosing
bony injury is limited. Likewise, MRI can be useful to fur-
ther characterize soft tissue abnormalities such as tumor;
however, its use in trauma is rare due to expense, speed,
and availability.
Deformities
The most common fracture from blunt orbital trauma is
the inferior wall blowout fracture medial to the groove
of the infraortibal nerve with extension onto the inferior
portion of the medial orbital wall. In one series, this pattern
occurred in roughly 40% of isolated orbital trauma. 2 In this
same series, fractures of the orbit involved NOE or ZMC
over 50% of the time. Although fl oor and medial wall frac-
tures are the most common injury patterns, patients may
present with lateral wall or roof fractures with resultant
deformities.
One clinical deformity common to many orbital frac-
tures is enophthalmos whereby the globe is inferiorly and
posteriorly displaced ( Figure 22-4 ). In addition, examina-
tion may show pseudoptosis in which the superior eye-
lid appears to droop with a deepened superior tarsal fold.
If enophthalmos is not initially present in the setting of
a known fracture, this does not mean it will not develop
later. Often, there is concomitant edema and/or hema-
toma which masks the ability to predict the position of
the globe in the future. This may be particularly true in
cases where the zygoma is fractured as well. The etiology
of enophthalmos has been studied extensively with several
different theories; however, it is likely the combined effect
of increased orbital bony volume, fat herniation into the
maxillary sinus and fat atrophy. All contribute to a globe
to orbit volume discrepancy. 3
In addition to enophthalmos, entrapment is one of the
more common conditions resulting from an inferior wall
blowout fracture. In this condition, the periorbital fat or
extraocular muscles become caught in the fracture line or
wall deformity. This tissue is interlaced with a fi ne network
of fascia and as a result may result in tethering and restric-
tion of motion. Due to restriction of motion of the inferior
orbital contents, the most common clinical symptom is
diplopia in superior gaze. The degree of diplopia is usually
proportional to the degree of tissue entrapment and restric-
tion may be further documented with forced duction. It is
important to recognize, however, that diplopia can occur
with a small nondisplaced fracture as well due to hematoma
and edema limiting motion. This type of diplopia is usually
temporary and resolves without intervention. Entrapment

ORBITAL FRACTURES AND DEFORMITIES • 239
and resultant diplopia is more common in children owing
to more fl exible bone. A linear fracture in children snaps
back into place leading to a trapdoor with incarcerated
contents; whereas, in adults the fracture tends to result in
multiple fragments and a frank defect. Due to this trapdoor
effect, children without any sign of trauma can present
with severe diplopia and oculocardiac refl ex symptomatol-
ogy, the so-called “white-eyed blowout” fracture.
On examination, binocular diplopia must be distin-
guished from monocular diplopia. The occlusion test
is useful for this purpose. Each eye is alternatively cov-
ered and the patient is asked to report the presence or
absence of diplopia. In diplopia resultant from disconju-
gate gaze, the patient’s symptoms resolve with covering
of either eye. The examiner should look at the uncov-
ered eye to determine what corrective measures the eye
makes when the contralateral side is occluded. This test
helps differentiate vertical from horizontal diplopia. If the
diplopia is present in one eye when the other is covered,
this is called monocular diplopia. This may be the result
of diffraction errors from corneal or lens pathology or a
supratentorial problem.
Orbital Apex Syndrome
Although the vast majority of orbital trauma results in frac-
ture of the middle third of the orbit involving thin bone,
occasionally posterior orbital fractures do occur. When this
occurs, the fracture typically involves the superior orbital
fi ssure and may include optic nerve injury. The pentad of
fi ndings includes loss of vision, ophthalmoplegia, ptosis,
pupillary dilation, and anaesthesia of the upper eyelid—
together known as orbital apex syndrome. While tradition-
ally this fi nding was considered permanent obviating the
FIGURE 22-3. This patient was punched
in the left eye and presented with a complaint of
paraesthesias of the left upper lip extending up to the
left eye. (A, B) Two coronal sections of a CT scan of
the face showing a left orbital fl oor blowout fracture
with herniation of the orbital contents including
the inferior rectus muscle into the maxillary sinus.
(C) Axial imaging of the same patient also showing
extensive subcutaneous air due to the maxillary sinus
involvement.
A
C
B

240 • CHAPTER 22
need for surgical intervention, the overall approach has
changed in recent times and surgery has become more
heavily utilized.
PATIENT PREPARATION
The fi nal common indication for any type of orbital frac-
ture is globe malposition or persistent visual changes such
as diplopia. Not all orbital fractures require surgical repair;
however, with proper evaluation and dialogue between
surgeon and patient, the end results should be predictable
through minimally invasive means. Patients with minimal
displacement on CT and no or minimal enophthalmos
or diplopia on examination do not need immediate sur-
gical intervention and may be followed conservatively.
Signifi cant entrapment, enophthalmos of greater than
2 mm, diplopia on primary gaze and fractures occupying
more than 50% of the fl oor are all indications for repair. 4
Although some would argue that conservative manage-
ment will lead to resolution of diplopia and visual changes,
enophthalmos and resultant poor cosmesis rarely, if ever,
resolve spontaneously. Thus, patients should be prepared
for poor cosmetic outcomes without surgery, even if their
vision improves over time.
Timing of orbital fl oor repair has been a controversial
subject historically. The initial thought was that time led
to resolution of symptoms and more predictable surgi-
cal planes. In recent times, there has been a trend toward
early intervention as several studies have shown improved
cosmetic results when surgery is offered within at least
2 weeks, if not immediately. 4 Most would agree that imme-
diate surgical repair is indicated in patients with signifi cant
diplopia in primary or vertical gaze and those with a persis-
tent oculocardiac refl ex (bradycardia, heart block, nausea,
vomiting or syncope). In addition, children with a “white
eye” blowout fracture should be operated on immediately.
Signifi cant immediate enophthalmos will not improve and
warrants immediate repair. Of those patients followed,
many eventually need an operation. Those with persistent
diplopia, latent enophthalmos or progressive lower eyelid
sensory loss all should be operated on by 2 weeks. 5 The
2-week timeline avoids the fi brosis and scarring of waiting
for a prolonged period. If there are concomitant injuries
such as retinal detachment, hyphema, or severe edema,
delayed surgery is still preferred to avoid further injury to
the visual axis.
Once a decision has been made to proceed to the
operating room, the patient should undergo general anes-
thesia and be placed in a supine position with the endotra-
cheal tube taped away from the working fi eld. Reversing
the direction of the table may be helpful. The patient is
prepped and draped and preoperative antibiotics should
be administered. Either a corneal protection device or, in
some cases depending on approach, transpalpebral sutur-
ing may be warranted to protect the cornea.
TECHNIQUE
Orbital Floor Fracture
For repair of an orbital fl oor blowout fracture, the two
most common incisions are transconjunctival and sub-
ciliary. A transoral approach is possible however no lon-
ger recommended. Although results are confl icting, most
authors report improved outcomes with a transconjunc-
tival approach owing to decreased rates of ectropion and
eyelid retraction in the long term. 6 In addition, a transcon-
junctival incision avoids an external scar on the face. A
canthotomy may be necessary to achieve adequate expo-
sure in this approach.
FIGURE 22-4. Preoperative photograph of a patient who had suffered trauma
to the right eye resulting in an orbital blowout fracture. (A) This patient suffered from
enophthalmos, best seen by looking coronally from below the face. (B) Following surgical
repair, the eye is signifi cantly less posteriorly displaced.
A
B

ORBITAL FRACTURES AND DEFORMITIES • 241
When performing the transconjunctival approach,
retraction sutures may be placed opposite one another
on the gray line of the eyelid margin and in the depth of
the fornix for exposure. Using a low setting on the elec-
trocautery, a curvilinear incision is made blow the level
of the tarsus. From here, either a preseptal or postseptal
path to the orbital rim may be chosen. The former tends
to avoid the fat that lies behind the septum allowing for a
less obstructive view. The latter tends to transverse the fat
compartment but leaves the attachment of the septum to
the rim intact and thereby further minimizes the risk of
eyelid retraction and ectropion.
Regardless of the incision, dissection is carried down to
the level of the infraorbital rim. Here, an incision is made
in the periosteum, allowing for a subperiorbital plane
to be developed into the inferior orbit with an elevator
( Figure 22-5 ). With an extensive fracture, the posteriorly
directed dissection will lead to easy identifi cation of the
fracture and dissection continues until the furthest extent
of the fracture is identifi ed. Similarly, the dissection is car-
ried medially and laterally to identify an area around the
fracture to support a graft or implant. Commonly, there
is a medial component of the fracture necessitating fairly
extensive medial dissection. Care should be taken to not
injure the infraorbital nerve at this time.
Once completely dissected, a decision is made as to
the type of implant needed to span the defect and recre-
ate a new fl oor. In the past, the calvarial bone graft was the
workhorse for this application; however, donor site mor-
bidity has led most surgeons away from this technique. In
addition, most of the bone graft is resorbed over time, thus
a thick initial graft is necessary to compensate. This leads
to initial overcorrection which can be unsatisfactory to
the patient. Other autologous options include the conchal
or nasal cartilage graft, although these have a tendency to
warp and in complex fractures, prevent their use for nasal
fracture repair.
As material science has progressed, use of alloplastic
material for reconstruction has become more common.
Alloplastic options include silastic, nylon, polyethylene,
polytetrafl uoroethylene, and titanium. When comparing
alloplastic materials, no one type has been shown to be
FIGURE 22-5. A subciliary incision allows
for adequate exposure of the orbital fl oor and any
traumatic defect in the thin wall of bone. Once
exposed, placement of a graft/implant for structure is
fairly straightforward.
A
B
C

242 • CHAPTER 22
superior to another in a prospective trial. The most com-
monly used implants are Suprafoil (nylon), titanium mesh,
and Medpor Titan (titanium embedded polyethylene).
They are all fairly easy to use, readily available, and avoid
donor site morbidity. Although rare, when infected these
implants do unfortunately require explant.
In cases of complex fractures, the horizontal and verti-
cal buttress system of the orbital rim must be stabilized
and fi xed fi rst (see other chapters for complete descrip-
tion). Only at that time is the implant able to be secured
in place. In the case of a titanium implant, this is typi-
cally done with a single titanium screw driven into the
inferior orbital rim ( Figure 22-6 ). It is crucial that the
posterior edge of the fracture is found and spanned with
the implant to prevent eventual inferior displacement of
the globe or residual hypoglobus. This obviously must be
balanced with caution due to the devastating consequence
of severing the neurovascular structures entering the orbit
from the posterior apex. Once in place, the soft tissue is
re-approximated and closed over the implant. This should
include the periosteum to help prevent implant migration
and fi brosis leading to motility restriction. The surgeon
should ensure no ocular limitation of range of motion with
forced duction prior to allowing the patient to emerge
from anesthesia. If a corneal protection device or trans-
palpebral suturing were used, these should be removed
at this time. Although not performed routinely, repair-
ing the orbital fl oor through a transconjunctival incision
can be performed in standard fashion without closing the
wound. The implant is not fi xed in place and the incision
is not closed primarily. Overall results appear equivalent
in small series, with excellent spontaneous wound closure
and implant stability. 7
Medial Orbital Wall
Historically, a coronal incision was used to reach the medial
orbit, but this is no longer routinely used. Inferomedial
fractures can usually be reached in similar fashion to the
technique described above. True medial or superomedial
fractures typically require a separate incision. Most authors
recommend a transcaruncular or precaruncular incision.
Through this incision, exposure is generally acceptable;
however, care must be taken not to injure the lacrimal sys-
tem. In addition, a W-shaped medial canthal skin incision
may be used with fairly predictable results. The incision is
carried down to the periosteum and the fracture is identi-
fi ed at that time. An implant is used in similar fashion to
the fl oor fracture, although Tisseel glue may be used to
affi x the implant as there is generally less room for screw
fi xation.
Orbital Roof
Fractures of the orbital roof are rarely seen in isolation.
Most commonly, they involve the orbital rim or frontal
sinus and management of this injury pattern will be dis-
cussed in another chapter. Nondisplaced roof fractures do
not require surgical repair, although an isolated roof frac-
ture resulting in signifi cant proptosis should be fi xed sur-
gically. A standard superior blepharoplasty incision allows
for the easiest access to the orbital roof. Through this
incision, the periosteum is easily identifi ed and able to be
lifted in similar fashion to that described above. Care must
be taken to avoid injury to the superior oblique muscle
and lacrimal gland during this dissection. The fracture may
be plated in similar fashion.
Endoscopic Approach
There has been an increasing interest in endoscopic
approaches to medial and fl oor fractures. Through either a
transnasal or transmaxillary sinus approach, this technique
offers excellent visualization of the fracture. In particular,
this technique allows better visualization of the poste-
rior orbit without the need for retraction of the globe. 8
FIGURE 22-6. Placement of an implant is fairly straightforward with adequate
access to the inferior orbital rim (A), and performed with fi xation of the mesh with titanium
screws (B).
B
A

ORBITAL FRACTURES AND DEFORMITIES • 243
Authors have advocated either manual reduction of a
trapdoor, or insertion of an infl atable balloon in the maxil-
lary sinus which allows for bony healing over a month at
which point the balloon is removed. The second branch of
the trigeminal nerve is at greater risk of injury. Although
a novel approach, not all fractures are amenable to this
repair and aside from incision size, there is little if any
added outcome benefi t. 9
COMPLICATIONS
Edema is quite common following orbital trauma and frac-
ture. Steroids have been advocated as a method to decrease
edema and some studies have shown faster resolution of
diplopia and edema even in those who underwent imme-
diate surgical correction. 10 Standard dosing of dexametha-
sone does not appear to interfere with wound healing. 11
Eyelid abnormalities, including hypoaesthesia and ectro-
pion, are common following orbital trauma and subsequent
surgical correction. As noted above, this may be less pro-
nounced if a transconjunctival approach is taken; but over-
all, ectropion may be as high as 12.5%. 6 Transconjunctival
approaches are not without risk however, as this does
place the patient at risk for entropion. As many as 28%
of patients complain of lower eyelid hypoaesthesia likely
from infraorbital nerve injury either from the fracture itself
or subsequent surgery. 2
Retrobulbar hematoma is a potential devastating com-
plication of orbital fracture and can occur with or without
surgical intervention. The managing physician needs to be
immediately aware of any complaint of sudden vision loss,
developing proptosis, periocular ecchymosis, or eye pain.
Surgical evacuation is mandatory to prevent permanent
visual loss.
Given that the sinuses and nasal passages are not ster-
ile and cannot be sterilized in a surgical fi eld, infection is
possible. The use of prophylactic antibiotics to prevent
this is controversial. No randomized control trials exist
to support this practice; however, most surgeons treat
patients with a week of broad spectrum antibiotics follow-
ing surgical repair. Overall infectious risk is roughly 3%. 2
With signifi cant implant infection, the prosthesis needs to
be removed; likewise, severe orbital cellulitis is possible,
necessitating incision and drainage.
OUTCOMES
Following orbital trauma, a patient should follow-up with
an ophthalmologist for a complete eye exam within 1 week
to ensure no changes in vision. Overall, patients tolerate
surgical repair well and assuming no other traumatic injury,
may return to full function soon after repair ( Figure 22-7 ).
Persistent diplopia is particularly meddlesome and should
be discussed with the patient preoperatively. The vast
FIGURE 22-7. (A) Preoperative photograph of a young boy with an isolated left
orbital fl oor fracture. Note the signifi cant periorbital edema and ecchymosis associated
with hypoglobus and enophthalmos. (B) The patient has signifi cant entrapment causing
diplopia in vertical gaze. (C) Postoperative photo of the same patient showing excellent
alignment in primary gaze and (D) resolved entrapment.
A
B
D
C

244 • CHAPTER 22
majority of patients will still complain of diplopia immedi-
ately following surgical intervention and up to one third of
patients with preexisting diplopia will never be completely
asymptomatic. 12 Older patients appear to be at greater risk
for persistent diplopia. 13
One of the primary goals of repair of the orbital
blowout fracture is to correct enophthalmos and pro-
vide for improved overall aesthetics and facial sym-
metry. While surgical repair offers a better chance for
improved cosmesis, not all patients are corrected satis-
factorily. In as much as 2.7% to 7.0% of surgical repairs
for enophthalmos, persistent asymmetry will be present
in long-term follow-up. 2 , 13 Not surprisingly, this is more
common in patients who have suffered multiple facial
fractures.
Although patient satisfaction postoperatively has not
been addressed for isolated orbital fl oor pathology, this has
been studied for complex facial fractures, specifi cally ZMC
with orbital fl oor fracture repair. In this series, 80% of
patients were satisfi ed with their results in the long term.
Reasons for dissatisfaction were primarily centered around
residual diplopia and enophthalmos. 14
REFERENCES
1. Ahn HB, Ryu WY, Yoo KW, et al. Prediction of enophthal-
mos by computer-based volume measurement of orbital
fractures in a Korean population. Ophthal Plast Reconstr
Surg . 2008;24:36–39.
2. Hwang K, You SH, Sohn IA. Analysis of orbital bone frac-
tures: a 12-year study of 391 patients. J Craniofac Surg .
2009;20(4):1218–1223.
3. Clauser L, Galiè M, Pagliaro F, Tieghi R. Posttraumatic
enophthalmos: etiology, principles of reconstruction, and
correction. J Craniofac Surg . 2008;19(2):351–359.
4. Liss J, Stefko ST, Chung WL. Orbital surgery: state of the art.
Oral Maxillofac Surg Clin North Am . 2010;22:59–71.
5. Burnstine MA. Clinical recommendations for repair of iso-
lated orbital fl oor fractures: An evidence-based analysis.
Ophthalmology. 2002;109:1207–1210.
6. Ridgway EB, Chen C, Colakoglu S, et al. The incidence of
lower eyelid malposition after facial fracture repair: a retro-
spective study and meta-analysis comparing subtarsal, sub-
ciliary, and transconjunctival incisions. Plast Reconstr Surg .
2009;124(5):1578–1586.
7. Ho VH, Rowland JP Jr, Linder JS, Fleming JC. Sutureless
transconjunctival repair of orbital blowout fractures. Ophthal
Plast Reconstr Surg . 2004;20:458–460.
8. Farwell DG, Sires BS, Kriet JD, Stanley RB. Endoscopic
repair of orbital blowout fractures. Arch Facial Plast Surg.
2007;9:427–433.
9. Cheong EC, Chen CT, Chen YR. Endoscopic management
of orbital fl oor fractures. Facial Plast Surg . 2009;25:8–16.
10. Flood TR, McManners J, el-Attar A, Moos KF. Randomized
prospective study of the infl uence of steroids on postop-
erative eye-opening after exploration of the orbital fl oor.
Br J Oral Maxillofac Surg . 1999;37:312–315.
11. Thoren H, Snall J, Kormi E, et al. Does perioperative gluco-
corticosteroid treatment correlate with disturbance in surgi-
cal wound healing after treatment of facial fractures? A retro-
spective study. J Oral Maxillofac Surg . 2009;67:1884–1888.
12. Biesman BS, Hornblass A, Lisman R, Kazlas M. Diplopia
after surgical repair of orbital fl oor fractures. Ophthal Plast
Reconstr Surg . 1996;12:9–16; discussion 17.
13. Hosal BM, Beatty RL. Diplopia and enophthalmos after sur-
gical repair of blowout fracture. Orbit . 2002;21:27–33.
14. Folkestad L, Åberg-Bengtsson L, Granström G. Recov-
ery from orbital fl oor fractures: a prospective study of pa-
tients’ and doctors’ experiences. Int J Oral Maxillofac Surg .
2006;35(6):499–505.

23
Frontal Sinus Fractures
Matthew G. Stanwix, MD / Eduardo D. Rodriguez, MD, DDS
c h a p t e r
INTRODUCTION
Frontal sinus fractures represent 5% to 15% of all crani-
omaxillofacial fractures. 1 Improper management leads
to devastating and potentially fatal complications due to
the proximate relationship of the frontal sinus with the
anterior cranial fossa. Concomitant facial fractures along
with associated intracranial and bodily injuries confi rm the
severity of impact required to produce these fractures.
PATIENT EVALUATION AND SELECTION
Evaluation of the patient by the craniomaxillofacial sur-
geon begins with a thorough physical examination to
assess appearance and contour of the frontal sinus region,
presence of a cerebral spinal fl uid leak, associated frac-
tures and injuries, and neurological status. Although this
initial assessment gives an overall impression of the injury,
computed tomography (CT) scans direct patient selection
and evaluation. Fine, thin sections in a multidetector CT
scanner can provide near-anatomic representation of the
fracture pattern. Radiographic evaluation must assess the
table(s) involved, presence or displacement or comminu-
tion, sidedness (with regard to intersinus septum), and
degree of nasofrontal outfl ow tract injury.
Injury to the nasofrontal outfl ow tract stands as the cor-
nerstone of treatment; its presence or absence will predict
complications in surgical or conservative management. 1 , 2
Note the use of the term nasofrontal outfl ow tracts in this
chapter, as only 15% or individuals have a true nasofrontal
duct, while the majority drains directly into the anterior
ethmoidal cells. 1 There are three indicators of nasofron-
tal outfl ow tract injury: fracture in the fl oor of the frontal
sinus, anterior table medial wall fracture (anterior ethmoi-
dal cells), and gross outfl ow tract obstruction (fracture frag-
ments lying in the tract itself) ( Figure 23-1 ). Management
of frontal sinus fractures according to the algorithm in
Figure 23-2 shows the importance of nasofrontal outfl ow
tract injury in surgical versus nonsurgical management.
Patients who do not have nasofrontal outfl ow tract injury
(no criteria met) can be safely observed with almost no
incidence of complications. Although the presence of one
or more of these criteria can indicate nasofrontal outfl ow
tract injury, obstruction is the most powerful and impor-
tant criterion of the three. Obstruction is almost always
associated with a more devastating and assiduous injury
( Table 23-1 ), directing surgeons toward prompt and aggres-
sive defunctionalizing surgery (ie, cranialization or obliter-
ation). Those patients with nasofrontal outfl ow injury, but
absence of obstruction, can be either observed or surgically
contoured depending on displacement of the fragments. 1
PATIENT PREPARATION
Patients encountered in the emergency room or trauma
bay frequently have polytrauma that requires a team
approach from multiple surgical subspecialties. Serious
intracranial, thoracic, or abdominal injuries must be treated
with emergent surgery when required. Stabilization of the
patient hemodynamically, including proper intracranial
pressures, must be met prior to any surgery. Therefore,
although prompt and immediate surgical repair of frontal
sinus fractures has been shown to decrease complications, 3
ultimately, the timing of the surgery depends on clearance
from trauma and/or neurosurgery colleagues.
Frontal sinus fractures with concomitant cranial base
injuries (frontobasal fractures) should heighten the crani-
omaxillofacial surgeon awareness for cerebrospinal leaks.
Often, cerebrospinal leaks evade clinical diagnoses, delaying
a potentially fatal scenario of subsequent abscess or menin-
gitis. Patients with associated cranial base injuries, especially
in the setting of midfacial fractures, must be aggressively
worked up for dural fi stulae. 3 Beta-2 transferrin detection,

246 • CHAPTER 23
FIGURE 23-2. Frontal sinus fracture
treatment algorithm. NFOT, nasofrontal
outfl ow tract. (Rodriguez ED, Stanwix MG,
Nam AJ, et al. Twenty-six-year experience
treating frontal sinus fractures: a novel
algorithm based on anatomical fracture pattern
and failure of conventional techniques. Plast
Reconstr Surg. 2008;122(6):1852.)
Observation
NFOT –
Obstruction
No
obstruction
Observation
Non-
displaced
Reconstruction
Displaced
Cranialization
or
obliteration
Frontal sinus fracture
NFOT +
FIGURE 23-1. Computed tomographic diagnosis of
nasofrontal outfl ow tract injury. Fracture of the sinus fl oor
(Left); (Middle) fracture of the medial aspect of anterior table;
and (Right) frank obstruction. (From Rodriguez ED, Stanwix
MG, Nam AJ, et al. Twenty-six-year experience treating frontal
sinus fractures: a novel algorithm based on anatomical fracture
pattern and failure of conventional techniques. Plast Reconstr Surg.
2008;122(6):1852.)
Fracture
Fractures
Obstruction
period; and for those who require dural repair, also limited
to the fi rst 24 hours of the perioperative period. 4
Once the patient is hemodynamically stable for sur-
gical repair, and neurosurgical team is available for dural
laceration repair or assistance with exposure, the patient
is brought to the operating room. General anesthesia is
administered in the supine position with the vertex of the
head at the edge of the bed or in a halo device, both arms
tucked at the side, and the bed turned 90 degrees for full
access. Consent for and preparation of autologous bone
graft sites (calvarium, iliac crest, or tibial tuberosity) must
always be pursued. Essential equipment for the procedure
include a craniomaxillofacial plating set of the surgeons
choice (with available mesh plates), power drills and bone
burring tips, protected needle-tip cautery set at 18, a head
light, liposuction tools if indicated, and osteotomes. Skin
preparation with betadine, lubricated corneal eye shields,
and strict sterile techniques must fully be implemented.
SURGICAL TREATMENTS
Appropriate surgical management of frontal sinus frac-
tures with outfl ow tract obstruction relies on defunc-
tionalizing the sinus cavity (removing mucous producing
cells by cranialization or obliteration) and proper par-
titioning of the upper aerodigestive system from the
anterior cranial base. If the outfl ow tract is injured, but
patent, then surgery shifts to providing proper contour
isotope investigations, intrathecal fl uorescein tests, and non-
contrast, high-resolution CT scans play a signifi cant role
in detecting cerebrospinal leaks. Importantly, the risk of
meningitis correlates with duration of dural fi stula; thus a
team approach of neurosurgical dural laceration repair in
coordination with frontal sinus treatment must be pursued
without delay. Although many centers use prophylactic
antibiotics for cerebrospinal fl uid leaks until defi nitive treat-
ment, evidence-based medicine establishes they should only
be administered within the immediate (24 hours) postinjury

FRONTAL SINUS FRACTURES • 247
Treatment of concomitant facial fractures must also
be taken into consideration, and proper sequencing pur-
sued. 5 Surgical approach to the frontal sinus area must
begin through an inconspicuous bicoronal approach.
For reconstruction and contouring alone, very specifi c
instances may arise where a bicoronal approach is not
required. Rarely, direct horizontal incisions in the fore-
head over the fracture fragments may be used in select
balding men with thick frontalis rhytids. Additionally,
large lacerations or frontal soft tissue loss may be encoun-
tered and serve as access for contour alone procedures.
Minimally invasive endoscopic techniques seem like
a reasonable alternative to large coronal incisions, but
utilize foreign bodies (porous polyethylene), have worse
contour results, and have higher complication rates. 6
For the overwhelming majority of patients, a bicoronal
approach serves as appropriate access for contouring and
defunctionalizing surgery, dural laceration repair, and
split calvarial bone graft harvesting.
Although the algorithm described thus far in this chap-
ter uses only three surgical techniques (reconstruction,
obliteration, and cranialization), there are others currently
used which have been found to be inadequate and lead
to unacceptably high complication rates (ablation and
osteoneogenesis). 1
Ablation (Exenteration)
Riedel initially described the technique of frontal sinus
ablation in 1898, with removal of the frontal bone, supraor-
bital bandeau, proximal nasal bones, all sinus mucosa, and
often the posterior table. 1 This then allows for skin involu-
tion against the posterior wall or dura itself. Delayed recon-
struction of this severe cosmetic defect at a subsequent
surgery is then dangerous and diffi cult. The only poten-
tial indication for the ablation procedure is severe acute
infection, where collapse of the dead space and removal
with open-reduction internal fi xation, while not pursu-
ing the sinus cavity and its drainage ( Figure 23-2 ). As
noted previously, preoperative radiological diagnosis of
nasofrontal outfl ow tract injury, particularly obstruction,
fully determines which surgical treatment is indicated
( Fig ure 23-3 ). Therefore, intraoperative assessment of
outfl ow tract patency through direct outfl ow tract visu-
alization, probing, or colored fl uid investigation (ie,
instillation of methylene blue from the sinus to assess
drainage inferior to middle meatus) is never required.
TABLE 23-1. Higher Associated Injuries
With Outfl ow Tract Injuries
Injury
NFOT2
NFOT1
Brain
31%
76%
Cerebral spine
7%
14%
Upper extremity fracture
15%
25%
Lower extremity fracture
13%
23%
Pneumothorax
12%
24%
Abdominal
7%
13%
Orbital roof
13%
40%
Orbital wall
7%
13%
Orbital fl oor
2%
7%
Naso-orbitoethmoid
12%
31%
Zygoma
8%
18%
LeFort
2%
17%
Mandible
3%
5%
NFOT2, nasofrontal outfl ow tract uninjured. NFOT1, nasofrontal
outfl ow tract injury.
Data from Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-
year experience treating frontal sinus fractures: a novel algorithm
based on anatomical fracture pattern and failure of conventional
techniques. Plast Reconstr Surg. 2008;122(6):1853.
FIGURE 23-3. Obstruction of the nasofrontal outfl ow tract. CT scans (Left, Middle)
demonstrating a patent outfl ow tract (red arrows) as well as obstructed outfl ow tracts
(white arrows). On the right is an artist’s rendition of outfl ow tract obstruction.

248 • CHAPTER 23
box-, T-, L-, or X-shaped 1.3-mm plates can be used to
anatomically align the fracture fragments and secure to
stable frontal bone ( Figure 23-4 ). Occasionally a 1.3-mm
titanium mesh is needed to assist in achieving proper con-
tour in a comminuted section. Cortical bone graft and split
calvarial bone grafts are almost never needed, as these are
reserved for worse fracture patterns, commonly associated
with nasofrontal obstruction.
When sinus defunctionalization and separation of sinon-
asal communication is required for patients with nasofron-
tal outfl ow tract obstruction, cranialization or obliteration is
indicated. Although outcome differences are not signifi cant
between these techniques, cranialization has several distinct
advantages: wide exposure of the injured area allows assess-
ment and repair of dural injury, access to the cranial base
for complex frontobasal repair, and elimination of the sinus
with its propensity for infection and mucocele formation in
a single stage. Although some surgeons advocate combining
both of these techniques for one frontal sinus if the intersi-
nus septum is uninjured (cranialize the left, and obliterate
the right side), higher complications occur.
Complications of improper fracture management often
arise due to inadequate removal of the mucous producing
cells, particularly the posterior table. The frontal sinus lin-
ing is a tenacious mucoperiosteum that regenerates from
residual basilar mucosal cells if simple stripping alone is
used. To eliminate the mucosa, the walls must be burred
deep to the diploic veins of Breschet, removing all the tails
and cells of the mucosa. The fear of the inexperienced sur-
geon is burring too deep at the posterior table and com-
promising the dural layer.
Cranialization
Cranialization removes the ducts, posterior sinus wall,
and mucosa, and creates a partition between the intracra-
nial and nasal cavities. The area previous occupied by the
frontal sinus, in fact, becomes a portion of the intracranial
cavity through expansion of the dura and brain after sev-
eral months. Cranialization often requires the assistance of
of infected, nonvascularized bone nidus, will protect from
mucocele and devastating intracranial infections.
Osteoneogenesis
Much like the other defunctionalizing surgeries that will
be discussed below, this procedure strips the mucosa of the
sinus cavity, obstructs the nasofrontal outfl ow tracts, and pre-
serves the empty cavity itself. Spontaneous obliteration then
proceeds in a slow, indolent fashion by which scar tissue and
bone theoretically fi lls the empty frontal sinus cavity.
For patients who have displacement or comminution of
the anterior table of the frontal sinus, and lack nasofron-
tal outfl ow tract obstruction, proper contouring by open
reduction internal fi xation (reconstruction) is indicated.
Reconstruction
Reconstruction of the anterior table of the frontal sinus
begins with a bicoronal scalp incision for exposure.
Alopecia can be avoided by making the incision parallel
to the hair follicles and meticulous pinpoint hemostasis
(thereby avoiding the use of scalp clips). Dissection is then
directed with electrocautery in the loose areolar subgaleal
plane past the frontal sinus. Preservation of the facial nerve
can be guaranteed by sharp dissection deep to the super-
fi cial temporal fascia laterally and under the pericranium
centrally. At the location of the temporal fat pad, a com-
bination of blunt and sharp dissection is used to protect
blood supply to the fat pad (minimizing the risk of tempo-
ral hallowing). If one seeks improved lateral supraorbital
rim exposure, then extension of the bicoronal fl ap to the
preauricular area at the junction of the tragus and helix
is performed. Dissection around the fracture is performed
to facilitate reduction of the individual fragments. Careful
attention to location and orientation is made before any
removal or manipulation. A small hole or removal of a
fragment may be needed to create access for instruments
to reduce an indented large fracture fragment. Plating is
then performed either in situ or on back table. Straight,
FIGURE 23-4. Open reduction internal fi xation of the anterior table. A blunt injury
to this patient resulted in an anterior table frontal sinus fracture as well as a concomitant
zygomaticomaxillary complex fracture. A bicoronal approach is pursued exposing the
fracture segments (Left). Appropriate reduction management by elevating the depressed
segments and assuring proper contour is made with various miniplatefi xation (Middle). A
postoperative CT scan demonstrates proper contour and reduction (Right).

FRONTAL SINUS FRACTURES • 249
a neurosurgery colleague. After bicoronal fl aps by the pri-
mary team are raised in the standard fashion, the neuro-
surgeons can proceed with a careful frontal craniotomy to
permit frontal lobe retraction for posterior wall visualization
( Figure 23-5 ). Importantly, when raising the coronal inci-
sion for a cranialization, care must be made to preserve the
pericranium such that one can rotate either a centrally or
laterally based pericranium fl ap. Careful removal of the pos-
terior wall then proceeds by rongeuring larger segments or
power-burring techniques. Close attention should be paid to
the inferolateral aspect of the posterior table, as the mucosa
here is often inadequately eradicated. Meticulous burring of
anterior table segments, lateral recesses, and other residual
mucosal areas past the foramen of Breschet will eliminate
the remaining mucous cells. Attention is then turned to
the nasofrontal outfl ow tracts for defi nitive separation of the
aerodigestive tract from the anterior cranial base. Here the
surgeon must fully occlude the nasofrontal outfl ow tract.
Importantly, we use the term “occlude” here to differentiate
from the commonly used term “obliterate.” “Obliterate” or
“obliteration” is a surgical treatment for frontal sinus frac-
tures, and should not be confused with “occlude,” when one
seals the nasofrontal outfl ow tracts. Autologous bone graft
can be placed in the nasofrontal outfl ow tract. Fibrin glue
sealant or other modalities may be further implemented
to create complete occlusion. The pericranial fl ap that was
preserved during the coronal incision is now rotated down
into the aperture of the outfl ow tracts.
Replacement of the frontal craniotomy segment, cover-
ing of the burr hole sites with titanium mesh plates, and
frontal contouring is then pursued. Proper reduction of
the anterior table by techniques presented above in the
“reconstruction” section provides anatomical re-alignment.
Titanium mesh may have to be implemented in order to
achieve proper frontal contouring. When anterior table
defects preclude the use of conventional hardware, split
calvarial bone grafts harvested from the parietal lobe are
indicated. Prior to fi nal closure of the coronal fl ap, a suc-
tion drain should be placed to eliminate the dead space
and prevent seroma formation. Typically, these drains only
stay for 2 to 3 days postoperatively. Limitation of postop-
erative antibiotic therapy to only 24 hours must strictly be
adhered to. Importantly, extra vigilance for any cerebral
spinal fl uid leak in the drain must be monitored as sinona-
sal communication has been surgically separated preclud-
ing typical cerebrospinal fl uid rhinorrhea visualization.
Obliteration
Obliteration involves complete removal of the sinus mucosa,
burring the sinus walls to eliminate mucosal invaginations,
and fi lling the sinus cavity with fat, muscle, or bone. Exposure
of the frontal area follows a typical bicoronal approach iden-
tical to cranialization, with specifi c attention to preserving
a pericranial fl ap. Neurosurgical assistance is not required,
as exposure to the contents of the frontal sinus cavity is
accessed through comminuted bone segments or removal
of an adequate surface area of the anterior table via a recip-
rocating power saw. Wide exposure is imperative to assure
meticulous burring of the posterior and lateral recesses of
the bone past the foramen of Breschet. Once all mucosa is
stripped, and invaginations burred, occlusion of the nasof-
rontal outfl ow tract is performed in an identical manner to
that of cranialization. Placement of an obliterating mate-
rial follows subsequently with the autologous material of
choice and then proper frontal vault contouring.
Autogenous materials, including fat, muscle, and bone
have been used for decades, but newer alloplastic biomate-
rials have also been used. Bioactive glass, methylmethacry-
late, oxidized regenerated cellulose, and calcium phosphate
bone cement harbor intrinsic antibacterial properties and
avoid donor site morbidity. 6 However, these potential ben-
efi ts have not matriculated, and higher complication rates
repeatedly are published. 1 Controversy even within autolo-
gous materials choices seems to undergo continuous debate.
Cancellous bone grafts force the sinus to undergo ossifi ca-
tion and provide progenitor cells and integral growth factors,
providing an environment suitable for successful oblitera-
tion. Fat grafts rely on the viability of damaged bony walls
that are poorly vascularized. In fact, over 50% of the fat
FIGURE 23-5. This patient has a simultaneous
anteroposterior displaced fracture seen on the axial cut
(Above, left) and a three-dimensional reconstruction (Above,
right) following a motor vehicle accident. The fracture meets
all criteria for nasofrontal outfl ow tract injury: fracture of
the medial aspect of the anterior table, sinus fl oor fracture
(f ), and outfl ow tract obstruction (o) (Below, left). (Below,
right) Photograph obtained intraoperatively with frontal lobe
retraction showing comminution and obstruction around the
nasofrontal outfl ow tract. (Rodriguez ED, Stanwix MG, Nam AJ,
et al. Twenty-six-year experience treating frontal sinus fractures: a
novel algorithm based on anatomical fracture pattern and failure of
conventional techniques. Plast Reconstr Surg. 2008;122(6):1860.)
f
o

250 • CHAPTER 23
placed into the cavity is resorbed or atrophies, creating an
inadequate obliteration. If the doctrines of careful mucosal
removal, proper occlusion of the nasofrontal outfl ow tracts
with bone graft, surgical debridement of mucosal invagina-
tions, and attention to dural integrity are followed, oblitera-
tion with cancellous bone graft may be a suitable alternative
to cranialization in experienced hands. 7
COMPLICATIONS
Inadequate treatment of frontal sinus fractures, unlike
management of other craniomaxillofacial injuries, leads to
severe and potentially fatal injuries. Mucoceles, meningitis,
brain abscesses, and death may arise from inadequate par-
titioning of the upper aerodigestive system from the ante-
rior cranial base and proliferation of unextirpated sinus
mucosa. Complications arise in 3% to 10% patients follow-
ing frontal sinus fracture treatment, but can be minimized
by three tenets: meticulous eradication of sinus mucosa,
occlusion of the sinonasal communication, and complete
elimination of dead space (expanding brain in cranializa-
tion or cancellous bone grafting in obliteration). 8
Complications may be major or minor and arise in the
acute post-treatment period (fi rst 6 months) or chronic
period. Acutely minor complications proceeding sur-
gery are typical of any procedure: hardware palpability/
migration, contour irregularities, wound/skin infections,
or skin breakdown. Major acute complications, on the
contrary, are serious problems requiring a multiteam
approach and intensive care. Meningitis, brain abscesses,
and prolonged dural fi stula, and death are fortunately rare
entities but humble the craniomaxillofacial surgeon.
Late complications arise from inadequate sinus drain-
age; mucous is continuously produced resulting in
pain, mass-like effect, erosion, and ultimately infection.
Although early diagnosis seems critical, the propensity
of this patient population is to disregard follow-up until
clinical manifestations of frontal sinusitis or mucocele for-
mation manifest. Chronic complications have very indo-
lent courses, arising upward from 5 to 20 years after initial
management. Surgical intervention is often required to
correct complex bone and soft tissue deformities, while
eradicating infectious material from the frontobasilar
region ( Figure 23-6 ).
FIGURE 23-6. Sequelae of improper frontal sinus fracture management. This
patient underwent management of panfacial fractures after a motor vehicle collision
4 years previously, which included obliteration of the frontal sinus with bone graft. She
presented to our clinic with months of progressive frontal pressure, headaches, and
throbbing. A mucopyocele formed after inadequate occlusion of the nasofrontal outfl ow
tract (Above, left). The direct sinonasal communication seen in the axial cut (Above, right)
resulted in persistent air and an indolent infection. Images of a 30-year-old patient treated
1 month previously with obliteration of the frontal sinus after sustaining a simultaneous
anteroposterior fracture with nasofrontal outfl ow tract injury (Below, left, right). Pus (arrows)
is expressed from the superior orbital rim and left medial canthus (Below, left). Complete
removal of previous hardware and anterior table along with extensive burring of the sinus
was performed (Below, right). (Above from: Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-
year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern
and failure of conventional techniques. Plast Reconstr Surg. 2008;122(6):1862.Below from: Rodriguez
ED, Stanwix MG, Nam AJ, et al. Defi nitive treatment of persistent frontal sinus infections: elimination
of dead space and sinonasal communication. Plast Reconstr Surg. 2009;123(3):962.)

FRONTAL SINUS FRACTURES • 251
Mucoceles as the result of sinus malfunction have an
insidious course and are the most frequently encoun-
tered long-term complication. Typically, this collection of
mucous undergoes recurrent bouts of infection, which is
commonly misdiagnosed for frontal sinusitis or chronic
headaches by primary care physicians. Initial complaints of
frontal pressure or throbbing slowly progress to debilitat-
ing periorbital pain, and culminate with central nervous
system sequelae. Clinical symptoms of seizures, headaches,
photophobia, visual disturbances, and nuchal rigidity may
be the only symptoms to push front line clinicians toward
proper diagnostic studies. Overall, patients have limita-
tions in activities of daily living, multiple abstained days
from work, and a diminished quality of life. Chronicity of
the disease, along with recurrent infectious bouts, leads to
skin and bony changes.
Eczematous skin changes can be seen along with
fi stular drainage tracts, and the underlying soft tis-
sue becomes indurated and scarred ( Figure 23-6 ). The
bony structure of the anterior table is attenuated and
may have smoldering osteomyelitis. Occasionally, the
infection will compromise the bone completely, creat-
ing a source for intracranial or periorbital extension.
The disease perseveres, despite conventional treatment
approaches (antibiotics, endoscopic techniques) due to
the duration and extent of bony and soft tissue involve-
ment. Ultimately, treatment requires a combined intrac-
ranial-extracranial approach.
Traditionally, initial treatment involves debridement
of the infection with hardware and graft removal, and
re-obliteration or cranialization ( Figure 23-7 ). Depending
on the skin, soft tissue, and bony involvement, single-stage
or multiple-stage approaches can be used. Regardless of
the treatment pursued, successful management relies
on wide local debridement, meticulous reburring of the
tables beyond the foramen of Breschet, and removal of
infected bone and previous obliteration material. Patients
previously obliterated with bone graft or hydroxyapatite
may need deeper burring than anticipated because of its
osteoinductive capabilities. After completion of debri-
dement, attention must be turned to fi nalize re-obliter-
ation, cranialization, and reconstruct the anterior table.
However, treatment for prolonged infected mucoceles by
cranialization or re-obliteration is unsuccessful in over
50% of patients. 8 This is likely due to inadequate debri-
dement, use of nonvascularized or foreign materials in an
infected area, poor outfl ow tract occlusion, or inability to
fi ll all dead space. Previous intracranial manipulation or
FIGURE 23-7. Treatment algorithm for indolent infectious complications following
frontal sinus fractures. (Rodriguez ED, Stanwix MG, Nam AJ, et al. Defi nitive treatment of
persistent frontal sinus infections: elimination of dead space and sinonasal communication. Plast
Reconstr Surg. 2009;123(3):964.)
Acute infection
(Frontal bone resorption,
skin eczematous lesion,
cutaneous fistula)
Obliteration
Debridement
Cranialization
Resolution
(–) Chronic infection
Debridement +
Vascularized free fibula
Cranioplasty
Ablation
(+) No infection
Cranioplasty

252 • CHAPTER 23
FIGURE 23-8. Artist’s rendition of the free fi bula osteocutaneous reconstruction
procedure. A bird’s eye view after radical debridement of all infected materials
demonstrates exposure of the nasofrontal outfl ow tracts (Left). The free fi bula bone with
one osteotomy is placed as a horizontal buttress to form a neo-bandeau and ensure
proper contour (Center). The attached fl exor hallucis longus occludes the nasofrontal
outfl ow tracts and provides a source of rich tissue for obliteration of dead space (Right).
(Rodriguez ED, Stanwix MG, Nam AJ, et al. Defi nitive treatment of persistent frontal sinus infections:
elimination of dead space and sinonasal communication. Plast Reconstr Surg. 2009;123(3):958.)
FIGURE 23-9. A mucocele developed 32 years after
a Riedel (ablation) procedure. A raised coronal fl ap displays
mucus contamination of the frontal bone and alloplast
(Above, left). The instrument is pointing to the source of the
mucopyocele. After radical debridement and removal of
infected methyl methacrylate, the large defect is ready for
defi nitive free tissue reconstruction (Above, right). Formal
reconstruction of the 9 3 5 cm bony defect, sinonasal
separation, and softtissue reconstruction with a one-stage,
single osteotomy fi bular free fl ap were performed. The pedicle
is anastomosed to the superfi cial temporal vessels (white
arrow), the fl exor hallucis longus obliterates the sinus and
occludes the nasofrontal outfl ow tract (blue arrow), and the
fi bula forms the frontal neo-bandeau (yellow arrow) (Below,
left). The titanium mesh can now be safely secured to stable,
healthy bone for fi nal contour (Below, right). (Rodriguez
ED, Stanwix MG, Nam AJ, et al. Defi nitive treatment of persistent
frontal sinus infections: elimination of dead space and sinonasal
communication. Plast Reconstr Surg. 2009;123(3):960.)
cranialization forces the dura to scar down and inhibits
the expansion of the brain to fi ll this space. Furthermore,
wide local debridement of all infected, necrotic, and non-
viable tissues may leave devastating defects that conven-
tional salvage techniques stand inadequate. After salvage
techniques fail or extensive defects are encountered,
reconstruction commences with assessment and replace-
ment of key missing components along with complete
sinonasal separation.
Several donor sites have been used to reconstruct the
skin, soft tissue, and bony loss following debridement of
persistent frontal sinus infections. Autologous nonvascular-
ized bone grafts such as calvarium, iliac, or ribs have been
used to recontour the frontal area. Additionally, alloplastic
materials, such as methymethacrylate, titanium mesh, or
hydroxyapatite provide for easy on table contouring and
avoid donor site morbidity. However, each autogenous or
alloplastic materials used are nonvascularized or foreign
materials that may predispose an already vulnerable area to
re-infection. Nonetheless, each of the above grafts requires
a secondary donor site for sinonasal separation by occlud-
ing the nasofrontal outfl ow tracts and a third for soft tissue
bulking and dead-space obliteration. Galeal, temporalis
muscle, and other local vascularized fl aps have donorsite
morbidity, and are likely unavailable due to previous surgi-
cal attempts or concomitant trauma.
The osteoseptocutaneous-free fi bular fl ap is an ideal
choice for single-staged treatment of the infected oblit-
erated frontal sinus as it provides healthy bone and soft
tissue ( Figure 23-8 ). 8 The fi bular bone recreates the fron-
tal bandeau, and supplies rich vascularity to promote
bony union and overcome local infection and osteomy-
elitis. Additionally, soft tissue and fl exor hallucis longus
muscle fully separate the anterior cranial base from the
aerodigestive system while obliterating all dead space and
occluding the nasofrontal outfl ow tracts ( Figure 23-9 ).

FRONTAL SINUS FRACTURES • 253
FIGURE 23-10. Photographic and CT depiction of the patient in Figure 23-9. The
patient presented with severe cosmetic deformity and diffuse erythema extending over
forehead, nasal side walls, and frontal processes of the maxillary bones (Above, left).
The white arrows demonstrate an abundance of undrained mucus found in the frontal
sinus on axial (Above, center) and coronal views (Above, right), along with air (red arrow)
and slow resorption of the bony posterior wall (blue arrow). Three-month postoperative
photograph demonstrating resolution of erythema and restoration of contour (Below, left).
This patient had complete cessation of all preoperative frontal symptoms, allowing for
discontinuation of migraine, pain, and other related medications. A CT scan illustrates a
neo-bandeau (Below, center), along with complete sinonasal separation as noted by the
absence of air (Below, right). (Rodriguez ED, Stanwix MG, Nam AJ, et al. Defi nitive treatment of
persistent frontal sinus infections: elimination of dead space and sinonasal communication. Plast
Reconstr Surg. 2009;123(3):959–961.)
Also, careful dissection of the superfi cial temporal ves-
sels proximally provides for an ideal anastomotic recipi-
ent. Radical debridement, meticulous mucosa removal,
and obliteration with a free fi bula fl ap achieve all goals of
treatment for persistent infectious complications follow-
ing frontal sinus fractures: a secure horizontal buttress,
obliteration of dead space, and occlusion of the nasofron-
tal outfl ow tracts ( Figure 23-10 ).
OUTCOMES ASSESSMENT
Outcomes following sinus fracture treatment must be
assessed as two separate entities: acute and chronic. The
initial bodily and cranial trauma the patient endures
resulting in frontal sinus fracture should make all survi-
vors of the injury fortunate. Acute management, observa-
tion or surgical, may potentially lead to devastating and
fatal complications. Patients who withstand this hospital
course, and subsequently discharged, are usually satisfi ed
with no acute concerns. They may have initial hardware
or contour complaints, but fortunately avoided fatal
acute complications. Patients should then be followed
long term as the indolent and persistent course of late
complications may take many years before culminating.
Unfortunately, the nature of this patient population is to
forego any postoperative care or monitoring and follow-
up is often poor. If willing, patients must be indefi nitely
monitored for signs of infectious chronic complications.
Prompt radiological studies must be pursued if any symp-
tom or sign arises. Inadequate or delayed treatment will
generate severe multifaceted soft tissue and bony issues
that require intracranial-extracranial salvage approaches,
or possibly free tissue transfer.

254 • CHAPTER 23
REFERENCES
1. Rodriguez ED, Stanwix MG, Nam AJ, et al. Twenty-six-year
experience treating frontal sinus fractures: a novel algo-
rithm based on anatomical fracture pattern and failure of
conventional techniques. Plast Reconstr Surg . 2008;122(6):
1850–1866.
2. Rohrich RJ, Hollier L. The role of the nasofrontal duct in
frontal sinus fracture management. J Craniomaxillofac
Trauma. 1996;2(4):31–40.
3. Manson PN, Stanwix MG, Yaremchuk MJ, et al. Frontobasal
fractures: anatomical classifi cation and clinical signifi cance.
Plast Reconstr Surg . 2009;124(6):2096–2106.
4. Holloway KL, Smith K. Antibiotic prophylaxis during clean
neurosurgery: A large, multicenter study using cefuroxime.
Clin Ther. 1996;18(1):84–94.
5. Markowitz BL, Manson PN. Panfacial fractures: organization
of treatment. Clin Plast Surg . 1989;16(1):105–114.
6. Manolidis S, Hollier LH. Management of frontal sinus frac-
tures. Plast Reconstr Surg. 2007;120(7 suppl 2):32S–48S.
7. Mickel TJ, Rohrich RJ, Robinson JB Jr. Frontal sinus oblit-
eration: a comparison of fat, muscle, bone, and spontane-
ous osteoneogenesis in the cat model. Plast Reconstr Surg.
1995;95(3):586–592.
8. Rodriguez ED, Stanwix MG, Nam AJ, et al. Defi nitive treat-
ment of persistent frontal sinus infections: elimination of
dead space and sinonasal communication. Plast Reconstr
Surg . 2009;123(3):957–967.

24
Nasal Fractures
Ronald E. Hoxworth, MD / Rod J. Rohrich, MD, FACS
INTRODUCTION
The nose is the most prominent facial feature. The nasal
pyramid consists of the paired nasal bones, the frontal
process of the maxilla, the paired nasal cartilages (upper
lateral and lower lateral), and the nasal septum. The sep-
tum is composed of the quadrilateral cartilage anteri-
orly, the vomer inferiorly, and the perpendicular plate of
the ethmoid posteriorly ( Figure 24-1 ). A fracture of the
nasal pyramid is the third most common bone fracture
in the body and the most common facial fracture, requir-
ing less force than that for any other facial bone. 1 – 5 The
increasing prevalence of this injury presents the plastic
surgeon with challenging treatment options. Although
nasal fractures are often discussed as minor injuries, 6 the
incidence of posttraumatic nasal deformity as reported
in the literature is not insignifi cant (9%–50%). Revision
rhinoplasty for traumatic nasal deformity is a diffi cult
procedure; accordingly, guidelines are needed to opti-
mize the management of acute nasal fractures in order
to minimize secondary deformities.
The numerous factors that contribute to suboptimal
aesthetic and functional results include timing, edema,
undetected preexisting nasal deformity, and occult septal
deviation/injury. Thus, it is essential for the physician to
have a systemic approach or algorithm for acute nasal
fracture management that includes a complete evalu-
ation of the nasal deformity (both internal and exter-
nal) and a precise anatomic reduction under controlled
conditions. This algorithmic approach can be used to
improve long-term results and to reduce the incidence
of posttraumatic nasal deformities.
PATIENT EVALUATION AND SELECTION
A detailed nasal history and a physical examination are
essential to diagnosis and treatment. To begin the assess-
ment, a precise account of the mechanism, including
injuring agent, direction of blow, and timing of nasal
injury, is recorded. A history of epistaxis (sine qua non
for a nasal fracture) indicates a laceration of the involved
nasal mucosa. 4 The essential aspects of the nasal history
are noted on the nasal fracture datasheet ( Figure 24-2 ).
Patients may vary in assessment of preinjury nasal shape;
differentiating between new and old nasal deformity is
sometimes diffi cult and must be correlated with patient
history and physical fi ndings. To this end, a review of old
photographs or a driver’s license photo can be very help-
ful as one third of individuals may have nasal deviation
present prior to their injury. Finally, standard seven-view
nasal photographs (anteroposterior, right and left later-
als, right and left obliques, low and high basals) are taken
to complete the nasal history.
The physical examination consists of an integrated sys-
tematic approach. During the course of the examination,
the physician needs to be aware of the patient’s overall
status. Quite often the mechanism of injury results in
concomitant injuries which may prove more threaten-
ing for the patient. As such, the physician must strictly
adhere to the ABCs of patient resuscitation prior to con-
ducting any secondary evaluation of nasal injury. Further,
cooperation with all members of the team caring for the
acutely injured patient is essential. The presence of con-
comitant life-threatening injuries precludes the need for
urgent management of nasal fractures unless there is an
associated airway issue involved with the injury.
c h a p t e r

256 • CHAPTER 24
The external examination includes an inspection for
lacerations, wounds, swelling, and deviation. Palpation of
the proximal nasal skeleton is done to identify tenderness,
crepitus, depression and/ or nasal shortening, and widen-
ing of the nasal base. Accurate intercanthal measurements
are done to rule out a naso-orbitalethmoid (NOE) frac-
ture, which is especially common in severe, high-velocity
frontal or inferior injuries. Next, if present, the fracture
type is then defi ned. Various nasal fracture classifi ca-
tions have been reported in the literature. 7 , 8 We adopted
a practical, clinically applicable nasal fracture classifi ca-
tion based on the physical examination as recorded on
the nasal fracture datasheet ( Figure 24-2 ). Fractures are
graded as simple unilateral (type I) or bilateral (type II),
comminuted (type III), and complex with bone and sep-
tal disruption (type IV). The most serious fractures (type
V) involve associated midfacial or NOE involvement.
Edema is graded by the degree of periorbital edema (11,
minimal/no periorbital edema; 21, moderate periorbital
edema; 31, severe periorbital edema).
A complete assessment of the nasal septum is the single
most important step in determining aesthetic and func-
tional outcome in nasal fractures. 4 , 6 Verwoerd 6 describes
the pathogenesis of septal fractures as including three
septal zones composed of thicker cartilage-dorsoposterior,
basal, and caudal. Conversely, the central caudal portion
of the septum is thin. The thicker, posterior septal carti-
lage provides the primary support for the nasal dorsum.
Trauma to the nasal dorsum leads to lesions in the caudal-
basal to cephalodorsal supporting cartilage and to horizon-
tal fractures of the thinner central region. 6
Fry 9 , 10 presented the progressive distortion of fractured
septal cartilage caused by the release of locked internal
stresses. Verwoerd 6 and Wexler 11 demonstrated that the
septum does not remain straight after manipulation and
that the nasal bones tend to unite in the direction of the
deviated septum. Accordingly, the septum is the key struc-
ture to consider for optimal management of nasal fractures
and the prevention of secondary deformities. 12 The extent
of septal injury determines the proper technique for sep-
tal correction. Renner reported that closed reduction with
intranasal splints and packs yielded satisfactory results in
most simple septal injuries involving the distal portion
of the quadrangular cartilage. 2 Pollock advocated a low
threshold for open reduction, with precise septal correc-
tion for moderate to severe septal injuries with a complex
fracture pattern or an involvement of the perpendicular
plate of the ethmoid or vomerine groove. 7 In the absence
of a complete evaluation of the entire septum, the mobile
anterior portion is reduced, leaving a dislocated, rigid
posterior septum that results in late functional deformity
after closed reduction. 13 In 1968, Adamson et al. advo-
cated acute submucous resection for severely fractured
septums. 14 Eleven years later, Harrison recognized that
low horizontal submucous septal resection removing only
the quadrangular cartilage-vomerine groove interface was
often inadequate because of the overlapping, fractured
segment in the perpendicular plate of the ethmoid. To
fully address the septal pathology, he recommended an
extended low horizontal and posterior vertical submu-
cous resection. 13 Murray et al. 15 also attributed the high
rate of postreduction nasal deformity requiring salvage
FIGURE 24-1. Sagittal view of the nasal septum, with red and green depicting the
most common septal fractures seen with low-velocity (A) and high-velocity (B) injuries.
QC, quadrangular cartilage; PPE, perpendicular plate of the ethmoid; Vom, vomer.
(Reprinted with permission from Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing
secondary nasal deformities. Plast Reconstr Surg. 2000;106(2):266–273.)
A
B

NASAL FRACTURES • 257
septorhinoplasty to an unrecognized septal injury. They
found that patients with nasal bones deviated more than
half the nasal bridge width had a concomitant, C-shaped
fracture of the bony and cartilaginous septum. They also
concluded that acute open reduction with submucous
septal resection resulted in an improved long-term cos-
metic and functional outcome due to the alleviation of
overlapped, interlocking fragments of the septum that
usually resulted in the secondary nasal bone deformity.
The most common septal fractures in low-velocity
injuries occur inferiorly along the vomerine groove as
fractures or fracture dislocations. 16 High-velocity injuries
or frontal impacts result in more extensive septal frac-
tures through the thin central region of the quadrangular
cartilage that extend posteriorly across the interface with
the perpendicular plate of the ethmoid and inferiorly
to the vomer ( Figure 24-1 ). Aggressive management of
these septal injuries is a major key to the successful man-
agement of the nasal fracture.
Plain fi lm radiographs are not necessary for the clini-
cal diagnosis of isolated nasal fractures. 2 , 17 Approximately
half of all patients with nasal fractures will have negative
x-ray fi ndings. Logan et al. reported a prospective series
evaluating the use of routine x-rays in the diagnosis of
nasal fractures, ultimately concluding that they are not
cost-effective. 18 However, patients found by x-ray to have
displaced nasal fracture are at a higher risk for long-term
nasal deformity, thus, anatomic reduction was highly rec-
ommended for these individuals. CT scans are likewise not
essential for isolated nasal fractures unless there is a suspi-
cion of associated complex facial fractures based on clini-
cal fi ndings or mechanism of injury.
Nasal Fracture Data Sheet
Name:
Date:
Age:
Mode of Injury:
Low Energy
High Energy
Direction:
Appearance:
Time Since Injury:
Associated Injury:
Soft Tissue
Facial Fracture
Patient Medical History:
Allergies
Previous Nasal Trauma
Previous Nasal Surgery
Airway Obstruction History
Medications
Pretraumatic Photographs:
Yes
No
Physical Examination:
External
Unilateral
Bilateral
(Width of Nasal Base)
Intercanthal Distance
Edema
1+
1+
2+
3+
Ecchymosis
2+
3+
Nasal Bleeding
Right Left
Bilateral
None
Intranasal
Septal Deviation/Dislocation/Fracture
Mucosal Status
Septal Hematoma Yes No
Nasal Fracture Classification:
I. Simple (Unilateral)
II. Simple (Bilateral)
III. Comminuted
a. Unilateral
b. Bilateral
c. Frontal
IV. Complex (Nasal Bone & Septal Disruption)
a. Associated Septal Hematoma
b. Associated Open Nasal Laceration
V. NOE Fracture/Midface Fracture
FIGURE 24-2. Nasal fracture datasheet for documenting clinical fi ndings. (Reprinted
with permission from Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary
nasal deformities. Plast Reconstr Surg. 2000;106(2):266–273.)

258 • CHAPTER 24
PATIENT PREPARATION
At minimum, the internal examination requires halogen
lighting, good suction, a nasal speculum, vasoconstrictive
anesthesia, and a 30-degree, 3-mm rigid nasal endoscope
of type III or greater. A complete evaluation of the inter-
nal structures is performed with particular attention paid
to the septum. Specifi cs of the deformity and evidence
of obstruction are recorded on the datasheet. The rigid
nasal endoscope is used to fully evaluate the entire sep-
tum, especially the posterior bony septum and vomerine
regions in types III, IV, and V nasal fractures. A topical
anesthesia of 4% lidocaine and oxymetazoline (Afrin)
or phenylephrine hydrochloride (Neo-Synephrine) is
adequate to perform a full waking examination of the
patient. The total septal examination is central to the
evaluation of nasal fractures and to the optimization of
results; therefore, adequate anesthesia is essential for
complete systematic evaluation. After adequate vasocon-
striction and topical anesthesia of the nasal mucosa, the
diagnostic endonasal procedure can proceed. The patient
is seated in an examining chair with the examiner usually
sitting or standing to the right side of the patient.
TECHNIQUE
Endoscopic Evaluation
The endoscope is placed in the nasal vestibule and
advanced posteriorly under direct vision. This pass of
the endoscope is advanced along the fl oor of the nose,
beneath the inferior turbinate. Areas examined include
the inferior meatus, turbinates, septum, and the postero-
inferior septal junction with the perpendicular plate of
the ethmoid. Withdrawal of the scope allows for con-
fi rmation of fractures and septal disruption while these
areas are re-inspected.
The septal mucosa is inspected for disruptions and
evidence of septal fractures. Prompt diagnosis and treat-
ment of septal hematoma are essential to the reduction
of fi brosis and subsequent septal distortion, abscess, and
complete necrosis with saddle nasal deformity. Wide,
dependent drainage followed by careful packing with
antibiotic gauze 19 and systemic antibiotic coverage is rec-
ommended. Small hematomas are aspirated, 2 followed
up closely, and re-aspirated if re-accumulation occurs.
Management of Nasal Fractures
Once a nasal fracture has been diagnosed, the physician
needs to consider the proper timing for repair. In the
absence of any prevailing injuries or comorbidities, closed
reduction should be undertaken within 3 hours of the
initial injury. If there is excessive edema due to a delay
in treatment, the patient is managed expectantly with
head elevation, ice packs, and pain management until
the edema resolves in 3 to 5 days. If closed reduction is
not accomplished within 5 to 7 days, fi brous union of the
fracture may make manipulation diffi cult. In the case of
a missed diagnosis or unsuccessful reduction in the fi rst 5
to 7 days, it is recommended that an open reduction be
planned for 3 to 6 months post injury ( Figure 24-3 ).
Numerous prospective series have been published
comparing local versus general anesthesia for the manip-
ulation of nasal fractures. 20 – 22 In most cases, these studies
found local anesthesia to be as clinically effective and less
expensive than general anesthesia for closed reduction.
Wang et al. 4 stated that most adults with uncomplicated
fractures can be treated using either the closed or open
technique with topical/local anesthetics and intravenous
sedation. Cook et al. 23 found externally infi ltrative fi eld
anesthesia to the nasal dorsum to be as effective as, and
better tolerated than bilateral specifi c internal blocks of
the infraorbital, infratrochlear, and external nasal nerves.
This external technique introduces the needle bilaterally
at the caudal edge of the nasal bone, midway between
the nasal bridge and maxilla.
Brief general anesthesia is recommended for complete
nasal fracture reduction, 2 , 16 on account of its safety, airway
control, and unhindered ability to examine, reduce, and
manipulate the nose. Local anesthesia with intravenous
sedation is used for simple types I and II fractures or at
the patient’s request. Nasal reductions can be performed
in a day-surgery center regardless of the anesthesia type,
thereby maximizing the use of superior lighting, nasal
fracture/rhinoplasty instruments and enhanced technical
assistance available in that setting. This approach yields
a more consistent and controlled outcome with less
patient discomfort. Pediatric patients, however, routinely
undergo nasal manipulation with general anesthesia, as do
adults with polytrauma who require the repair of multi-
ple injuries. A topical vasoconstrictive agent (Afrin) and
8 to 10 cc of 1% lidocaine with 1:100,000 epinephrine
are always used for nasal hemostasis. The reduction of
external nasal bones to their anatomic position is initially
accomplished by recreating the fracture; molding the
nasal bones with the fi ngers is the simplest approach. 7 , 8 , 24
Impacted nasal bones require instrumentation for reduc-
tion and restoration of nasal length, which is the most
critical dimension to regain. The Walsham forceps are
designed for the reduction of impacted nasal bones, 2 , 8
whereas the Asch forceps are designed for reduction of
the nasal septum, although they may also successfully
restore the alignment of impacted nasal bones. Both of
these instruments can cause damage to the nasal mucosa;
therefore, we prefer using a less traumatic Boies elevator
( Figure 24-4 ). Placing the elevator intranasally and the
surgeon’s thumb externally over the nasal bones allows
appreciation of subtle osseous movements. 2
The reduction of the fractured nasal septum begins by
relocating the displaced base into the vomerine groove
( Figure 24-4 ), a process that may be accomplished with
either the Asch forceps or the blunt Boies elevator. If the
reduction of the septum is accomplished with this sim-
ple technique, it should be reexamined endoscopically or
with a nasal speculum and headlight to ensure alignment
of posterior elements. The nasal bone reduction should

NASAL FRACTURES • 259
also be reassessed, because shifting may occur during
septal manipulation. 7 Comminuted nasal bones may be
reduced, followed by dorsal-posterior intranasal packing
with gel foam to prevent collapse after reduction.
A nonreducible posteroinferior or anterior septum is
considered for acute septal reconstruction, especially in
type IV fractures. This has a slightly increased risk of los-
ing traumatized nasal mucosa during undermining with
subsequent septal perforation. Nevertheless, given the
extremely high rate of posttraumatic nasal deformity
secondary to malaligned or occult septal injury, a total
anatomic septal reduction and/or reconstruction should
be performed if the injury is acute or if the septum is
irreducible and posteriorly displaced.
A hemitransfi xion or Killian incision is made, and the
bilateral inferior mucoperichondrial fl aps are developed.
Complete visualization of the septum is then able to defi ne
the extent of the injury. An inferior and posterior sep-
tal reconstruction to dislodge and align the septum and/
or to implement septal repositioning may be performed
with anterior septal spine fi gure-of-8 sutures, using 5-0
polydioxanone suture to keep the septum aligned and
straight ( Figure 24-5 ). Reduced fractures of the septum
are precisely re-approximated using through-and-through,
mucosal-septum-mucosal, 4-0 chromic mattress suture
( Figure 24-6 , Left). Doyle splints are recommended to
further stabilize the caudal septum ( Figure 24-6 , Right).
Intranasal and external splints are used for 5 to 7 days,
Nasal trauma algorithm
without fracture
Discharge
Type IVa –
Associated septal
hematoma
Drain/pack septal
hematoma
Elevation/ice
Reassess 3 to 5 days
After severe nasal
Swelling subsides
Irrigation/wound
closure
3 mm axial/coronal CT
Early open reduction
Internal fixation
Nasoorbitoethmoid/nasal fracture reduction
- Reduce septal fractures/dislocations
- Consider limited inferior septal
reconstruction/resection for
irreducible inferior septal fractures
Antibiotics/steroids/external and intranasal splints
History; Physical examination, including nasal endoscopy
Assess fracture classification
Significant edema
Yes
No
Fracture reduction
- Anesthesia (intravenous sedation versus general)
- Meticulous septal examination with or without endoscope
- Closed reduction nasal fracture
with fracture
Type I, II, III, fractures
Type IV fractures
Type I – Simple unilateral
Type II – Simple bilateral
Type III – Comminuted

a. Unilateral

b. Bilateral

c. Frontal
Type V – Nasoorbitoethmoid
Type IV – Complex
(nasal bone & septal
disruption)
Type IVb –
Associated open nasal
laceration
FIGURE 24-3. Algorithm for the management of nasal fractures. (Reprinted with
permission from Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal
deformities. Plast Reconstr Surg. 2000;106(2):266–273.)

260 • CHAPTER 24
as are prophylactic antibiotics (Cephalexin) and 3-day
steroid-dose packs to reduce postreduction nasal edema.
Clinical Algorithm
A clinical algorithm for acute nasal fracture management
was formulated ( Figure 24-3 ) to minimize the incidence
of post-traumatic nasal deformity requiring revision sep-
torhinoplasty; however, an algorithm is merely a frame-
work on which to base clinical decisions and does not
supplant sound, individualized clinical judgment. Points
of emphasis include the following:
1. The diagnosis of an acute nasal fracture is based on a
patient’s complete history and physical examination,
including intranasal examination (6 nasal endoscopy),
not on radiographic studies.
2. In patients with signifi cant posttraumatic swelling
precluding immediate precise reduction, a clinical
examination is performed and local measures (eg,
ice and elevation) are prescribed, with follow-up in
3 to 5 days. Defi nitive treatment is instituted 5 to
7 days postinjury, depending on edema resolution in
the nose.
3. The septum is the key to nasal fracture manage-
ment. Using clinical examination and rigid nasal
endoscopy, all septal pathology, especially posteri-
orly, must be identifi ed. Signifi cant septal fractures
are directly visualized and limited septal reconstruc-
tion/repositioning is considered.
4. This algorithm will yield improved, long-term func-
tional and aesthetic results; however, all patients
should be counseled initially regarding the possibility
of further nasal procedures.
Previous acute nasal fracture management has been
inadequate, with a high incidence of long-term nasal
deformity. Primary factors contributing to poor long-term
results include acute traumatic edema, unrecognized pre-
existing nasal deformity, and undetected posteriorly and
inferiorly displaced septal fractures. Given these vari-
ables, we have devised an algorithm for acute nasal frac-
ture management.
This algorithm was developed and refi ned during the
past 15 years. In the original series of 110 patients, 16 these
principles were followed; however, albeit was not possi-
ble to stratify these patients with regard to fracture type.
The treatment failures were generally those patients with
FIGURE 24-4. (A) Bimanual reduction of a nasal bone fracture using the Boies
elevator to minimize nasal mucosa trauma, injury, and bleeding. The inset depicts
an anatomic reduction of nasal bones. (B) Relocation of a septal disruption. The
inset depicts a septal dislocation out of the vomerine groove, which may be similarly
reduced using the Boies elevator. (Reprinted with permission from Rohrich RJ, Adams WP
Jr. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg.
2000;106(2):266–273.)
A
B

NASAL FRACTURES • 261
severe, diffi cult-to-reduce septal injuries, which empha-
sizes the importance of the septum. Further detailed data
on the type of patients most prone to failure is presently
being collected and will further refi ne the algorithm.
Most reductions are done 3 to 4 days postinjury with
appropriate anesthesia in the operating room. Irreducible
septal injuries should be treated with limited inferior
septal reconstruction in the acute phase to diminish sec-
ondary nasal deformity. Using the described algorithm,
the need for extensive and diffi cult posttraumatic revi-
sion rhinoplasty should be signifi cantly reduced.
COMPLICATIONS
Incidence of Post-traumatic Nasal Deformity
In 1947, Maliniac’s classic description of the manage-
ment of acute nasal injuries was published. 25 Since then,
there has been considerable debate over the optimal
care of acute nasal fractures. Discrepancies in timing,
method, and postoperative management are common
in the literature. 1 – 3 , 7 , 19 , 26 The incidence of postreduction
nasal deformities requiring subsequent rhinoplasty or
septorhinoplasty ranges from 9% to 50%. 16 , 20 , 26 , 27 Several
authors 15 , 20 – 23 , 26 report suboptimal results when using
simple closed manipulation for acute nasal fractures.
Fry 9 , 10 and Mayell 28 described unfavorable structural
and aesthetic outcomes after nasal fractures. In a study
of 29 patients who underwent acute closed nasal fracture
reduction, Watson et al. noted a 29% to 50% incidence
of secondary nasal deformity. 22 Waldron et al. 20 presented
a prospective study of 100 patients comparing local ver-
sus general anesthesia for closed reduction. Three months
postoperatively, a 14% to 15% incidence of postreduction
deformity was found, requiring further surgery. Of those
patients with initially identifi ed traumatic septal deviation,
40% to 42% had a signifi cant septal deformity at 3 months
that required septorhinoplasty. Cook et al. 21 published a
randomized prospective series of 45 patients, again com-
paring anesthesia for the simple reduction of nasal frac-
tures, resulting in a 14% to 17% incidence of postreduction
deformity that required further surgery. Murray and
Maran’s 26 prospective series of 756 patients treated with
simple reduction resulted in a 41% incidence of postreduc-
tion deformity. They stated that “When outcome of simple
manipulation is assessed objectively the technique has
poor success rate; only a proportion of noses are made
straight and quite a number left unaltered.” 26 Rohrich and
Adams 16 presented better outcomes for closed reduction
when a systemic approach was employed. Their review of
management techniques over an 11-year period involved
110 cases with a 9% (10/110) nasal revision rate. This low
FIGURE 24-5. (A) Submucous resection of an inferior septum. (B) Midline fi xation of
a dislocated septum using a fi gure-of-8 suture at the nasal spine. (Reprinted with permission
from Rohrich RJ, Adams WP Jr. Nasal fracture management: minimizing secondary nasal deformities.
Plast Reconstr Surg. 2000;106(2):266–273.)
A
B

262 • CHAPTER 24
incidence of revision was attributed to complete nasal
assessment, use of outpatient controlled general anesthe-
sia, and primary septal reconstruction in cases with severe
septal fracture dislocation. The details of the algorithm
have been outlined within this chapter ( Figure 24-3 ).
The fi rst step in the treatment of complications is pre-
vention. The authors believe that adoption of a systemic
approach to injury may not abolish complications but
certainly can minimize the prevalence. It is essential that
the physician include the potential for postoperative com-
plications in any preoperative discussion and consent. In
the case of nasal fractures, a discussion of the occurrence
of secondary deformities requiring further surgical proce-
dures is mandatory.
FIGURE 24-6. (A) Stabilization of a septal fracture using through-and-through, 4-0
chromic horizontal mattress sutures. (B) Added septal stabilization using intranasal Doyle
splints. (Reprinted with permission from Rohrich RJ, Adams WP Jr. Nasal fracture management:
minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106(2):266–273.)
A
B
REFERENCES
1. Haug RH, Prather JL. The closed reduction of nasal frac-
tures: an evaluation of two techniques. J Oral Maxillofac
Surg . 1991;49(12):1288–1292.
2. Renner GJ. Management of nasal fractures. Otolaryngol Clin
North Am . 1991;24(1):195–213.
3. Tremolet de Villers Y. Nasal fractures. J Trauma . 1975;15(4):
319–327.
4. Wang TD, Facer GW, Kern EB. Nasal fractures. In: Gates
GA, ed. Current Therapy in Otolaryngology: Head and
Neck Surgery . Vol. 4. Philadelphia: B. C. Decker; 1990:
105–109.
5. Swearington JJ. Tolerances of human face to crash impact.
Oklahoma City, OK: Federal Aviation Agency; 1965.
6. Verwoerd CD. Present day treatment of nasal fractures:
closed versus open reduction. Facial Plast Surg . 1992;8(4):
220–223.
7. Pollock RA. Nasal trauma. Pathomechanics and surgical
management of acute injuries. Clin Plast Surg . 1992;19(1):
133–147.
8. Stranc MF, Robertson GA. A classifi cation of injuries of the
nasal skeleton. Ann Plast Surg . 1979;2(6):468–474.
9. Fry HJ. Interlocked stresses in human nasal septal cartilage.
Br J Plast Surg . 1966;19(3):276–278.
10. Fry H. Nasal skeletal trauma and the interlocked stresses
of the nasal septal cartilage. Br J Plast Surg . 1967;20(2):
146–158.

NASAL FRACTURES • 263
11. Wexler MR. Reconstructive surgery of the injured nose.
Otolaryngol Clin North Am . 1975;8(3):663–677.
12. Gunter JP, Rohrich RJ. Management of the deviated nose.
The importance of septal reconstruction. Clin Plast Surg .
1988;15(1):43–55.
13. Harrison DH. Nasal injuries: their pathogenesis and treat-
ment. Br J Plast Surg . 1979;32(1):57–64.
14. Adamson JE, Horton CE, Crawford HH, Taddeo RJ. Acute sub-
mucous resection. Plast Reconstr Surg . 1968;42(2):152–154.
15. Murray JA, Maran AG, Mackenzie IJ, Raab G. Open v
closed reduction of the fractured nose. Arch Otolaryngol .
1984;110(12):797–802.
16. Rohrich RJ, Adams WP Jr. Nasal fracture management:
minimizing secondary nasal deformities. Plast Reconstr Surg .
2000;106(2):266–273.
17. Humber PR, Horton CE. Trauma to the nose. In: Starks RB,
ed. Plastic Surgery of the Head and Neck. New York: Churchill
Livingstone; 1989.
18. Logan M, O’Driscoll K, Masterson J. The utility of nasal
bone radiographs in nasal trauma. Clin Radiol . 1994;49(3):
192–194.
19. Kurihara K, Kim K. Open reduction and interfragment wire
fi xation of comminuted nasal fractures. Ann Plast Surg .
1990;24(2):179–185.
20. Waldron J, Mitchell DB, Ford G. Reduction of fractured
nasal bones; local versus general anaesthesia. Clin Otolaryn-
gol Allied Sci. 1989;14(4):357–359.
21. Cook JA, McRae RD, Irving RM, Dowie LN. A randomized
comparison of manipulation of the fractured nose under
local and general anaesthesia. Clin Otolaryngol Allied Sci .
1990;15(4):343–346.
22. Watson DJ, Parker AJ, Slack RW, Griffi ths MV. Local ver-
sus general anaesthetic in the management of the fractured
nose. Clin Otolaryngol Allied Sci . 1988;13(6):491–494.
23. Cook JA, Murrant NJ, Evans K, Lavelle RJ. Manipulation of
the fractured nose under local anaesthesia. Clin Otolaryngol
Allied Sci . 1992;17(4):337–340.
24. Dingman RO, Converse JM. The clinical management of fa-
cial injuries and fractures of the facial bones. In: Converse
JM, ed. Reconstructive Plastic Surgery. Vol. 2. Philadelphia:
Saunders, 1977.
25. Maliniac JW. Rhinoplasty and Restoration of Facial Contour:
With Specifi c Reference to Trauma. Philadelphia: F. A. Davis;
1947:29.
26. Murray JA, Maran AG. The treatment of nasal injuries
by manipulation. J Laryngol Otol . 1980;94(12):1405–1410.
27. Crowther JA, O’Donoghue GM. The broken nose: does
familiarity breed neglect? Ann R Coll Surg Engl . 1987;69(6):
259–260.
28. Mayell MF. Nasal fractures. Their occurrence, management
and some late results. J R Coll Surg Edinb . 1973;18(1):
31–36.

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25
Midface and Maxillary Fractures
Adam J. Oppenheimer, MD / Steven R. Buchman, MD, FACS
INTRODUCTION
The principles of reconstructive surgery, namely restora-
tion of form and function, have particular importance
in traumatic midface reconstruction. Given the density
of specialized functional units and highly expressive
mimetic tissue, midface fractures can incur signifi cant
dysfunction on an individual’s way of life. Accordingly,
patients sustaining severe midfacial fractures report sub-
stantially worse health outcomes and demonstrate poorer
occupational productivity than general injury-matched
control patients. 1 It is the responsibility of the maxillo-
facial surgeon not only to prevent short-term morbidity
and mortality, but ultimately to restore the patient to
their preinjury condition. This chapter keeps this goal in
mind, focusing on key reconstructive principles and the
avoidance of commonly encountered complications.
While the midface consists of the entire central third
of the facial skeleton, this chapter will limit its focus to
maxillary fractures and palatal fractures. Those fractures
involving the zygoma, naso-orbitoethmoid (NOE) com-
plex, and orbital fl oor will be discussed elsewhere.
EPIDEMIOLOGY
Motor vehicle accidents and interpersonal violence
account for greater than two thirds of all facial fractures.
Alcohol intoxication is frequently cited as an associ-
ated and etiological factor. Not surprisingly, facial frac-
tures are intimately related to socioeconomic status and
geographic locale. Men are twice as likely to experience
facial fractures compared with women, the average age
being approximately 33 years. 2
Associated Injuries
Although facial fractures are rarely a threat to life, those
involving the midface are associated with a high proportion
c h a p t e r
of life-threatening injuries. This may be due, in part, to the
severity of impact and the degree of force required to sus-
tain this type of fracture. Cerebral trauma, hemorrhagic
shock, and airway compromise have all been strongly
correlated. Injuries to the cervical spine are reported in
approximately 6% of maxillofacial trauma. 3 Stabilization
of the cervical spine should be maintained in maxillofacial
trauma patients until radiographic and clinical clearance
is possible. When traumatic brain injury occurs in concert
with facial fractures, patient mortality increases from 5.8%
to nearly 17%. 4 Death is also strongly linked to midface
fracture. In one study, 84% of patients who died from neu-
rologic injuries had a facial fracture pattern that included
the midface. 5 In contrast, isolated mandibular fractures
were rarely associated with fatal neurologic complications.
MIDFACIAL ANATOMY
The anatomy of the maxilla is complex: alternating seg-
ments of thick and thin bone are admixed with sinuses and
cavities, and neurovascular pathways course throughout.
A sound understanding of regional anatomy is therefore
crucial to proper midface reconstruction. The maxilla is
the keystone of the facial skeleton, establishing the central
portion of the midface. The paired maxillary bones defi ne
the orbital, nasal, and oral cavities: the so-called functional
units. 6 The physiological importance of these units in respi-
ration, mastication, and vision is axiomatic. Reestablishing
the functional units of the midface is, therefore, a central
goal of posttraumatic midface reconstruction. In addition,
several specifi c anatomic structures deserve additional
attention ( Figure 25-1 ). They will be discussed in the con-
text of their relationship to the buttress system.
The Buttresses of the Midface
The maxilla’s ability to resist fracture resides in several for-
tifi cations of bone: the maxillary buttresses ( Figure 25-2 ).

266 • CHAPTER 25
Frontal bone
Sphenoid bone
Zygomaticofrontal suture
Zygomaticomaxillary suture
Infraorbital foramen
Pyriform aperture
Alveolar process (Maxilla)
Frontal bone
Sphenoid bone
Zygoma
Nasomaxillary suture
Frontal process (Maxilla)
Zygomaticofrontal suture
Zygomaticomaxillary suture
Infraorbital foramen
Pyriform aperture
Alveolar process (Maxilla)
Pterygoid plates (Sphenoid)
Maxillary tuberosity
Zygoma
Nasomaxillary suture
Frontal process (Maxilla)
FIGURE 25-1. Key anatomical structures in the midface. (Reprinted with permission
from Netter FH, Dalley AF. Atlas of Human Anatomy. 2nd ed. New York: Elsevier; 1997.)

MIDFACE AND MAXILLARY FRACTURES • 267
The buttresses may be likened to the trusses and beams of
a building. In the midface, the buttress system is comprised
of thick confl uences of bone that do not transilluminate.
The buttress system provides a framework for dissipating
forces to the cranial base. They are either horizontally or
vertically oriented, each projecting into the sagittal plane.
The midfacial buttresses are a key component in the
reconstruction of the midface as they meet the following
criteria: (1) they are linked to the skull base; (2) they have
suffi cient bone to allow stable plate and screw fi xation; and
(3) they are accessible through standard surgical incisions. 7
In contradistinction to the buttresses, the transilluminat-
ing portions of the maxilla (eg, the walls of the maxillary
sinus and laminae paprycea) are particularly susceptible
to fracture, owing to their thin, weak structure. Suffi cient
anterior and/or lateral impact to these areas results in frac-
ture, often associated with comminution.
The Vertical Buttresses. The midface is primarily
designed to absorb vertically directed forces, namely, the
forces of occlusion. Finite element analysis has confi rmed
that forces indeed fl ow through these buttresses to the
skull base. Aptly, the vertical buttresses are the strongest
structural components of the midface. There are three
pairs of vertical buttresses in the maxilla. The nasomaxil-
lary buttress is also known as the medial maxillary or naso-
frontal buttress. It runs from the anterior alveolar process
cephalad along the border of the piriform aperture and
across the frontal process of the maxilla. After forming the
medial orbital rim, it crosses the nasofrontal junction to
the frontal bone. Its sagittal projection defi nes the medial
orbital wall. The zygomaticomaxillary buttress or lateral
maxillary buttress originates at the posterior alveolar pro-
cess and travels cephalad over the body of the zygoma. It
extends superiorly to comprise the lateral orbital rim and
then crosses the zygomaticofrontal suture into the frontal
bone. The pterygomaxillary buttress is also known as the
posterior maxillary buttress. It is unique in that it is not
commonly used in rigid fi xation. Nonetheless, fractures
across this buttress—and the pterygoid plates—are the
common thread of all LeFort fractures. This represents the
key point of separation (pterygomaxillary dysjunction)
between the maxilla and the cranial base. The pterygo-
maxillary buttress joins the pterygoid plates of the sphe-
noid bone to the posterior maxilla.
The Horizontal Buttresses. When compared with the
vertical buttress system, the horizontal buttresses
Frontal bar
Inferior orbital rim
Hard palate
Nasomaxillary
Zygomaticomaxillary
Pterygomaxillary
Vertical mandible
Horizontal buttresses:
Vertical
buttresses:
FIGURE 25-2. Midface buttress anatomy. The orange lines (1-4) represent the
vertical buttresses, while the green lines (A-C) represent the horizontal buttresses.
Vertical: (1) nasomaxillary, (2) zygomaticomaxillary, (3) pterygomaxillary. Horizontal:
(B) upper transverse maxillary (inferior orbital rim), (C) lower transverse maxillary
(hard palate). Also shown: (4) the vertical mandibular buttress, and (A) the frontal bar.
(Reprinted with permission from Mann FA. Imaging of high-energy midfacial trauma: what the
surgeon needs to know. Eur J Radiol. 2003;48:17–32.)

268 • CHAPTER 25
are relatively weak, particularly in the sagittal plane
( Figure 25-3 ). Accordingly, the maxilla is highly suscep-
tible to fracture from horizontally directed forces. The
upper transverse maxillary buttress runs from the tem-
poral bone to the infraorbital rim via the zygomatic arch.
It then travels over the frontal process of the maxilla to
the nasal radix, continuing to the contralateral side via a
similar path. Throughout its course, the upper transverse
maxillary buttress crosses several sutures, which are
commonly involved in fracture patterns: the zygomati-
cotemporal, zygomaticomaxillary, and nasomaxillary. Its
sagittal projections are the zygomatic arches laterally and
the orbital fl oors medially. The lower transverse maxil-
lary buttress follows a horseshoe-shaped path along the
alveolar process, and includes the hard palate.
The Soft Tissues and Musculature
The facial soft tissue envelope makes a signifi cant con-
tribution to the perception of appearance. Its shape is
largely predicated on the underlying skeletal structure.
Following injury, internal fi brosis can occur, making sub-
sequent repositioning an onerous and challenging task.
Early primary repair of the soft tissues in a layered fash-
ion is advocated, along with tissue resuspension in early
fracture reduction. This approach will achieve the best
aesthetic result and avoid the long-term consequences of
scarring and contraction.
The highly specifi c facial musculature permits a
remarkable diversity of human expression and function-
ality. The muscles attached to the maxilla include those
of facial expression anteriorly, and mastication posteri-
orly. Standard surgical techniques diffusely elevate, or
deglove, the anteriorly located mimetic muscles, poten-
tially disrupting their osseous attachments. Resuspension
of the soft tissue envelope should therefore be included
as a component of midface fracture repair.
The Neurovasculature
Blood Supply. The dual system of carotid perfusion to
the midface permits both tissue viability and resistance
to infection following facial injury. A necessary corollary,
however, is the coincident possibility of profuse bleeding.
The major culprits are the internal maxillary artery, a
branch of the external carotid system, and the ethmoidal
arteries, branches of the internal carotid system.
Innervation. The maxillary division of the trigeminal
nerve (CN V2) provides sensation to the cheek, nasal
sidewall and ala, upper lip, and maxillary dentition. The
infraorbital nerve, its major branch, exits its named fora-
men 1 cm below the infraorbital rim in the midpupillary
line. This nerve is frequently injured in midface frac-
tures.8 Paresthesia or anesthesia may be noted in its dis-
tribution, depending on the degree of injury. The facial
nerve (CN VII) is usually spared in midface fractures.
Damage to this nerve is more common in fractures of the
cranial base, temporal bone, and mandible.
PATTERNS OF MIDFACIAL FRACTURE
Rene LeFort, a French orthopedic surgeon, published his
classical treatise on facial fractures in 1901. 9 Therein, he
described “the great lines of weakness” of the facial skele-
ton ( Figure 25-4 ). His experimentation on human skulls
defi ned a lexicon for midface fractures that is still widely
used more than 100 years later. Although he reported
midface fractures with bilateral symmetry, seldom are
they seen in pure form. In clinical practice, a myriad of
patterns are observed, as the thin bone of the midface
is susceptible to multiple fractures that easily collapse.
Comminution is the rule, and synchronous injuries to
the mandible and the frontal bones are commonplace.
In addition, the LeFort classifi cation does not adequately
FIGURE 25-3. Buttresses in the sagittal
plane. (A) the sagittal extensions of the horizontal
buttresses (black arrows) are relatively weak.
(B) The central midface (shaded area) is therefore
prone to collapse and defi cient projection.
(Reprinted with permission from Manson P. Subunit
principles in midface fractures: the importance
of sagittal buttresses, soft-tissue reductions, and
sequencing treatment of segmental fractures. Plast
Reconstr Surg. 1999;103:1287–1307.)
A
B

MIDFACE AND MAXILLARY FRACTURES • 269
address palatal fractures or descriptions of coincident
bone loss. Regardless, with minimal modifi cation, *
LeFort’s original classifi cation scheme continues to pro-
vide surgeons with a simple, reproducible language for
describing midface fractures and their relative points of
stability ( Figure 25-5 ).
LeFort I Fractures
Also known as a transverse maxillary fracture, the
LeFort I fracture extends across the maxilla in a hori-
zontal fashion above the dental apices. The maxillary
sinus is traversed, and the base of the piriform aperture
is disrupted. The pterygoid plates are also disrupted (the
commonality of all LeFort fractures). A so-called “fl oating
palate” ensues. In essence, the lower transverse maxillary
buttress is mobile in relation to the skull.
LeFort II Fractures
The LeFort II fracture assumes a triangular shape and is
therefore known as a pyramidal maxillary fracture. The
fracture extends through the maxilla across the infraor-
bital rim and medially to the nasal radix. The orbit is
*The numerical designation of fracture levels has since been inverted
from LeFort’s initial proposal.
LeFort I
LeFort II
LeFort III
FIGURE 25-4. “The great lines of weakness.”
(Reprinted with permission from Mann FA. Imaging of high-energy
midfacial trauma: what the surgeon needs to know. Eur J Radiol.
2003;48:17–32.)
invariably involved. In this fashion, LeFort II fractures
separate and mobilize the midfacial skeleton.
LeFort III Fractures
Most rare of the midfacial fractures, LeFort III fractures
occur at the juncture of the cranial and facial skeletons.
Apropos, this type of fracture results in craniofacial
dysjunction. LeFort III fractures extend into the orbit,
and concomitant injury to orbital structures may ensue.
The fractures necessarily include a separation of the
zygomatic arch. In strictest terms, most LeFort III frac-
tures are actually zygomaticomaxillary complex frac-
tures in combination with LeFort I and/or II fractures
( Figure 25-6 ).
LeFort IV Fractures
Not described in Rene LeFort’s original classifi cation,
LeFort IV fractures result when the upper midface is frac-
tured in conjunction with the frontal bone. Injury to the
NOE complex is nearly ubiquitous with this pattern.
LeFort fractures occur in a relatively predictable fre-
quency, with LeFort II being the most common, followed
by LeFort I and LeFort III. 2 Concurrent palatal fractures
are observed in approximately 8% of maxillary fractures.
FIGURE 25-5. LeFort fractures. (Upper Left, blue)
LeFort I. (Upper Right, orange) LeFort II. (Center, green)
LeFort III. (Lower Left) classic “panda facies” appearance.
(Lower Right) Edema and hematoma as seen on sagittal
section. (Reprinted with permission from Hansen, J. Netter’s Clinical
Anatomy. New York: Elsevier; 2006.)

270 • CHAPTER 25
Conversely, palatal fractures are rarely observed in iso-
lation: LeFort I fractures are almost uniformly present.
Fractures of the other facial bones (eg, nasal, mandibular)
are clinically more common than those of the midface.
Palatal Fractures
Fractures of the palate occur in approximately 8% of
all midface fractures. 7 A wide variety of patterns may
be observed, based on patient age and nature of injury.
Alveolar and para-alveolar fractures cause mobility in an
isolated segment of the dentition. They may be misinter-
preted as LeFort fractures on bimanual intraoral examina-
tion if not carefully delineated.
Sagittal fractures result in a “split palate.” The fracture
occurs along the intermaxillary and midpalatal sutures.
This pattern is commonly seen in children. The palatal
suture does not fuse until age 20 to 30 years, allowing for
maxillary expansion and growth. For this reason, parasag-
ittal fractures are much more likely in adults. These frac-
tures extend through the piriform aperture anteriorly,
and deviate toward the maxillary tuberosity posteriorly.
The transverse palatal fracture is addressed here for com-
pleteness sake, as this pattern is rarely observed in clini-
cal practice. The palatal vault is well buttressed sagittally,
preventing this type of injury.
Severe palatal fractures may divide the palate obliquely
and transversely, comminuting the palate and alveolus.
These fractures are extensive, involving combinations of
fracture patterns. In summary, the particular pattern of
palatal fracture is not as important as the simple recog-
nition of their presence; their management is discussed
below.
ASSESSMENT
Facial trauma is a harbinger of life-threatening injury,
indicating the possibility of concomitant injury to the
airway, neuroaxis, viscera, and axial skeleton. The poten-
tial for unstable hemodynamic phenomena must also
be realized. Treatment of these concurrent, systemic
injuries should take precedence over maxillofacial
reconstruction.
FIGURE 25-6. Midface fractures. (Left) Simultaneous LeFort I and II fractures
associated with zygomaticomaxillary complex, zygomatic arch, and orbital fl oor
fractures. (Right) Appearance following reduction and rigid plate fi xation. Titanium
mesh has been placed in the orbital fl oor defect and arch bars have been applied.
Note the incorrect placement of the L plate, which should be located medially over the
nasomaxillary buttress. (Illustration Copyright © 2006 Nucleus Medical Art. All rights reserved.
)

MIDFACE AND MAXILLARY FRACTURES • 271
Patients with maxillofacial injuries are often prema-
turely assigned to the care of subspecialty services. In
these cases, it is important that this team reevaluate the
patient for the possibility of evolving, life-threatening
injury.
Airway
In all trauma settings, adherence to Advanced Trauma
Life Support protocol is essential. As such, the initial
management of the maxillofacial trauma patient begins
with securing the airway. These patients are particularly
prone to asphyxia from prolapsed bone and soft tissue,
laryngeal fractures, aspiration of dental fragments, and
oropharyngeal hemorrhage. While maintaining inline sta-
bilization of the cervical spine, anterior traction on the
mandible and direct intraoral examination should be fol-
lowed by vigorous suctioning to remove blood clot and
debris.
A low threshold for intubation should be maintained. In
most cases, this can be achieved via orotracheal approach.
The endotracheal tube may be wired to the anterior den-
tition for additional security. Inspection for cerebrospinal
fl uid (CSF) leakage and consideration of skull base frac-
ture should occur prior to blind insertion of nasogastric
tubes or nasal airways. In all facial trauma patients, caution
should be used to avoid the inadvertent entry of these
devices into the cranial vault through fracture lines. Fiber
optic intubation techniques may be implemented for guid-
ance, but careful manual placement is generally suffi cient
to avoid this complication. The examiner’s fi nger may be
placed into the patient’s oropharynx to help guide the
endotracheal tube inferiorly. If an adequate airway cannot
be established through these means, a cricothyroidotomy
or tracheostomy should be performed without delay in
cases of airway compromise.
Hemorrhage
As previously noted, the blood supply to the maxilla is
robust and redundant. Exsanguination and hemorrhagic
shock, although rare, may rapidly ensue following severe
midface fracture. A thorough knowledge of vascular anat-
omy permits rapid hemostasis.
The majority of uncontrolled bleeding arises from the
internal maxillary artery or its branches. Following the
application of direct pressure, persistently bleeding ves-
sels may be carefully ligated. This approach minimizes
the damage to adjacent structures, which may result from
blind clamping in the fi eld. The superfi cial temporal and
external carotid arteries may be similarly ligated in cases of
severe uncontrolled bleeding.
Epistaxis can result from either the anterior or pos-
terior nasal cavity. Anterior bleeding originates from
Kiesselbach plexus, which is located on the anterior nasal
septum. This vascular confl uence is composed of the ante-
rior ethmoidal, sphenopalatine, and superior labial arter-
ies. Anterior epistaxis responds well to topical vasoactive
compounds and bilateral, direct, and external pressure to
the nasal septum. Posterior bleeding is more diffi cult to
access. It usually arises from Woodruff plexus, which is
located on the middle nasal turbinate, and is composed
of the posterior nasal, sphenopalatine, and ascending pha-
ryngeal arteries. Layered gauze packing of the nasal fl oor
with bayonet or Debakey forceps is often successful in
this context. Tamponade may also be achieved with the
introduction and infl ation of 30-cc Foley balloon cathe-
ters into each nostril. The catheter may be secured at the
columella and the balloon released intermittently to avoid
pressure necrosis of the nasal septum.
Manual fracture reduction is the defi nitive manage-
ment of bleeding and should be employed in a con-
trolled setting as soon as the patient’s condition allows.
Angiographic embolization, while increasingly facile with
interventional techniques, is rarely necessary. The afore-
mentioned means of attaining hemostasis are suffi cient in
the vast majority of cases.
Physical Examination
A complete maxillofacial examination includes observation
for symmetry, palpation for step-off and contour deformi-
ties, examination of the visual axis, otoscopy, assessment of
the occlusion, and neurological evaluation, including cra-
nial nerve testing.
Midface fractures may present with a combination
of ecchymosis, edema, malocclusion, and missing denti-
tion with osseous deformity and mobility. The latter is
routinely assessed through bimanual examination. With
one hand intraorally on the maxillary alveolus and the
other across the midface, a gentle rocking motion will
frequently elicit the level(s) of fracture. An overzealous
examination, however, may worsen the injury and cause
instability where none was previously present.
Prima Non Nocere. An additional stumbling block for
the uninitiated examiner is the misinterpretation of a
mobile alveolar segment for a complete LeFort fracture.
Gently assess the entire midface for mobility. In the max-
illofacial trauma patient, malocclusion is assessed through
subjective and objective means. Asking the patient, “Does
your bite feel normal?” is a highly sensitive way to deter-
mine the presence of fracture. The present and pretrau-
matic status of the occlusion should always be solicited
if the patient’s clinical condition allows. If there has been
a past history of orthodontic treatment, these records
should be sought out.
Objectively, the Angle classifi cation of malocclusion
is used. In normal occlusion, the mesiobuccal cusp of
the fi rst maxillary molar contacts the buccal groove of
the fi rst mandibular molar. A class III malocclusion with
anterior open bite (ie, negative overbite) is often associ-
ated with a LeFort fracture. Inferior maxillary displace-
ment causes an elongated and retruded midface. This
“facies equine” results from premature contact of the
posterior dentition.

272 • CHAPTER 25
Radiographic Analysis
As noted above, the clinical diagnosis of midface fractures
may be complicated by the presence of edema, incom-
plete fracture, impaction, or a combination of fracture
types. Advances in radiographies, particularly in the realm
of computed tomography, have greatly enhanced diagnosis
and preoperative planning. Plain fi lms are no longer rou-
tinely recommended in the evaluation of midface fractures.
Far superior in resolution and sensitivity, maxillofacial CT
scans have moved to the fore. Sections are generally taken
1.0 to 1.25 mm apart. Coronal reformatting is frequently
performed to further delineate fracture lines in alternate
planes. Three-dimensional computed tomography permits
further analysis of fracture patterns. With this modality,
volume and proportionality may be directly assessed.
Particular clues to radiographic diagnosis include the
presence of step-off deformities and sinus opacifi cation.
Pneumocephalus indicates the possibility of high LeFort
fractures with breach of the cranial base. Cerebral edema
and diffuse axonal injury may also be appreciated.
Postoperative computed tomography is often eschewed
because of its cost and associated radiation exposure.
Nonetheless, it is frequently used in the fi elds of ortho-
pedics and neurosurgery. When used in the reconstructive
algorithm, postoperative CT scanning provides a powerful
educational tool. It should be considered more strongly in
the routine postoperative care of patients with maxillofa-
cial trauma in order to confi rm surgical effi cacy.
RECONSTRUCTIVE PRINCIPLES
Historically, multiple treatment modalities have been
employed for the stabilization of midface fractures,
including external fi xation, Kirschner wires, and internal
wire suspension. The introduction of rigid plate fi xation
and its associated benefi ts has reduced the utility of these
earlier forms of repair. 5 It is now generally accepted that
rigid osteosynthesis with titanium plating provides the
best stability and long-term results. Wide surgical expo-
sure has enabled precise anatomic reduction under direct
visualization. In the cases where rigid fi xation is diffi -
cult to achieve (because of severe comminution or bony
instability), more creative solutions must be employed.
A thorough understanding and deft skill with mandib-
ulomaxillary fi xation (MMF) is a requisite to profi cient
midfacial fracture management. The judicious use of
autogenous bone grafting at the time of injury has yielded
additional improvements in bone healing, augmenting the
stability and durability of fracture repair. The continued
evolution of these techniques has afforded the maxillofa-
cial surgeon the capacity to provide prompt and defi ni-
tive management in a single-stage operation. 7
Sequencing
Multiple authors have proposed various methodolo-
gies for appropriate sequencing in traumatic midface
reconstruction: top-down, bottom-up, inside-out, and vice
versa, all have been purported to be ideal. Aptly, Manson
states, “The exact order of treatment is not as important as
the development of a plan that permits both fl exibility and
reproducibly accurate positioning.” 5 For this to be achieved,
a thorough preoperative assessment of the involved facial
bone fragments is necessary. This is particularly important
in cases of panfacial fracture, which result from concomi-
tant fractures of the mandible, midface, and frontal bones.
Midface fractures are generally repaired in the following
sequence: arch bar application, fracture exposure, disim-
paction and reduction, restoration of occlusion with MMF,
rigid fi xation, and soft tissue re-suspension and repair. All
these techniques are performed with a keen eye to gaining
symmetry, restoring projection, and providing a durable
and stable repair.
Exposure
The need to widely expose the involved bony buttresses
must be balanced against the possibility of iatrogenic
soft tissue injury. Accordingly, surgical approaches that
maximize exposure and minimize conspicuous scarring
are preferred. If signifi cant lacerations are present, these
may be used for access; oftentimes, the injury has par-
tially completed the dissection. Based on the location
and degree of fracture, several classical approaches to the
midfacial skeleton may be used ( Figure 25-7 ).
Gingivobuccal Sulcus. The gingivobuccal sulcus inci-
sion is the most commonly used approach to access the
midfacial skeleton. It is the least conspicuous incision,
and provides exceptional exposure for lower maxillary
fractures. Alveolar fractures can also be reduced via this
approach. Periosteal elevation permits skeletonization of
the fractures while protecting the mimetic muscles and
neurovasculature of the soft tissue fl ap. The naso- and
zygomaticomaxillary buttresses are also accessible from
this approach, and the infraorbital rim may be reached
if the dissection is carried out superiorly. Care should
be taken, however, to avoid inadvertent damage to the
infraorbital nerve. The gingivobuccal sulcus incision
should preserve a 5-mm cuff of tissue on the gingiva and
should not be placed at the apex of the sulcus. This tech-
nique permits a facile and watertight closure.
Orbital. Transconjuctival, subcilliary, subtarsal, and midlid
approaches to the orbit provide the best access to the
infraorbital rim component of LeFort II fractures. Each
of these approaches has its strengths and weaknesses.
The subciliary incision, for example, carries an increased
risk of ectropion and scleral show. Extended lateral
canthotomy or upper blepharoplasty incisions may be
added for access to the zygomaticofrontal suture. Care
must be taken to avoid placing incisions within the brow,
which can yield a conspicuous and untoward result.
Corneal shields are essential when any orbital exposure
is attempted.

MIDFACE AND MAXILLARY FRACTURES • 273
Coronal and Hemicoronal. Wide exposure to the cra-
nial region, upper midface, zygomatic, and nasoethmoid
area can be gained through a coronal incision. Such an
approach is often indicated when high LeFort fractures
with severe comminution are encountered. A “stealth”
technique may be used to camoufl age the scar. This is
performed by making a zig-zag (or sinusoidal) incision,
the limbs of which should be approximately 2 cm in
length and mutually orthogonal to one another. The inci-
sion is carried out from ear to ear (posterior to the ear
is better aesthetically) with dissection carried out ante-
riorly in the subgaleal plane. When the scalp is incised
parallel to the hair follicles, the severity of cicatricial alo-
pecia is reduced. Removable surgical clips are applied to
the free edge of the fl ap for hemostasis.
Palalal. Palatal incisions are used if rigid fi xation of
the hard palate is attempted, which may be considered
based on surgeon preference. If utilized, incisions should
be kept in the midline or paramedian position to avoid
mucosal devascularization. The greater palatine vessels
course posterolaterally, adjacent to the maxillary tuber-
cles. Care should also be taken to avoid the nasopalatine
Coronal incision
Transconjuctival,
transcaruncular,
and blepharoplasty
incisions
Extraoral incision
Intraoral incision
FIGURE 25-7. Commonly used exposures in midface
fracture. (Reprinted with permission from Mathes S. Plastic Surgery.
2nd ed. Vol 3. New York: Elsevier; 2006.)
neurovascular bundle as it exits the incisive foramen
anteriorly. Access may be achieved through preexisting
lacerations, if present.
Anatomic Reduction
For defi nitive repair of midface fractures, the buttresses
must reassume their preinjury alignment. All three
dimensions—vertical, horizontal, and sagittal—must be
satisfactorily restored. The sine qua non of midface frac-
ture repair is anatomic reduction along buttress lines.
Closed reduction techniques are no longer routinely
recommended in maxillary fracture management. The
use of Rowe or Hayton-Williams disimpaction forceps
can create new and undesirable fracture lines that may
extend into the orbit or skull base. Nonetheless, when
severely impacted fractures are encountered, these
instruments may be used in an open and controlled fash-
ion. In general, open techniques provide a safer and more
predictable means of reduction. Precise reduction under
direct visualization is only possible after adequate expo-
sure and skeletonization of the fracture segments. 7
Mandibulomaxillary Fixation
MMF is required intraoperatively to restore the prein-
jury occlusion. Once rigid fi xation has been achieved,
however, MMF is no longer necessary. Prolonged MMF
as a primary treatment strategy has become less com-
monplace, and is often reserved for situations where true
rigid fi xation cannot be attained. In these cases, a 2 to 6
week course of MMF may be required. If left in place
during the acute phase of hospitalization, it is impor-
tant to keep wire cutters at the bedside. Should vomiting
ensue, MMF must be released to protect the airway and
avoid the possibility of aspiration.
After the appropriate fi xation period, the wires may
be removed and replaced with traction elastics. These
can be modifi ed on a weekly basis to make fi ne adjust-
ments in the occlusion. Frequent observation is suggested
during this time period, as “off-axis” forces may disrupt
alignment or cause dental extrusion. After several weeks,
the elastics may be discontinued, leaving the arch bars
in place for an additional “test” week. If centric occlu-
sion has been maintained, the arch bars may be removed.
Orthodontic realignment may be required if occlusal
restoration is not possible. This strategy, however, should
be considered as a last resort.
Splinting may be used as an additional means of stabi-
lization for midfacial fractures. When employed in con-
cert with MMF, splints are particularly effi cacious in the
fi xation of comminuted, unstable, small bone fragments
(eg, alveolar fractures). The dentition bearing these frac-
ture segments can also be etched and wired to achieve
requisite stability.
Rigid Osteosynthesis
Fractures must be stabilized in three dimensions against
both translational and rotational forces. 9 Plates and screws

274 • CHAPTER 25
are fi xed across adjacent fractures in order to prevent
micromovement, thus providing rigid osteosynthesis
( Figure 25-6 ). The most common plating sets used in the
maxilla are equipped with 1.5 to 2.0 mm diameter screws.
Plates of varying shapes and sizes are part of the surgeon’s
armamentarium and are used according to the demands of
local anatomic topography.
Plates should be placed along the natural lines of
force (ie, the buttresses) to permit maximum load bear-
ing. 7 They may be conceptualized as synthetic buttresses,
which augment those injured during trauma. At least
two screws should be used on either side of the frac-
ture. Interfragmentary wires are a versatile tool that may
be used to create an ideal reduction prior to defi nitive
fi xation. 7
Both the amount of bone and degree of comminution
largely determine the ability to achieve suffi cient fi xa-
tion. The highest probability of attaining rigid fi xation
will be realized if the solid bone of the nasomaxillary and
zygomaticomaxillary buttresses is used when anchoring
screws. It must be reemphasized that other means of
stabilization (ie, MMF) should be used for maintaining
reduction and fi xation if plate deformation or semirigid
fi xation is present.
Bone Grafting
Bone grafting in maxillofacial injuries was fi rst proposed
by Bonanno and Converse, 10 and pioneered by Gruss. 11
The use of interpositional bone grafts along the course
of the native vertical buttresses provides functional and
structural support to the fractured midface. These grafts
enhance bony consolidation and restore facial height.
Although not always required, bone grafting to large
defects in the anterior maxilla may prevent soft tissue
prolapse into the maxillary sinus. Bone grafts are indi-
cated when gaps of 5 mm or wider are found between
fracture segments.
Plate and screw fi xation or wiring may be used for
graft stabilization, but rigid fi xation is preferable to
attain optimal osteosynthesis. 6 Fracture fragments should
be re-used as the primary bone graft source until they
are exhausted, thereby limiting donor site morbidity. In
severely contaminated wounds, or when tissue cover-
ing is inadequate or nonviable, bone grafting is generally
contraindicated.
The rib, calvarium, and iliac crest are among the more
commonly used donor sites for bone grafting in maxil-
lofacial trauma. The surgeon considers three variables
when harvesting bone grafts: (1) bony characteristics; (2)
ease of access; and (3) donor site morbidity. Rib grafts, for
example, allow for superior contouring, but experience
high resorption rates, and carry the risk of pneumothorax
during harvest. Calvarial bone, in comparison, is less mal-
leable, but shows decreased resorption over time and is
close to the operative fi eld. The risks of dural tears and
cerebral injury during harvest, however, must also be
considered. The iliac crest provides abundant bone and
is easily accessible. The greatest drawback of this site is
postoperative pain.
Palatal Reconstruction
The palate, because of its intimate involvement with the
occlusion, requires unique reconstructive consideration.
The palate is composed of relatively thin bone, making
plate and screw fi xation a diffi cult task. Because these small
bony fragments are often not amenable to the aforemen-
tioned techniques of rigid fi xation, adjunctive stabilization
methods are often required. While some authors advocate
that rigid osteosynthesis be applied to palatal fractures/
occlusal splinting is both a viable and effective strategy for
their management.
Splinting of palatal fractures provides stability against
rotation, creating a point of fi xation away from the frac-
ture site. Etched interdental (“buddy”) wiring may also
be used in this context. Splinting is mandatory in cases of
severe palatal comminution.
In order to create an adequate splint, impressions of
the dentition must be taken. Dental models are made
from these impressions, and then mounted on an articula-
tor. The models are then cut and manipulated in order to
restore centric occlusion on the articulator based on facet
wear patterns. Once this is established, an acrylic mold,
or splint, is created along the restored occlusion. The
occlusal splint is then used as a surgical guide. Once the
major fracture fragments have been reduced, the splint
is then used to facilitate MMF. The rigid osteosynthesis
of other maxillary fractures, if present, can then be per-
formed. On release of MMF, the maxillary splint is left in
place for approximately 6 weeks.
Soft Tissue Management
The shape of the soft tissue envelope of the face is highly
dependent on the underlying skeleton. Upon disruption
of the bones of the midface, the overlying soft tissue
often suffers concomitant damage resulting in swelling
and local response to injury. A thorough understanding
of the interactions between the soft tissue and the midfa-
cial fracture is of paramount importance. Remodeling of
the soft tissues can occur within 7 to 10 days postinjury,
generating problematic contraction and/or tissue atrophy.
Internal fi brosis gives the injured tissue “memory,” and
subsequent repositioning becomes diffi cult. Therefore,
repair of both the bone and soft tissue need to be done
in a timely fashion in order to preclude permanent disfi g-
urement. In order to restore a natural appearance, simul-
taneous soft tissue repair and re-suspension is advised.
The soft tissues should be closed in a standard lay-
ered fashion. Re-approxirnation of muscle and soft tis-
sue also provides bulk over low-profi le plates, making
step-offs less visible. If this is not performed, soft tissue
diastasis may result. The related changes of soft tissue
descent (ptosis) result from improper re-suspension of
the soft tissues to the underlying skeleton. 7 Periosteal

MIDFACE AND MAXILLARY FRACTURES • 275
reattachment is required at the malar eminence, infraor-
bital rim, and medial and lateral canthi. Drill holes may
be created at these locations to facilitate re-suspension.
SPECIAL CONSIDERATIONS
Pediatric facial fractures and panfacial fractures require
nuanced management and will be addressed elsewhere in
this volume. Several other special considerations merit fur-
ther discussion here.
The Edentulous Maxilla
The management of the fractured maxilla in the eden-
tulous patient requires special consideration because
the occlusion is no longer available as a reconstruc-
tive guide. 12 In these patients, the mandibulomaxillary
relationship assumes the utmost reconstructive signifi -
cance. An important corollary is the need to restore the
space between the maxilla and the mandible. Adequate
intermaxillary space allows for dentures to fi t without
diffi culty.
If the maxilla is not displaced, the fracture may be
managed conservatively with a soft diet for 2 to 3 weeks,
followed by a gradual reincorporation of dentures. When
the maxilla is displaced and the patient’s condition is
stable, the surgeon should proceed with bony reconstruc-
tion. The patient’s dentures, or gunning splints, may be
used to stabilize MMF and establish the aforementioned
requisite intermaxillary height.
Gunshot Wounds
In general, the same principles of midface reconstruc-
tion—open reduction, rigid fi xation, and early soft-tissue
management—are applied to gunshot wounds of the face.
After standard resuscitation and stabilization, the man-
agement of the patient with a gunshot wound to the
face should proceed conservatively: the facial soft tissues
should be minimally debrided, and only if clearly devital-
ized. Packing or loose closure of the skin can be performed
between early serial debridements, with a focus on keep-
ing the soft tissues on stretch in preparation for primary
closure after bony reconstruction.
The early restoration of the skeletal scaffolding improves
facial contour, minimizes soft tissue deformity and
decreases the need for extensive reoperation. Therefore,
the reconstructive surgeon should employ a low threshold
for the use of primary bone grafting. 11
After the facial skeleton has been adequately restored,
external coverage with primary closure, local or free fl aps
is required.
COMPLICATIONS
The complications related to midface reconstruction
occur on a continuum, beginning at the time of injury. The
earliest complications of maxillofacial fracture—airway
compromise and uncontrolled hemorrhage—should always
be considered prior to further assessment. The following
sequelae also deserve attention.
Infection
Although continuous with the sinuses and oropharynx—
areas of rich bacterial colonization-maxillary fractures are
rarely complicated by infection. This is attributable to the
rich blood supply of the face.
Blindness
Blindness is a rare complication of midface fractures,
occurring in less than 1% of cases. Blindness at the time
of presentation is usually the result of direct optic nerve
(CN 2) injury. Postoperative blindness resulting from
reduction of facial fractures is exceedingly rare. When
observed, it is related to increased pressure in the optic
canal. A retro-orbital hematoma is commonly responsi-
ble. Steroids are mandated, and a lateral canthotomy is
required for decompression. It is important to document
visual acuity prior to operative management.
Cerebrospinal Fluid Rhinorrhea
Cerebrospinal fl uid leaks may occur with high LeFort
injuries when the cribriform plate has been fractured.
The diagnosis should be suspected when clear rhinor-
rhea is observed in the maxillofacial trauma patient.
The presence of glucose corroborates the diagnosis, and
b-2-transferrin positivity is confi rmatory. Meningitis is
the feared complication. Nose blowing may cause ret-
rograde bacterial dissemination through the dural defect
and should be avoided. Nasal packing is similarly unde-
sirable as it provides a stagnant reservoir for bacterial
growth. Prophylactic intravenous antibiotics with good
blood–brain barrier penetration (eg, ceftriaxone) should
be instituted.
Severely impacted LeFort III and IV fractures, how-
ever, may actually “block” a CSF leak. Oftentimes, fracture
reduction will restore the fl ow of CSF and a leak that was
not present preoperatively ensues. A high index of suspi-
cion should be gleaned from the fracture pattern on preop-
erative CT. Early neurosurgical consultation will facilitate
their intraoperative availability, if ultimately needed. A
lumbar CSF drain may be required in cases of persistent or
copious drainage. The majority of cases, however, resolve
spontaneously following reduction and fi xation. 8
Nerve Injury
The infraorbital nerve (CN V2) is the most commonly
nerve injured in midface fractures.
Paresthesia is frequently related to neuropraxia, resolv-
ing over the convalescent period. Unfortunately, permanent
sensory disturbance in the cheek, upper lip, and nasal side-
wall may also occur. The incidence of this complication was

276 • CHAPTER 25
reported as 17% in series of 240 patients. Anosmia (CN I)
and ageusia (CN VII, chorda tympani nerve) have also
been demonstrated in high LeFort fractures with frequen-
cies up to 20% to 30%. Whether the lesion is related to the
fracture itself or proximal brain injury remains unclear.
Soft Tissue Deformities
Soft tissue malpositioning, as previously discussed, may result
in descent and deformity. Specifi cally, canthal dystopia, malar
sagging, ectropion, and eclabion may be encountered.
Malocclusion
Malocclusion is a signifi cant deleterious complication
that impacts mastication and speech. It can also cause
headaches, chronic facial pain, and temporomandibu-
lar joint dysfunction. Most commonly, malocclusion is a
technical error related to insuffi cient disimpaction and a
poor anatomic reduction of a displaced maxillary fracture.
When MMF is performed in these cases, the mandible is
forced in centric occlusion (ie, intercuspation of the den-
tition) at the expense of centric relation (ie, anatomic
seating of the mandibular condyle in the glenoid fossa).
Upon release of MMF, the condyle translates back into
centric relation, but the occlusion is lost. Unfortunately,
this error may not be noted until the patient emerges
from anesthesia, or worse, when MMF is released several
weeks postoperatively. If discovered early, an expeditious
return to the operating room for correction is mandated.
Otherwise, reoperation with LeFort I advancement is
required. This is further evidence for the overall supe-
riority of rigid fi xation, which mandates the release of
MMF at the end of the case to assess the occlusion before
the patient emerges from anesthesia.
Alveolar fractures can cause distinct problems with
occlusion in isolated areas. A crossbite (laterognathism)
may result if palatal width is not suffi ciently restored. This
problem is avoided with the proper use of occlusal splints.
Close follow-up with dentistry is suggested in this setting,
and the reinstitution of MMF may be required.
Malunion and Nonunion
In cases of malunion with partial bony healing, LeFort I
osteotomies with repositioning provide a safe and effi -
cient means of secondary repair. Rigid fi xation may then
be employed without the need for prolonged MMF.
Complete nonunion of the maxilla is rarely encountered.
When it does occur, the same principles of primary recon-
struction apply: the site of nonunion is exposed, the inter-
vening fi brous tissue is resected, and rigid osteosynthesis is
then implemented with or without bone grafting.
Symptomatic Hardware
Plates, although inert, are not wholly benign. Common
reasons for plate removal include prominence, loosening,
pain, infection, and exposure. In cases of symptomatic
hardware, secondary operations are required for their
removal, which occurs 12% to 18% of the time. 13 Palatal
plates display a similar incidence of symptomatology,
with resultant plate removal in approximately 10% of
cases. In the midface, plate discomfort is particularly
likely with close proximity to the infraorbital foramen
and nasal spine ( Figure 25-8 ), and when screws pene-
trate the tooth roots. Preoperative plain fi lms are useful
to document hardware location and provide intraopera-
tive guidance.
The loosening of screws postoperatively may result from
osteonecrosis, which can be induced at the time of high-
speed drilling. Resident osteoblasts adjacent to the screws
die, resulting in bone loss and screw loosening. Cool, con-
stant irrigation during screw placement is recommended
to protect against this complication.
SUMMARY
An early, single-stage repair provides ideal outcomes in
traumatic midface reconstruction.
Rigid osteosynthesis is imperative to achieve a stable
reduction, and should be universally considered for frac-
ture fi xation. Mandibulomaxillary fi xation should be used
intraoperatively and/or adjunctively in situations where
rigid fi xation is not possible or less than ideal. These prin-
ciples allow the maxillofacial surgeon to restore form and
function to the facial skeleton, and ultimately return the
patient to a meaningful way of life.
70%
60%
50%
40%
30%
20%
10%
0%
FIGURE 25-8. The distribution of plate removal in
craniomaxillofacial surgery. (Reprinted with permission from
Nagase D. Plate removal in traumatic facial fractures: 13-year
practice review. Ann Plast Surg 2005;55:609.)

MIDFACE AND MAXILLARY FRACTURES • 277
REFERENCES
1. Girotto JA, MacKenzie E, Fowler C, et al. Long-term physi-
cal impairment and functional outcomes after complex
facial fractures. Plast Reconstr Surg. 2001;108(2):312–327.
2. Lee R, Robertson S, Manson P. Current epidemiology of
facial injuries. Semin Plast Surg. 2002;16:283.
3. Tung TC, Tseng WS, Chen CT, et al. Acute life-threatening
injuries in facial fracture patients: a review of 1,025 patients.
J Trauma. 2000;49(3):420–424.
4. Plaisier SR, Punjabi AP, Super OM, et al. The relationship
between facial fractures and death from neurologic injury.
J Oral Maxillofac Surg. 2000;58(7):708–712; discussion
712–713.
5. Manson P, Hoopes J, Su C. Structural pillars of the facial
skeleton: an approach to the management of LeFort frac-
tures. Plast Reconstr Surg . 1980;66(1):54–62.
6. Rudderman R, Mullen R. Biomechanics of the facial skel-
eton. Clin Plast Surg . 1992;19(1):11–29.
7. Gruss JS, Mackinnon SE. Complex maxillary fractures: role
of buttress reconstruction and immediate bone grafts. Plast
Reconstr Surg. 1986;78(1):9–22.
8. Steidler NE, Cook RM, Reade PC. Residual complications in
patients with major middle third facial fractures. Int J Oral
Surg. 1980;9(4):259–266.
9. LeFort R. Etude experimentale sur les fractures du la ma-
choire superieure. Riv Chir de Paris. 1901;23:208.
10. Bonanno PC, Converse JM. Primary bone grafting in man-
agement for facial fractures. N Y State J Med. 1975;75(5):
710–712.
11. Gruss JS, Mackinnon SE, Kassel EE, Cooper PW. The role of
primary bone grafting in complex craniomaxillofacial trau-
ma. Plast Reconstr Surg. 1985;75(1):17–24.
12. Farmand M, Baumann A. The treatment of the fractured
edentulous maxilla. J Craniomaxillofac Surg. 1992;20(8):
341–344.
13. Orringer JS, Barcelona V, Buchman SR. Reasons for remov-
al of rigid internal fi xation devices in craniofacial surgery.
J Craniofac Surg. 1998;9(1):40–44.

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26
Mandibular Fractures
Jack C. Yu, DMD, MD, MS Ed, FACS / Ian F. Wilson, MD, MPH
INTRODUCTION
The mandible is one of the strongest bones in the
craniofacial skeleton. Aesthetically, it defi nes the lower
facial contour in three anatomic planes and structurally it
is integral to the masticatory function. In treating patients
with mandibular fracture, the overall goal is to restore this
lower facial form and return the patient to full masticatory
function. In other words, a restored mandible must look
and function as a mandible. The patients should be able
to open and close their mouth with good occlusion of the
dentition and enough strength to chew and swallow food
without pain or oral incontinence. The goal of the chap-
ter is to provide a concise and complete overview of the
current understanding and practice of mandibular fracture
management; it is hoped that after reading this chapter,
one would be able to properly diagnose and treat com-
mon mandibular fractures effectively and effi ciently, and
explain the rationales that underpin their management.
BIOMECHANICS OF THE MANDIBLE
AND MECHANOBIOLOGY
The mature mandible is like a long bone bent back on
itself, forming a blunted V with identical 160-degree, out-
of-plane, oblique extensions on both ends. These ends
articulate with the skull base at the glenoid fossa forming
the complex ginglymo-diarthroidial temporo-mandibu-
lar joints. Like other bones of the body, the mandible is
rigid, which means for a large amount of force, it deforms
only very slightly. Force is that which makes mass alter its
velocity, or F = ma , where F is force and m is mass and a
is acceleration. The unit of force is therefore product of
mass unit and acceleration unit, for example, kg m/sec 2 .
F = ma is Newton’s Second Law of Motion and 1 kg m/
sec 2 is known as a Newton or N. During normal chewing,
the force generated from the contraction of temporalis and
masseter is in the range of 500 N. This magnitude of force
causes deformation of the mandible, or Δ L , in the range of
0.6 mm. When Δ L is normalized to the original dimension,
L 0 , this ratio is known as strain. That is strain, usually rep-
resented by ´, = Δ L / L 0 . Strain, therefore has no units. When
the force causing deformation is normalized to the cross-
sectional area on which it is acting, the result is known
as stress, S , which has N/m 2 or pascal (Pa) as its unit. The
typical stress experienced by the mandible is in the range
of millions of Pa, or mega pascals (MPa). Fundamentally,
all stresses can be broken down into three basic types: ten-
sile, compressive, and shear. Tensile and compressive are
the principle stresses; they will change the volume of the
object they are acting on, although by a very minuscule
amount, that is, they cause nonisovolumetric strains. Shear,
on the other hand, causes isovolumetric strain which is
much less well tolerated. When the mandible is subjected
to high enough stress, the deformation will be permanent.
In engineering terms, it has exceeded its elastic limit and
has undergone plastic deformation. The stress at which
the plastic deformation occurs is called yield stress and the
corresponding strain is the yield strain. A very important
parameter for any material, bone included, is this ratio of
stress to strain, S/´ which is known as the elastic modulus,
or Young’s modulus. The longitudinal elastic modulus for
human mandible is 16 to 18 billion Pa, or GPa for giga pas-
cals. If the applied stress continues to increase above the
yield stress, the strain will reach a maximum point and the
mandible will break apart. The strain at which this frac-
ture occurs is known as the ultimate strain and the respon-
sible stress is the ultimate stress. The ultimate stress, also
known as the strength, for human cortical bone is 67 MPa
in shear, 135 MPa in tension, and 205 MPa in compres-
sion. Bone as a material, can only elongate or compress
1% to 2 % before it will break. That is the ultimate tensile
and compressive strain is no more than 1% to 2%; it is
c h a p t e r

280 • CHAPTER 26
therefore understandable why reducing interfragmentary
strain by fi xation is so important.
There is a key difference between living tissues such
as bone and other nonliving rigid materials, and that is
bone is continuously remodeled. Because all living tissues
undergo cyclic strains, the repeated loading and unload-
ing produce microcracks. These microcracks are initiated
from the inevitable imperfections at the nanometer level
and create sites for tremendous stress concentration and
given enough loading cycles will eventually propagate to
macroscopic level failure. This deterioration of material
property as a result of cyclic loading is known as fatigue.
The higher the stress, the fewer cycles a material can with-
stand; at lower the stress, more cycles can be tolerated.
When the stress is suffi ciently low, the number of cycles
tolerated approaches infi nity. This “tolerable” level is called
the endurance limit. For almost all the plates and screws
used in fi xation of mandibular fractures, the loading is
higher than the endurance limit. That is why unless bone
heals and resumes the load-bearing function, the plates
will fail given enough loading cycles. How does bone
overcome this problem of fatigue damage? The answer is
Haversian systems. Living bone is not a static entity. It is a
“smart material” in that sensors are embedded throughout
and they monitor the complete strain state of the bone.
There is a constant conversion of liquid to solid (osteo-
genesis) as well as the reverse (osteolysis). At a particular
point in time, within a particular location in the bone, the
end outcome of this balance depends on the strain, the
age of the individual, and the systemic conditions. Bone
will reinforce itself in areas of high strain and remove
bone in areas where the strain is too low. There is thus an
anabolic window defi ned by the strain which is critically
important in bone homeostasis. Excessive strain, like insuf-
fi cient strain, will suppress osteogenesis and favor osteoly-
sis. The putative sensors in bone are the osteocytes. There
are 20,000 osteocytes in every mm 3 of lamellar bone, and
each osteocyte occupies a lacuna and has a life span of
25 years. These osteocytes have several hundred cytoplas-
mic processes, each housed within a canaliculus measuring
only 350 nm in diameter. Through these cytoplasmic pro-
cesses, gap junctions are formed to allow direct cell-to-cell
communication. It has recently been determined that this
lacuno-canalicular system will amplify the macroscopic
bone strain by 10 to 15 fold. The loading and unloading of
bone also forces fl uids within the canaliculus to fl ow, gen-
erating fl uid shear stress at about 1.6 Pa level. Subjected
to this appropriate quantity and duration of fl uid shear
stress, osteocytes change their transcriptome to stimulate
surface osteoblast to produce more bone. Without suffi -
cient cellular strain, the osteocytes will not elicit osteo-
blasts to form more osteoid; it is therefore undesirable to
have excessive amount of rigidity in fracture fi xation for
the salutary effects of physiologic loading cannot occur,
creating a condition called stress-shielding. The ideal fi xa-
tion system should allow for about 1200 microstrains or
0.12% of strain at the bone level.
PATTERNS OF MANDIBULAR
FRACTURES
Fracture is macroscopic material failure; it occurs when-
ever the stress exceeds the ultimate stress and the resulting
strain is greater than the ultimate strain of the material. Due
to the particular geometry and the materials property, the
human mandible contains areas of stress risers—location
where the forces are supported by less cross-sectional
areas. The space occupied by muscles, nerves, blood ves-
sels, major salivary glands, and developing tooth buds are
necessarily not occupied by bone and this inevitably weak-
ens the mandible at these particular areas. Looking at this
from the other perspective, where the ridges and cortical
thickenings are, the mandible is relatively stronger. In the
midface, these cortical thickenings are called the buttresses.
The mandible, all things considered, is a very sturdy bone.
The typical areas where the mandible breaks up during
sudden impact are subcondylar, angle, body, parasymphy-
seal, and the alveoar regions. The condylar neck is very nar-
row and if there is latero-cursive movement at the time
of impact, the entire force will be concentrated on one
side; this small 0.0003 m 2 area can tolerate a maximum of
18,000 N, given an ultimate shear stress for cortical bone
of 67 MPa.
Several classifi cation systems exist for mandibular frac-
tures, some use location, others use dentition, still others
use muscular actions. Of all these classifi cation schemes,
the most commonly used, and the most helpful, remains
to be the classifi cation by location. In an edentulous man-
dible, the fractures are considered class 3. For mandibles
with teeth, if the fracture occurs outside of the tooth-
bearing segment, it is a class 1 fracture; and class 2 if it
is within the tooth-bearing segment. Due to the muscu-
lar actions, the gap of mandibular fractures can either be
increased or decreased. If muscular action tends to reduce
the fracture gap width, it is considered a favorable fracture.
If the gap width increases with the muscular contraction,
then it is unfavorable. These can be further divided based
on the anatomic plane: horizontal (axial or transverse)
and vertical (parasagittal). A fracture at the angle of the
mandible, anterior to the masseter-medial pterygoid sling,
that extends from superior-anterior to inferior-posterior
will have a tendency to be distracted into a wider gap
upon contraction of these muscles; it is therefore verti-
cally unfavorable. On the other hand, an angle fracture
that is oriented from posterior-superior to anterior-inferior
will have the fracture reduce automatically when masseter
and medial pterigoid contract. Thus, it is called a vertically
favorable fracture. Whether a fracture is favorable or not
assists in the management of mandibular fracture; it does
not, however, determine if surgical treatment is indicated
or not. More importantly, the consideration of muscular
actions will give a better understanding, or even relatively
accurate prediction, of how the fragments tend to displace
once the mandibular integrity is lost. It is particularly
important to recognize that in bilateral body or angle frac-
tures, the suprahypoid musculatures such as geniohyoid

MANDIBULAR FRACTURES • 281
and genioglossus tend to pull the tongue posteriorly and
produce serious upper airway compromise. These patients
should be intubated early or transported in either upright
or prone position to avoid the soft tissue collapse in the
oropharyngeal region due to supine positioning. In bilat-
eral subcondylar and condylar fractures, the posterior ver-
tical support is lost, this reduction in posterior occlusal
vertical dimension will result in tilting of the mandibular
occlusal plane in a clockwise fashion and produce ante-
rior open bite, or traumatic anterior apertognathia. Should
there be unilateral subcondylar fracture or condylar frac-
ture occurring inferior to the attachment of the inferior
belly of the lateral pterigoid muscle, the contralateral lat-
eral pterigoid pull upon mandibular opening will cause the
lower jaw to deviate toward the side of the fracture. The
pull of the ipsilateral inferior belly of the lateral pterigoid
muscles tends to displace the proximal fragment medially
and anteriorly. Isolated fracture of the coronoid is very rare,
and there is usually very little displacement. In the absence
of other associated fracture, this frequently requires no sur-
gical treatment and can be managed by placing the patient
on a soft diet.
The mandibular fracture pattern in the pediatric popu-
lation differs from that of the adults due to several rea-
sons. Children do not experience with nearly the same
frequency the type of high impact trauma due to motor
vehicle collisions or personal violence from altercations.
Pediatric mandibles are structurally and geometrically
different from adult mandibles. The elastic modulus of
younger bones is less than that of the adult bones. They
are also more ductile; they have more capacity to undergo
plastic deformation before reaching breaking. Stated more
precisely, their stress-strain curve has a lower slope and
reaches yield point earlier, but the failure point is moved
further to the right. As a result, green-stick fractures can
occur and may complicate the treatment. In children
younger than 6 years, their mandible is packed with devel-
oping permanent tooth buds and these liquid-fi lled sacs
alter the biomechanical behavior of the bone. The gonial
angle is more obtuse than the 160- to 165-degree range
seen in adults, and the length of the ramus is shorter.
Condylar fracture and alveolar fracture are more common,
usually from blunt trauma due to falls. After the eruption
of the maxillary central incisors, around ages 6 to 8 years,
they are particularly prone to apical-posterior impaction
type of alveolar fractures, especially if the occlusion is
Angle’s class II division 1, where there is increased over-
ject. Mandibular dentoalveolar fractures are not as com-
mon. More inferior frontal impact with the mouth open,
such as what happens during tripping and falling, directs
the load posteriorly to the condyles and may result in frac-
tures in that region. It is thus important whenever one is
treating a child with chin laceration to evaluate the status
of the condyle and subcondylar region by observing the
occlusion and mandibular opening. Tenderness to palpa-
tion in the pre-tragal area is a very sensitive sign of condy-
lar and subcondylar fractures.
SURGICAL AND
TOPOLOGICAL ANATOMY
The functional restoration of the mandible requires a sound
knowledge of the osteology of the mandible, dental anat-
omy, occlusion, and muscles of mastication. The mandible
articulates with the temporal bone at the skull base. It is
unique among all bones in that two symmetrical synovial
joints exist and that both must perform in concert; there is
never an instance when movement in one joint can occur
without some corresponding movement of the other.
The mandibular condyles are irregular ellipsoid with a
major axis of 18 to 20 mm and about half of that length
for the minor axis. The two major axes point poste-
rior-medially, forming an angle of 165 degrees. The glenoid
fossa is just anterior to the osseous external auditory canal;
superiorly, it is bordered by the root of the zygomatic pro-
cess of the temporal bone and anteriorly by the articular
eminence. Three named bony openings aligned almost lin-
early in a sagittal plane about 10 mm medial to the gle-
noid fossa: foramen spinosum, carotid canal, and jugular
foramen. The joint itself has two compartments separated
by the meniscus which is attached anteriorly to the supe-
rior belly of the lateral pterygoid muscle. Posteriorly, the
disc is held by the retrodiscal tissue. The insertion of the
inferior belly of lateral pterygoid is the pterygoid fovea.
During mandibular opening, the inferior belly of the
lateral pterygoid contracts fi rst while the superior belly
relaxes, thus allowing the condyle to slide anteriorly and
inferiorly down the articular eminence with the menis-
cus trailing posteriorly. Upon closing, the opposite occurs:
the inferior belly of the lateral pterygoid relaxes while the
superior belly of the lateral pterygoid contracts, resulting
in condyle returning to the original posterior location and
the meniscus being pulled anteriorly back onto the top of
the condyle.
Below the insertion of the inferior belly of the lateral
pterygoid and above the insertion of the masseter, is the
“surgical neck” where fractures often occur obliquely from
superior-anterior to inferior-posterior. In this subcondylar
region, the ramus is robust in the sagittal plane measuring
12 to 14 mm at the narrowest point but only about half
of that in the coronal plane. The length of the ramus is
about 60 mm from the very top of the condyle (condylion)
to the inferior-posterior most aspect of the gonial angle
(gonion). At its narrowest, near the level of occlusal plane,
the ramus is about 30 mm in the anterior-posterior dimen-
sion. Bisecting the ramus, on its medial surface, is the lin-
gula to which the sphenomandibular ligament is attached.
The lingula marks the opening to the mandibular canal,
which houses the inferior alveolar neurovascular bundle.
Immediately posterior and inferior to this is the mylohyoid
groove housing the mylohyoid nerve and artery. There
are two thickened bony ridges extending from the coro-
noid process which is a triangular-shaped traction process
formed partly as a result of the action of the temporalis
muscle. These ridges extend inferiorly and anteriorly, cre-
ating the external and internal oblique ridges with the