MIDFACIAL FRACTURE

TREATMENT
MIDFACIAL FRACTURE TREATMENT
 BIOMECHANICS OF THE MIDFACE
• THE MIDFACE EQUATES TO A TENT,
WHERE:
• THE TENT POLES REPRESENT THE
BONY MIDFACE
• THE TARPAULIN REPRESENTS THE
OVERLYING SOFT TISSUES.

• THE VECTORS OF THE MIDFACE

ADDRESS ALL THREE DIMENSIONS IE:
• VERTICAL
• SAGITTAL
• TRANSVERSE, WHICH MAKES IT MUCH
MORE DEMANDING THAN THE
CONSTRUCTION PLAN OF A TENT.
 • The reconstruction sequence to reestablish
midfacial pillars and dimensions begins with
Reestablish establishing the most reliable reference structures.

• Occlusion:
• an outside-to-inside
occlusion • an up-to-down procedure as a first step
• EVERY UNDER OR OVERCONTOURING OF
THE BONY MIDFACE IN PRIMARY FRACTURE
REPAIR  VERY LIKELY IN UNFAVORABLE
PROJECTION OF THE SOFT-TISSUE MASK
 ESTHETIC COMPROMISE.
• FUNCTIONAL DISORDERS MAY FOLLOW
SUCH AS MALOCCLUSION OR ORBITAL
DYSFUNCTION.
VERTICAL AND TRANSVERSE BUTRESSES
VERTICAL BUTTRESSES
TRANSVERSE/HORIZONTAL BUTTRESSES
 AIRWAY PRINCIPLES
Airway of
Intraoperative
MMF

Nasotracheal Other Option

Intubation

Submental /
Submandibular Tracheostomy
intubation
 MIDFACIAL FRACTURE TREATMENT

• OBSERVATION
• DEPEND ON THE TYPE OF FRACTURES, BUT IF THERE IS A SIGNIFICANT
RISK OF FISTULA FORMATION, OBSERVATION ALONE IS NOT A GOOD
CHOICE

• CLOSED TREATMENT

• OPEN REDUCTION INTERNAL FIXATION

 CLOSED TREATMENT

• A CLOSED REDUCTION OF THE MIDFACE MAY BE PART OF AN

EMERGENCY TREATMENT TO REDUCE BLEEDING AND CSF LEAK
• FRACTURES WITH MINOR MALOCCLUSION WHICH ARE READILY
CORRECTABLE WITH MAXILLARY DISIMPACTION AND MANIPULATION,
AND NOT GROSSLY MOBILE AFTER REPOSITIONING MAY BE TREATED
CLOSED
• PATIENTS WITH MALOCCLUSION UNABLE TO HAVE GENERAL
ANESTHESIA CAN BE TREATED BY APPLICATION OF ARCH BARS AND
ELASTIC TRACTION
 OPEN REDUCTION INTERNAL FIXATION

1. PRINCIPLE

2. REDUCTION

3. FIXATION

4. COMMINUTED FRACTURES
 1. PRINCIPLE

• CONSIDERATIONS RELATED TO DENTAL OCCLUSION RENDER NASOTRACHEAL INTUBATION

NECESSARY

• THE AIM OF SUCCESSFUL RECONSTRUCTION OF MIDFACE FRACTURES IS REESTABLISHING THE

MIDFACIAL BUTTRESSES

• THE GOAL IS TO ACHIEVE AN ANATOMICAL CORRECT REPOSITIONING BY MEANS OF 3-D

RECONSTRUCTION

• AS A GENERAL PRINCIPLE, ALL FRACTURES SHOULD BE EXPOSED AND REDUCED BEFORE PLATING

• CHOICE OF IMPLANT
 1. PRINCIPLE: CHOICE OF IMPLANT

• INTERNAL PLATE FIXATION ADVANTAGES:

• ANATOMICAL REDUCTION
• DECREASED RECUPERATION
• DECREASED POSSIBILITY OF RELAPSE

• MIDFACIAL PLATING
• ALWAYS STRIVE FOR A PASSIVE CONTOUR
• PANFACIAL FRACTURES (RECONSTRUCT FROM BUTTRESS REGIONS)
• INDICATIONS FOR 1.2MM, 1.6MM AND 2.0MM IN THE MIDFACE
 MIDFACIAL PLATE SYSTEM

1.2mm

2.0mm
1.6mm
 SCREW SELECTION
• THE QUALITY AND THICKNESS OF THE BONE DETERMINE THE CHOICE OF
SCREW TYPE.
• THE PITCH OF THE THREAD IS IMPORTANT FOR ANCHORAGE.
• THERE ARE TWO KINDS OF SCREWS USED IN THE MIDFACE:
• AUTODRIVE (SELF DRILLING)
• NO PRE DRILLING, REDUCE OPERATING TIME, SIMPLE TO PLACEMENT
• STANDARD SCREW (SELF TAPPING)
• NEED PRE DRILLING PRIOR TO PLACING SCREW
 2. REDUCTION

• ARCH BARS OR QUICK-FIX (MMF SCREW)

• MOBILIZATION

• REDUCTION INSTRUMENTS

• ROWE DISIMPACTION FORCEPS

• BONE HOOKS
ARCH BARS OR QUICK-FIX
SECURED TO THE DENTITION
 ARCHBAR VS QUICK-FIX

ARCHBAR QUICK-FIX
 LESS CONVENIENCE THE EASY ALTERNATIVE TO ARCH BARS
PATIENTS
• PATENTED AUTO-DRIVE SELF DRILLING SCREWS
• REQUIRE TEETH FOR FIXATION
• DRAMATICALLY REDUCES APPLICATION TIME OF
• DAMAGE TEETH AND PERIODONTAL TISSUE MMF (ONLY 5 MINUTES)
• UNCOMFORTABLE DURING THE FIXATION PERIOD • SIMPLE
• DIFFICULT DAILY MAINTENANCE OF ORAL HYGIENE
• MINIMIZES RISK OF WIRE PUNCTURE WOUND
OPERATOR
• BETTER ORAL HYGIENE MAINTENANCE
• RISK OF BLOOD-TRANSMITTED DISEASES
• IDEAL FOR EDENTULOUS OR PARTIALLY
• NEED LONGER TIME TO USE EDENTULOUS
QUICK-FIX RESULT
• Less operating time
• Oral hygiene
maintenance is better in
patients with MMF screws.
• Fewer complications
• Comfortable for the
patient
• No pain during removal
MMF screw
 MOBILIZATION

• AFTER EXPOSURE OF THE FRACTURE SEGMENTS THROUGH A

MAXILLARY VESTIBULAR APPROACH, THE FRACTURE HAS TO BE
MOBILIZED TO ENABLE REDUCTION AND FIXATION.
 REDUCTION INSTRUMENT

• USE OF ROWE DISIMPACTION FORCEPS AND BONE HOOKS

Rowe disimpaction forceps Bone hooks

3. FIXATION: GENERAL CONSIDERATION
• NUMBER OF PLATES AND SCREWS
• AUTODRIVE SCREW IS BETTER OPTION  NO DRILLING AND
NO TAPPER  REDUCE OPERATING TIME
• FIXATION USUALLY STARTS AT THE MOST RELIABLY REDUCED
BUTTRESS, ALWAYS CONSIDERING ANY FRACTURE LINE IN ALL
THREE DIMENSIONS
• TWO SCREWS PER FRACTURE SIDE SHOULD BE ATTEMPTED
• COMPLETE REDUCTION AND FIXATION OF THE LE FORT
FRACTURES SHOULD TAKE PLACE BEFORE ADDRESSING THE
ORBITAL WALL FRACTURES
 FIXATION: PLACEMENT PLATE
AND SCREW

FIRST PLATE
SECOND SCREW IN
INSERTION OF
FIRST PLATE REMAINING
SCREW
 FIXATION: PLACEMENT PLATE
AND SCREW
• PLATING THE • PLATES AT INFRAORBITAL RIM

CONTRALATERAL
ZYGOMATIC BUTTRESS

• ADDITIONAL SCREW & PLATE

PLACEMETN
FIXATION: PLACEMENT PLATE
AND SCREW
Nasofrontal Plate
 FIXATION: PLACEMENT PLATE
AND SCREW
Check Occlusion: After internal fixation has been completed,
MMF is released and the occlusion checked.
 4. COMMINUTED FRACTURES

Communution of Comminution of the facial

buttresses maxillary sinus wall
 4. COMMINUTED FRACTURES
Defect Fractures: If there is a large defect of the facial maxillary sinus wall,
the defect may be bridged by a mesh to reconstruct the original outer
contour and thus support the overlying soft tissues.