BDS10022

Maxillofacial Trauma 2
Aims
The aim of this lecture is to detail the clinical, diagnostic and
management aspects of orbital and zygomatic trauma.

Objectives
On completion of this lecture, the student should be able to:
Understand the clinical manifestations or orbital and/or zygomatic
traumatic injuries
Understand the diagnostic processes for orbital and/or zygomatic
traumatic injuries
Understand the principles of management of orbital and/or
zygomatic traumatic injuries
Etiology

• Motor Vehicle Accidents (MVA)

• Violence (12-68%)
• Sport injury
• Daily life activity
Etiology

• Motor Vehicle Accidents (MVA)

• Violence (12-68%)
• Sport injury
• Daily life activity
Etiology
• Motor Vehicle Accidents
(MVA)
• Violence (12-68%)
• Sport injury
• Daily life activity
Orbital Fractures
• Internal orbital
skeleton
• Involve the orbital rim
• Associated with other
fractures
• Orbital apex fractures
Orbital Fractures
• Internal orbital
skeleton
• Blow out
• Blow in
Orbital
Fractures
• Internal orbital
skeleton
• Blow out
• Blow in
 Orbital Fractures

• Internal orbital
skeleton
• Blow out
• Blow in
Orbital
Fractures
• Associated with other
fractures of the facial
skeleton
• Zygomaticomaxilla
ry complex
fracture (ZMC)
• Naso-orbital-
ethmoidal Fracture
(NOE)
• Le Fort fractures
Orbital Fractures

• Associated with other

fractures of the facial
skeleton
• Zygomaticomaxillary
complex fracture (ZMC)
• Naso-orbital-ethmoidal
Fracture (NOE)
• Le Fort fractures
Orbital
Fractures
• Associated with other
fractures of the facial
skeleton
• Naso-orbital-
ethmoidal Fracture
(NOE)
• Zygomaticomaxilla
ry complex
fracture (ZMC)
• Le Fort II or III
Orbital
Fractures
• Associated with other
fractures of the facial
skeleton
• Naso-orbital-
ethmoidal Fracture
(NOE)
• Zygomaticomaxilla
ry complex
fracture (ZMC)
• Le Fort II or III
Orbital Fractures
• Orbital apex fractures
• Optic canal injury
• Superior orbital fissure syndrome
Diagnosis of orbital
fractures
 • The initial ophthalmologic evaluation
should include
• Internal orbital injuries
• Periorbital examination
Diagnosis of orbital • visual acuity
fractures • ocular motility
• pupillary responses
• Visual fields
• fundoscopic examination
 • Inspection
• Palpation
• bony orbital rim should be
Diagnosis of orbital palpated for steps,
fractures crepitus, and mobility.
• Subjective findings
• Nerve impairment,
• Diplopia
• Malocclusion
Orbital
Fractures
• Periorbital edema
and ecchymosis
• Subconjunctival
hemorrhage
• Enophthalmos
• Extraocular muscle
entrapment
Orbital Fractures

• Periorbital edema and

ecchymosis
• Subconjunctival hemorrhage
• Enophthalmos
• Extraocular muscle entrapment
Orbital
Fractures
• Periorbital edema and
ecchymosis
• Subconjunctival hemorrhage
• Enophthalmos
• Hertel
exophthalmometer
• Extraocular muscle
entrapment
Orbital Fractures

• Periorbital edema and

ecchymosis
• Subconjunctival hemorrhage
• Enophthalmos
• Extraocular muscle entrapment
Orbital
Fractures
• Periorbital edema and
ecchymosis
• Subconjunctival
hemorrhage
• Enophthalmos
• Extraocular muscle
entrapment
• Forced duction
test
ZMC Fractures
• Cosmetic deformities
• flattening of the malar eminence
• widening or depression of the arch
• orbital dystopia
• Enophthalmos
ZMC Fractures
• Functional disturbance
• Trismus
• Infraorbital nerve
paresthesia
• Diplopia
 Traumatic telecanthus

Rounding of canthal angle Bow-string test

(lake) Kelly clamp

Naso-orbital-
ethmoidal Fracture Epiphora
(NOE)

CSF leak

Anosmia
NOE Fractures
• Traumatic telecanthus
• Normal intercanthal distance
28-34 mm
• More than 35 is suggestive of
NOE
• More than 40 is diagnostic
• Shortened palpebral fissure
• Rounding of canthal angle (lake)
• Bow-string test
• Kelly clamp
NOE Fractures
• Traumatic telecanthus
• Normally 28-34mm
• More than 35 is
suggestive of NOE
• More than 40 is
diagnostic
• Rounding of canthal angle
(lake)
• Bow-string test
(traction test)
• Kelly clamp
NOE Fractures
• Traumatic telecanthus
• Normally 28-34mm
• More than 35 is
suggestive of NOE
• More than 40 is
diagnostic
• Rounding of canthal angle
(lake)
• Bow-string test
• Kelly clamp
NOE Fractures
• Epiphora
• CSF rhinorrhea
• Anosmia
• Epiphora
• Jones lacrimal tests
NOE Fractures
• CSF rhinorrhea
• Anosmia
Diagnosis of orbital fractures
• Le Fort I
Diagnosis of orbital fractures
• Le fort II
Diagnosis of orbital fractures
• Le fort III
 • Imaging
• 2D radiography
• PA
Diagnosis of orbital
• Water’s view
fractures
• Submentovertex view
• Fine cut CT scan (1.0 mm slice
thickness)
 Diagnosis of orbital
fractures

• CT findings
• Herniation of
orbital contents
• Intraorbital &/or
subcutaneous
emphysema
 Principles of
management
Principle of management

Objectives
Restore functional disturbance Timing
• Extraocular muscle entrapment 2 weeks
• Diplopia Immediate
Correct cosmetic deformity
 Treatment Planning

Surgical approach

Principle of Reduction & Fixation/Reconstruction

management
Follow up

complications
Management

Medical Therapy Surgical Therapy

avoid blowing the nose Transcutaneous
Antibiotics transconjunctival, or
Analgesics endoscopic (transmaxillary or
Steroids transnasal) approaches
Surgical Approaches

Transcutaneous approaches

Transconjunctival

Transantral Orbital Floor

Endoscopic endonasal transmaxillary

 Surgical Approaches

• Transcutaneous approaches
• Coronal Approach
• Through existing
laceration
• Subciliary approach
• Subtarsal approach
• Infraorbital (skin crease)
approach
• Transconjunctival approach
 Surgical Approaches

• Gillies approach
• Kilner zygomatic arch
elevator
Surgical Approaches

• Keen Approach
 Surgical Approaches

• Transcutaneous approaches
• Coronal Approach
• Through existing
laceration
• Subciliary approach
• Subtarsal approach
• Infraorbital (skin crease)
approach
• Transconjunctival approach
 Surgical Approaches

• Transconjunctival
approach
• Transantral orbital Floor
repair
• Endoscopic endonasal
transmaxillary
 Surgical Approaches

• Transconjunctival
approach
• Transantral orbital
Floor repair
• Endoscopic endonasal
transmaxillary
Reduction & fixation/Reconstruction
• Internal orbital fractures
• Reduction with no
fixation required
• Reduction with fixation
• Orbital floor
reconstruction
• Medial wall
reconstruction
• Combined orbital floor
and medial wall
Reduction & fixation/Reconstruction
• Internal orbital fractures
• Reduction with no
fixation required
• Reduction with fixation
• Orbital floor
reconstruction
• Medial wall
reconstruction
• Combined orbital floor
and medial wall
Reduction &
fixation/Reconstruction
• Internal orbital fractures
• Reduction with no fixation required
• Reduction with fixation
• Orbital floor reconstruction
• Medial wall reconstruction
• Combined orbital floor and medial wall
Reduction &
fixation/Reconstruction
• Internal orbital fractures
• Reduction with no fixation required
• Reduction with fixation
• Orbital floor reconstruction
• Medial wall reconstruction
• Combined orbital floor and medial wall
 Reduction &
fixation/Reconstruction

• Internal orbital fractures

• Reduction with no
fixation required
• Reduction with fixation
• Orbital floor
reconstruction
• Medial wall
reconstruction
• Combined orbital floor
and medial wall
Reduction &
fixation/Reconstruction
• ZMC fractures
• Closed reduction
• Open reduction
• NOE fractures
• Le fort II, III
Reduction &
fixatioan/Reconstruction
• ZMC fractures
• Closed reduction
• Open reduction
• NOE fractures
• Le fort II, III
 Reduction &
fixation/Reconstruction

• ZMC fractures
• Closed reduction
• Open reduction
• NOE fractures
• Le fort II, III
Reduction &
fixation/Reconstruction
• ZMC fractures
• Closed reduction
• Open reduction
• NOE fractures
• Le fort II, III
Complications
 Malunion
Non-union
Infection
Enophthalmos
Orbital Telecanthus
Fractures
Extraocular muscle entrapment
Infraorbital paresthesia
Persistent diplopia
Traumatic optic neuropathy
• Reading material:
1. Wray D et al; Textbook of General and Oral Surgery, Churchill Livingstone
2003 pp 89-102
2. Kerawala C, Newlands C. Oral and Maxillofacial Surgery. Oxford University
Press, 2010 pp 32-56
3. Brennan et al. Maxillofacial Surgery Volume 1. Elsevier 2017 pp 93-132
TO SUM IT UP :
• Diagnosis of conditions that require immediate interventions and
conditions that contraindicate surgery is mandatory
• Excellent communication between the ophthalmologist and the
maxillofacial surgeon is essential
• Strict adherence to systematic diagnostic protocol ensures a complete
record of all the findings
• The zygomatic fractures are the most common type of midfacial
fractures (62%) followed by le fort II fractures (22%)
Aims
The aim of this lecture is to detail the clinical, diagnostic and
management aspects of orbital and zygomatic trauma.

Objectives
On completion of this lecture, the student should be able to:
Understand the clinical manifestations or orbital and/or zygomatic
traumatic injuries
Understand the diagnostic processes for orbital and/or zygomatic
traumatic injuries
Understand the principles of management of orbital and/or
zygomatic traumatic injuries
Thank you