11.4.2.4  Complex Midfacial Fractures

• Subcranial midfacial fractures

In the majority of cases, combined midfacial fractures (complex midface fractures/complex maxillomandibular fractures) have irregular fracture courses. Therefore, depending on their course, these fractures often require osteosynthesis with multiple 1.3-, 1.5-, and 2.0-mm miniplates in the region of both the vertical and horizontal struts. Bony fragments are stabilized with 1.3-mm microplates. Autogenous bone grafts are necessary in case of structural deficits (Manson 1986; Markowitz and Manson 1998; Gruss et al. 1990; Manson et al. 1995, 1999; Prein et al. 1998; Marchena and Johnson 2005; Stewart 2005a; McGraw-Wall 2005) (Figs. 11.16 and 11.17).

Procedure (complex midface fractures) (Gruss and Philipps 1989; Manson et al. 1990; Prein et al. 1998)

•Fracture exposition:

––At the zygomatico-maxillary and naso-maxil- lary struts through an intraoral-­vestibular incision

––At the infraorbital margin through bilateral subcilliary or medio-palpebral incision

––At the zygomatico-frontal suture through a supraorbito-lateral incision

––Optional supplementary medio-nasal or coronal incision (fracture: NOE complex)

•Mobilization and repositioning of the maxillary segments and intermaxillary fixation

•Reposition of small bony fragments in the region of the vertical struts (reestablishment of maxillary and midfacial vertical height)

•Zygomatico-maxillary, naso-maxillary, infraorbital, zygomatico-frontal, and fronto-nasal osteosynthesis. Optional osteosynthesis to bridge the gaps between fractured osseous struts is achieved with osteosynthesis plates or bone grafts to prevent midfacial collapse

•Reconstruction of orbital floor/orbital wall defects using bony fragments, bone grafts, membranes or microtitanium meshes

•Central upper midface fractures — NOE fractures

Following a coronal or case-related individual approach and repositioning of the naso-ethmoidal complex

(Markowitz and Manson 1998; Markowitz et al. 1991; Mathog 1992, 1995; Gehrke et al. 1996; Kessler and Hardt 1998; Oeltjen and Hollier 2005; Stewart 2005a,) stabilization is performed along the naso-frontal suture using 1.5-mm miniplates. Paranasal and infraorbital osteosynthesis of the lateral naso-frontal and nasomaxillary bone fragments is performed with 1.3-mm microplates as well as interfragmental stabilization (Leipziger and Manson 1992; Mathog et al. 1995). Displaced naso-orbital bone fragments with an attached medial palpebral ligament are fixed using micoplates and transversal, intercanthal wire osteosynthesis (Hammer and Prein 1998) (Fig. 11.18).

Naso-Ethmoidal (NOE) Fractures: Type 1

Following open transfacial “en bloc” reduction, type 1 NOE fractures are fixed along the fronto-maxillary strut in the region of the anterior bony aperture of the nose, in the fronto-nasal region and at the infraorbital margin using 1.5/1.3-mm mini-/microplates (Ellis 1993; Mathog et al. 1995; Prein et al. 1998; Donald 1998).

Naso-ethmoidal (NOE) Fractures: Types 2 and 3

In fracture type 2 with multifragmental injuries to the NOE compartment and loss of intercanthal ligament insertion, correct osseous reconstruction of the nasoorbital structures is mandatory. Following reduction of bony fragments and provisional, interfragmental wire osteosynthesis, the NOE complex is then definitely fixed to the surrounding, stable midface structures, beginning in the region of the medial orbital border, superiorly to the cranial and caudally to the maxillary complex using 1.5/1.3-mm mini-/microplates (Prein et al. 1998).

Osteosynthesis of small fragments in the medial orbital region is carried out using 1.0/1.3-mm micro­ plates (Markowitz et al. 1991; Leipziger and Manson 1992; Ellis 1993; Prein et al. 1998). However, 2.0- mm miniplates are not suitable because of the delicate soft tissues in the medial orbital region (medial and anterior to the lacrimal fossa) (Hammer and Prein 1998). An additional direct transnasal wire-fixation of the ligament-bearing fragments avoids dislocation of the reduced fragments at a later date (Figs. 11.19 and 11.20).

Fig.11.16  Examples of osteosynthesis with multiple 2.0/1.5-mm mini-plates of three different types of subcranial fractures (CMF and CUMF). (a) Internal fixation in a CMF fracture. (b) Internal

fixation in a CCMF without frontobasal fracture. (c) Internal fixation in a CUMF with frontobasal fracture

Fig.11.17  Gun shot trauma with burst fracture of the maxilla and mandible. (Submental gun position). (a, b, c, d) Internal osteosynthesis with multiple 2.0-mm miniplates (e, f). Postoperative control demonstrating reconstruction of the left maxillo-zygomatic-orbital

complex and the mandible. The reconstruction of the orbital floor and anterior wall of the maxillary sinus was performed with microtitanium mesh. Antral balloon catheter for hemostasis (g, h)

Fig.11.20  Upper midface fracture (CUMF: central midface, NOE and anterior sinus wall fracture). (a) CT scan demonstrating fractures in the upper medial quadrant of the orbit (arrows).

(b) Exposition and reconstruction of the fronto-naso-maxillary complex using the coronal approach

Canthal ligament insertion (see Chap.12.2)

• Combined cranial and midface fractures

In extensive craniofacial fractures of the types comminuted upper midface fractures (CUMF) and comminuted cranio-maxillary fractures (CCMF)/comminuted panfacial fractures (PF), the skull base-related frontofacial and zygomatico-orbital structures must be accurately reconstructed prior to midface reconstruction (Gruss et al. 1989).

The frontofacial and glabellar bone fragments are stabilized with 1.5-mm miniplates. In aesthetically

important regions such as the naso-frontal region, 1.3- mm microplates are applied. Smaller frontal fragments are reintegrated and stabilized with 1.3/1.0-mm micro­ plates.

For stability reasons, the subsequent osteosynthesis of the reduced zygomatico-orbital complex is performed as follows (Figs. 11.21 and 11.22):

•Supraorbital-lateral with 2.0-mm miniplates

•Zygomatic arch and infraorbital with 1.5-mm mini­ plates

•For reconstruction of the maxillary complex, the above mentioned criteria apply