Fractures of the edentulous mandible pose unique challenges. Old age itself is a risk factor for poor outcomes following trauma. There are associated comorbidities like hypertension, diabetes mellitus, dementia, or stroke which limit the functional capacity of the patient to bear the stress of surgery and postoperative recovery. Also, the atrophic mandible has compromised blood supply with little osteogenic potential resulting in delayed bone healing. Bilateral mandibular fracture (bucket handle fracture) occurs most commonly in elderly (Fig. 52.48).

#### **52.12.1 Management**

Controversy exists in the treatment of edentulous mandibular fracture. One school of thought advocated closed reduction, and another school is in favor of open reduction and internal fxation. According to Bradley [47] the major blood supply to the mandible is "sub periosteal Plexus," and refection of periosteum in ORIF may seriously impair vascular supply to the bone resulting in non-union.

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.48** Bilateral mandibular fracture (bucket handle fracture) in edentulous patients

Controversy again exists in the use of bone grafts in edentulous mandible. Are bone grafts necessary? Answer is not always. Reconstruction plates (load-bearing plates) can be used for comminuted fractures and with large defects. Bone morphogenic proteins and tricalcium phosphate can be used as alternative to autogenous grafts in patients whom multiple comorbidities may infuence local or systemic outcomes [48].

Few authors advocated extramucosal intraoral plating for the ORIF of the edentulous mandibular fracture. It preserves the blood supply to the mucosa and bone, at the same time provides adequate stability [49, 50].

The techniques of edentulous atrophic mandible fracture management are:

#### 1. Closed reduction (CR)

This technique is opted when the patient's systemic condition does not allow for an open surgery. CR can be accomplished if the mandibular height is at least 30 mm. It is diffcult to achieve CR if the mandibular height is <10 mm. CR can be accomplished using a preexisting denture. If there is no denture, gunning splint can be prepared. The denture/splint is used for immobilization and fxed to the mandible with circum-mandibular wiring (Fig. 52.49a, b).

Advantages: Periosteal supply to the bone is maintained.

Disadvantages: Chances of infection and pulmonary issues

2. Open reduction and internal fxation (ORIF)

This involves use of plates and screws for fxation of fractures. Options for ORIF include use of miniplates or larger reconstruction plates. Miniplates are small and

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.49** (**a**) Securing gunning splint by circum-mandibular wiring, (**b**) MMF with gunning splint in situ

hence require smaller incision. Screws of miniplates are also small which can easily involve thin fragments. However, in cases of larger fractures, a load-bearing reconstruction plate is preferred.

Advantages: Adequate fxation with no/minimum MMF

Disadvantages: Delayed healing with periosteal blood supply loss

#### **52.13 Pediatric Mandibular Fractures**

Among all the maxillofacial fractures, the incidence of pediatric facial fracture is 1–15%. After nasal bone fracture, the second most common fractures in children are mandibular fracture with an incidence of 5–50% [51]. In mandible, the condyle is the commonest site of fracture in pediatric patients followed by symphysis and parasymphysis. The most common mechanisms of injury in children are [52]:

In children, the developing tooth buds of canine approximate the lower border of mandible. This creates a stress point making the mandible susceptible to fracture in this location. Once the canine erupts, this weak point is reinforced with the bone and is not weaker than any other regions of the mandible. This is the reason probably why parasymphysis fracture is more common in children than adolescents.

With increasing age, the skull-to-face ratio decreases. The larger cranium shields the smaller middle and lower thirds of the face from injuries. This prevents mandibular fracture in small children; however, with increasing age the mandible becomes more prominent resulting in more injuries to this region.

#### **52.13.1 Management**

The management of pediatric mandibular fractures is different in comparison to adults due to [53]:

Pediatric mandibular fractures are treated in the following ways:

However the absence of teeth due to exfoliation and poor retention of wires on the deciduous teeth crowns makes the ligature wire and traditional use of arch bars diffcult or sometimes impossible [54]. In such cases splinting with acrylic splint retained with circum-mandibular wires remains a viable option in treatment of pediatric mandibular fractures.

Cap splints are secured to mandible by circum-mandibular wiring. Kelsey Fry bone awl is used for this purpose. A widebore needle can also be used for the same (Fig. 52.51a, b). Intravenous cannula stillete (IVCS) is also mentioned in the literature for performing circum-mandibular wiring. The 16-gauge IVCS was used instead of conventional awl [55].

However, management of pediatric mandibular fracture with ORIF is controversial as the fxation of plates may hamper the growth and development of jaw. Titanium miniplates have been successfully used for ORIF, but the implants are to be removed within 3- to 12-month period [56].

Yerit et al. [57] proposed use of biodegradable plates for ORIF. These plates should be mechanically strong and must undergo resorption within a predictable time frame.

The advantages of biodegradable plates (polyglycolic and poly-L-lactic acid plating system) in comparison to titanium plates are [58]:

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**Fig. 52.50** (**a**) Pediatric mandibular fracture, (**b**) cap splint secured using circum-mandibular wiring, (**c**) postoperative orthopantamogram

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.51** (**a**, **b**) Securing cap splint by circum-mandibular wiring using wide-bore needle

#### **52.14 Use of Bone Grafts in Mandible Fracture Treatment**

Anterior iliac crest (cancellous or cortico-cancellous) and fbula (free microvascular reconstruction) are the most commonly used sites from where the bone grafts are used for mandibular reconstruction. All the cases required bone grafting in cases of mandibular fracture treated with ORIF should be kept in MMF of 4 weeks postoperatively.

Bone grafts are indicated in some cases of:

Rachmiel et al. [59] advocated two-stage reconstruction of mandibular bone defect after trauma by bone grafting followed by alveolar distraction osteogenesis (ADO). This modality helps in correction of intermaxillary vertical relationship and provides suffcient amount of bone for the placement of dental implants and prosthesis.

### **52.15 Postoperative Care**

1078

#### **52.16 Complications of Mandible Fracture**

#### **Immediate**

#### **Delayed**

• **Infection:** Found to be the most common complication (Fig. 52.52)

	- 1. Preoperative oral sepsis
	- 2. Tooth in the line of fracture
	- 3. Improper reduction and fxation (Fig. 52.53)
	- 4. Alcoholic or metabolic disturbances
	- 5. Prolonged time before treatment
	- 6. Poor patient compliance
	- It indicates that a fracture has healed but in less than an optimal position.
	- It may result when bone is shorter than normal, rotated or twisted in a bad position, or bent.
	- It may cause pain, joint degeneration, posttraumatic arthritis, or catching episodes resulting from instability.
	- It is a type of uncommon complication of mandibular fracture, with reported incidence of 2.8–3.9% [60].
	- It is failure of fracture hematoma to become transformed into an osteogenic matrix so that it is converted into non-osteogenic fbrous tissue.
	- Non-union identifed by mobility in all planes after interval of minimum 10 weeks.
	- Histologically there is absence of identifable osteogenic tissue.
	- Radiographically no evidence of progressive decrease in radiolucency at the fracture site and rounding off of the bones' end in the later stages. It can be treated by ORIF by rigid fxation (load-bearing reconstruction plate and sometimes in combination with bone graft) (Fig. 52.54a, b).

©Association of Oral and Maxillofacial Surgeons of India

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.53** Postoperative infection due to improper reduction and fxation

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**Fig. 52.54** (**a**) Non-union due to closed reduction, (**b**) management of fracture non-union by load-bearing reconstruction plate

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.55** Showing malocclusion

### **52.16.1 Management of Mandibular Non-union Depending upon the Size of the Defect** (Table 52.10) [61]

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.56** Facial asymmetry

### **52.17 Recent Advances**

Kokosis et al. [62] advocated use of virtual surgical planning (VSP) with subsequent computer-aided design and manufacturing in management of acute mandibular trauma patients.

The advantages of the use of custom titanium plate in mandibular trauma are:

Computer-assisted surgery (CAS) including computer-aided design and manufacturing, surgical navigation techniques, and rapid prototyping (RP) has been used with lot of success in mandibular reconstruction (refer Chap. 41 of this book). CAS helps in [63]:

#### **Some Important Facts from Review of Literature Regarding Mandible Fracture [64, 65]**

#### **52.18 Case Scenarios**

#### **Case Scenario 1**

A male patient reported with a gunshot injury over right side of face. Patient's Glassgow coma scale (GCS) was 15/15 with stable vital signs, but the patient has diffculty in breathing. On maxillofacial examination, a gunshot wound was present over right side of face at the right mandibular angle region. Deviation of mandible was present on right side with cross bite on right side and open bite on left side. Tenderness was present over right mandibular angle region. On palpation, intersegmental mobility was present over right angle region.

Provisional diagnosis: Right mandibular angle fracture following gunshot

Investigation: Apart from blood investigation, a CT scan was performed, and a fnal diagnosis of comminuted right mandibular ramus and angle fracture with bullet in situ was made (Fig. 52.57a).

Management: Patient was subjected to emergency surgery under general anesthesia with a treatment plan of bullet retrieval, debridement, and open reduction and internal fxation of fracture. After the anesthesia was induced, patient preparation was done; the fracture site was exposed through an extraoral approach. Thorough debridement was done, and bullet was retrieved in multiple pieces (Fig. 52.57b). The bone segments which were detached were removed, and the fracture segments were fxed using a reconstruction plate following achieving occlusion (Fig. 52.57c). The use of bone graft was eliminated considering the risk of postoperative infection due to scattering of bullet particles. Moreover, the fracture site was a nondentate site; hence bone grafting was not mandatorily indicated for postoperative dental rehabilitation. Figure 52.57d shows postoperative OPG and fxation of fracture with reconstruction plate (refer Chap. 59 on Gun shot injuries).

#### **Case Scenario 2**

A female patient reported with the chief complaint of diffculty in chewing following operation to treat mandibular fracture. Patient gave a history of fall from height following which she was operated for ORIF elsewhere. The general condition of patient was good. On maxillofacial examination, mandible was deviated on right side with cross bite on right

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.57** Case Scenario 1 (**a**) DVT showing comminuted right mandibular angle and ramus fracture with bullet in situ; (**b**) retrieved bullet; (**c**) bullet retrieval, debridement, and fxation of fracture with recon-

struction plate; (**d**) postoperative OPG showing fxation of fracture with reconstruction plate

side and open bite with lingualized occlusion on left side (Fig. 52.58a). Patient provided us with a pretreatment OPG which revealed right subcondylar with left side mandibular comminuted body and angle fracture (Fig. 52.58b). We subjected the patient to another OPG which revealed improper fxation of left mandibular body fracture and no fxation of left angle and right subcondylar fracture (Fig. 52.58c).

Diagnosis: Malunited left mandibular body, left angle fracture, and right subcondylar fracture

Management: Patient was subjected to general anesthesia. Once the anesthesia was induced, patient preparation was done, and fracture site was exposed through extraoral incision for all the fractures. Existing implants were removed which resulted in removal of few small bone fragments. The fractured and carious teeth were extracted and reduction was done by MMF. Occlusion was achieved (Fig. 52.58d), and fxation was performed using two miniplates at subcondylar site and load-bearing reconstruction plate at the body-angle unit. A postoperative OPG was done (Fig. 52.58e). Patient was discharged in stable condition. After 6 months, dental rehabilitation was performed for missing teeth by delivering dental bridge (Fig. 52.58f).

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 52.58** Case scenario 2 (**a**) Deranged occlusion when patient reported to us, (**b**) pretreatment OPG, (**c**) improper fxation of left mandibular body fracture and no fxation of left angle and right subcondylar fracture at other centre, (**d**) intraoperative occlusion achieved, (**e**) postoperative OPG, (**f**) postoperative accurate occlusion

#### **References**

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## **Fracture of the Mandibular Condyle**

Vikas Dhupar

### **53.1 Introduction**

Maxillofacial surgeons commonly come across a high incidence of condylar fractures in their practice. A French surgeon [1] in the eighteenth century described a high propensity for a narrow portion in the subcondylar region to fracture, which is a common occurrence even today. In spite of a common occurrence, the management has been controversial as there is no established consensus in the treatment of condylar fractures. Traditionally closed reduction has been the treatment of choice for condylar fractures and have been treated by various forms of intermaxillary fxation. With the improvement in radiographic imaging and biomaterials used in the fxation, surgical management has gradually found acceptance as it restores early function.

### **53.2 Surgical Anatomy**

The mandibular condyle forms a part of the temporomandibular joint which is unique (Box 53.1), and it is made of the following structures:

V. Dhupar (\*)

#### **Box 53.1. TMJ—Unique Characteristics**

#### **53.2.1 Condyle**

The condyle is one of the two processes of the mandible present on the superior portion of the ramus. The condylar head is ovoid in shape measuring approximately 15–20 mm mediolaterally and 8–10 mm anteroposteriorly in dimension [2]. The mandibular condyle articulates with the glenoid fossa present in the squamous portion of the temporal bone to form the temporomandibular joint (Fig. 53.1). Squamous portion of the temporal bone is as thin as 2 mm as a result; the condylar processes maybe driven into the middle cranial fossa following trauma.

#### **53.2.2 Articular Disc**

The squamous portion of the temporal bone and the condyle is separated by a dense fbrous connective tissue called the articular disc. The disc is frmly anchored to the condyle by the medial and lateral collateral ligaments, and it merges with the capsule in the periphery. The joint space is divided into superior and inferior compartments by the disc.

#### **53.2.3 Capsule and Ligaments**

The capsule surrounds the TMJ and is reinforced by the medial and lateral ligaments which connect the mandible to the temporal bone. The synovial membrane lines the capsule.

Department of Oral & Maxillofacial Surgery, Goa Dental College & Hospital, Bambolim, Goa, India

K. Bonanthaya et al. (eds.), *Oral and Maxillofacial Surgery for the Clinician*, https://doi.org/10.1007/978-981-15-1346-6\_53

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 53.1** Bony structures of TMJ

This membrane produces synovial fuid which aids in the lubrication and nourishment of the joint. The lateral ligament also known as temporomandibular ligament has a horizontal and an oblique component which stabilizes the joint. The strength of the lateral ligament may be partly responsible for the fracture at the neck of condyle just below the insertion of the ligament [3]. The medial and lateral discal ligaments which are present inside the capsule are also called collateral ligaments. These ligaments connect the disc to the poles of the condyle. In addition to these ligaments, there are two non-capsular ligaments, namely, sphenomandibular and stylomandibular which may have a limited function.

#### **53.2.4 Muscles of Mastication**

There are four muscles of mastication, namely, the medial and lateral pterygoid, masseter, and the temporalis. Lateral pterygoid is attached to the pterygoid fovea at the condylar neck and is responsible for the displacement of the condylar fractures. Change in the direction of resultant forces post fracture will alter the function of the mandible during various excursion movements.

#### **53.2.5 Vascularisation**

The arterial blood supply to the TMJ is derived from the two terminal branches of the external carotid artery, namely:

It may be noted that the condyle receives blood supply from three sources

This may explain the reason for the fractured condyle to remains viable even after stripping of the periosteum during the surgical procedure as the lateral pterygoid muscle remains attached to the fractured fragment [4]. The venous drainage starts in the retrodiscal plexus which drains into the superfcial temporal and maxillary veins that join to form the retromandibular vein, which in turn drains into the external jugular vein.

#### **53.2.6 Innervation**

It is imperative to understand the innervation of the joint so as to minimize the complications following fracture of the mandible and its management. Both the sensory and motor innervation is encountered while approaching the joint. The sensory nerves are auriculotemporal, masseteric, and posterior deep temporal. Auriculotemporal nerve crosses the condyle medial to it and lies in contact with the condylar neck and capsule [5]. It is encountered in the preauricular incision and may result in postoperative complications.

#### **53.2.7 Facial Nerve**

It is the key nerve that transverses the face, and it is liable for the motor function of the muscles of facial expression. This nerve transverses the temporoparietal fascia and fnally divides into fve terminal branches in the parotid gland (Fig. 53.2). Hence all the extraoral approaches for the condylar fractures are designed keeping the facial nerve in mind. Al-Kayat and Bramley [6] found the nerve was at an average distance of 20 mm with a range of 8–35 mm from the anterior margin of the auditory canal. This is the reason the preauricular incision is given in the skin crease near the tragus or placed endurally. The neck of the condyle can be exposed via the transparotid approach. In this approach the condyle is reached through the space between the temporozygomatic and buccocervical trunks of the nerve. This results in a direct and safe approach to the neck of the condyle. The marginal mandibular nerve is encountered in the submandibular or periangular approach. This branch may further subdivide into two or more branches [7]. As a rule, the submandibular incision is given 2 cm below the lower border of the mandible to prevent paresis of the lower lip.

**Fig. 53.2** Terminal branches of facial nerve with Al Kayat and Bramely's [6] measurements for trunk of facial nerve. (A) .8–3.5 cm, (B) 2.4–3.5 cm, (C) 1.3 cm

#### **53.3 Biomechanics of Condylar Fracture**

U-shaped mandible supports the condyles on either side. There are two major movements while opening the mouth, rotational, and translational which occur in the inferior and superior compartments, respectively. Mandibular function is characterised as a class III lever with the joint being the fulcrum [8]. The musculature applies the force between the joint and the masticatory load (Fig. 53.3).

#### **53.3.1 Mechanism of Injury**

Trauma causing condylar fracture was explained by Lindahl [9]. It is important to understand the pattern as it gives the type of injury sustained (Fig. 53.4).

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 53.3** Function of mandible as class III lever

condyle on the opposite side. Fracture is usually at the base of the condyle.

3. Combination of the above two is seen in a road traffc accident and may result in more severe injuries.

An external force applied generally gets distributed over the entire mandible. However these forces result in the fracture of the subcondylar region which is weak and are subject to tensile stresses. A counter-coup injury is often noted in the condylar region. This prevents displacement of the condyles into the middle cranial fossa especially in bilateral fractures resulting from injuries over the chin.

#### **53.3.2 Efect of Condylar Fracture**

The signs and symptoms seen following trauma are due to the functional loss resulting from the disruption of the local anatomy. Following trauma a protective mechanism is triggered. It is generally expected that due to premature contact on the fractured side, excessive forces would be generated during loading of the non-fractured site on mastication. However, it is noted there is a shift of mean force vector towards the non-fractured site which results in protecting the fractured site during biting [10]. This results in neuromuscular adaptation. An increase in the muscle activity on the nonfractured side and a decrease of active force on the opposite 1088

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**Fig. 53.4** Mechanism of fracture of condyle

side results in this process. Hence most of the masticatory forces are directed towards the non-fractured site and resulting in less neuromuscular adaptation on the fractured site. Refer to the article by Ellis et al. [8] for a comprehensive understanding of the biological considerations of fractures of mandibular condyle.

#### **53.3.3 Adaptation to Fracture**

Following condylar fracture of the mandible, patients adapt to the injury by compensation mechanism which is divided as follows:

Intervention by the surgeons either by open or closed reduction minimizes the dental compensation. It is noted that there is a decreased masseter activity on the fractured site transferring load to a non-fractured site. This results in neuromuscular adaptation which may also be a protective phenomenon [8]. In case of an open reduction, there is minimum amount of neuromuscular adaptation. Usually a closed reduction results in an articulation which is inferior and anterior to the articular eminence which may limit the transitional movement. This can be avoided by open reduction and fxation. Minimum complications have been reported in the studies evaluating closed reduction in treatment of condylar fractures as pain and mouth opening were the only criteria which were evaluated. A statistically signifcant reduction in the incidence of malocclusion and lateral deviation on opening, along with an improved protrusive and laterotrusive movements, were noted in patients treated with surgical therapy vis-á-vis closed therapy in a recent meta-analysis report [10]. Compared to closed reduction where skeletal and neuromuscular adaptation is seen, in open reduction only neuromuscular adaption will take place following treatment.

#### **53.4 Classifcation of Condylar Process Fractures**

Condylar fractures can be described as a fracture line above the mandibular foramen that runs from the posterior border of the ramus to sigmoid notch or the condylar head (Fig. 53.5). Literature mentions numerous classifcations of condylar fractures. Most classifcations described the fracture based on the anatomical site, displacement, and fracture level, inclined towards close reduction. With the advancement of imaging modalities and better understanding of open reduction procedures, classifcations which are relevant are discussed.

Various terms describing the condylar fractures have appeared in the English literature (Fig. 53.6):

In 1927 **Wassumund** [11] differentiated between the head and neck fractures of the condyle. Early classifcation only described anatomical position but had no relevance in treatment as it did not document the angulation of displacement or dislocation. Condylar fractures were classifed as:

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 53.5** Area of condylar fracture

**MacLennan** [12] was the frst to differentiate between simple bending, displacement, and dislocation fractures of the condylar process.

Class I: no deviation (bending)

Class II: deviation (bending) at the fracture level

**Spiessl and Schroll** [13]. A classifcation well accepted in the European literature, which differentiated between fractures of the base and neck of the condyle, it also noted the range of angulation with deviation, displacement, or dislocation (Fig. 53.7).

	- IIIa: ventral
	- IIIb: medial
	- IIIc: lateral
	- IIId: dorsal

There are numerous modifcations of Spiessl and Scholl classifcations and were given over a period of time as a result subtypes has evolved especially in type V and VI fractures. Modifcations included Rasse [14], Neff et al. [15], Hlawitschka and Eckelt [16], and Loukota et al. [17].

**Fig. 53.6** (**a**) No displacement. (**b**) Deviation. (**c**) Displacement. (**d**) Dislocation (deviation). (**e**) Dislocation (displacement)

**Fig. 53.7** (continued)

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**Fig. 53.7** (continued)

**Fig. 53.8** Modifed classifcation Type A, B, C

**Lindahl** [9] gave the most comprehensive classifcation. Although descriptive, it is a complicated classifcation [9].

	- (a) Condylar head
	- (b) Condylar neck
	- (c) Subcondylar/condylar base
	- (a) Bending/deviation with medial overlapping segments
	- (b) Bending/deviation with lateral overlapping segments
	- (c) Bending/displacement without overlapping
	- (d) Nondisplaced fracture without deviation
	- (a) No dislocation
	- (b) Slight dislocation
	- (c) Moderate dislocation
	- (d) Severe and/or complete dislocation
	- (a) Horizontal
	- (b) Vertical
	- (c) Compression fracture

#### *Lindahl's Defnition*

A most common classifcation of diacapitular fractures was given by He et al. [18]. The types of fractures that can be recognized are (Fig. 53.9):

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**Fig. 53.9** Classifcation of diacapitular fractures (Type M not shown in fgure)

Loukota et al. [19] proposed a system of classifcation for condylar processes fractures of the mandible. This classifcation was adopted by SOR group which is based on a line A drawn perpendicular from the lowest portion of the sigmoid notch to the posterior border of the mandible. This helps in identifying the anatomy of the mandibular ramus even in cases following severe trauma. A clarifcation is also given on the condylar head fracture, and it clearly defned the term minimal displacement.

**AO Foundation** in 2010 expanded on Ellis [20] classifcation with the determination of "high-neck" and "low-neck" fractures in the online AO Surgery Reference, which pro-

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 53.10** (**a**) Dicapitular fracture. (**b**) Condylar neck. (**c**) Condylar base

vided a great detail to the location of "high and low" fractures as explained by Loukota:

Neff et al. [21] published the Comprehensive AOCMF Classifcation System: Condylar Process Fractures. It is a system that highlights fracture location, identifcation, displacement, comminution, and dislocation. Location of the condylar fracture is clearly identifed:

In the early days classifcation systems for the condylar fractures were entirely focused in locating the fracture. This was followed by systems which added the relation of the condyle with the adjacent structure. Loukota [19] gave a

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 53.11** AO foundation classifcation

classifcation which accurately locates the fracture with reference to treatment which is a simple classifcation to follow.

The aim of classifying the condylar fractures of the mandible is to locate the type and nature of the fracture which in turn will give a clear understanding of the nature of injury. This in turn will help the surgeon make a decision on the modality of treatment which may be open or closed.

#### **53.5 Incidence and Pattern**

In the facial skeletal, one of the most common bones to fracture is the mandible. Analysis of the fracture of different anatomical sites of the mandible revealed that there was a 10–40% incidence of condylar fractures [22–24]. Ellis et al. [25] published a study that showed condyle fractures represented 29.3% of all mandibular fractures. Zachariades et al. [26] stated that 72% of the condylar fractures were associated with other mandibular fractures. Isolated condylar fractures were rare, and occurrence of malocclusion was more dependent on the site of fracture. Incidence of fractures of condylar base were 57%, neck 31%, and head 12% as reported by Maclennan [27]. Incidence of condylar head was the least with the majority fractures at the condylar base. Frequency of unilateral fractures is higher than the bilateral fractures.

The highest incidence of mandibular fractures in males was 20–30 years and females 30–40 years [25] with the male-tofemale ratio 3:1 [26]. Condylar fracture can result from direct or indirect trauma. The degree, direction, magnitude, and point of application of force determine the severity of displacement [27]. Personal violence [28] followed by fall [29– 31] is the most common aetiology of condylar fractures.

#### **53.6 Clinical Features**

The patient may show mild to severe signs and symptoms following a condylar fracture. These are entirely dependent on the amount of displacement of the fractured fragments. Condylar fractures infrequently occurred in isolation and are generally associated with fractures of other sites of the facial bones. Surgeons may overlook subtle clinical features.

*Signs and symptoms:*

#### **53.6.1 Condylar Fractures: Unilateral**

#### **53.6.2 Condylar Fractures: Bilateral**

#### **53.6.3 Radiographic Assessment**

Condylar fractures can be evaluated by a number of conventional views. A set of two radiographs are usually taken perpendicular to each other for optimum evaluation. However the assessment has become more descriptive with availability of specialized radiographs. Various views which can be taken to evaluate the condylar fracture are as follows (Fig. 53.13):

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**Fig. 53.12** Occlusion post condylar fracture. (**a**) Unilateral condylar fracture of the left. (**b**) Bilateral condylar fracture

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 53.13** A case of unilateral fracture of the right side of condyle with a left body of mandible. (**a**) OPG. (**b**) PA mandible. (**c**) Coronal view. (**d**) Axial view. (**e**) 3D view of the CT scan

However it may be noted that with conventional radiography, very limited information is available. CT scans in the three plains, namely, coronal, axial, and sagittal, with volumetric studies can reveal the true picture of the fracture both for the terms of evaluation and treatment planning. MRI are essential to evaluate the disc injuries specially in dislocation and intracapsular condylar fractures; however MRI are not taken as a routine practise

#### **53.7 Management**

Historically there has been no clear agreement among the surgeons on the line of management of the fractures of the condyle. The goals of treatment which were enumerated by Walker [32] (Box 53.2) are well accepted.

#### **Box 53.2. Treatment Goals** [32]

#### **Box 53.3. Indications for Open Reduction Zide and Kent's** [33]

#### **Absolute**

#### **Relative**

#### **Box 53.4. American Association of Oral and Maxillofacial Surgeons [34]**

Literature has indicated that closed reduction has been the treatment of choice. This may be due to the complexities involved with open reduction. Surgical approach is technically demanding and associated with complications in inexperienced hands. As a result, some centres have exclusively treated condylar fractures by closed reduction. However as opposed to closed reduction, a few centres follow a protocol for management where open reduction is treatment of choice. Patients managed by surgical treatment have a superior outcome in term of post-treatment malocclusion, protrusion, laterotrusion, and lateral deviation during mouth opening. However, there was a higher infection rate as compared to non-surgical treatment. However, there is no statistical difference in post-treatment pain and maximum mouth opening in the two modalities of management [10]. Management can be divided as non-operative and operative (Box 53.6).

#### **53.7.1 Non-operative**

Some patients can be managed by observations provided they have a minimal nondisplaced fracture, dentate with a stable occlusion and having minimum pain. An important factor is that the patient must be complaint. At the onset of the treatment, patient must be explained about the possibility of additional treatment in the form of closed reduction which may be required.

Protocol followed is as follows:

**Box 53.5. Indication for Open and Closed Reduction Fonseca** [35] adapted from references [36–43]

#### **Absolute**

#### **Strong evidence for open reduction**

**Mixed evidence for open reduction**

• Moderate condylar displacement, 10–45°

#### **When to treat with closed reduction**

#### **Box 53.6. Management of Condylar Fractures**

#### **Non-operative:**

• Observation, physiotherapy, etc.

#### **Operative:**

	- (i) Surgeon preference
	- (ii) Fracture location
	- (iii) Type of fxation

#### **Box 53.7. Factors Taken into Consideration for Treatment**

#### **Box 53.8. Closed Reduction**

#### **Advantages**

#### **Disadvantage**

#### **53.7.2 Closed Reduction**

Closed reduction is a misnomer. It is never possible to achieve anatomic reduction as seen in management of other fractures. Closed reduction relies on the functional adaptation where a stable occlusion is achieved. Advantage of this technique is that it is minimally invasive and may not require hospitalization. It is entirely possible to carry out the procedure under local anaesthesia. However adaptation is never complete in adults as opposed to children. It may be possible to treat all types of condylar process fractures by this technique, but the surgeon must exercise his judgement based on the case and patient requirements. Closed reduction may involve the following:

#### **53.7.3 Open Reduction and Fixation**

This modality is technically challenging due to the complexities in terms of anatomy, approach, and fxation. It has been observed that by achieving anatomical reduction irrespective of the type of fxation used, it will result in restoring back the skeletal architecture. This in turn would require only neuromuscular adaptation for full recovery of the patient. According to the reports, this may be the reason for open management to be superior to the closed [36].

*Surgical approaches* to the condylar fracture are entirely dependent on the following factors (Fig. 53.14):

Incisions used to approach the fractures are divided as

#### **Box 53.9. Open Reduction and Fixation**

#### **Advantages**

	- Early function

#### **Disadvantage**

## **<IP_ADDRESS> Submandibular/Periangular**

(Fig. 53.15a, b) (Video 53.1)

This is an approach most maxillofacial surgeons are familiar with in their practise popularly known as Risdon approach. It exposes the base along with the neck of the condyle. Incision can either be parallel to the lower border or placed in a skin crease for maximum cosmetic results. For the condylar, fracture's incision is extended backward and upward to give a maximum exposure hence also referred to as periangular incision. The marginal mandibular nerve is protected by marking the incision 2–3 cm below the lower border of the mandible. Incision transverses through the skin, subcutaneous fat, and platysma. A superior platysmal dissection will expose the marginal mandibular nerve; however this may not be necessary. After dissection of the platysma, superfcial layer of deep cervical fascia is transected; this may expose the facial artery and vein. These may be required to be ligated and refected superiorly. This will protect the marginal mandibular nerve. Then pterygomasseteric sling is divided and periosteum refected to expose the lower border of the mandible. This gives an adequate exposure for osteosynthesis.

A modifcation of the submandibular/periangular approach known as the high submandibular approach or the high cervical transmassetric anteroparotid approach provides good aesthetics and reduces the chances of damage to the facial nerve [44]. A curved incision measuring three to fve cm in length is placed about 1 cm from the angle of mandible [45]. This is followed by layered dissection. An avascular pouch is created superiorly, and the pterygomasseteric sling is identifed. Stripping the masseter muscles of its attachments will lead to the exposure of the fracture [46] (Video 53.2).

**Fig. 53.14** Various incisions possible for condylar fractures based on location

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**Fig. 53.15** (**a**) Incision for submandibular/periangular approach. (**b**) Area exposed marked green in the mandible

#### **<IP_ADDRESS> Retromandibular** (Fig. 53.16a, b)

#### (Video 53.3)

Entire posterior border can be exposed via the retromandibular approach [47]; hence this approach is useful in treating fracture of the condylar neck and the base. The anatomic structures encountered in this approach are the main trunk of the facial nerve and retromandibular vein. It has two main variations transparotid and retroparotid. In both the variation marking of the incision is 5–10 mm below the lobule of the ear, parallel to the posterior border usually 3–4 cm long.

#### **Transparotid Approach**

In this approach incision is extends from the skin to the subcutaneous tissue, and it is undermined to reach the parotid capsule which is divided horizontally between the path of the buccal and zygomatic branches of the facial nerve. Dissection is carried out parallel to the direction of the facial nerve branches, and it is not important to locate the branches. Pterygomasseteric sling is sectioned, and periosteal fap elevated to expose the posterior border of the mandible.

#### **Retroparotid Approach**

In this approach parotid gland is lifted rather than transected to approach the posterior border of the mandible. Incision in this approach is placed more posterior as compared to transparotid approach as a result exposure is also restricted. After the parotid fascia is identifed, dissection is carried out behind the gland. The gland is lifted to expose the posterior border; from here the dissection carried out is the same as the transparotid approach.

V. Dhupar

## **<IP_ADDRESS> Preauricular Approach** (Fig. 53.17a, b)

or parotid fstula. Drains can also be placed.

parotid fascia should be sutured tightly to prevent sialocele

#### (Video 53.4)

This incision is most commonly used by the surgeons in the TM joint surgeries. Diacapitular fractures are approached via this approach [48]. Branches of facial nerve are involved in this approach along with the superfcial temporal artery and vein. Incision is placed along the crease of the skin following the tragus and helix of the ear which can be extended in the temple region. This extension on the temple minimizes traction and prevents weakness of facial nerve. Incision is carried from the skin to the subcutaneous tissue till the white glistening temporal fascia is reached. Root of the zygoma is palpated, and an oblique incision is given parallel to the frontal branch of facial nerve. Superfcial temporal fascia is incised, and a periosteal elevator is inserted below the fascia to strip the periosteum of the zygomatic arch. This will expose the capsule of the temporomandibular joint. Capsule is incised in an open method to expose the head of the condyle. The neck is exposed by doing a subperiosteal dissection. Closure is done in layers frst being the capsule followed by temporalis fascia, subcutaneous tissue, and the skin. The main disadvantage of this approach is an unaesthetic scar. This can be overcome by placing the incision endurally. The scar hides behind the tragus, but it can cause perichondritis.

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**Fig. 53.16** (**a**) Incision for retromandibular approach. (**b**) Area exposed marked in mandible (dark green, retro parotid exposure; light green, transparotid exposure)

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**Fig. 53.17** (**a**) Preauricular approach incision. (**b**) Area exposed marked in the mandible

#### **<IP_ADDRESS> Retroauricular Approach**

This is an approach which will provide best cosmetic results. However major disadvantage is that it can result in stenosis of the external auditory canal. Also, the closure takes a longer time. Incision runs parallel to postauricular fexure approximately 3 mm behind it. Skin followed by postauricular muscles and fascia overlying mastoid are incised. External auditory canal is identifed and completely transected at bony cartilaginous junction. Temporalis fascia is identifed, and from here dissection followed is similar to preauricular approach to expose the condylar head. Closure is done in layers with a special attention given to the external auditory canal.

#### **53.7.4 Reduction**

After the adequate exposure of the fractured fragments reduction is achieved under direct vision. If the distal fragment is placed laterally, reduction tends to be easy. However, in most of the cases, the fragments tend to be displaced medially resulting from the pull of lateral pterygoid muscle. A medially displaced fragment must be lateralized before an attempt is made to reduce the fracture. For easy manipulation, a plate with a single screw is fxed on the distal fragment. This will help in easy lateralization of the distal fragment and prevent the fragment from slipping back as the lower end of the plate acts as a rest on the proximal segment. Before an attempt is made to reduce the fracture, manual traction is applied to the mandible so that the vertical height of the posterior mandible is restored. This can be achieved as follows (Fig. 53.18a–d):

Once the fracture is reduced with the help of a clamp in the lowermost hole of the plate, pressure is applied to keep the fractured end in place. Figure 53.19a–d shows the reduction and fxation of a medially displaced condyle fracture.

In a case where two plates are planned for fxation, the smaller plate along the anterior border of the condyle is fxed frst with a screw. Once the anterior plate is fxed on the distal segment, similar steps are followed as mentioned earlier for single plate for reduction and fxation.

Sequencing the case of multiple fractures is as follows:

1. Fractures with contralateral condylar fractures—Fractures in the tooth bearing anterior segment are fxed before the condyle is fxed.

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**Fig. 53.18** (**a**) Manual digital reduction. (**b**) Traction using bite block. (**c**) Transosseous wiring. (**d**) Towel clip

### **53.7.5 Fixation Techniques** (Fig. 53.20a–d),

(Case 1: Fig. 53.21a–b), (Case 2: Fig. 53.22), (Case 3: Fig. 53.23a–e), (Case 4: Fig 53.24a–d)

The most signifcant advances that have taken place in the management of fracture of condylar process include the osteosynthesis material and the technique. Fixation with titanium plates and screws has given optimal results when adequate bone, proper site selection with proper techniques

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**Fig. 53.19** (**a**) Medially displaced condylar fracture. (**b**) Fracture lateralized. (**c**) Distal segment secured with a plate. (**d**) Fracture reduced

followed [49]. At the time of surgery fxation, technique is selected based on the following parameters:

Fixation can be in the form of one plate, two plates, hybrid plates, lag screws, or restorable plates. Studies have shown that use of two plates is superior to one plate [40, 50]. Two plates must be used for lower level fractures to overcome tension and stress in the neck region by placing plates along the anterior and posterior border in a triangular fashion (Fig. 53.20a–d). In cases where there is limited bone, available fixation can be done with heavier single plate. Single plate is fixed along the long axis of the condyle. There are many types of hybrid plates available. These are designed to incorporate the principle of two plates in a single plate. However, this makes the plates bulky as a result it may be at times difficult to fix them especially when there is limited bone available. Irrespective of the type of plate used, there should be at least two screws on either side of fracture.

Fixation of condylar head is a challenge because of the limited space available and the fractures are intracapsular. In addition, there could be multiple small fragments and associated injury to the disc and the capsule which may be required to be repaired. Several osteosynthesis techniques are available for fxation like the mini plates, stainless steel wire, standard lag screws, resorbable screws, resorbable pins, and cannulated lag screws (Fig. 53.25). Reduction and fxation of the condylar head is technically challenging as the small fragments can easily necrose if stripping of the muscle is done. Use of two lag screws would be idle as it will prevent the reduced fragments from displacement during function, but times it may not be possible to fx two screws due to limited space Table 53.1 [51].

Intraoral endosocpic approach for treatment of condylar fractures is given in detail in Chap. 54 of this book.

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**Fig. 53.20** (**a**) Single plate. (**b**) Two plates. (**c**) Lambda plate. (**d**) Delta plate

**Case 1: Fig. 53.21** (**a**) OPG view showing left condyle fracture (**b**) Post operative OPG showing single plate fxed via retromandibular transparotid approach

**Case 2: Fig. 53.22** (**a**) Intra operative view showing two plates fxed for condyle fracture via retromandibular transparotid approach. (**b**) Post operative radiograph of showing fxation with two plates

**Case 3: Fig. 53.23** (**a**) PA view showing right condyle fracture. (**b**) Intraoperative view via retromandibular transparotid approach shows the displaced condyle. (**c**) Reduction and fxation done with Lambda plate. (**d**, **e**) Post operative PA view and OPG showing the fxed Lambda plates

#### **Box 53.10. Functional Exercise: Rehabilitation Targets [52]**

#### **53.8 Condylar Fractures in Children**

The most common fracture seen in the maxillofacial region in children is fracture of the condylar process [53]. Condyle is unique in children as there is a very thin cortical bone surrounding a highly vascular cancellous bone. This can result in a comminuted type of fracture also called mushrooming. Condylar fractures can result in defnitive deformities, both in terms of function as well as

**Case 4: Fig. 53.24** (**a**, **b**) Pre operative PA view and OPG showing fracture left condyle. (**c**, **d**) Post operative PA view and OPG showing the fxed Delta plate via Periangular approach

a facial asymmetry in cases of inappropriate treatment. Intracapsular fractures can result in retardation of growth [54, 55] or in excessive growth on the fractured site [56]. Remodelling of the condyle is inversely proportional to age [9, 25, 26]. Children have a better adaptation than the adults. Adaption in children is skeletal, neuromuscular, as well as function. In adults only functional adaptation is seen. For this reason, literature has supported conservative management of fracture of the condylar process. It is paramount to rehabilitate the patient with the restoration of minimum mouth opening, lateral excursion movement with stable occlusion. However, a long-term follow-up showed 50–53% of patients had complaints even though minor in nature irrespective of the type of treatment carried out [57]. Early mobilization is recommended in children below 15 years. Patients are encouraged to be on soft diet to avoid pain. In cases where an open bite is present, guiding elastics will help in restoring the occlusion. There is no concrete evidence of prolonged period of maxillomandibular fxation.

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tures of the mandibular condyle

**Table 53.1** Comparison of different fxation methods used for frac-

**Case 5: Fig. 53.26** Shows improperly reduced fracture condyle which has been fxed in a dislocated position of the condyle-arrow points towards the plate fxed in wrong position

**53.9 Complications of Condylar Fractures**  (Case 5: Fig. 53.26) (Case 6: Fig. 53.27a–c)

**Case 6: Fig. 53.27** (**a**) Chronic infection left side condyle region following reduction and fxation, (**b**) CT scan showed osteomyelitis like changes at left condyle (**c**) the fractured infected plate removed

#### **Box 53.11. Recent Advances [49]**

#### **53.10 Conclusion**

There have been numerous controversies in management of condylar fractures. They have ranged from which classifcation to use, surgical approach, type of fxation, and outcome of the treatment. But till date even with all the advances available to us, we still cannot agree on the two schools of thought for management of condylar fracture that is closed or open. Danda et al. [38] concluded in their study that there was no difference in treatment outcome in both the groups. This can be debated as it is not possible to compare the two modalities of treatment in absolute terms. Although it is pointed out that there are better results in function with open reduction and fxation, there are inherent complications that are only seen in cases treated by open reduction [62] such as nerve injuries and scars.

In an alternative interpretation of evidence, Leon A Assael [63] opined that both open and closed reduction have a critical role in management of condylar fractures. Treatment outcome such as full pain free range of movement and good aesthetics is seen in both the groups. Malocclusion, functional defcit, and internal derangement are seen irrespective of line of treatment. Over the years, complications noted in open reduction have reduced with the better understanding and improvement of technique, but it can be burden on the patient. These complications can only be weighed against the functional advantage patient gets in open reduction and fxation. Treatment of a condylar fracture will entirely be dependent on multiple factors.

To conclude it can be safely stated that management of condylar fractures should be patient centric not entirely based on absolute indications mentioned by various authors. Generally, in children and dentulous adult patients, closed reduction is the choice of treatment, whereas open reduction and fxation would be the choice of treatment for the patients with multiple fractures of mandible, panfacial trauma, partially or totally edentulous jaws, and underlying medical conditions preventing maxillomandibular fxation. Finally, function should be considered as an important parameter while formulating a treatment plan along with the resources available and skill of the surgeon.

#### **References**

ized prospective, multicenter study with special evaluation of fracture level. J Oral Maxillofac Surg. 2008;66:2537–44.

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# **54**

## **Intraoral Endoscopic Approach for Treatment of Condylar Fractures of the Mandible**

Frank Wilde

#### **54.1 Introduction**

The literature is replete with techniques regarding the open reduction and fxation of the condylar fractures of the mandible. The extraoral approach is preferred by the majority of surgeons in comparison to the intraoral approach. Nevertheless, open reduction and internal fxation by an extraoral approach has the evident risk to cause transient or even permanent facial nerve injury [1–4], leads inevitably to a facial scar [1, 5], and can course salivary fstulas, sialoceles [1, 6], Frey syndrome, or disturbance of the great auricular nerve [1]. In contrast, an intraoral approach is minimizing these abovementioned risks and facial scars can be avoided in general [7, 8].

Silverman in 1925 was the frst person to mention about the intraoral approach to condylar fractures [9]. However, at that time, the surgeons were facing several diffculties treating those fractures due to a lack of adequate instruments. Fritzemeier and Bechthold developed the 90-degree angular screwdriver, and it served as a milestone in the intraoral management of condylar neck fractures. In their study, there were 32 fractures of which 2 cases showed early failures. Other cases during follow-up showed minor deviation from axis, but there were no evident problems in the temporomandibular joint function [10].

Based thereupon, several authors were reporting about the use of an intraoral approach treating condylar fractures surgically. Forty-eight cases of displaced and shortened mandibular condyle fractures were treated by an intraoral approach and studied by Mokros and Erle in 1996. In 2/3 of the treated fractures, the reduction was successful, and no

F. Wilde (\*)

Department of Oral and Maxillofacial Surgery, University Hospital, Ulm, Germany e-mail<EMAIL_ADDRESS>
signifcant complications were noted in the intraoperative or postoperative period.

TMJ function was good in 90% of the patients, 43% were free of symptoms, and 47% had minor dysfunction. The authors came to the result that proper reduction of the bone fragments is most important for therapeutic success [11].

Schön et al. [8] compared in a study an intraoral endoscopy-assisted approach with an extraoral approach for the treatment of condylar fractures. A reduced risk of facial nerve damage and no visible scars were the major conclusion of the study, and they also opined that intraoral endoscopic approach is a reliable technique for treating condylar fractures [8]. Veras et al. [12] were looking in their study on 25 patients with condylar fractures which were treated surgically by an intraoral approach. The mean mouth opening postoperatively was 4.8 cm. Patients postoperatively did not have clicking of the joint, facial nerve weakness, or pain of the muscles or the joint. They opined that intraoral reduction allowed the anatomic ramus height to be restored and that the functional results were acceptable [12].

Other authors like Jensen et al. [13] or Schneider et al. [14] were not so enthusiastic about the outcome of surgicaltreated condylar fractures employing an intraoral approach [13, 14]. Jensen et al. in 2006 stressed on the fact that intraoral approach for the condylar fractures is very technically demanding and there is a chance of getting postoperative complications [13]. Schneider et al. [14] compared in a retrospective study 21 fractures which were treated with an intraoral approach with 24 fractures which were reduced by an extraoral perimandibular approach. In their study, the cases treated by intraoral approach showed suboptimal radiologic fndings, and the patients' subjective feelings pointed to less favorable clinical results. They put forward the suggestion that fractures which do not require extensive manipulation and fractures which can be reduced exactly under a limited view only should be approached intraorally. For all other fractures, they recommend extraoral approaches [14].

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K. Bonanthaya et al. (eds.), *Oral and Maxillofacial Surgery for the Clinician*, https://doi.org/10.1007/978-981-15-1346-6\_54

Department of Oral and Plastic Maxillofacial Surgery, Armed Forces Hospital, Ulm, Germany

#### **54.2 Surgical Technique**

From the authors' experience, fractures of the condylar base and the low and medial part of the condylar process can be addressed typically by the following described technique. Treating high condylar neck fractures is demanding and requires experience in using such an approach. Fractures of the condylar head or the transition zone between the neck and head cannot be reached with this approach, and extraoral incisions are still required when this kind of fractures is getting treated surgically.

For the below-described technique, a team of three surgeons (one leading surgeon and two assistant surgeons) are highly recommended.

#### **54.2.1 Special Surgical Instruments and Devices**

To facilitate open reduction and internal fxation of condylar fractures via an intraoral approach with predictable results, special equipment is mandatory.

The most important instruments are a 90° angled screwdriver and drill (Fig. 54.1a). The screwdriver should have necessarily a sliding screw-holder which facilitates to hold the screw and plate together (Fig. 54.1b), because positioning a plate with one hand and fxing the screw with the other hand is not appropriate and will lead to unsuccessful procedures. Self-retaining screwdriver-bits or even selftapping screws should be avoided as well. The authors recommend a straight 90° angled screwdriver with the aforementioned sliding screw-holder and centric-positioned screwdriver-bits. Screwdrivers with eccentric-positioned screwdriver-bits show a lower height indeed.

Besides the 90° angled screwdriver and drill, extra-long instruments in the form of raspatories and reposition hooks have to be recommended insistently (Fig. 54.2). They simplify the manipulation and reduction of the fractured condyle with a good direct view into the operation site. Using standard confgurated instruments results in less vision due to obstructing the view by the operator's hands.

An appropriate light-intensive headlight is necessary for proper illumination of the operation site (Fig. 54.3).

A 4 mm caliber 30° angled endoscope has to be recommended as well. In combination with a special retractor in which the endoscope can be inserted, a good visualization, especially of the posterior border of the ramus, can be achieved (Fig. 54.4).

In addition, a special retractor with a fber-optic light guide which can be positioned buccally to the posterior border of the ramus enables good illumination of the surgical site (Fig. 54.5). Nevertheless, having an appropriate headlight, this instrument seems to be dispensable.

It can be further useful to fx the patient during surgery in a Mayfeld head clamp as it is commonly used by the neurosurgeons. This allows traction with the retractors without any movement of the head.

Besides the described instruments, there are several special instruments and devices available on the market to facilitate open reduction and internal fxation using an intraoral approach. However, from the authors' experience, the aforementioned instruments and devices are the most helpful in treating condylar fractures by an intraoral approach.

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**Fig. 54.1** (**a**) 90° angled screwdriver and drill. (**b**) Sliding screw-holder which facilitates to hold the screw and plate together (Medartis, Basel, Switzerland)

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**Fig. 54.2** Extra-long instruments in the form of raspatories and reposition hooks (Karl Storz, Tuttlingen, Germany)

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**Fig. 54.3** LED headlight (KLS Martin, Tuttlingen, Germany)

#### **54.2.2 Surgical Access**

By extending the standard vestibular incision in a superior direction along the ascending ramus, the ramus and the condyle region can be exposed intraorally (Fig. 54.6). The approach is following Obwegeser's principles of avoiding visible scars by extending his approach to the mandibular ramus for sagittal split osteotomy. During the incision of the oral mucosa, the anatomical course of the buccal nerve has to be taken into account. The dissection of the mucoperiosteal fap starts from the mandibular corpus in the region of the frst molar to mandibular angle and far up to the condyle until the facture line can be explored. To get an appropriate

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**Fig. 54.5** Retractor with a fber-optic light guide (Karl Storz, Tuttlingen, Germany)

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**Fig. 54.4** (**a**) 4 mm caliber 30° angled endoscope (asterisk) and retractor in which the endoscope can be inserted (hash symbol). (**b**) Retractor with inserted endoscope (Karl Storz, Tuttlingen, Germany)

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**Fig. 54.6** Intraoral approach to the condyle region by extending the standard vestibular incision in a superior direction up the ascending ramus

visualization of the condylar neck region, the mucosa including the fbers of the temporal muscle had to striped from the coronoid process up to or even higher than the mandibular notch. During dissecting the posterior border of the mandibular ramus, the retromandibular vein has to be taken under consideration. Coagulation in this region has to be done carefully, due to the anatomical proximity to the facial nerve which is running laterally in the parotid gland. This is the region where the facial nerve may be damaged during the procedure. In addition to coagulation, vigorous traction can damage the facial nerve in this location as well.

#### **54.2.3 Surgical Procedure**

After dissection to get suffcient access to the condylar neck region, the displaced condyle has to be identifed. The best instrument for this is the extra-long raspatorium depicted in Fig. 54.2. During this procedure, the ramus has to be distracted. This can be performed by pulling the mandible caudally by hand. Another option is to fx one mini-screw in the

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mandibular angle to twist a wire around, which is diverted out of the skin in the mandibular angle region by a stab incision. However, this leads to a small extraoral scar.

For this maneuver, a full relaxation of the patient by the anesthesiologist is recommended. Due to the very low risk for facial nerve damage employing this approach, this can be done without increasing this risk.

For medial displaced condyles in high condylar neck fractures, it is sometimes helpful to perform a temporary osteotomy of the coronoid process to get better access for repositioning. A later re-fxation of the osteomized coronoid process by a miniplate is in theory not needed but recommended by the authors (Fig. 54.7).

Once the dislocated fragment is identifed, it has to be repositioned anatomically. MMF cannot be recommended in all cases. In some cases, it can be helpful to get a stable reduction during osteosynthesis; however, in most cases, MMF is not very helpful. This decision has to be made individually case by case.

In most cases, the reposition of the proximal fragment is not stable from the beginning (Fig. 54.8). Therefore, the authors recommend to drill the frst screw hole in the condyle fragment close to the fracture line in the region of the sigmoid notch. A four- or fve-hole 1.0 mm up to 1.2-mm-thick miniplate is fxed in this hole with a 5- to 6-mm-long screw with a diameter of 2.0 mm. The screw should not be tightened completely. Then the reduction of condyle fragment

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**Fig. 54.8** Endoscopic view after repositioning of a condylar neck fracture

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**Fig. 54.9** Endoscopic view after fxation of a four-hole miniplate close to the sigmoid notch with two screws adjacent to the fracture line

can be achieved by pulling on the miniplate with one of the extra-long reposition hooks. By visual control of the repositioned fragment, the miniplate should now be fxed in the ramus part of the fracture close to the sigmoid notch by eccentric drilling of the screw hole for fracture line compression during screw insertion. After fxing the second screw, the frst screw has to be tightened completely (Fig. 54.9).

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**Fig. 54.10** Endoscopic view after fxation of a fve-hole miniplate at posterior border with two screws adjacent to the fracture line

Once this is facilitated, often a small gap and faring can be identifed at the posterior border of the condylar neck. To close this gap, a second four- to fve-hole miniplate has to be fxed at the posterior border of the condylar neck. Here also the hole has to be drilled in the condyle fragment close to the fracture line. First, the plate has to be fxed in this hole and should be aligned along the posterior border of the condylar neck respectively the ramus. Again, the screw should not be tightened completely at this stage. After exact anatomical reposition of the condyle, the next screw is now drilled for compression osteosynthesis in the ramus part of the ramus close the fracture line and immediately fxed with the fourth screw (Fig. 54.10). The third screw is then tightened completely to stabilize the fracture. After attaining control of the anatomical correct reposition with the endoscope or in low condylar neck fractures even with a simple dental mirror, the other screw holes in both plates are drilled and fxed, starting with the plate at the posterior border and ending with plate close to the sigmoid notch. Figure 54.11 shows the fnal endoscopic view with the two plates fxed. Figure 54.12 is illustrating the recommended sequencing of plate and screw positioning to facilitate open reduction and internal fxation via an intraoral approach using two miniplates.

In addition, the authors recommend intraoperative imaging with a 3D C-arm device at the end of the procedure when available (Fig. 54.13). This allows the intraoperative radiologic control and documentation of the reduced fracture and of the position of the plates in a multiplanar view and enables an immediate intraoperative correction when the result of the

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**Fig. 54.11** Endoscopic view after complete fxation of a condylar neck fracture with two miniplates. One four-hole plate in the region of the sigmoid notch and a second fve-hole miniplate at posterior border

procedure is not satisfactory. This reduces the risk for revision surgeries considerably [15, 16].

When the result is satisfactory, the intraoral mucosa has to be closed in the standard way like every intraoral incision. Even when the fracture is reduced and stabilized with success, the authors still recommend a light MMF with elastics strained over two or four MMF screws or arch bars for approximately 1 week for slight immobilization and guidance into the proper occlusion. In case of a postoperative insuffcient occlusion, a prolonged functional treatment as in nonsurgical treated condylar fractures with elastics or an orthodontic device like an activator or bionator has to be recommended.

#### **54.2.4 Osteosynthesis Material**

As mentioned before, the author is recommending the usage of two miniplates. The plate at the posterior border is responsible for the stability primarily, whereas the plate in the region of the sigmoid notch prevents faring of the distal fragment during function additionally.

For osteosynthesis, 1.0-mm up to 1.2-mm-thick miniplates can be recommended (Fig. 54.14). It can be favorable to use 1.2-mm-thick miniplates at the posterior border due to stability reasons. The screws should be usually 5–6 mm long with a diameter of 2.0 mm. Locking screws

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**Fig. 54.12** Recommended sequencing of plate and screw positioning to facilitate open reduction and internal fxation via an intraoral approach using two miniplates

are not necessary and should never be used for the screw holes which are adjacent to the facture line. These holes should be drilled eccentric to achieve compression at the facture line. In modern osteosynthesis systems, locking and non-locking screws can be used with the same plates. Using such a system, it may be advantageous to use locking screws for the fracture-distant screw holes. Nevertheless, as mentioned before, locking screws are not needed in this technique.

Besides standard miniplates, there is the option for the use of so-called 3D plates or special designed condylar neck plates (Fig. 54.15). However, from the authors' experience, plating with two miniplates enables the aforementioned successive repositioning and fxation of the facture most easily and leads to suffcient stability.

There are new developments of anatomically preformed 3D condylar neck plates with integrated reposition wings for the posterior border and the sigmoid notch (Fig. 54.16). Whether these kinds of plates are benefcial or not has to be investigated in the future.

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**Fig. 54.13** Intraoperative imaging with a 3D C-arm device (Ziehm, Erlangen, Germany) at the end of the procedure and multiplanar view of the surgical result

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**Fig. 54.14** 1.0-mm and 1.2-mm-thick standard miniplates (DePuySynthes, Zuchwil, Switzerland)

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**Fig. 54.15** 3D miniplate (asterisk) and special condylar neck plate (hash symbol) (DePuySynthes, Zuchwil, Switzerland)

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**Fig. 54.16** (**a**) Anatomically preformed 3D condylar neck plates with integrated reposition wings for the posterior border and the sigmoid notch (KLS Martin, Tuttlingen, Germany). (**b**) Displaced right condylar neck fracture. (**c**) Condylar neck fracture after repositioning and fxation employing an intraoral approach

#### **54.3 Complications**

There is no much difference in complications by treating condylar factures via an intraoral approach in comparison to all other treatment options. Postoperative infection is the most common complication followed by malocclusion. Dysfunctional degeneration of the injured joint can lead to joint clicking, pain, reduced mouth opening, and mandibular deviation during opening and closing. Even severe arthritis or condylar resorption can occur up to the total destruction or loss of the joint. Hardware failure in form of plate fractures or loosening of screws can be seen occasionally as well.

In addition to the avoidance of any visible extraoral scar, the biggest advantage in comparison to all extraoral approaches for surgical treatment of condylar fractures is the very low complication rate concerning facial nerve injuries, salivary fstulas, sialoceles, Frey syndrome, or disturbance of the great auricular nerve.

#### **54.4 Conclusion**

The described intraoral approach for the treatment of condylar fractures is favorable for fractures of the condylar base and the condylar process. The biggest beneft and advantage in comparison to all extraoral approaches is the very low complication rate concerning facial nerve injuries and the **Table 54.1** Advantages and disadvantages of an intraoral approach for the treatment of condylar fractures

avoidance of extraoral scars. A disadvantage is the need for special equipment to facilitate this technically demanding procedure with regular success (Table 54.1).

#### **54.5 Case Scenario**

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**Fig. 54.17** (**a**) 3D reconstruction of the preoperative CT scan showing the medial displaced condylar process fracture right and slightly displaced paramedian fracture left. (**b**) Coronal view of the preoperative CT scan showing the medial out of the fossa displaced condylar process

#### **References**

1. Rozeboom AVJ, Dubois L, Bos RRM, Spijker R, de Lange J. Open treatment of condylar fractures via extraoral approaches: A review of complications. J Craniomaxillofac Surg. 2018;46(8):1232–40.

fracture right. (**c**) Postoperative panoramic X-ray showing well-suffcient reduced and with miniplates stabilized fractures paramedian left and at the condylar process right

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## **Maxillary Fractures**

Oommen Aju Jacob and Akhilesh Prathap

#### **55.1 Introduction**

Complex midface trauma has challenged the diagnostic and operative skills of surgeons through the decades. Robert Marciani in his ffty year review article dated 1993, vividly described the challenges faced by early surgeons regarding the clinical and radiological diagnosis of mid face fractures and the compromised surgical results that may ensue [1].

#### **55.1.1 History (Table 55.1)**

In an area so anatomically complicated as the midface, the lines of fracture produced in the middle third are classifed based upon the experimental studies of René Le Fort in 1901 [2]. The earliest known writings of maxillofacial fractures were recorded in the Edwin Smith papyrus in 1650 BC. Hippocrates who is often portrayed as the "Father of Medicine" described a myriad of facial injuries around 400 BC and his insight provided the basis for bandages and single jaw interdental wiring as methods of fxation and stabilization of facial fractures. Over the subsequent centuries, there appeared many techniques which in essence were variations of what Hippocrates had described. In the nineteenth century, Charles Fredrick Reiche provided the frst detailed treatise on maxillary fractures [3]. It was also in the same century that Garretson and Blair advocated mandibularmaxillary fxation with the aid of splints to primarily treat maxillary fractures.

In 1901, a French surgeon René Le Fort published his classic paper on midfacial fracture patterns. He inficted blunt facial trauma on cadavers, then subsequently removed the soft tissue and examined fracture patterns of the facial skeleton. This study has ever since been the basis for the description of maxillary fractures.

O. A. Jacob (\*)

Department of Oral and Maxillofacial Surgery, Ananthapuri Hospitals and Research Institute, Trivandrum, Kerala, India

Kerala Institute of Medical Sciences, Trivandrum, Kerala, India

A. Prathap Pushpagiri College of Dental Sciences, Thiruvalla, Kerala, India

© The Association of Oral and Maxillofacial Surgeons of India 2021 1125

K. Bonanthaya et al. (eds.), *Oral and Maxillofacial Surgery for the Clinician*, https://doi.org/10.1007/978-981-15-1346-6\_55

**Table 55.1** Milestones of maxillary fractures

**55**

#### **55.1.2 Surgical Anatomy/Osteology**

The middle third of the facial skeleton is made up of the following bones (Fig. 55.1)

The middle third of the face is made up of a number of bones which rarely fractures in isolation. The complex nature of the midface is such that it will withstand the forces of mastication from below and provide protection in certain areas for vital structures. The middle third of the facial skeleton consists of a series of bone struts (buttresses) passing upwards from the upper teeth to the bones of the skull [4] (Fig. 55.2).

The relative fragility of the midface skeleton makes it act as a cushion for trauma directed towards the cranium from an anterior or anterolateral direction. The facial skeleton can be designated by this famous fgure, where the skull is similar to a helmet, the midface is similar to a matchbox (crumble zone) and the mandible is similar to a hockey stick (Fig. 55.3). The most common causes of facial fractures in the adult population are assaults and motor vehicle accidents [5].

**Fig. 55.2** Vertical and horizontal buttresses of the facial skeleton (Also refer Fig. 60.9 and Table 60.2)

#### **55.1.3 Applied Anatomy of the Midfacial Bones**

The midface is composed of the nasal, zygoma, maxilla, ethmoid and its conchae, palatine, inferior concha and vomer which are collectively referred to as the middle third of the facial skeleton. The facial bones in isolation are comparatively fragile but gain strength and support as they articulate with each other. It is this strength that has often been described as the facial buttresses which Manson alluded to when describing the vertical and horizontal struts that support the facial skeleton [6]. The horizontal pillars are formed by the frontal bar (composed of the supraorbital rims and nasal process of the frontal bone), the zygomatic arch, the infraorbital rims and the nasal bridge and fnally the alveolar process of the maxilla. The vertical pillars are the medial pillar formed by the piriform rims which continues superiorly as the frontal process of the maxilla. The zygomatic buttresses which continue superiorly with the lateral orbital rims form the lateral pillars, and the most caudal pillars are the pterygoid plates.

#### **<IP_ADDRESS> Maxilla**

The maxilla consists of a central body and four processes, namely, the frontal, zygomatic, alveolar and palatine process. The body is hollowed out and contains the maxillary sinus. It is pyramidal shaped with the base being the medial surface facing the nasal cavity and the apex being elongated into the zygomatic process. It has an orbital or superior surface which forms the foor and rim of the orbit, a malar or anterolateral surface which forms part of the cheek and a posterolateral or infratemporal surface which contributes to the infratemporal fossa. The base is rimmed inferiorly by the alveolar process. The alveolar process houses the dental arch with the sockets varying in size according to the teeth. The palatine process is a horizontal process from the body to the alveolar process and medially articulates with the palatine process of the opposite maxilla, while posteriorly it articu**Fig. 55.3** Helmet, matchbox and hockey stick to illustrate relative bone strength (the matchbox is the crumble zone)

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lates with the horizontal plate of the palatine bone. The zygomatic process is an extension of the anterolateral surface of the body which contributes to the zygomaticomaxillary suture. The frontal process projects upwards to articulate with the maxillary process of the frontal bone as well as the nasal bone anteriorly and the lacrimal bone posteriorly.

#### **<IP_ADDRESS> Vascular Supply and Innervation**

The blood supply to the maxilla and the palatine bones is through the periosteum, the incisive artery and the greater and lesser palatine arteries. The internal maxillary artery lies posterior to the maxillae and the palatine bones and anterior to the pterygoid plates of sphenoid.

The maxillary nerve enters the caudal maxilla ventral to the orbit via the maxillary foramen and runs through the maxilla in the infraorbital canal giving off branches to supply the maxillary cheek and teeth. The nerve then exits the maxilla at the infraorbital foramen.

#### **55.2 Classifcation**

#### **55.2.1 René Le Fort1901 [2]**

Maxillary fractures were classifed by René Le Fort based on his experiments on cadavers with low velocity unidirectional frontal trauma. Although the present-day maxillary fractures are caused due to high velocity multi directional trauma, the Le Fort classifcation is still widely followed due to its simplicity and the levels of anatomic differentiation it offers. Other authors have attempted classifcations based on the anatomical sites and based on the involvement of the occlusion. Marciani modifed the basic Le Fort classifcation by adding frontal bone and zygomatic fractures.

#### **<IP_ADDRESS> Le Fort I**

#### **Low Level Fracture/Guerin Fracture**

The fracture line extends backwards from the lateral margin of the anterior nasal aperture below the zygomatic buttress to cross the lower third of the pterygoid laminae. The fracture also passes along the lateral wall of the nose and the lower third of the septum to join the lateral fracture behind the tuberosity (Fig. 55.4a–c).

#### **<IP_ADDRESS> Le Fort II**

#### **Pyramidal or Sub-zygomatic Fracture**

This fracture runs from the thin middle area of the nasal bones down either side, crossing the frontal processes of maxillae into the medial wall of each orbit; the fracture line crosses the lacrimal bone behind the lacrimal sac before turning forwards to cross the infraorbital margins slightly medial to or through the infraorbital foramen. The fracture now extends downwards and backwards across the lateral wall of the antrum below the zygomaticomaxillary suture and divides the pterygoid laminae about half way up.

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**Fig. 55.4** (**a**, **b**) Le Fort I fracture lines. (**c**) CT of Le Fort I fracture

Separation of the block from the base of the skull is completed via the nasal septum and may involve the foor of the anterior cranial fossa (Fig. 55.5a–d).

#### **<IP_ADDRESS> Le Fort III**

#### **Transverse or Supra-zygomatic Fracture**

The fracture runs from near the frontonasal suture transversely backwards and parallel with the base of the skull and involves the full depth of the ethmoid bone including the cribriform plate. Within the orbit the fracture passes below the optic foramen into the posterior limit of the inferior orbital fssure. From the base of the inferior orbital fssure, the fracture line extends in two directions: backwards across the pterygomaxillary fssure to fracture the roots of the pterygoid laminae and laterally across the lateral wall of the orbit separating the zygomatic bone from the frontal bone. In this way the entire middle third of the facial skeleton gets separated from the cranial base (Fig. 55.6a–c).

Le Fort classifcation does not take into consideration:

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**Fig. 55.5** (**a**, **b**) Le Fort II fracture lines. (**c**) CT of Le Fort II fracture showing the midface segment impacted (red arrows). (**d**) Clinical image of case in **c**, showing the impacted area right side Le Fort II (yellow arrow)

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**Fig. 55.6** (**a**, **b**) Le Fort III fracture. (**c**) CT of Le Fort III fracture (the fracture lines shown with red arrows)

### **55.2.2 Killey's Classifcation (1965)** [2] (Table 55.2)

**Table 55.2** Killey's classifcation

### **55.2.3 Rowe and Williams's Classifcation (1985)** [2] (Table 55.3)

#### **Addenda**

#### **55.2.4 Marciani (1993: Modifcation of Le Fort Fractures)** [1]

Fractures involving the cranial base and other midface fracture confgurations, including severely comminuted segments of the facial skeleton, were not classifable by the

**Table 55.3** Rowe and Williams's classifcation

traditional Le Fort scheme. Hence Marciani proposed a more precise system of describing fracture patterns to defne the fracture confguration, establish an accurate diagnosis and to determine potential surgical approaches (Table 55.4).

### **55.2.5 Palatal Fractures Classifcation: Hendrickson's Classifcation (1998)** [7] (Figs. 55.7, 55.8, and 55.9; Table 55.5)

**Table 55.4** Marciani's modifcation of Le Fort fracture classifcation

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**Fig. 55.7** Hendrickson's classifcation of palatal fractures. (**a**) Type Ia, (**b**) Type Ib, (**c**) Type II, (**d**) Type III ,(**e**) Type IV, (**f**) Type V, (**g**) Type VI

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**Fig. 55.8** (**a**) CT of Hendrickson's type C fracture. (**b**) Clinical image of case of **a**, showing the midline diastema

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**Fig. 55.9** CT of midline palatal fracture with splayed segments, note the posterior displaced fragment, temporary bridle wire has been placed between upper central incisors

#### **55.3 Clinical Features** (Box 55.1)

#### **55.3.1 Le Fort I Fractures**

Gross facial swelling or facial disfgurement is generally not a feature of Le Fort I fractures, but oedema around the upper lip may occur. Soft tissue injury along the upper lip along with tearing of gingivae may occur due to the causative impact. There can be mobility of the upper dentoalveolus when digital pressure is applied. Mobility of the maxilla at the Le Fort I level must be differentiated from extended maxillary dentoalveolar fracture. Malocclusion may occur if the fracture is displaced or impacted. Dorsal and caudal pull of the medial pterygoid muscles can contribute to the posterior displacement of the maxilla and the resultant anterior open bite (Fig. 55.10a, b). Bilateral epistaxis is rare although emphysema may occur if the patient blows his nose. Ecchymosis in the upper buccal sulcus is a frequent fnding. Percussion of the maxillary teeth produces a dull cracked cup sound. In case of inferiorly displaced Le Fort I fractures, the patient may have to keep the mouth open to accommodate the increased vertical dimension. Due to the extreme downward displacement of the maxilla, the nasal base is lost, leading to stretching of the soft tissues of that area, which makes it possible to see directly into the nares.

The posteriorly impacted Le Fort I fracture may result in an anterior open bite and in these cases the maxilla may be immobile. Usually the impacted maxilla can be mobilized by grasping the maxillary teeth and applying a frm anterior pull. A grate may be felt due to the movement between the fractured segments. In posteriorly impacted fractures, there may be damage to the cusps of maxillary teeth usually in the premolar region, caused by the upward impact of the mandibular teeth at the time of the trauma. The complete Le Fort I fracture may be associated with a split along the median palatal suture. Sometimes more than one fracture line may be present in the palate, so that either one or both fragments may be mobile (Fig. 55.11a–c).

#### **55.3.2 Le Fort II Fractures**

Marked facial disfgurement resulting from circumorbital ecchymosis and gross oedema can be a feature of Le Fort II fractures. Frequently the patient will not be able to open

**Table 55.5** Hendrickson's classifcation: of Palate fractures

#### **Box 55.1 Clinical features of Le Fort fractures**

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**Fig. 55.10** (**a**, **b**) A posteriorly telescoped Le Fort I fracture maxilla clinically manifesting as anterior open bite

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**Fig. 55.11** CT images (**a**, **b**) showing a right zygomatic complex fracture associated with a Hendrickson's type B fracture where the right posterior alveolar and palatal segment was displaced palatally and extruded, causing the occlusal discrepancy (crossbite) as seen in **c**

his eyelids to allow an ocular examination. Subconjunctival haemorrhage may be present, the posterior limit of which cannot be identifed. Bilateral peri-orbital oedema and circumorbital ecchymosis (described as circumorbital as it follows the shape of the orbicularis oculi muscle) are described as racoon eyes or panda facies. There can be severe oedema of the face which is sometimes described as moon facies. Enophthalmos in case of orbital foor fractures may go undetected due to oedema. Considerable lengthening of face with posterior gagging of teeth can also occur. Bilateral epistaxis is common, and CSF leak may be present. The loss of maxillary prominence may result in a dish face appearance. If the fracture line passes through the infraorbital canal there can be associated paresthesia in the infraorbital nerve region. While clinically mobilizing the maxilla in a Le Fort II fracture, transmitted mobility may be felt at the infraorbital rim and the frontonasal suture. Figure 55.12 shows a CT image where Le Fort II and III lines are seen

#### **55.3.3 Le Fort III Fractures** (Also see Fig. 49.5)

This fracture is clinically similar to the Le Fort II fracture but can demonstrate a more serious condition. Bilateral ecchy-

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**Fig. 55.12** CT image showing Le Fort I and II fractures. Note that maxilla is rotated to the right side with canting on the left side.

mosis with circumorbital oedema may close the eyes completely. As in Le Fort II, the posterior limit of the subconjunctival haemorrhage cannot be seen. The lengthening of the face occurs due to the loss of bony fxation to the base of the skull. The fattening of the face from the disrupted zygomatic bones is usually masked by the gross oedema. The fracture passes above the Whitnall's tubercle and so the support by Lockwoods, suspensory ligament is lost. This results in hooding of upper eyelid which becomes obvious when the oedema subsides. Gagging of occlusion and shift of the maxillary midline may occur. Gross posterior displacement of the maxilla can result in the soft palate touching the posterior part of the tongue causing airway and speech impairment. As with other maxillary fractures, percussion of teeth might produce a cracked cup sound. .

The clinical differentiation between Le Fort II and Le Fort III fractures can be assessed by palpating for step deformity in the infraorbital rim in the former.

#### **55.3.4 Unusual Fracture Patterns**

The Le Fort fractures may manifest without the classic fracture patterns as described above. An unilateral fracture at Le Fort I level may occur (identifed through imaging) which warrants no intervention unless accompanied by a palatal fracture causing occlusal derangement and/or mobility. Such a unilateral fracture pattern can cause unilateral gagging causing open bite on the contralateral side

The clinician must be aware of the two types of Le Fort I fractures, the mobile and impacted variants; lack of mobility should not be presumed as absence of fracture.

#### **55.4 Radiographic Examination**

It is diffcult to diagnose fractures of the middle third of the face with plain flms and CT scans have now largely replaced radiographs.

The commonly used radiographs for identifying maxillary fractures are occipitomental view (OMV) 10° and 30° and paranasal sinus view 37° (PNS -Waters view).

While assessing maxillary fractures with these radiographs, Mcgregor-Campbell and Trapnell's lines and Dolan's lines (elephant of Rogers) may be kept in mind [8].

#### **McGregor-Campbell's lines**:

These lines were described by McGregor and Campbell for ease of searching on an occipitomental view 10-degree frontal projection.

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**Fig. 55.13** McGregor-Campbell and Trapnell's lines

The **four S's described by Delbalso, Hall and Margarone** [8]

In PNS view, the following four features are to be verifed/compared with the unaffected side

#### **Dolan's Lines** [8] (Fig. 55.14)

**Dolan's lines** are the collective name given to three lines described by Dolan and Jacoby that aid in evaluating for maxillofacial fractures on an occipitomental skull radiograph. They are usually used as an adjunct to McGregor-Campbell lines.

• **Orbital line (line 1)** traces the inner margins of the lateral, inferior and medial orbital walls and the nasal arch.

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 55.14** Dolan's lines (also see Fig. 56.22)

#### **Elephant of Rogers** [8]

Lee Rogers pointed out that the second and third lines of Dolan give the outline of the head of an elephant.

#### **55.4.1 CT Scans**

CT scans are now the gold standard for a defnitive diagnosis in fractures of the maxilla. A CT scan in all three planes (axial, sagittal and coronal) along with a 3D reconstruction will aid the surgeon in accurate assessment of fracture patterns and also will aid in preoperative planning. The surgeon must never rely on the 3D CT alone but should correlate the images with those obtained in axial sagittal and coronal planes, as there could be reconstruction-related errors which appear as fracture lines or bone defects. CT scan-based fracture patterns may be classifed as low, middle or high energy, defned solely by the pattern of segmentation and displacement in the CT scan [9].

#### **55.5 Treatment of Maxillary fractures**

The primary aim of treatment of maxillary fractures is to reestablish the dental occlusion and masticatory effciency. The contribution of the maxilla to the projection and contour of the midface has also to be considered in the management of maxillary fractures and requires a clear understanding of the facial buttress system, subunit anatomy and interrelationships of the various bones [10]. This aesthetic aspect is often compromised by associated injuries of the zygomatic complex, nose and orbits.

The basic principles of the treatment of maxillary fractures are:

Factors that infuence improved treatment outcome in maxillary fractures are:

#### **55.5.1 General Considerations in Treatment of Maxillary Fractures**

Proper reduction of maxillary fractures is the key to achieving good dental occlusion and needs proper clinical examination of the fracture pattern after all the accessible fracture sites are exposed. A repeat study of the CT scans (axial, coronal and 3D) and correlation with the exposed maxilla will aid the surgeon in planning adequate reduction and rigid fxation. It should be kept in mind that the fractured maxilla is usually displaced backwards and downwards and hence the reduction should in the forward and upward direction. To obtain reproducibly good results, even with the most extensive facial dislocations, the surgeon should restore the facial architecture at the Le Fort I Level [12]. In rare occasions, lateral en bloc displacement of the maxilla is seen, and this requires transverse reduction to achieve the correct dental occlusion. A depressed zygomatic fracture can physically prevent reduction of the maxilla. Hence the fractured zygomatic bone should be reduced prior to manipulating the maxilla.

The most useful instruments for reduction of the maxilla are the Rowe's disimpaction forceps. Even in cases where the fractured maxilla appears to be minimally displaced, it is prudent to mobilize the bone with the disimpaction forceps so as to overcome any bony interferences and thus freeing the maxilla completely. When using this paired forceps, care should be taken to avoid injury to the anterior teeth and also to the palatal mucosa. Mobile, extruded and proclined anterior teeth are at particular risk, and an assistant should closely observe the anterior teeth, while the surgeon is manipulating the fractured maxilla. It would also be advisable to obtain informed consent regarding mobility or loss of these teeth. Trauma to the nasal foor is inevitable when mobilizing the maxilla using the reducing forceps, and some nasal bleeding is usually observed, but this rarely requires a nasal pack.

frmed by:

Problems arise when the patient has few or no teeth and when there is gross comminution of maxilla. In these situations the surgeon has to make do with whatever landmarks are available, and in such cases compromised functional and cosmetic results are not uncommon.

Direct manipulation at the fracture lines is sometimes required especially when the fractured maxilla is telescoped into the superior normal bone. Care must be taken to prevent additional fractures at the bony margins during direct manipulation as this would make fxation more demanding. Using tie wires at the zygomatic buttresses, around the second maxillary premolars/frst molars bilaterally and through anterior nasal spine is often useful to physically disimpact and pull the maxilla forwards and upwards thus ensuring good reduction.

When the maxilla is fractured in multiple levels (e.g. Le Fort I and III levels), reduction using the disimpaction forceps alone may not be adequate. The dental occlusion can be achieved, but the midface projection may be compromised. Here also a combination of reduction with disimpaction forceps, direct manipulation at the fracture site and the use of the above mentioned tie wires is often indicated.

Once adequate reduction of the fractured maxilla is obtained, it is mandatory that rigid maxillomandibular fxation (MMF) is applied. In almost all cases, well-adapted maxillary and mandibular arch bars are required as this ensures multiple points for the MMF. Failure to obtain rigid MMF or manually maintaining the dental occlusion during fxation can result in post-operative occlusal discrepancies. If surgical reduction and fxation of the maxilla has to be delayed, elastic traction will be helpful in obtaining a functional occlusion. The use of MMF screws defnitely saves operating time but can be problematic if elastic traction is required later.

If the mandibular condylar fracture exists, this should be reduced and fxed prior to the MMF. Failure to do so may result in an open bite due to loss of posterior mandibular height.

#### **55.5.2 Suspension Wiring**

Internal wire suspension involves sandwiching the fractured portion of the maxilla between the mandible and the superior part of the facial skeleton/skull that is not fractured. The use of internal suspension wires is more or less obsolete unless there is severe comminution which precludes rigid internal fxation. Suspension wiring may also be the surgeon's choice

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**Fig. 55.15** Various types of suspension wiring employed for midface fractures

when there is presence of severe infection at the site of surgery (Fig. 55.15).

#### **55.5.3 Rigid Internal Fixation**

Although many wiring techniques were practised in the past, rigid internal fxation with titanium bone plates and screws of suffcient rigidity is now the standard of care. For internal fxation of the maxilla, titanium bone plates and screws of suffcient rigidity are used. For providing rigidity, screws with an outer diameter of 1.5 mm is commonly used.

#### **55.5.4 Approaches to the Maxilla**

When treating a very high Le Fort I fracture and in Le Fort II and III fractures, it may be necessary to use one or more of the following incisions, which are described in chapter 56 and 57 of this book:

#### **<IP_ADDRESS> Maxillary Vestibular Approach**

The maxilla can be approached through a variety of incisions, the most common being the maxillary vestibular approach. In addition to providing access to the lower part of the entire midfacial skeleton, this approach results in a hidden intraoral scar. This approach may result in disruption of the attachments of the facial muscles of the nasolabial region; hence careful repositioning during closure is recommended to avoid unaesthetic changes to the face. The muscles of importance are the nasalis group, the levator labii superioris alaeque nasi, the levator labii superioris, the levator anguli oris and the orbicularis oris. The vestibular incision and subsequent dissection causes stripping of origin/insertion of most muscles originating in the maxilla. These muscles tend to get reattached in a shortened manner due to the action of the zygomaticus muscle. Deepening of the alar groove and splaying of the alar bases, nostrils and nasal tip may occur following lateral displacement of the nasal modiolus. Soft tissue fullness loss in the naso-alveolar region may result in thinning and retraction of upper lip, reduced vermillion exposure and a obtuse nasolabial angle. Detachment of the levators of the upper lip may cause down turning of the corner of the mouth (Fig. 55.16).

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**Fig. 55.16** Maxillary vestibular incision with adequate gingival cuff. Yellow arrows denoted the Le Fort I fracture lines

#### **Clinical Tips for approaching the Le Fort fracture via maxillary vestibular incision**

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**Fig. 55.17** A clinical situation where the separate vestibular maxillary incisions were given to approach anterior maxilla, due to deep through and through lip laceration upper lip extending down to the frenum region

Early intervention (7–10 days) with open reduction and fixation is the treatment of choice for maxillary Le Fort I fractures. Restoration of normal facial contour and occlusion is considered as optimal outcome of treatment. Bone reconstruction should be completed as early as possible to minimize shrinkage, stiffness and scarring of soft tissues [12].

In complex panfacial fracture management, many authors have stressed the importance of managing the Le-Fort fracture while reconstituting the facial architecture [13, 14].

#### **55.5.5 Fixation of Le Fort I #**

Adequate fxation of the fractured bone depends on two factors, namely, the rigidity of the plate and the friction between the bone fragments (buttressing of the bony segments). When a gap exists between the bone ends, the latter factor is missing. In these cases, non/fbrous union can result if the masticatory forces are greater than the rigidity of the plate. As a general principle, the paranasal and zygomatic buttresses must be rigidly fxed. The plates should be well adapted especially where the bone stock is poor. At least two screws must be present on either side of the fracture and more the number of screws, better the, load sharing, between the plate and the subjacent bone. Opposed to this is when there is no bone buttressing and the plate has to be 'load bearing'. Also a minimum of two threads of the screw should engage the cortical bone. This may be a problem in thin areas as the anterior wall of the maxillary sinus and the alveolus where roots are present. In the edentulous maxilla, the bone quality is often compromised, and the lower end of the plate may need to be placed on the alveolus. This may necessitate removal of the plate prior to prosthodontic rehabilitation.

Obtaining rigid fxation becomes diffcult when the buttresses are comminuted. If only one buttress is amenable for plating the reduction at this fracture interface along with reconstitution of the occlusion must be used as the template for repositioning the maxilla. When all the buttresses are comminuted, the surgeon has to "eye ball" the maxilla into the reduced position. In these situations, a long-span plate extending from the body of the zygomatic bone to the relatively thick bone in the area of the anterior nasal spine with or without a bone graft is often the only option available to maintain the vertical position of the foating maxilla. It has been stated that the lip-tooth relationship is helpful in deciding the position of the reduced maxilla, but in practice this is of limited use.

Loss of bone at the buttresses may require the use of primary bone grafts [10]. Though it has been suggested that a In essence the decision to graft will depend on:

gap of more than 5 mm at the buttresses requires a graft, rigid plate fxation followed by MMF is often enough to ensure bony healing.

Primary bone grafting can be done using iliac bone (Fig. 55.26), split calvarium or split ribs. The calvarium is the preferred source because of the following reasons:

The disadvantage is that these grafts are brittle and cannot be contoured. The bone graft has to be mortised to ft the defect and must be fxed rigidly to the plate or lag screwed.

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**Fig. 55.18** A clinical situation where the defect in the anterior wall maxilla due to comminution of the wall was partly covered by fxing the free segment (red arrow). The long-span plate from the buttress to the anterior maxilla region can also be seen

Incisions for open reduction can be placed from frst molar to frst molar regions through a vestibular approach for

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**Fig. 55.19** The surgeon stands behind the patient and applies the disimpaction force, while the head is stabilized by the assistant surgeon

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wide exposure of the fracture sites. Rowe's disimpaction forceps and/or Hayton-Williams forceps can be used for mobilizing and reducing the fracture into position. The impacted type of Le Fort I fracture manipulation has to be done by grasping the maxilla with two pairs of Rowe's disimpaction forceps. Osteotomizing the maxilla should be considered if there is signifcant interval between the time of trauma and surgery. Whenever possible a passive reduction of the maxilla with condyles frmly seated in their correct position should be ensured to avoid post-operative anterior open bite (Figs. 55.19, 55.20, and 55.21).

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 55.21** Use of Hayton-Williams forceps

Use of Rowe's disimpaction forceps Rowe's disimpaction forceps are available as paired (right and left) instruments Each instrument has two blades, one for engaging the palate (to be padded before use to avoid injury to the palatal mucosa) and one to be inserted through the nostril The instrument has an outward bend at the handle which aids in the use of two forceps simultaneously After engaging the forceps, the maxilla has to be moved in all planes to ensure adequate mobilisation

After reduction the maxilla should be placed into maxillomandibular fxation. The fxation of the fracture sites (fourpoint fxation) is done at the vertical pillars of nasomaxillary and zygomaticomaxillary (lateral piriform rim and zygomatic buttress regions) for which the preferred plates and screws used are 1.5-mm thickness with 6-mm long screws. In the zygomatic buttress regions, 2.0-mm profle plates also can be used. The mini-plates are fxed as close as possible to the lateral pyriform rim as the bone is thickest there. Usually stabilization of the fracture is achievable even if any three of the four buttresses are fxed. Apparently, gross communition at one of the buttress regions will not cause a signifcant risk of inadequate stabilization. The associated anterior wall of the maxillary sinuses is generally not fxed due to the relative thin nature of bone in this region. The larger free bone fragments can be repositioned and immobilized using wires or be used for reconstruction of orbital foor defects. The circumvestibular incision is closed with running resorbable sutures after ensuring that the midline of upper lip coincides with the facial midline (Fig. 55.22).

Maxillomandibular fxation of up to 6 weeks also can be considered as alternative for treatment though the results may be less satisfactory with added morbidity to the recovering patient. The readers are advised to refer chapter 50 to read about closed reduction / wiring and intermaxillary fxation techniques.

#### **55.5.6 Fixation of Le Fort II Fractures**

The pyramidal fracture has the apex of the fracture located at the nasofrontal suture region or at the midnasal bone level. The Le Fort II fractures are ideally fxed at the frontonasal suture region, bilateral infraorbital rims and also both zygomaticomaxillary buttresses. However in majority of the clinical situations fxation at the infra orbital rims and the zygomatic buttress regions gives reasonably good results. Most Nasal bone fractures associated with Le Fort II fractures can be adequately managed by closed reduction techniques. This may require the anaesthetist to change nasal intubation to oral intubation. A submental intubation may also be considered at the beginning of the procedure. If the nasofrontal segment is unstable, fxation of the area can be done through various approaches (existing laceration, Gull wing approach, etc.). A maxillary vestibular incision can frequently provide access to infraorbital fracture alignment and fxation in some cases. The lower eyelid approaches are not always mandatory

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**Fig. 55.22** The zygomatic buttress and paranasal buttress fxed in a classical Le Fort I fracture maxilla

©Association of Oral and Maxillofacial Surgeons of India

**Fig. 55.23** Le Fort II fracture lines at the infraorbital rim area may have to be accessed directly, if required, especially with associated zygomatic/orbit fractures. In this case the lateral orbital rim reconstruction is done via combined access from left sub ciliary incision and left supra tarsal incision

for fxation unless simultaneous exploration and reconstruction of orbital foors are also planned.

In Le Fort II fractures that are complicated by an associated palatal fracture, surgical splints may be helpful in obtaining adequate reduction. Placement of maxilla mandibular fxation will ensure accurate alignment of midface structures (Fig. 55.23).

#### **55.5.7 Fixation of Le Fort III Fractures**

These are complex fractures which rarely occur in isolation and results in a dysjunction of the facial skeleton from the base of the cranium. The ideal repair time should be within 10–14 days following the injury but may get delayed due to neurosurgical issues and other comorbidities.

Incision design for Le Fort III fractures should facilitate adequate access for reduction as well as fxation of the nasofrontal, frontozygomatc and in some cases the zygomatic arches. Using existing lacerations for access avoids need of a coronal incision, as this allows for complete visualization, reduction and fxation of the frontal area and zygomatic arches. A lateral brow or upper blepharoplasty (supra-tarsal fold) incision may be used to approach the lateral orbital rims. Also in such cases, a thicker plate (2.0) placement at the lateral orbital rim may be benefcial. A coronal approach may have to be considered if bilateral fronto-zygomatic and nasofrontal fracture fxation is planned.

The occlusion is a reliable indicator of adequate reduction in cases where direct visualization of the fractured segment is not possible.

In Le Fort III fractures associated with other fractures (open facial/condyle fractures), various surgical sequences can be followed, which is discussed in chapter 60 on Panfacial fractures.

Rarely, Le Fort fractures may present without mobility, but show occlusal disturbances like crossbite, open bite or loss of intercuspation. These can be managed by using traction elastics but at times warrant mobilization and subsequent rigid fxation [15].

**Fig. 55.24** Infraorbital plate exposure

©Association of Oral and Maxillofacial Surgeons of India

#### **55.6 Complications of Le Fort Fractures**  (Table 55.6)

**Table 55.6** Complications of Le Fort fractures

Unlike many other areas of the midface, the palatal bone is relatively thick, and hence palatal fractures are not common. A palatal split makes reduction and fxation of maxillary fractures more diffcult mainly due to the transverse instability which can cause medial collapse or outward splaying of the maxilla. The use of the Hayton-Williams forceps along with the disimpaction forceps will control outward splaying of the maxilla but at the risk of medially displacement of the dentate segment of the maxilla. Moreover, the use of all the three forceps effectively requires some amount of surgical expertise.

Moss et al. [16] have proposed a classifcation for palatal fractures. There is no consensus regarding the management of palatal fractures, but various options have been suggested.

Transpalatal wires are simple to apply and do not have the problems of soft tissue dehiscence and infection seen in the more invasive methods [17]. However, the reduction of the palatal fracture cannot be ensured, and the wires can be cumbersome to the patient as it affects speech and swallowing. If the palatal wires are passed through an infant feeding tube or a small gauge urinary catheter, injury to the dorsum of the tongue can be minimized. It is also noticed that palatal wires tend to become slack after a few days, and then their value in reduction and fxation of the fracture is questionable. Moreover, these wires are not an option in the edentulous maxilla.

Direct exposure and plate fxation are surgically demanding, but the fracture can be reduced and fxed under direct vision. Ceinfuegos et al. have described the technique of fxing the plate over the palatal mucosa, but this plate would have to be removed at a later date [18]. An alternative would be to use a resorbable plate and screws.

Ma et al. has documented the use of self-drilling screws on either side of the palatal fracture with wires to fx the fracture [19].

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**Fig. 55.25** Oronasal fstula in a patient who had sustained palate fracture

Palatal fractures of the sagittal or parasagittal variety can be stabilized by placing a mini-plate across the fracture line on the labial side. Occasionally the prominence of the anterior nasal spine has to be reduced to facilitate mini-plate placement.

The transpalatal reduction should be supplemented by fxation at the zygomaticomaxillary and nasomaxillary buttresses and the use of an arch bar [20].

Palatal fractures accompanied by soft tissue lacerations often cause a serious challenge to the surgeon regarding its management. The healing of the palatal soft tissue laceration is dependent on the exact reduction of the palatal vault and stabilization. Overzealous attempts at closure of the laceration without accurate reduction may compromise wound healing. A tension-free closure of the palatal mucosa is imperative for wound healing. In some cases, the ensuing oronasal communication will have to addressed secondarily (Fig. 55.25).

#### **55.7.1 Surgical Splints**

Concomitant fractures of the palate present additional challenges to the treatment of Le Fort fractures. They complicate the re-establishment of proper width and height of the maxilla. Depending on the fracture type, patient comorbidities and associated injuries, either closed reduction and wiring or rigid fxation may have to be performed. Dental impressions can be obtained and occlusion assessed prior to surgery.

Fabrication of an acrylic splint may help in re-establishing the transverse width of the palate.

In cases of gross comminution with partial dentition, palatal splints are helpful. Splints are fabricated on casts on which model surgery has been performed. They are designed such that they cover the occlusal surfaces and heights of contour, and care should be taken as to not disturb the soft tissues. Holes placed in the occlusal surfaces in the splint aid in separately ligating it to the arch bar [21]. In case of edentulous patients, Gunning splints are usually used.

#### **55.8 Special Considerations**

#### **55.8.1 Maxillary Fractures in Geriatric Patients**

Advanced age and compromised medical ftness may increase the morbidity associated with surgical management of maxillary fractures. Loss of teeth leading to reduced alveolar bone, reduced vascularity of maxilla and greater pneumatisation of the maxillary sinuses, should be taken into consideration before attempting an open reduction and internal fxation. Modifcation of existing dentures or Gunning splints are viable options in this population.

#### **55.8.2 Maxillary Fractures in Children**

The long-term effects of maxillary fractures on skeletal growth are inconclusive at present. Mobile-displaced maxillary fractures in paediatric patients warrant open reduction and fxation. Removal of hardware in growing patients may be considered to overcome complications of plate translocation (shifting of the position of metal plate due to appositional bone growth), extrusion and possible growth restriction. Resorbable plating systems may offer a solution to overcome such complications.

#### **55.8.3 Haemorrhage Control in Maxillary Fractures**

Branches of the internal maxillary artery provide much of the vascular supply to the midface. In patients with epistaxis or bleeding, ligation of this artery may be necessary. Due to anastomoses from other branches of the internal and external carotid circulation, vascular insuffciency of the maxilla is unlikely even after ligature of maxillary artery. In certain conditions of intractable bleeding not amenable to control by normal packing methods, embolization methods have been used effectively.

#### **55.9 Recent Advances**

The use of pre-surgical stereolithographic models helps in plate contouring and precise positioning of fractured segments. Facilitation of the intraoperative three-dimensional bone positioning is possible due to development of sophisticated computed tomography, computer graphics hardware and image processing software capable of reproducing anatomic templates. Automated preoperative "mirroring" of the contralateral uninjured orbito-zygomaticomaxillary complex to the affected side can result in improved results. The use of intraoperative surgical navigation systems along with mobile cone beam CT improves intraoperative quality control. Endoscopic midface fracture management facilitates smaller incisions, reduced recovery time and minimal post-operative complications. These developments are discussed in the Chap. 41.

#### **55.10 Conclusion**

Maxillary fractures can sometimes occur with signifcant cosmetic and functional implications. Accurate diagnosis and early surgical intervention is essential for successful management of these fractures. The surgeon should keep in mind that the surgical management of maxillary fractures primarily aims at restoration of the vertical and horizontal support buttresses.

**55.11 Case Scenario - A case of maxillary Lefort I fracture where bone grafting was done** (Fig. 55.26a–g)

**Fig. 55.26** Case scenario (fracture maxilla fxation done with grafting in the anterior maxillary sinus wall). (**a**) 43-year-old man sustained bone deep laceration on face causing Le Fort I like fracture pattern. In the emergency department, oral intubation was required due to heavy bleeding. Nasal packs were placed, and the wound was primarily tacked as adjunct measures. (**b**) MIP view of CT scan showing the maxillary segment displaced downwards will loss of anterior maxillary wall height. (**c**) Intraoperative view showing the severely displaced maxillary segment. Access for the fxation was via the existing laceration. A maxillary vestibular incision was not placed. (**d**) The paranasal buttress was maintained, but loss of bone structure seen at the anterior wall sinus region. To attain primary healing and to avoid malunion, iliac crest bone grafts were procured and split into separate pieces. (**e**) (Right side maxilla) the green arrows point to the graft segments. Initially the graft segment was fxed with wire (blue arrow) and was attached to the titanium plate with screws (the plate was spanned from the zygomatic body to the displaced main fracture segment). (**f**) Similar technique done on left side. (**g**) Immediate post-operative view after closure of the laceration. Patient had arch bars fxed and underwent a period of intermaxillary fxation to help in primary union. Post-operative review showed good stability for maxilla and the occlusion was maintained

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**Fig. 55.26** (continued)

#### **References**

patterns, and treatment with rigid internal fxation. Plast Reconstr Surg. 1998;101(2):319–32.

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## **Fractures of the Zygomaticomaxillary Complex**

Elavenil Panneerselvam, Poornima Ravi, and B. Sasikala

#### **56.1 Introduction**

The zygomaticomaxillary complex (ZMC) refers to the skeletal unit [1] formed by the zygomatic bone and maxilla (Fig. 56.1). These two bones are referred to as a complex, because of the structural and functional relationship between them; they articulate with each other over a wider area, and any traumatic impact on one bone generally infuences the other. This duo complex also constitutes a major part of the orbit, spanning the infra-orbital rim, lateral wall, and foor. Hence the ZMC is also termed *orbitozygomaticomaxillary complex* [2]. Because of its multiple articulations, various names are commonly used to describe ZMC fractures such as "tripod, tetrapod, or pentapod" [3, 4] fractures.

Fractures of the ZMC commonly result in severe cosmetic and functional defcits because of the prominent anatomical position of the zygoma and its proximity to adjacent vital structures such as the globe. Precise reduction and fxation of these fractures is challenging due to their complex anatomic form, multiple articulations, and deformation in multiple planes. The scope of this chapter encompasses the biodynamics of ZMC fractures, clinical implications, and guidelines for successful management.

**Disclosure:** Authors have no fnancial conficts to disclose.

E. Panneerselvam (\*)

Department of Oral and Maxillofacial Surgery,

SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India

Department of Orbit and Oculoplasty, Aravind Eye Hospital, Chennai, Tamil Nadu, India

P. Ravi · B. Sasikala

#### **56.2 Surgical Anatomy**

The term zygoma denotes a "yoke or bar," in Greek. Quite aptly, the zygoma extends as a prominent, sturdy bar across the face, contributing to its transverse width and anteroposterior projection. The clinical signifcance of this bony complex is attributed to its role in defning facial esthetics and globe function.

#### **56.2.1 Articulations**

The zygoma articulates with four bones [5]; superiorly frontal, medially maxilla, laterally temporal bone, and posteriorly sphenoid, through fve processes [4] (Fig. 56.1), namely, the zygomaticotemporal (ZT), zygomaticomaxillary (ZM), infra-orbital (IOR), fronto-zygomatic (FZ), and sphenozygomatic (SZ) or zygomaticosphenoid (ZS). These processes are clinically signifcant in establishing the three-dimensional structural integrity of the upper lateral face.

Fractures of the ZMC have been traditionally called the "tripod or trimalar fractures" because it involved separation at the three processes of the zygoma—the FZ, IOR, and the ZM processes (Fig. 56.2a). The terminology was later modifed to "quadripod or quadramalar fracture" to include separation at the fourth point of articulation, the ZT process (Fig. 56.2b). However, the importance of SZ articulation along the lateral wall of the orbit has been recognized lately, and, hence, ZMC fracture is currently called a pentapod fracture (Fig. 56.2c), to emphasize the necessity of restoring the fve articulations during fracture management.

#### **56.2.2 Relations**

• Zygoma and orbit: ZMC forms the lateral and inferior part of the orbit, protecting as well as supporting the globe and associated soft tissues. The Whitnall's tubercle present on the zygoma (inferior to the FZ suture) provides

**Electronic Supplementary Material** The online version of this chapter (https://doi.org/10.1007/978-981-15-1346-6\_56) contains supplementary material, which is available to authorized users.

Department of Oral and Maxillofacial Surgery, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India

<sup>©</sup> The Association of Oral and Maxillofacial Surgeons of India 2021 1151

K. Bonanthaya et al. (eds.), *Oral and Maxillofacial Surgery for the Clinician*, https://doi.org/10.1007/978-981-15-1346-6\_56