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The authors first reported a 42-year-old female patient with carotid-cavernous fistula (CCF) that occurred after maxillary fractures. She developed unilateral exophthalmos, bulbar conjunctival hyperemia, and complained of tinnitus after the operation, and was diagnosed as internal CCF through computerized tomography and Digital Substraction Angiography. After the diagnosis, the internal carotid artery was embolized with a coil under general anesthesia. The treatment effect was satisfactory but the vision of the affected side was eventually lost due to the long course of congestion. Although patients with maxillary fractures can safely undergo surgery, some unexpected complications may occur in trauma, such as internal CCF. Therefore, each patient must be subjected to accurate posttraumatic examinations and inquiries to discover possible clinical complications. Patients with exophthalmos, tinnitus, and conjunctival hyperemia may be accompanied by internal CCF. Once diagnosed, appropriate treatment such as embolization should be carried out in time to eliminate further serious sequelae., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objective: To develop a reliable and accurate method to quantify the symmetry of the zygomaticomaxillary complex (ZMC)., Methods: Virtual three-dimensional models were created from 53 computed-tomography scans: 15 healthy cases without maxillofacial disorders and 38 patients with ZMC fractures requiring surgical treatment.Asymmetry of the ZMC was measured using a mirroring and surface-based matching technique that uses the anterior cranial fossa as reference to determine the symmetrical position of the ZMC. The measure for ZMC asymmetry was defined as mean surface distance (MSD) between the ZMC-surface and the symmetrical position.Reliability of the method was tested in the 15 healthy cases. Inter-and intra-observer correlation coefficients (Ce) and variabilities were assessed. Accuracy was assessed by comparing ZMC asymmetry between healthy and ZMC fracture cases, and by assessing correlation of ZMC fracture severity with ZMC asymmetry., Results: The average MSD of the 15 healthy cases was 1.40 ± 0.54 mm and the average MSD of the 38 ZMC fracture cases was 2.69 ± 0.95 mm ( P < 0.01). Zygomaticomaxillary complex asymmetry correlated with fracture severity ( P = 0.01). Intra-rater CC was 0.97 with an intra-rater variability of 0.09 ± 0.11 mm. Inter-rater Ce was 0.95 with an inter-rater variability of 0.12 ± 0.13 mm., Conclusions: Our method is reliable and accurate for quantitative three-dimensional analysis of ZMC-symmetry. It takes into account asymmetry caused by the shape of the ZMC as well as asymmetry caused by the position of the ZMC., Clinical Relevance: This method is useful for the evaluation of ZMC asymmetry associated with congenital and acquired disorders of craniofacial skeleton, for surgical planning and for evaluation of postoperative results., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Traumatic fracture of the premaxilla is a rare event, and there is minimal data regarding the presentation, management, and outcome of these patients. This article reports 2 patients with bilateral cleft lip and palate who each presented with traumatic fracture and displacement of the premaxilla. To authors' knowledge, the occurrence and management of a traumatic fracture and displacement of the premaxilla in a patient with cleft lip and palate has not been reported.

The aim of this study was to prospectively evaluate the use of a simultaneous Le Fort I osteotomy for completion of nonreducible Le Fort fractures. We analyzed the clinical and radiological data of 44 patients with Le Fort fractures, 9 of whom presented with a nonreducible type. Seven patients with an incomplete Le Fort I fracture had a contralateral Le Fort I osteotomy, and 2 patients with an incomplete Le Fort III fracture had a true bilateral Le Fort I-type osteotomy. We recorded age and sex, mechanism of injury, level of Le Fort fracture, concomitant mandibular fractures, concomitant maxillomandibular fixation (MMF) and its duration, surgical approach, status of healing, and complications. Follow-ups were at 1 week and 1, 3, 6, and 12 months.All patients recovered their normal pretrauma occlusion without the need for postoperative elastic guidance, except for 1 patient who required light class III traction elastics for 3 weeks to achieve the correct occlusion. None of the patients presented with intraoperative or postoperative complications.The present study has demonstrated that completion of nonreducible Le Fort fractures by Le Fort I osteotomy results in a high rate of success.

Purpose: With the increasing number of patients with facial trauma, orbital-zygomatic-maxillary (OZM) fracture combined with orbital wall fracture has become common. Such fractures always induce symptoms of enophthalmos, hypoglobus, and diplopia. This study was aimed to investigate the surgical technique and operative effect of late reconstruction of OZM fractures combined with orbital wall fractures., Methods: A retrospective analysis of the 46 patients (46 orbits) who were treated from January 2005 to December 2008 was performed. All cases had reconstruction of OZM fractures combined with orbital wall fractures at an average of 5.3 months after injury. Various incisions were selected. According to the computer-aided design/computer-aided manufacturing design, the osteotomy, reposition, and 4-point fixation of the fractured bones were individualized performed. Titanium mesh was preshaped according to the mirroring technology and inserted into the orbit with or without high-density polyethylene (HDPE) implant material to repair the orbital wall defect and the enlarged orbital volume. All patients were followed up 1 year after surgery., Results: Forty-two of the 46 patients who had enophthalmos were completely corrected. Forty patients who had hypoglobus were corrected postoperatively. Of the 43 cases with diplopia, 20 cases were resolved., Conclusions: Late reconstruction by osteotomy and 4-point fixation could recover midface cosmesis, correct the enophthalmos, and improve the diplopia of OZM fractures combined with orbital wall fractures. The computer-aided design/computer-aided manufacturing system and mirroring technology can help improve the outcome of surgery when repairing such fractures.

Retrobulbar hematoma is a rare condition but represents a diagnostic and therapeutic emergency. It occurs in between 0.3% and 3.5% of facial traumas and can be caused by direct or indirect injury of the orbit; they can be classified into intraorbital and subperiosteal hematoma. We describe 4 different cases of posttraumatic retrobulbar hematoma treated at the Unit of Maxillofacial Surgery of the Novara Major Hospital between January 2005 and December 2009, each different from the others for morphologic aspects, and we discuss its diagnosis and management. Surgery decompression of the orbit is recommended when visual deficit arises and when there is no response to pharmacologic therapy. Several techniques for orbital decompression have been proposed. The lateral canthotomy and/or the inferior cantholysis are the 2 techniques most practiced. Anterior-chamber paracentesis is effective, but it is rarely indicated for frequent complications such as cataract formation, herniation of the iris, infection, and trauma to the canal of Schlemm. Other procedures including transantral ethmoidectomy, transantral sphenoidectomy, and transfrontal craniotomy are described.

Many different materials are proposed for reconstruction of traumatic orbital floor defects. Donor-site morbidity of autologous transplants and infections or extrusions of nonresorbable implants lead to a widespread use of resorbable, alloplastic materials such as polydioxanone (PDS). The goal of this study was to evaluate the prevalence of orbital floor fracture-related problems after surgical treatment using PDS. Ophthalmologic and clinical examinations were performed at 194 patients before orbital floor reconstruction, 14 days and 6 months after surgery (approximate defect sizes: <1 cm², n=50; 1-2 cm², n=97; >2 cm², n=47). Clinical findings including the ocular motility, the sensibility of the infraorbital nerve, and the position of the globe were evaluated. For statistical analysis of categorical data, confidence intervals of percentages were determined. Linear relationships between 2 variables were assessed with Pearson correlation analysis. A reduced ocular motility was diagnosed in 60 patients (31%) before surgery; in 14 patients (7%), 2 weeks; and in 10 patients (5%), 6 months after surgery. Infraorbital hypesthesia was found in 120 patients (62%) before surgery; in 47 patients (24%), 2 weeks; and in 35 patients (18%), 6 months after surgery. An enophthalmos was present in 10 patients (5%) before surgery, and in 4 patients (2%), 6 months after surgery. Our data suggest that PDS is a suitable implant for orbital floor reconstruction with acceptable low rates of infraorbital hypesthesia, bulbus motility disturbances, and enophthalmos. Polydioxanone can also be used for orbital floor defects exceeding 2 cm².

A comprehensive study of adverse outcomes after pediatric facial fractures has not been published. This study aimed to determine the incidence and classify adverse outcomes after facial fractures in children while reporting our early results. A retrospective chart review was performed on facial fracture patients identified in the Craniofacial Trauma Database of the Children's Hospital of Pittsburgh and seen in follow-up from 2003 to 2007. An Adverse Outcome Classification Scheme was developed: type 1, outcomes resulting from the fracture; type 2, outcomes resulting from fracture treatment; and type 3, outcomes resulting from the interaction between the fracture, its treatment, and subsequent growth and development. Fisher exact or χ analyses were completed. A total of 177 pediatric facial fracture patients were identified with 13.3 months of average follow-up. Mean age was 9.8 years (range, 0.4-18.7 y). Of these patients, 41.8% underwent surgery and 57 patients (32.2%) had adverse outcomes (type 1, 14.1%; type 2, 11.3%; and type 3, 15.8%); 26.3% of these had multiple adverse outcomes. Isolated fractures resulted in fewer adverse outcomes and fewer multiple adverse outcomes compared with combined fractures (26.6% versus 45.3%, P = 0.015; 4% versus 18.9%, P = 0.002). Patients treated operatively exhibited more types 1, 2, and 3 and multiple adverse outcomes compared to those treated conservatively (P < 0.01). In our pediatric cohort, 32.2% of patients had an adverse outcome. With longer follow-up and growth and development studies, we will likely see an increase in the incidence of type 3 adverse outcomes. We recommend, whenever possible, conservative treatment of pediatric facial fractures.

This article describes a patient in whom significant oronasal bleeding developed after an injury to posterior superior alveolar artery of the maxillary artery in Le Fort I fracture.A 34-year-old man had a facial injury after an explosion of a furnace. Computed tomography demonstrated Le Fort I fracture, right open zygomatic tripod fracture, and open nasal bone fracture. Blood pressure, hemoglobin, and hematocrit levels had fallen to 110/60 mm Hg, 5.7 mg/dL, and 16.1%, respectively, 10 hours after injury despite continuous blood transfusion. Selective digital angiography confirmed an injury to the posterior superior alveolar artery, with extravasated pooling of contrast material in the maxillary sinus. The distal internal maxillary artery was embolized with n-butyl cyanoacrylate and lipiodol. Postembolization angiogram showed resolution of the contrast leak, and the patient's oronasal bleeding resolved.We suggest that if the oronasal bleeding continues in Le Fort fracture, bleeding from the posterior superior alveolar artery should be suspected. In case the vital sign is not stable, selective angiography should be performed before surgery.

Maxillofacial trauma may cause eye injury besides fractures of the facial skeleton. However, evulsion of the globe is a rare event, and there are only a few reports of true total enucleation of the globes in the literature. We report a 23-year-old man who was a victim of motorcycle accident, with enucleation of the globe, evulsion of the septal cartilage, and midfacial fractures. We reviewed and discussed the literature of traumatic evulsion of the globes in maxillofacial traumas.

High-density porous polyethylene (Medpor Surgical Implants, College Park, GA) enophthalmic implants are used in patients with sunken socket syndrome to augment the orbital volume. A transconjunctival or subciliary approach is used to access the orbital floor. We present a new approach for accessing the orbital floor using diced Medpor implants through a mini-lateral canthoplasty incision. Medpor particles diced about 1 x 1-cm diameter were inserted through alateral canthal incision to orbital floor. The advantages of this technique are limited incision, decreased postoperative edema, volumetric adjustability, and applicability under local anesthesia. Three cases with blow-out and neglected zygomaticomaxillary fractures underwent primary or secondary diced Medpor orbital implantation. No cases showed any implantial infection. Our preliminary results showed no complication, and this novel method seems to have no severe disadvantage in the surgical treatment of posttraumatic enophthalmos.