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While the state of the art of clinical assessment and imaging techniques were described in Part 1, this contribution presents a systematic review of the surgical treatment principles in the management of midface and internal orbit fractures from initial care to definitive treatment, including illustrative case examples. New developments and advances are characterized by limited versus extended surgical approaches, by standardization of osteosynthesis principles with regard to three-dimensional buttress reconstruction, by newly developed individualized implants such as titanium meshes and, especially for complex fracture patterns, by critical assessment of anatomical reconstruction through intraoperative endoscopy, as well as intraoperative and postoperative imaging. Newly developed resorbable soft tissue anchors can be used both for ligament and soft tissue resuspension in order to reduce ptosis effects in the cheeks and nasolabial area to achieve facial aesthetics similar to those prior to the injury.

In the case of displacement of the globe such as enophthalmos induced by trauma, the patient is affected on both counts: function and aesthetics. To prevent double vision or conspicuous asymmetry, exact correction of the globe position is required. The aim of this case report is to demonstrate an intraoperative computer-assisted, non-contact, optical 3D procedure for identification of the globe position to aid in placing the eyeball in the position required in complex reconstruction of the orbital floor. A 33-year-old man presented with a sunken eye on the right side in the horizontal and vertical plane 6 months after having undergone surgery elsewhere for a zygomatico-orbital fracture, also including the orbital floor. The patient was affected by double vision and a noticeable defective globe position. In planning the correction of the globe position, a three-dimensional image of the face with opened eyes was made with the optical sensor. Automatic comparison of symmetry revealed enophthalmos of 4 mm on relative en- and exophthalmometry. The decision was made to lift the orbital floor with a split calvarial bone graft. During surgery the position of the globe was also controlled by the three-dimensional optical technique. At the end of surgery there was exophthalmos of 1 mm. Six weeks after surgery the patient was not affected by any double vision. After 3 and 24 months enophthalmos was 1 mm. This case demonstrates how the non-ionizing, non-contact, optical 3D technique can help in planning, intraoperative transformation, and clinical monitoring to identify the correct position of the corneal vertex in complex orbital floor reconstruction.

This retrospective study included 148 patients who were evaluated for postoperative long-term results after osteosynthesis of isolated zygoma fractures. The influence of open reposition of the zygomaticoalveolar crest to middle face symmetry was evaluated quantitatively with a zygometer. In dependence on operative management patients were divided into two groups: In group I zygomaticofrontal suture (1-point-fixation) and infra-orbital rim were exposed (2-point-fixation), followed by osteosynthesis. In group II additional exposure of zygomaticoalveolar crest was performed and if required osteosynthesis was performed (3-point-fixation). For osteosynthetic reconstruction of isolated zygoma fractures the only 2-point-fixation is usually enough to achieve lateral middle face symmetry. In all cases zygomaticofrontal suture and alternatively infra-orbital rim or respectively zygomaticoalveolar crest should be supplied osteosynthetically. A further 3-point-fixation is indicated only in exceptional cases--for example comminuted fractures of lateral middle face columns. For an exact anatomical reposition of zygoma fractures the exposition and possible osteosynthesis of zygomaticoalveolar crest is recommended.

A solution to managing intubation difficulties during anaesthesia induction is described in this article. After two attempts at laryngoscopy had failed, endotracheal intubation was achieved by the combined use of a laryngoscope and the Bonfils rigid fiberscope. The successful technique involved two anaesthesiologists, one who displaced the patient's tongue to the left ventral part of the mouth with a laryngoscope and cleared the airway by suctioning, and one who accomplished the intubation using the Bonfils rigid fiberscope by following the blade of the laryngoscope to the larynx. After securing a good view of the vocal cords, the tube was successfully inserted into the trachea. The entire procedure of intubation was accomplished within 20 s.

Introduction: This study reports on a modified approach to treat zygomatic fracture. For the surgical approach, a transconjunctival incision and, instead of a lateral canthotomy, a superficial incision of the skin and subcutaneous tissue was used, preserving the lateral ligament. The results are compared with those of previous techniques, especially the subciliary incision., Patients: In a prospective study, 30 patients (9 females and 21 males, mean age 32.1 years) with zygomatic fractures were operated using this approach. Mean follow-up time was 6 months after removal of the plates. Fractures were caused by trauma due to fighting, bicycle falls, or sport accidents. Follow-up radiographs were used to evaluate the position of the zygoma after reduction and rigid fixation., Results: Reduction and rigid fixation of the fractures were possible to perform in all cases. The access to the orbital floor and the exposure of the inferior and lateral rim were satisfactory and an additional latero-orbital cut was not necessary. The disadvantage of the complete incision of the lateral ligament with the necessity of intraoperative refixation and possible ectropium of the eyelid could be avoided. Injuries or infections of the cornea or the bulbus did not occur. Postoperative complications such as scar formation resulting in entropium or ectropium were not seen., Conclusion: These results show that the transconjunctival approach with lateral superficial incision preserving the lateral ligament for treatment of zygomatic fractures is satisfactory in all cases of rigid fixation of both inferior and lateral rims. Because of its esthetic and functional advantages this approach has become standard in our department.

Aim: Fixed-angle osteosynthetic systems are characterized by mechanical "locking" of the osteosynthetic screw and plate. These systems have found increasing acceptance and use for osteosynthetic fixation and temporary reconstruction of the mandible. The aim of this study was to investigate the applicability and performance of fixed-angle systems in the treatment of midfacial fractures., Material and Method: A newly developed fixed-angle osteosynthetic plate system (smart lock) was compared to a conventional system using fresh human skulls. The iatrogenically produced zygomatic fractures of the human skulls were treated by osteosynthesis and biomechanically tested. Furthermore, in a dynamic test series, an artificial bone was subjected to an alternating force of 15 N of up to 1,000,000 cycles. The new screws and plates were subjected to further biomechanical tests., Results: The tests using the fixed-angle implants revealed that an increase of stability of up to 40% can be expected after osteosynthetic fixation. Furthermore, the plates resisted 1,000,000 cycles of alternating forces, whereby the conventional systems failed after 170,000 cycles on the average., Conclusion: Fixed-angle systems, due to their construction, provide a high degree of stability even in thin bones of the midface. They appear to be promising for the treatment of midfacial fractures.

Background: Multidirectional angularly stable interlocking plate systems are now available for the surgical treatment of the midface. After first experiences in cases of mandibular fractures, application to the facial skeleton was investigated using a cadaver study. Furthermore, three-dimensional imaging by means of the digital volume tomograph NewTom DVT 9000 after reduction of orbitozygomatical fractures was performed and evaluated., Material and Methods: After artificial osteotomy and reduction of both zygomatical complexes, osteosynthesis of the left side was performed with three 4-hole miniplates (2.0). On the right side, three angular stable 2-hole plates (2.3) were used. Thereafter, a three-dimensional data set was generated using the NewTom DVT 9000. After DICOM-import in eFilm reconstructions were evaluated by six examiners regarding defined criteria., Results: After adaptation and fixation of the angular stable interlocking plate system without complications, manual checking revealed that the primary stability did not seem inferior to the other side. Defined criteria were sufficiently evaluable, even close to the osteosynthetic material, using reconstructions of the digital volume tomography data set., Conclusion: Surgical treatment of midfacial fractures using a multidirectional angularly stable interlocking plate system seems promising. The NewTom DVT 9000 proved to be suitable to visualize even fine osseous structures of the midface.

Aims: The possibility of performing intraoperative computed tomography may add to the safety and efficiency of some maxillofacial procedures. It would be preferable for intraoperative image data acquisition to be available to a surgeon on demand for immediate control of therapy results., Methods: In a pilot study, the use of a mobile computed tomographic scanner (Philips Tomoscan M, Philips Medical Systems, Eindhoven, Netherlands) was evaluated in our unit. The scanner is equipped with wheels, draws power from wall outlets in combination with batteries, and has a translating gantry., Results: Experience to date with six patients has confirmed the feasibility of intraoperative CT. All patients operated on were treated for craniofacial trauma. The CT images showed good spatial resolution. In all cases, visualization of the correct fragment position was excellent without causing significant delay of the operative procedure., Conclusions: Intraoperative computed tomography could be the new state-of-the-art method for direct control of treatment results in maxillofacial traumatology. Nevertheless, the high expenses for installation of such technical infrastructure has to be pointed out; therefore, the routine use of this technique might be questioned.

Advances in intra-operative imaging and the development of new minimally invasive techniques are having an ever greater impact on modern surgery. Mobile CT scanners in the operating room is a new technique that permits image-guided surgery, and helps minimize postoperative complications. We report on our initial experience with intraoperative CT scanning during surgery on patients suffering lateral midface trauma. A mobile CT unit, the Tomoscan M (Philips, Utrecht, Netherlands) set up in the operating room, was evaluated in 6 patients with zygomatic bone fractures. The patients were placed on the CT scanner table, which is detachable from the gantry. The unit is powered by batteries charged from an ordinary ring mains supply via a conventional plug. The CT images obtained were of good quality in all cases. No technical problems were observed during surgery. Using repeat CT scans, the procedure also permits accurate intraoperative monitoring of the anatomical repositioning of the bone fragments, and accurate implantation. No intraoperative or early postoperative complications were observed. This new technical aid ensures highly accurate reduction of the bone fragments, and minimizes the need for reoperation. High-quality intraoperative imaging with surgical navigation increase surgical outcome, and expand the spectrum of minimally invasive surgery.

The pre- and postoperative symptoms of zygomatic bone fractures were examined in a follow-up study to prepare a classification proposal. A differential indication for minimally invasive therapy modes was looked for with respect to this proposal. Therapy of isolated zygomatic bone fractures consisted in repositioning with a hook and miniplate fixation across the frontozygomatic suture. The aims of this study were clinical and radiological assessment of the repositioning result in terms of aesthetics and stability and quantification of the postoperative remission of disturbances of sensitivity of the infraorbital nerve. A total of 52 patients were examined. After the operation (on average after 3.5 days following the trauma) they were followed-up postoperatively for 12 months according to a strict schedule. Preoperatively, 49 patients reported disturbances of sensitivity of the infraorbital nerve. Other symptoms, such as periorbital haematoma and flattening of the zygomatic prominence, were observed in 49 patients and 45 patients, respectively. All fractures were repositioned well as assessed clinically and radiologically. The aesthetic result was evaluated as symmetric and durable in all cases. Six months postoperatively 41 patients reported normal sensitivity in the area of the infraorbital nerve. In only five patients (10.2%) was the sensitivity loss persistent throughout the entire follow-up period. Patients with primarily lacking diplopia developed neither eye motility disturbances nor postoperative enophthalmus in the following period. It can be concluded that the treatment of an isolated zygomatic bone fracture which satisfies aesthetic and functional requirements is possible by reposition and fixation with one miniplate at the lateral orbital rim. An additional osteosynthesis at the infraorbital rim or at the zygomaticomaxillary crista is not necessary. A routine revision of the orbital floor is only indicated in cases of preoperative diplopia. A zygomatic bone fracture connected with diplopia should be classified as combined zygomatic-/orbital floor fracture.

Background: Unsuitable instruments are often used for the reduction of nasal fractures and fractures of the zygomatic arc. A new instrument for elevation and reduction of these common fractures is presented., Method: The special shape of the elevator, which is adapted to the anatomy of the nasal dome, is helpful in nasal surgery. The bayonet-shaped angle also allows elevation of compressed fragments of the zygomatic arc., Results: This instrument was successfully used in the reduction of 107 bony fractures of the nose and 36 fractures of the zygomatic arc., Conclusion: From the clinical point of view the elevator can be recommended for ENT specialist working in a trauma setting.

Laryngeal incompetence is characterised by incoordination in deglutition and fluid leakage around the tracheostomy tube. It occurs very rarely and is attributed to injury of the recurrent laryngeal nerve. To our experience this condition demands no treatment and gradually disappears. In this paper we present a case of a 24-year-old male patient with facial fractures presenting laryngeal incompetence.

Ultrasound and standard x-ray investigations before and after the reduction of the fractures were performed in 17 patients with zygomatic arch fractures. The ultrasound investigation of the bone surface is recommended as an additional diagnostic tool in the diagnosis and control of the reduction of zygomatic arch fractures. Intraoperative ultrasound imaging under sterile conditions is easy to apply and enables the surgeon to optimise therapeutic results. In 5 cases based on an intraoperative sonogram further reductions of zygomatic arch fractures were carried out. In another referred patient the diagnosis of a zygomatic arch fracture was excluded by ultrasound and confirmed by standard x-ray examinations.

Over a 12 year period 56 patients presented for secondary corrections of the periorbital region after trauma. Corrections after isolated fracture of the zygoma improved the final result in 75% of the cases. Further correction seems useless. After midface fractures 85% became acceptable or good results. Tertiary corrections are usefull. The results after front-basal fractures were comparable. Twenty percent of the secondary canthopexies had to be revised once more. The final result was at least acceptable in all cases. Not all secondary nose-corrections lead directly to success, however, after further corrections only 5 percent remained unacceptable. Finally, overall good results were established in 60 percent and in another 20 percent at least an acceptable result could be reached.

The range of indications for and the surgical technique of the extended transconjunctival approach to the inferior and lateral orbital margin, the floor of the orbit, the upper part of the facial wall of the maxillary sinus and the medial part of the zygomatic bone are described. We present 64 patients with mid-face fractures: 9 with fractures of the orbital margin, 48 with isolated blow-out fractures, and 7 with zygomaticomaxillary fractures. All have been operated on in the last 5 years. The transconjunctival approach extended by a lateral canthotomy is better than infraorbital or subciliary access. Exposure and cosmesis are excellent. None of the complications that follow other methods were seen after our surgical treatment.

295 patients with midfacial fractures were treated on an inpatient basis between 1975 and 1989. 185 patients underwent a follow-up examination. Discomfort was reported by patients in 43% of the cases, whereas pathological clinical findings were observed in 39% of the patients followed up. The late sequelae, which were only slight in extent, were increasing in frequency with the severity of the injury. The use of miniplate osteosynthesis resulted in improved clinical results. Apart from early diagnosis, immediate referral to a specialized hospital and immediate therapy, more emphasis must be placed on interdisciplinary cooperation.

A prospective study of was made on 100 patients with fractures of the orbital floor, the zygoma and/or midface who were surgically treated and investigated (before and 3 days, 7 days, 1 month and 6 months after surgery) with regard to their eye motility (Hess screen) and their double vision (Harms tangent screen). Stable results were obtained at least 30 days after surgery. Patients in whom early surgery was performed (within 7 days after trauma) showed better results (82% improvement) compared with those operated on in the second week after the trauma (50% improvement) or later (27% improvement). Young patients (less than 10 years of age) and patients with midface fractures (LeFort II and III) showed significantly poorer results with regard to eye motility.

The treatment of malar bone fractures by stable osteosynthesis represents a well established method. The necessity of a second surgery is one of the major disadvantages of using metal implants. Resorbable plates can only be deformed by very difficult methods. We found out that, cause of the anatomical structure of malar bone region, only three types of plates are necessary to treat every kind of malar bone fracture of males and females.

This study investigated the occurrence of primary and secondary complications following conservative versus surgical intervention in the treatment of midface and lower jaw fractures. Follow-up studies were undertaken on 81 patients who had been admitted to the above clinic with such fractures during their adolescence. It was found that more complications developed after surgical intervention.

1423 patients with maxillo-facial trauma were admitted for hospital treatment from 1980-1986. Midfacial and/or mandibular corpus fractures were present in 87 juvenile cases. The follow-up study of 64 patients of this group revealed some interesting points: 1. Fractures of the juvenile skull must be reduced exactly. There will be no "smoothing of edges" during the later growth period. 2. Teeth which had been left in the fracture line showed no disturbance during their eruption. 3. An enlargement of the zygomatic-alveolar crest was a frequent observation in zygoma fractures. 4. There is no need for regular follow-up examinations if the primary treatment has been successfully done.

A study of midfacial fractures in 28 children under 16 years of age treated at the Medical School Essen is reported. All children underwent surgical treatment. 18 patients with fractures of the zygomatic complex were treated by open reduction and miniplate osteosynthesis. 10 patients with blowout fractures were treated with "Lyodura"-implants. To prevent persistent diplopia an early surgical treatment is recommended. An adverse effect on the growth of facial bones has not been seen.

The cases of 173 children (under 16 years of age) treated for facial injuries at the Department of Oral and Maxillofacial Surgery. Cologne, FRG, between 1981 and 1989 are reported. 63 of these patients had fractures of the body of the mandible. 32 patients could be treated with miniplate osteosynthesis (after Champy). Our results show that accurate diagnosis is imperative if complications and late sequelae are to be avoided.

The conservative treatment of fractures of the visceral cranium and the base of the skull has become separated to an increasing extent from the earlier reconstructive measures of the facial surgeon. The skull is restored with due consideration for the anatomical function and cosmetic factors. Wire osteosynthesis, maxillary and mandibular splinting, fixing to the skeleton by Adam's clasp, reconstruction of soft parts, filling of skin defects precede the subsequent functional follow-up therapy. Exact diagnosis and interdisciplinary planning of treatment before the early intervention are of more value for the patient with a damaged skull than precipitate emergency measures under conditions of inadequate equipment and personnel. A plan of treatment from a background of 230 of our own cases is presented.

Between 1973 and 1974, 96 zygomatic fractures were diagnosed of which 89 were surgically treated. 75 fractures were set openly and of these 65 were joined by osteosynthesis. 75 patient were examined later. Results show that posttraumatic complications occurred more frequently in fractures set without opening than in fractures set by osteosynthesis. Open reposition is therefore recommended, along with stabilization by osteosynthesis.

The incidence of fractures of the jaws and facial bones in children is less frequent than these same fractured bones in adults. The relative low incidence of facial fractures in children can be related to certain growth factors. Details of facial trauma and associated injuries were collected in 50 patients referred from the Medical School in Hannover. The age and sex distribution, anatomical types of fractures, associated nonmaxillofacial trauma and causes of the injuries are described. Fractures of the mandible occur in greater frequency than those of the middle third of the face in children. Emphasis is placed on paediatric mandibular and condylar fractures and their treatment difference from those in adults are noted. Facial bone fractures in children have the potential of deformity due to growth disturbances. Fractures of the facial skeleton are often accompanied by associated injuries, especially fractures of the skull and intracranial injuries. Of primary importance is an early assessment of the patient's general condition and associated injuries.

The conjunctival approach combined with the lateral canthotomy incision is very appropriate for exploration and reconstruction of orbital fractures and provides exposure medially and laterally. 18 pure blow-out fractures, 16 zygomaticomaxillary fractures and 6 other middle-face traumas were treated in that way. No serious complications ever occurred in our series, except one suture granuloma. Based on own experience and satisfactory functional and cosmetic results this technique should be preferred instead of the infraorbital and the subciliary incision.

From 1982 to 1985 65 patients with a fracture of the cranial and middle portion of the visceral skull underwent surgical reconstruction using mini-plate osteosynthesis (Champy set). In this group we can distinguish four typical fractures where plate osteosynthesis with functional stability has proved successful (e.g.: piece fracture of the inferior margin of the orbita, bursting fracture of the zygomatic bone, impression fracture of the anterior wall of the frontal sinus, comminuted fracture of the interorbital region). The technical details of surgery are given special emphasis and possible complications are discussed.

Three unusual cases of posttraumatic upper eyelid retraction are described. They were observed following orbital trauma without apparent involvement of the superior rectus muscle after latency periods ranging from several months to years. As other reasons for the lid retraction were ruled out the question arises as to whether peripheral neurogenic or muscular upper eyelid retraction must be assumed to be a consequence of trauma, although this has never been described before.