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Objective: To highlight the various causes of gaze-evoked amaurosis., Design: Retrospective noncomparative interventional case series., Participants: Five patients treated at our facility over the past 6 years., Methods: Clinical presentation, radiologic studies, surgical management, and postsurgical results are presented., Main Outcome Measures: Visual acuity, clinical findings of gaze-evoked amaurosis., Results: Only two patients had classic intraorbital etiologies, one with an intraconal cavernous hemangioma and one with an intraconal foreign body. Three patients had extraorbital processes, two with orbital fractures and one with a sinus tumor. Only two of our patients initially were aware of the gaze-evoked amaurosis at presentation. Appropriate surgery was curative in all cases., Conclusions: Gaze-evoked amaurosis is a rare condition, classically implicating intraconal orbital pathology. In one of the largest case series published to date, we found extraorbital etiologies are also capable of producing gaze-evoked vision loss. Gaze-evoked amaurosis should be suspected and tested for in any orbital condition.

The ideal modality for fixation of pediatric craniomaxillofacial fractures remains elusive for a number of reasons. Surgeons who manage these injuries have replaced wiring techniques with the introduction of some form of reconstructive implant. The most commonly used implants are either resorbable or semi-rigid titanium. This presentation is a synopsis of the past 30 years of the English-speaking scientific literature including plastic and reconstructive surgery, otolaryngology, head and neck surgery, oral and maxillofacial surgery, pediatric, trauma, craniofacial, materials, and biomaterials publications. While no consensus on ideal management was observed, various implant treatment options are discussed, including their indications, contraindications, considerations, and consequences after implant placement.

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified. Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records. Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent). When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms. The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance. Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.

Objective: To compare fracture locations, repair methods, complications, and outcomes of horses with fractures of the rostral portions of the mandible and maxilla., Design: Retrospective study., Animals: 89 horses with fractures of the rostral portions of the mandible and maxilla., Procedure: Medical records and radiographs were reviewed. Fractures were categorized by fracture location and stability. Postoperative complications and long-term outcome were determined by clinical examination and telephone interviews with horse owners., Results: 4 fracture types were recognized. Fractures involving just the alveolar plate (33%) and those involving the alveolar plate and the body of the bone (32%) were most common and were often repaired by interdental wiring. Unilateral fractures of the mandible (11%) were managed without surgery if stable. Unstable fractures were repaired with wires, a U-shaped bar (U-bar), or a bone plate. Bilateral fractures (24%) were often repaired with orthopedic wires in foals or with a U-bar, acrylic splint, wires, or bone plate in adult horses. In 2 horses, bilateral fractures were managed conservatively. Short-term complications developed in 24 of 89 (27%) horses. Soft tissue infections and wire loosening or failure were the most common short-term and long-term complications. Wire replacement was not required in any horses after release from hospital. Persistent draining tracts were most often associated with bone sequestration. Long-term functional and cosmetic outcomes were favorable for all fracture types and repair methods., Clinical Implications: Although complications in horses with fractures of the mandible and maxilla are common, long-term prognoses for functional and cosmetic outcome are favorable.

Eight cats with stable impaction fractures of the maxilla, sufficient to cause malocclusion, were treated by mandibular symphyseal realignment. The mandibular symphyseal realignment allowed occlusion to be restored with a minimal amount of dental work (e.g., enameloplasty, endodontics, or tooth extraction) in a majority of the cases. Enameloplasties were performed in two cats, one of which had a vital pulpotomy. Tooth extractions (range, two to five teeth; mean, 3.3 teeth) were performed in four cats. All cats were doing well at the time of in-hospital follow-up at one month to four years (mean, 2.1 yrs) postoperatively. Further telephone follow-up was obtained, from 1.5 to five years (mean, 3.4 yrs) after surgery, from all but one owner, with no change from the in-hospital evaluations. All owners contacted were pleased with the long-term outcome.

We report 3 cases of unusual dental injuries following facial fractures. The first patient sustained intrusion of a maxillary incisor into the nasal cavity following a mandibular fracture. The tooth dislocated into the pharynx and was found lodged in the piriform fossa during surgery. The second patient sustained intrusion of molars into the maxillary sinus following maxillary and mandibular fractures. His treatment was delayed due to life-threatening hemorrhage. The third case involved ingestion of multiple avulsed teeth into the alimentary tract following severe maxillofacial fractures. Although the diagnosis was made more than a week after the injury, the patient did not suffer any complications as a result of the dental avulsion. The aim of this report is to emphasize the possibility of associated dental injuries in patients with facial fractures. The trauma surgeon should be cognizant of the importance of carrying out a thorough intraoral examination during the initial evaluation. Any missing tooth should be considered as possibly displaced into other tissue compartments, and must be routinely searched for with x-rays of the skull, cervical spine, chest, and abdomen. If full intrusion injury is suspected, further diagnostic investigation with facial computed tomography scanning may be worth while.

Purpose: The efficacy of the current methods for the treatment of fractures of the zygomaticomaxillary complex was evaluated., Patients and Methods: One thousand two hundred seventy-seven patients with fracture of the zygomaticomaxillary complex and 196 patients with fractures of the zygomatic arch that were admitted between 1984 and 1995 were evaluated. One thousand one hundred fifty surgical procedures were performed, and in 401 cases, no operative treatment was considered necessary. The Gillie's approach was used in 514 cases, intraosseous wiring in 89 cases, bone plate osteosynthesis in 322 cases, Roger-Anderson pins in 180 cases, antral packing in 17 cases, and elevation with a hook in 28 cases., Results: The best results were achieved with the use of semirigid fixation with miniplates applied at one or more sites of the fractured complex, occasionally used in combination with other methods such as Roger-Anderson pins., Conclusions: Semirigid fixation with miniplates offers the most reliable method available today for the treatment of zygomatico-orbital complex fractures and has practically replaced every other method in our institution. The increased cost and occasionally the necessity to remove the hardware are the main disadvantages of the method.

This case report demonstrates how to use intraoral mechanics to correct facial planes that are not parallel, namely the eye plane, ear plane and occlusal plane. Currently, our protocol states that the cranial and occlusal planes are treated first, followed by expanding (transversely or sagittally), if necessary, the maxillary arch to accommodate the dentition. This creates the template from which the remaining treatment will be rendered, which would include, proper TMJ position, correction of mandibular facial asymmetries that result from ramus growth deficiencies, (both frontal and profile), and determining the correct posterior vertical. At this point the case is in a Class I osseous relationship with all expansion completed. The teeth are then erupted into the correct positions for the orthodontic finishing of the case.

Background: Orbital fractures are frequently accompanied by ocular injury. Any findings that provide information for diagnosing a concurrent ocular injury should improve patient care. A greater incidence of severe ocular injury with certain fracture types was hypothesized, based on orbital wall thickness., Methods: A retrospective review of 87 consecutive patients (107 fractured orbits) was performed by the Ophthalmology Department of an urban Level 1 trauma center., Results and Conclusions: Severe injuries were associated with orbital apex fractures (p = 0.00001), with lateral wall fractures (p < 0.04), and with Le Fort Type III fractures (p < 0.02). Moderate injuries were associated with isolated orbital floor fractures (p < 0.01). Apex, lateral wall, and Le Fort Type III fractures have a greater association with severe ocular injuries than other fracture types.

35 cases with bony malunion following maxillofacial fractures had been treated successfully by orthognathic surgery technique. Mini-titanium plate had been used in the rigid internal fixation. The article introduced the surgical method and discussed some primary principals which should be paid attention during operation.

We report a case of bilateral switch nerve palsy following minor head trauma. We discuss available literature, frequency and pathophysiology of bilateral abducens nerve palsy after minor head trauma. We also present current knowledge of prognosis and treatment of oculomotor palsies after trauma.

A case of successful closure of a large maxillary defect is presented, using a free bone graft, rigid fixation and hydroxylapatite particles.

The CT appearances of three cases with severe nasopharyngeal cavity narrowing are described. In all cases the facial trauma was due to a motor vehicle accident. These cases demonstrate that posterior maxilla and pterygoid plate fractures can cause significant nasopharyngeal soft tissues swelling, most likely due to haemorrhage and/or oedema. Severe nasopharyngeal cavity narrowing could cause difficulty in elective nasogastric tube and endotracheal tube intubation via the nasopharyngeal route.

A retrospective series of orbital, axial, and coronal computed tomography scans from 24 orbital floor fractures was studied to define the anatomic location of the fracture. Floor fractures without rim involvement, which are referred to clinically as blowout fractures, were located medial to the infraorbital nerve or extended on both sides of the nerve. Floor fractures with rim involvement were associated with zygomatico-orbital or Le Fort II or III fractures, and were located either lateral to or on both sides of the infraorbital nerve. No blowout fractures were confined to the lateral half of the orbital floor and no floor fractures with rim involvement were confined to the medial half of the orbital floor. The authors propose a classification system for describing orbital floor fractures based on their anatomic location relative to the infraorbital nerve.

Myiasis is a disease commonly seen in animals, especially sheep and cattle. The condition is rare in man. A patient with a neglected fractured mandible with superimposed myiasis is reported.

The authors share their experience gained in the treatment of 11 patients with different fractures of the lower orbital wall in remote periods after the injury (1 month to 4 years). A specific feature of late injury in all the patients we observed were disorders of binocular vision presenting as diplopia due to cicatricial changes in the orbit. X-Ray examinations showed deep fractures of the lower orbital wall involving the posterior half of the orbital space in all cases. An operation had to be performed in all the patients: inferior orbitotomy via a transcutaneous access combined with anterior highmorotomy and submucosal refracture of the upper wall of the maxillary sinus within the framework of improperly consolidated fracture along the borders of the orbital hernia. The choice of this operation was dictated by specific localization of the fractures (zones difficult to access), solidity of scar growth at the site of the fracture (because of long period elapsed after the injury), and by limited possibility of intervention via an isolated transorbital access. An accessory element: refracture of the lower deformed wall and its reposition in the proper state helped repair the defect in the wall with a homocartilage on the side of strips and the orbit. Binocular vision and mobility of the eyeball in the orbit were repaired in all the patients, the degree of posttraumatic enophtalmos was appreciably decreased.

A rare case of massive maxillofacial hemorrhage, which was controlled by transcatheter arterial embolization, is reported. A 23-year-old man with massive nasal and oral hemorrhage caused by maxillofacial fracture was admitted. Emergency angiography demonstrated extravasation of contrast material from the posterior superior alveolar artery, which was immediately embolized using gelatin sponge particles. This case shows that transcatheter arterial embolization is useful and effective for the treatment of massive hemorrhage resulting from severe maxillofacial injury.

Blindness after facial fractures has been reported to occur with an incidence that ranges between 0.67% and 3% depending on the reporting institution. To verify this finding we undertook a retrospective chart review of 5936 patients with facial fractures that occurred over a 12 1/2-year period. We found that vision in 19 eyes were lost in 18 patients. Vision loss was more frequently encountered in Le Fort III level fractures (2.2%) followed distantly by Le Fort II level fractures (0.64%), and zygomatic fractures (0.45%). The cause of blindness was most frequently associated with motor vehicle accidents and gunshot injuries. Injuries of this type require immediate and prompt consultation by the ophthalmologic surgery service.

Two cases of post-traumatic aneurysm of the maxillary artery are described. The first patient was a 20-year-old man who sustained a Le Fort III type fracture in a road traffic accident. He experienced two episodes of significant maxillofacial haemorrhage, the first following admission and the second 5 days after initial reduction and fixation of his midfacial fractures. The second patient was a 23-year-old man with a bilateral cleft palate and extreme midfacial hypoplasia who underwent Le Fort I osteotomy. Significant bleeding commenced 3 h postoperatively and was not completely controlled by anterior and posterior nasal packing. Both the aneurysms were diagnosed on selective carotid angiography and successfully treated by embolization.

Superior orbital fissure syndrome complicates zygomatic fractures either when the nerves that cross the fissure are damaged by bone fragments, or when the increased pressure in the orbit at the time of the injury compresses the nerves against the rim of the fissure. Oedema and bleeding may also have the same effect. We present a patient who was treated conservatively, and the ophthalmological problem subsided, although not completely, within a year.

From January 1983 through December 1990, we treated 703 patients with central craniofacial fractures. Among them 177 had maxillary fractures, with or without frontonasoethmoidal involvement. Of the 177, 151 patients were diagnosed in the acute stage. Using the Glasgow Coma Scale, these 151 patients were divided into three groups: group I (GCS score 13-15), 100 patients; group II (GCS score 9-12), 33 patients; group III (GCS score 3-8), 18 patients. The patterns of facial fractures were analyzed and surgically corrected after the following average postadmission lags: group I, 7.1 days; group II, 11.5 days; group III, 13.3 days. The average hospital stay for each group was: group I, 15.6 days; group II, 19.5 days; and group III, 27.2 days. The mean follow-up period was 12 months. The physiologic, functional and esthetic outcomes were assessed. Regardless of initial head injury severity, the outcomes in each group showed almost no statistically significant differences, and unnecessary extended hospital stays may be avoided by early surgical management.

Objective: To demonstrate the techniques, advantages, indications, and potential pitfalls of the transconjunctival approach with lateral canthotomy, sublabial approach, and coronal approach in the treatment of complex trimalar fracture with associated blow-out fractures., Design: All patients diagnosed as having complex trimalar fractures with or without blow-out treated by either of us over a 2-year period were included. Follow-up ranged from a minimum of 6 months to 2 years., Setting: All patients were treated with December 1989 to December 1991 at either Louisiana State University Medical Center, Shreveport, or University of Kansas Medical Center, Kansas City., Patients: Eighteen patients with complex trimalar fractures were included in this study. Eight patients had associated orbital blow-out fractures. Simple isolated arch fractures were excluded., Intervention: All subjects underwent a transconjunctival approach with lateral canthotomy. Seven subjects also had associated sublabial flaps. Five patients required hemicoronal or coronal approaches., Results: There were seven minor complications. Ninety-three percent (14/15 [three didn't respond to the survey]) of patients surveyed were either very satisfied or satisfied with their functional and cosmetic results., Conclusion: The management of complex trimalar fracture with blow-outs is greatly facilitated by the rational application of the described techniques.

The present article deals with the surgical experience of treating 72 patients for posttraumatic enophthalmos. Patients were divided into the following 4 groups with respect to the type of injury and the time of surgery: Group 1, recent midfacial injuries with orbital floor fractures; Group 2, recent blow-out fractures; Group 3, neglected blow-out fractures; and Group 4, neglected fractures of the zygoma or the zygomatic-maxillary complex. Osteoplasty of the floor of the orbit was performed in all groups with bone or cartilage grafts such as lamina from the anterior maxillary wall, iliac and calvarial graft as well as rib cartilage. In addition to osteoplasty, reposition and fixation of fractured bones as well as refracture of malunited zygomatic-maxillary complex were performed in patients in Groups 1 and 4, respectively. Enophthalmos was recorded in 5 and 2 of 20 patients from Groups 1 and 2, respectively. In Group 3, enophthalmos was corrected in 3 of 7 patients, whereas 16 patients were corrected of 25 from Group 4. Advantages and disadvantages of applied surgical techniques are discussed and personal observations emphasized.

Thirty-three cases of complicated zygomatic-maxillary complex fractures and their complications and sequelae are analysed. Permanent alterations in infraorbital nerve sensitivity (4 cases), amaurosis caused by enucleation of globus (2 cases), diplopia recovered in sixteen cases without treatment and after operation in two cases, ectropion (1 case), subcutaneous emphysema (1 case), scars (3 cases) have been surveyed.

Failure to treat the soft tissue component of dento-alveolar wounds may complicate wound healing mechanisms, retarding the rate of healing and increasing the risk of infection. A case is presented of a five-year-old with an intra-oral wound which, left untreated for eleven days, failed to resolve.

A clinico-statistical and long-term follow-up study was performed on 81 pediatric fractures seen during the 14 years between 1977 and 1990. Of all maxillofacial fractures, the incidence of pediatric fractures was 14.7%. The ratio of boys to girls was 2.1:1, and the highest incidence involved boys over 13 years of age. Fractures of the upper alveolar bone and mandible were common. Conservative therapy, such as maxillomandibular fixation using orthodontic brackets was usually performed and was found to be successful. The long-term follow-up study revealed that 5 out of 21 patients with alveolar fractures complained of malocclusion and it is suggested that a longer duration of intramaxillary fixation and long-term follow-up might be needed for alveolar fractures in children.

Intractable epistaxis developed in a 13-year-old girl after she fell down a flight of stairs sustaining facial fractures and fracture of the skull base. Epistaxis was found to emanate from a right ascending pharyngeal artery, which the authors promptly and successfully embolized using polyvinyl alcohol particles and microfibrillar collagen.

Le Fort's fractures of maxillary bones are referred to grave injuries that require an accurate and urgent diagnosis. A total of 70 patients with different variants of such fractures were examined. The x-ray examination included polypositional roentgenography, linear tomography and panoramic sonography with the Sonarc apparatus. The injuries with all signs of Le Fort's fractures of two and even three types predominated, asymmetric injuries were rather frequent. Panoramic sonography with the patient in a modified position helped specify the volume and extension of the injury to the facial bones, but it should be supplemented with linear tomography to detect the injuries of the pterygoid processes of the major bone of the anterior and posterior walls of the maxillary sinuses, of the frontonasal channel opening, of the posterior wall of the frontal sinuses and the anterior cranial fossa structures, the detection of injuries of the pterygoid processes being the key sign in the differential diagnosis of Le Fort fractures.

The authors report a case of a post-traumatic salivary fistula originating in the parotid gland, evacuating into the maxillary sinus and revealed by rhinorrhea. The mechanism and treatment of the fistula were analyzed.

Fifty patients with maxillary fractures treated by closed reduction over an 85 month period at a Level I trauma center were reviewed. Thirty patients (60%) experienced forty-one midfacial complications. The most frequent problems were infraorbital nerve paresthesia (12), enophthalmus (5), septal deviation (3), and altered vision (3). No relationship could be established between complications and age, sex, cause of injury, or the method of suspension used. Most complications were related to concomitant injury or the concurrent management of fractures of other facial bones. Only eight problems (16%) were directly attributed to the closed reduction of maxillary fractures. Patients treated by closed reduction and maxillomandibular fixation without suspension experienced no surgical complications.

One hundred closed head injuries associated with facial fractures treated over a 78-month period at a level I trauma center in Northeast Ohio were reviewed. The incidence of closed head injury in patients with facial fractures was 17.5%. Males suffered closed head injuries four times more often than females, and sustained severe intracranial injuries eight times as often. The 16- to 30-year age group predominated (59%). Although motor vehicle accidents were the most frequent cause of injury (61%), motorcycle accidents were associated with the most severe head injury. The mandible/midface fracture ratio (1.3:1) was almost half that of the non-head-injured population (2.1:1). Facial fracture complications were found to have a similar incidence (14%) as in the non-head-injured population, but were associated with more severe intracranial injuries.

Over a period of 2 years, 363 patients who had sustained a total of 438 midfacial fractures due to blunt trauma received a full ophthalmological examination within 1 week of injury. Of these, 72 patients (19.8%) developed diplopia. Diplopia was most common following road traffic accidents (31%) and least common with simple falls (10%). Blow-out fractures of the orbit led to double vision in 58% of cases. Eighty two percent of patients recovered from diplopia within 6 months of injury; only 1 patient required squint surgery for double vision. The principal risk factors for diplopia comprise road traffic accidents, blow-out fractures and comminuted malar fractures. Early surgical reconstruction of midfacial fractures with conservative management of concomitant motility disorders has, in our series, resulted in very few patients having diplopia in the long term.

The proper diagnosis of ocular emergencies is usually straightforward since the patient generally can communicate the nature and circumstances of the injury. However, the mental status of the patient occasionally may seriously complicate obtaining an accurate history of the trauma. This may be particularly important when the patient has been physically abused by a relative. Ectopia lentis is a possible consequence of trauma. The elderly patient herein presented suffered ectopia lentis and had evidence of other systemic trauma. The proper management of a patient of this type will be discussed.

Cervical spine fractures are a serious complication of maxillofacial trauma because of the high potential for mortality and neurologic morbidity. This study reviewed 563 patients with facial fractures treated by the Division of Oral and Maxillofacial Surgery at a level I trauma center and identified 11 concomitant cervical spine fractures (2.0%). These patients were almost exclusively male (91%), white (100%), between 20 and 35 years of age (64%), involved in a motor vehicle accident (91%), with a concomitant mandibular fracture (91%). The examination, diagnosis, and management of patients with cervical spine injuries are discussed.

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.

The retrospective examination of 70 patients who had suffered fractures in tooth-bearing segments of the maxilla and the mandible when they were between one and twelve years old revealed a high incidence of late pathologic changes (in 39 out of 70). Disorders in odontogeny, eruption of the teeth and occlusion were observed. Primary and secondary loss of teeth did also occur. Our results show the necessity to inform both the young patients and their parents about the high incidence of late changes after jaw fractures in childhood. An effective recall-system is required in order to diagnose and treat such changes as soon as possible.

Fracture of the left maxillary tuberosity during surgical extraction of multiple teeth, involving the maxillary sinus and pterigomaxillary fossa in a male patient with classic hemophilia due to factor VIII deficiency, is reported. The subject was treated by a private dentist and afterwards admitted at the Oral and Maxillofacial Surgery unit of the "20 de Noviembre" Hospital, ISSSTE, where extraction was completed and the fracture detected at surgery. The patient was then referred to Hematology and substitute therapy of factor VIII for two weeks was prescribed but, eventually, persistent bleeding led to suturing the external carotid.