Executive Editor: Edward Ellis III, Kazuo Shimozato General Editor: Daniel Buchbinder

Authors: Carl-Peter Cornelius, Nils Gellrich, Søren Hillerup, Kenji Kusumoto, Warren Schubert, Stefano Fusetti, Coauthors: Enno-Ludwig Barth, Harald Essig

Midface

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Glossary

Le Fort I, linear fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally mobile Le Fort I fractures with unaffected occlusion in compliant patients with good dentition. Basic surgical experience, no specialized skills Basic equipment only
Closed treatment Non- or minimally displaced fractures in a compliant patient amenable to MMF. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation Mobile maxillae with resulting malocclusion in cases where vertical restoration of one or more of the buttresses are indicated. Some specialized surgical experience Simple surgical and imaging resources

Le Fort I, unilateral comminution

Please select a treatment option:
Treatment Main indication Skill Equipment
Closed treatment Unilateral fractures in patients with minor malocclusion correctable with maxillary disimpaction in compliant patients amenable to MMF. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation Unilateral comminuted fractures where vertical restoration of the buttress is required. Some specialized surgical experience Simple surgical and imaging resources

Le Fort I, bilateral comminution

Please select a treatment option:
Treatment Main indication Skill Equipment
Open reduction internal fixation Bilateral comminuted fractures where vertical restoration of the buttress is required. Some specialized surgical experience Simple surgical and imaging resources

Le Fort I, edentulous patients

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Standard treatment of edentulous patients with atrophic maxilla. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation Malposition of the fractured maxilla resulting in inadequate support to wear prosthesis. Some specialized surgical experience Simple surgical and imaging resources

Le Fort II

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally mobile Le Fort II fractures with unaffected occlusion in compliant patients with good dentition. Basic surgical experience, no specialized skills Basic equipment only
Closed treatment Non- or minimally displaced fractures in a compliant patient amenable to MMF. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation Displaced Le Fort II fractures resulting in malocclusion or facial deformity. Some specialized surgical experience Simple surgical and imaging resources

Le Fort III

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally mobile Le Fort III fractures with unaffected occlusion in compliant patients with good dentition. Basic surgical experience, no specialized skills Basic equipment only
Closed treatment Non- or minimally displaced fractures in a compliant patient amenable to MMF. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation Displaced Le Fort III fractures resulting in malocclusion or facial deformity. Some specialized surgical experience Simple surgical and imaging resources

Palatoalveolar fracture, simple injury

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally displaced fractures in a compliant patient with good occlusion. Basic surgical experience, no specialized skills Basic equipment only
Closed treatment Non- or minimally displaced fractures in a compliant patient amenable to MMF. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation When MMF alone is unable to prevent splaying of the segments and a palatal splint is not available. Some specialized surgical experience Simple surgical and imaging resources

Palatoalveolar fracture, complex injury

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Rarely indicated in complex injuries. Basic surgical experience, no specialized skills Basic equipment only
Closed treatment Severely comminuted fractures difficult to fix adequately with plates and screws without compromising the blood supply to the comminuted segments. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation When MMF alone is unable to prevent splaying of the segments and a palatal splint is not readily available. Some specialized surgical experience Simple surgical and imaging resources

Nasal bone

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non-displaced fractures without nasal deformities or airway obstruction. Basic surgical experience, no specialized skills Basic equipment only
Closed reduction Displaced, unilateral or bilateral, nasal bone fractures. Basic surgical experience, no specialized skills Basic equipment only
Open reduction Unstable or dislocated nasal bone fractures. Some specialized surgical experience Simple surgical and imaging resources
Septorhinoplasty Persistent septal deformity leading to external nasal deformity and/or airway obstruction. Some specialized surgical experience Simple surgical and imaging resources
Nasal septal hematoma drainage Emergent procedure to evacuate septal hematoma preventing necrosis of the cartilage. Basic surgical experience, no specialized skills Basic equipment only

NOE Type I

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally displaced fractures without telecanthus. Basic surgical experience, no specialized skills Basic equipment only
Open reduction internal fixation Clinically significant displacement of the fracture results in telecanthus or malposition of the medial canthal ligament. Some specialized surgical experience Simple surgical and imaging resources

NOE, Type II

Please select a treatment option:
Treatment Main indication Skill Equipment
Open reduction internal fixation Clinically significant displacement of the fracture results in telecanthus or malposition of the medial canthal ligament. Some specialized surgical experience Simple surgical and imaging resources

NOE, Type III

Please select a treatment option:
Treatment Main indication Skill Equipment
Open reduction internal fixation Clinically significant displacement of the fracture resulting in telecanthus or malposition of the medial canthal ligament. Some specialized surgical experience Full specialized surgical and imaging resources

Orbit, orbital floor fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally displaced fractures without orbital deformity and intact ocular motility. Basic surgical experience, no specialized skills Basic equipment only
Open reduction with or without internal fixation Indicated for the rare cases where the reduced fracture segment is stable. Some specialized surgical experience Simple surgical and imaging resources
Orbital reconstruction Standard method of treatment for the repair of critical sized orbital wall defects. Some specialized surgical experience Simple surgical and imaging resources
Orbital reconstruction, CAS: Intraoperative imaging Ideal method for control of treatment for the repair of critical sized orbital fractures, when intraoperative imaging is available. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Orbital reconstruction, CAS: Virtual planning and intraoperative navigation Ideal method for control of treatment for the repair of critical sized orbital fractures, when intraoperative navigation equipment is available. Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Orbit, medial orbital wall fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally displaced fractures without orbital deformity and intact ocular motility. Basic surgical experience, no specialized skills Basic equipment only
Orbital reconstruction Standard method of treatment for the repair of critical sized orbital wall defects. Some specialized surgical experience Simple surgical and imaging resources

Orbit, combined fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally displaced fractures without orbital deformity and intact ocular motility. Basic surgical experience, no specialized skills Basic equipment only
Orbital reconstruction Standard method of treatment for the repair of critical sized orbital wall defects. Some specialized surgical experience Simple surgical and imaging resources

Orbit, orbital roof fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Observation Non- or minimally displaced fractures without orbital deformity and intact ocular motility. Basic surgical experience, no specialized skills Basic equipment only
Open treatment Critical sized fractures affecting ocular motility or resulting in orbital deformity. Some specialized surgical experience Simple surgical and imaging resources

Zygoma, isolated zygomatic arch

Please select a treatment option:
Treatment Main indication Skill Equipment
Closed treatment Displaced fracture amenable for minimally invasive reduction techniques. Some specialized surgical experience Basic equipment only
Open reduction without fixation Displaced fractures resulting in impingement of the coronoid process and/or facial deformities. Some specialized surgical experience Simple surgical and imaging resources
Open reduction with fixation Displaced unstable fractures resulting in impingement of the coronoid process and/or facial deformities requiring reduction and fixation. Some specialized surgical experience Simple surgical and imaging resources
CAS: Intraoperative imaging in closed treatment Whenever post reduction control imaging is available. Some specialized surgical experience Full specialized surgical and imaging resources

Zygoma, zygomatic complex fracture

Please select a treatment option:
Treatment Main indication Skill Equipment
Closed treatment Displaced fracture amenable for minimally invasive reduction techniques such as bone hook or a Carroll-Girard type screw. Some specialized surgical experience Basic equipment only
ORIF, 1-point fixation (without orbital reconstruction) Displaced simple noncomminuted fracture with minimal separation of zygomaticofrontal suture. Some specialized surgical experience Simple surgical and imaging resources
ORIF, 2-point fixation (without orbital reconstruction) Displaced fracture requiring 2-point exposure to verify reduction. Some specialized surgical experience Simple surgical and imaging resources
ORIF, 3-point fixation (without orbital reconstruction) Displaced and/or comminuted fracture requiring 3-point exposure to verify reduction. Some specialized surgical experience Simple surgical and imaging resources
ORIF, 3-point fixation (with orbital reconstruction) Displaced and/or comminuted fracture requiring 3-point exposure to verify reduction and need for orbital reconstruction. Some specialized surgical experience Full specialized surgical and imaging resources
ORIF, 4-point fixation (with orbital reconstruction) Complex zygomatic fractures where exposure of the zygomatic arch (4th point) is necessary to ensure proper reduction of the zygomatic complex. Some specialized surgical experience Full specialized surgical and imaging resources
CAS: Intraoperative imaging (ORIF without orbital reconstruction) Any zygomatic fracture benefits from intraoperative CT scanning to confirm fracture reduction. Some specialized surgical experience Full specialized surgical and imaging resources
CAS: Virtual planning and intraoperative imaging (ORIF without orbital reconstruction) Zygomatic fractures that have a significant amount of displacement, with or without internal orbital disruption, benefit from virtual planning. Some specialized surgical experience Full specialized surgical and imaging resources
CAS: Virtual planning and intraoperative imaging (ORIF with orbital reconstruction) Zygomatic fractures that have a significant amount of displacement, with internal orbital disruption benefit from virtual planning. Some specialized surgical experience Full specialized surgical and imaging resources
CAS: Virtual planning and intraoperative navigation (ORIF with orbital reconstruction) Zygomatic fractures that have a significant amount of displacement, with internal orbital disruption, benefit from virtual planning and intraoperative navigation. Some specialized surgical experience Full specialized surgical and imaging resources

Special considerations

Airway considerations
Panfacial fractures (sequencing of repair)
Computer assisted surgery - Zygomatic arch
Intraoperative imaging (closed reduction)
Computer assisted surgery - Zygomatic complex
Intraoperative imaging
Virtual planning and intraoperative imaging
Computer assisted surgery - Orbit
Intraoperative imaging
Virtual planning and intraoperative navigation
Computer assisted surgery - Zygomatic complex and orbit
Virtual planning and intraoperative imaging
Virtual planning and intraoperative navigation
Computer assisted surgery - Gunshot
Virtual planning and intraoperative navigation
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2009-12-03