**3.4. Naso-orbital-ethmoid (NOE) fractures**

### *3.4.1. Classification*

According to Markowitz's classification naso-orbital-ethmoid (NOE) fracture is defined as three patterns [20] (**Figure 11**). Type I NOE fracture is defined as single-segment central fragment. This pattern could be in a uni- or bilateral form. The medial tendon is attached to the fractures segment in this pattern. Type II NOE fracture consists of comminuted central fragments external to the medial canthal tendon insertion. In type III fracture the fracture line

**Figure 10.** Titanium meshwork plate is used to reconstruct the orbital floor defect.


**Table 1.** Materials available for orbital reconstruction.

Timing of orbital reconstruction is categorized into three groups of immediate categories: within 24 h, early (between first and day 14), and delayed (after 2 weeks) [18]. When the reason of diplopia is muscle entrapment immediate reconstruction of the orbit is advocated by the investigators. Blow-out fracture in young patients is the other indication for immediate repair. Early orbital reconstruction is advocated by some surgeons in cases of early enophthalmus and symptomatic diplopia with positive forced duction test. Early reconstruction should also be considered in cases with large orbital wall defects (more than 50% defects). Symptomatic diplopia with negative force duction test and late-onset enophthalmus are indi-

Decision-making on the ideal material for orbital reconstruction is based on the surgeon's experience, cost, defect size, and medical history (**Figure 10**) [19]. The available material and

According to Markowitz's classification naso-orbital-ethmoid (NOE) fracture is defined as three patterns [20] (**Figure 11**). Type I NOE fracture is defined as single-segment central fragment. This pattern could be in a uni- or bilateral form. The medial tendon is attached to the fractures segment in this pattern. Type II NOE fracture consists of comminuted central fragments external to the medial canthal tendon insertion. In type III fracture the fracture line

cations for delayed orbital reconstructions [18].

their pros and cons are categorized in **Table 1**.

**Figure 10.** Titanium meshwork plate is used to reconstruct the orbital floor defect.

**3.4. Naso-orbital-ethmoid (NOE) fractures**

*3.4.1. Classification*

62 Trauma Surgery

**Figure 11.** Naso-orbital-ethmoid fracture types. A, type I Naso-orbital-ethmoid fracture. B, type II naso-orbital-ethmoid fracture. C, type III naso-orbital-ethmoid fracture.

**Figure 12.** Signs in a patient with naso-orbital-ethmoid fracture. Rounding of the left medial canthus (arrow) and traumatic telecanthus is obvious in this patient.

extends into the medial canthal insertion segment. The medial canthal tendon either remains

Maxillofacial Fractures: From Diagnosis to Treatment http://dx.doi.org/10.5772/intechopen.76166 65

Epistaxis is a common sign of NOE fracture. Involving the NOE complex in trauma patients results in splayed nasal complex and widened the nasal bridge. In the case of medial canthal tendon detachment or disruption of traumatic telecanthus and medial canthus rounding occurs (**Figure 12**). The intercanthal distance is usually half of the interpupillary distance (average of 28–35 mm in white adults). So when this measure is more than 40 mm or half of the interpupillary distance, the traumatic telecanthus is defined [21]. Bimanual test is a useful

Stabilization of the fractures segment is the only intervention advocated in NOE type I fracture (**Figure 13**A). Stabilizing the central fragment in which the medial canthal tendon is inserted is the treatment of choice in type II fracture (**Figure 13**B). Transnasal wiring simultaneously

Intraoral approach and vestibular incision is the most common technique used in treatment of Le Fort fractures (**Figure 14**). Circum-vestibular incision mesial to the second premolar is used to reach the nasal lateral walls and zygomatic buttresses. As mentioned earlier these buttresses are stable enough to maintain the maxilla at the right position following rigid fixation. Cinch suture and V-Y plasty is necessary when the incision involves the nasalis muscles.

After decision-making of rigid fixation of the Le Fort III fracture, extraoral approaches to the zygomaticofrontal and nasofrontal sutures are applied (**Figure 15**). Bicoronal flap is the common approach to achieve all three sutures by one sing incision. Also this is a good approach in repairing the NOE fracture. The incision is made several centimeters behind the hair line between the upper origins of the temporal muscles from one superior temporal line to the other. Dissection of the flap is performed in the subgaleal plane up to 2 cm above the superior orbital rims. The periosteum is incised at this level and subperiosteal dissection is continued to expose the zygomaticofrontal and nasofrontal sutures. Using a suction drain is optional

When there is no displacement of nasofrontal suture, fixation of zygomaticofrontal sutures is applicable by lateral brow approach. The incision is made almost 2cm parallel to the hair follicles

attached to the central segment or does not.

method in detecting the instability of NOE fracture [22].

with orbital medial wall reconstruction is considered in type III pattern.

**4. Surgical approaches in treatment of mid-face fractures**

*3.4.2. Signs and symptoms*

*3.4.3. Management*

**4.1. Intraoral approaches**

**4.2. Extraoral approaches**

during closure.

**Figure 13.** A, fixation of the type I naso-orbital-ethmoid fracture. B, reconstruction of left type II naso-orbital-ethmoid fracture.

extends into the medial canthal insertion segment. The medial canthal tendon either remains attached to the central segment or does not.

### *3.4.2. Signs and symptoms*

Epistaxis is a common sign of NOE fracture. Involving the NOE complex in trauma patients results in splayed nasal complex and widened the nasal bridge. In the case of medial canthal tendon detachment or disruption of traumatic telecanthus and medial canthus rounding occurs (**Figure 12**). The intercanthal distance is usually half of the interpupillary distance (average of 28–35 mm in white adults). So when this measure is more than 40 mm or half of the interpupillary distance, the traumatic telecanthus is defined [21]. Bimanual test is a useful method in detecting the instability of NOE fracture [22].

### *3.4.3. Management*

Stabilization of the fractures segment is the only intervention advocated in NOE type I fracture (**Figure 13**A). Stabilizing the central fragment in which the medial canthal tendon is inserted is the treatment of choice in type II fracture (**Figure 13**B). Transnasal wiring simultaneously with orbital medial wall reconstruction is considered in type III pattern.
