Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
The subject of Maxillofacial fractures is 
broad enough that it deserves its own chapter, as we 
have done here. However, fractures of the facial 
skeleton rarely exist without facial lacerations of 
some kind. These are addressed in a separate chapter; 
realistically you will be addressing both at the same 
time.  
Patients with both mandibular and maxillary 
fractures are especially challenging- it can be 
difficult to restore dental occlusion, and the danger 
of palate fistula or other complications is higher. As 
you begin to care for patients with facial fractures, 
approach these “combined” fractures very carefully; 
refer them if you can until you have some experience 
with each type individually.  
Remember that there is a frequent association 
between facial trauma, cervical spinal trauma, and 
head injury. It is common practice to empirically 
immobilize the patient’s cervical spine with a soft but 
rigid collar (“Philadelphia”) until cervical spine 
injury has been ruled out.  
Here, we discuss the relevant anatomy and 
diagnostic maneuvers to classify a midface fracture. 
Each separate operation is then considered in its own 
chapter.  
 
Anatomy:  
The skin and nerves, lips, salivary glands and 
ducts are considered in the chapter on facial 
lacerations and injuries. Lacerations of the eyelids 
are considered in their own chapter. The globe and 
orbit are so inter-related that they will both be 
considered here. 
When evaluating patients with facial injuries, 
it is crucial to understand the anatomy of the maxilla, 
zygoma, naso-orbito-ethmoid complex and the 
junction of these with the frontal bones.  
The midface can be conceptually pictured as 
a series of pillars, providing support and resisting 
injury, with very thin-walled spaces in between, 
filled with air or vital structures.  
The largest air-filled space is the maxillary 
sinus. Its anterior and superior walls are paper-thin 
providing little structural support. The anterior 
aspects of its medial and lateral walls, on the other 
hand, are quite thick and serve to connect the hard 
palate and the upper teeth to the rest of the midface.  
 
The maxillary sinuses (Light Blue) are air-filled spaces in the 
midface. Their anterior walls (including the foramena of the 
infraorbital nerves) and inferior walls (the orbital floors) are 
made of very thin bone which provides little structural support. 
The thickened portions of the zygoma (surrounded by dotted 
lines) are very thick: fractures rarely pass through these areas. 
 
 
Keeping the maxillary sinuses in mind, we 
can think of a series of “pillars” in the intact midface 
where the structural support is strongest. Fractures 
commonly pass through these areas. They are also 
called “buttresses,” after the support structures of a 
building. Understanding where these buttresses are 
located allows us to communicate types of fractures, 
plan management, and to anticipate complications.  
 
The buttresses of the midface, anterior view. These are the 
areas where fractures occur:  
 
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The buttresses of the midface, left lateral view. These are the 
areas where fractures occur  
 
Fracture Patterns 
 
With an understanding of the buttresses, we 
are well prepared to consider the typical fracture 
patterns and their classification.  
 
A 
LeFort 
1 
fracture 
includes 
the 
Nasomaxillary and Zygomaticomaxillary buttresses. 
It can occur bilaterally or unilaterally; if unilateral 
there must also be a vertical fracture through the 
maxilla, extending into the hard palate.  
LeFort 1 fractures occurring alone are 
somewhat less usual than LeFort 2 and 3 fractures. 
This is because trauma to the midface will usually 
involve the zygoma as well, as it protrudes farther 
and is more easily struck and displaced.  
 
LeFort 1 fracture (Dotted Line) passes through the 
Zygomaticomaxillary and Nasomaxillary buttresses. If the 
fracture is displaced, the patient will have malocclusion of the 
teeth. 
 
 
A LeFort 2 fracture is a “pyramid” shaped 
fracture of the midface, passing through the 
Zygomaticomaxillary buttress, the Inferior Orbital 
Rim, and the Frontonasal Buttresses. It is common 
for the nasomaxillary buttress to be fractured as well 
when the midface sustains enough force to cause a 
LeFort 2 fracture.  
 
A common complication with this type of 
fracture is orbital floor blowout and entrapment of 
the periorbital fat, with limitation of eye movement 
on the side of injury. Detection of this syndrome is 
described further below.  
 
LeFort 2 fracture (Dotted Line) passes through the 
Zygomaticomaxillary buttress, the Inferior Orbital Rim, and the 
Frontonasal buttresses. 
 
 
A LeFort 3 fracture is a complete dissociation 
of the midface from the skull. It would be extremely 
rare for a patient to have these fractures alone: 
usually this will exist concurrently with the LeFort 2 
pattern. If the patient sustains a strong enough impact 
to the midface to detach it from the skull, it is not 
uncommon for most, or even all, of the other 
buttresses to be fractured as well.  
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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LeFort 3 fracture (Dotted Line) passes through the Lateral 
Orbital Rims and the Frontonasal Buttresses. Usually there will 
be other midface fractures as well.  
 
 
A Zygomaticomaxillary complex fracture, 
sometimes called a “ZMC fracture,” is caused by a 
strong impact to the cheekbone. As above, the 
zygoma itself is very thick and strong, so the 
fractures are usually through its connections to the 
rest of the midface. A fracture of the orbital floor is 
always present with this fracture; sometimes the 
orbital floor contents will be entrapped and eye 
movement will be limited, as explained further 
below. The volume of the orbit itself will be changed, 
resulting in exophthalmos (outward protrusion of the 
eye) or enophthalmos (eye sunken inwards). 
 
Left Zygomaticomaxillary Complex fracture, anterior view. 
Fractures are through the attachments of the zygoma to the 
midface: the Lateral Orbital Rim, the Inferior Orbital Rim, the 
Zygomaticomaxillary Buttress, and the Zygomatic Arch (not 
shown.)  
 
Left Zygomaticomaxillary Complex fracture, lateral view. 
Fractures are through the attachments of the zygoma to the 
midface: the Lateral Orbital Rim, the Inferior Orbital Rim, the 
Zygomaticomaxillary Buttress, and the Zygomatic Arch. 
 
A Naso-Orbital-Ethmoid Complex fracture, 
sometimes called a “NOE Fracture” is caused by a 
strong impact to the bridge of the nose. This fracture 
is relatively rare in isolation, but it is common for the 
NOE complex to be displaced separately in a patient 
with a LeFort 2 fracture. Reducing this fracture will 
be key to normal function of the nose (breathing and 
smell) and appearance of the space between the eyes.  
 
Naso-Orbital-Ethmoid complex fracture, anterior view. 
Fractures are through the Frontonasal buttress, the inferior 
orbital rim, and the Nasomaxillary buttress. Note that there 
may also be a vertical fracture through the nasal bridge, which 
would lead to abnormal widening of the space between the eyes, 
also called “telecanthus.”  
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Principles:  
History 
 
The mechanism of injury can be very helpful 
in determining they type of fracture. A single blow 
to the face, sustained during an assault, is usually not 
enough to cause a LeFort fracture, although a 
Zygomaticomaxillary Complex fracture could easily 
result. Similarly, if the patient was struck from 
behind and lost consciousness while standing, a 
ZMC or mandible fracture is usually the result rather 
than a more severe LeFort fracture.  
 
Patients will complain of malocclusion if 
asked specifically, “Do you feel like your teeth fit 
together normally?” They may also complain of 
diplopia, sometimes after swelling has gone down 
enough for them to see again through both eyes.  
 
Physical Examination 
 
As always, trauma patients must be examined 
systematically with attention to the airway, breathing 
and circulation first. Most patients with maxillofacial 
fractures will not have airway compromise, but if 
they do, do not hesitate to intubate them (see Airway 
Management in Trauma.) Be prepared for a difficult 
airway, especially if the trauma occurred several 
hours previously. Do not attempt to nasally intubate 
anyone who has a mobile maxilla, as they may have 
a basilar skull fracture. (For similar reasons, do not 
insert a nasogastric tube.) 
 
A 
careful 
physical 
examination, 
supplemented with well-performed plain x-rays, can 
help you determine which fracture patterns are 
present without a CT scan. The key is to understand 
the anatomy and fracture patterns described above, 
and then carefully detect fractures in their usual 
locations.  
 
Start with one hand on the dome of the skull 
and the other grasping the maxillary teeth. Try to 
gently move them. If they move, try to determine 
whether they all move together, or whether the left 
and right maxilla move separately. Dental trauma can 
make this assessment confusing; try to assess the 
bone of the alveolar ridge, beneath the gingiva, rather 
than the teeth themselves.  
 
Assess the maxilla for mobility by holding the skull firmly with 
one hand and attempting to move the maxillary teeth with the 
other. 
 
 
Systematically assess all of the maxilla for mobility by grasping 
the bone of the alveolar ridge itself, rather than the teeth, which 
may move if injured even in the absence of a bony fracture. 
 
 
Next, stick your finger inside the mouth on 
the upper gingivolabial sulcus, the recess between 
the 
upper 
lip 
and 
the 
gums. 
Feel 
the 
Zygomaticomaxillary and Nasomaxillary buttresses. 
You may feel a step-off here, or elicit tenderness 
when you palpate a fracture line.  
 
If you have a mobile maxilla with tenderness 
in the gingivolabial sulcus, you have a LeFort 
fracture of some kind. If the maxilla is not mobile 
and the gingivolabial sulcus is tender on only one 
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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side, the patient probably has a Zygomaticomaxillary 
Complex fracture. 
 
Assess the nasomaxillary buttress by inserting your finger into 
the gingivolabial sulcus, just lateral to the midline. 
 
 
Assess the Zygomaticomaxillary buttress by sliding your finger 
laterally from the nasomaxillary buttress, to find the curve of 
the bone that unites the tooth-bearing maxilla and the 
cheekbone. 
 
 
Palpate the Zygomaticomaxillary buttress, in the area shown 
by the Black arrow. If you feel tenderness or a deformity here 
and the maxilla is not mobile, the patient has a 
Zygomaticomaxillary complex (ZMC) fracture (Left). If you 
palpate tenderness or a deformity and the maxilla is mobile, 
likely the patient has a LeFort 1 or 2 fracture (LeFort 2 is 
shown on the Right.) In the latter case, you will feel tenderness 
or a stepoff on the right zygomaticomaxillary buttress as well. 
 
 
Now, go to the bridge of the nose. If it is 
tender, has crepitance, or has a deformity, and the 
patient has a mobile maxilla, they have a LeFort 2 or 
3 fracture. If they have tenderness or deformity of the 
nose without a mobile maxilla, they have a nasal 
fracture or 
a Naso-Orbito-Ethmoid Complex 
fracture.  
 
Once you have established whether the maxilla is mobile, 
palpating the bridge of the nose will allow you to determine 
whether the fracture involves this structure, as explained 
further below. 
 
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
In a patient with a mobile maxilla, you can tell the difference 
between a LeFort 1 fracture (Left) and a LeFort 2 fracture 
(Right) by whether the bridge of the nose is tender or deformed. 
If the bridge of the nose is deformed or tender without a mobile 
maxilla, they have a fracture of the nasal bone or naso-orbito-
ethmoid complex.  
 
 
Try to palpate the inferior orbital rim: you 
may feel a discontinuity, indicating either a LeFort 2 
or a ZMC fracture. Numbness of the skin below the 
eye is a subtle sign of an inferior orbital rim fracture, 
passing through the foramen of the infraorbital nerve.  
 
Palpate the central part of the inferior orbital rim, the part 
which is usually affected by fracture. You can feel a stepoff, a 
discontinuity in the bone, if there is a fracture. After palpating 
the bone, gently brush this area. If the patient is insensate here, 
it strongly suggests a fracture passing through the infraorbital 
foramen, pinching the nerve.  
 
 
Now palpate the lateral orbital rim: 
crepitance, a deformity, or tenderness here indicates 
a lateral orbital rim fracture. If the maxilla is not 
mobile, a fracture here is likely part of a 
Zygomaticomaxillary Complex fracture. If the 
maxilla is mobile, the patient has a LeFort 3 fracture.  
 
Palpate the lateral orbital rim, which is very close to the skin 
here. A fracture with displacement can be felt as a “step off.” 
If there is no displacement, tenderness here suggests a 
nondisplaced fracture. Note that this patient grimaces when 
pressure is applied here.  
 
 
If you feel tenderness or deformity of the lateral orbital rim 
(Black arrow) the patient may have a Zygomaticomaxillary 
complex fracture (left) or a LeFort 3 fracture (right.) Note that 
a patient with a LeFort 3 fracture will almost always have other 
fractures of the maxilla or zygoma: the fracture will never be in 
only the straight dotted line shown here.  
 
 
Palpate the Zygomatic arch, as it can be 
fractured alone, or as part of a Zygomaticomaxillary 
Complex fracture. On rare occasions, a depressed 
Zygomatic arch fracture will contact the coronoid 
process of the mandible and prevent the patient from 
closing their mouth (although inability to close the 
mouth can also indicate mandibular condyle fracture 
or dislocation.)  
 
Inspect the eyes and the orbits, comparing 
them to each other. Bear in mind the effect that a 
fracture will have on the overall volume of the orbit, 
as shown here:  
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The orbit is shaped like a cone, with the globe (eyeball) floating 
inside it. A fracture that causes an increase in the cone’s volume 
(top images) will cause a “sunken eyeball” (enophthalmos) as 
the globe moves in the direction shown by the arrow. A fracture 
that causes a decrease in the cone’s volume (bottom images) 
will cause protrusion of the globe, a “bulging eyeball” 
(exophthalmos) as the globe moves in the direction shown by 
the arrow.  
 
 
Comparing both cheekbones and zygomatic arches, by 
inspection and palpation, will show deformity and asymmetry. 
In this case, the left cheekbone is depressed inferiorly and 
laterally, with resulting enophthalmos of the left eye and 
downward and lateral tension of the left eyelids. Source: 
https://doi.org/10.1007/978-981-15-1346-6_56  
 
 
Inspecting the face from inferiorly allows you to compare the 
eyes for degrees of protrusion, caused by loss or increase of 
volume in the orbit. In this case, the right eye protrudes 
(exophthalmos), likely due to a fracture involving the 
zygomaticomaxillary complex that has decreased the orbit’s 
volume. Source: 
https://doi.org/10.1007/978-981-15-1346-6_56  
 
A more dramatic example seen using the same inspection 
technique as above. The left eye is sunken into its orbit 
(enophthalmos) likely due to a fracture involving the 
zygomaticomaxillary complex that has increased the orbit’s 
volume. Note also that the patient is attempting to look 
upwards, but his left eye is unable to, likely due to periorbital 
fat entrapment by a fracture in the orbital floor. This is 
discussed further below. Source:  
https://doi.org/10.1007/978-981-15-1346-6_56  
 
 
Next, assess the eye movements. These 
maneuvers require a cooperative patient: in a 
comatose, or even a confused and combative patient, 
you may not be able to perform them. In the first few 
days after the operation, you may need to hold the 
affected eyelid open.  
 
Ask the patient to follow your finger with 
their eyes and move your finger so that they look to 
the right and left, upwards and downwards. At the 
extremes, especially up and to the side, ask if they 
see one finger or two. In cases of mild entrapment, 
the patient’s eyes will seem to move symmetrically 
but they will have diplopia when looking upwards or 
downwards to one or both sides. With severe 
entrapment, the affected eye will be unable to look 
either upwards or downwards at all. (Both mild and 
severe entrapment must be corrected surgically.)  
 
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Patient with entrapment of the periorbital fat of the left eye 
within a fracture of the orbital floor. Top: The left eye is unable 
to look all the way to the left. Middle” The left eye is unable to 
look simultaneously down and to the left. Bottom: The left eye 
is unable to look upwards and to the left.  
 
 
Long-term effects of untreated periorbital fat entrapment of the 
right eye, patient is attempting to look upwards. As seen here, 
the brain has started to ignore the input from that eye and the 
lid has closed- the examiner is holding it open. The patient also 
has a traumatic cataract of the right eye. 
 
 
The forced duction test can be done in an awake and 
cooperative patient after administering topical anesthetic to the 
affected eye. It can also be done while the patient is under 
general anesthetic. Grasp the conjunctiva right where it meets 
the sclera and try to rotate the eye upwards; if there is 
entrapment of the periorbital fat, you will be unable to do this. 
Avoid causing an abrasion to the cornea while performing this 
maneuver. Source:  
https://doi.org/10.1007/978-981-15-1346-6_56  
 
 
In all of your examinations, try to determine 
whether the fracture is mobile, or whether there is 
associated deformity. If the fracture is completely 
nondisplaced, the patient will have tenderness at all 
of the fracture sites, and may have numbness in the 
distribution of the infraorbital nerve, but they will 
have no other malfunction. Their occlusion will be 
normal, their extraocular movements will be intact, 
and their cheekbones will be symmetrical. A non-
displaced midface fracture with normal dental 
occlusion does not require surgical treatment.  You 
should follow such patients closely for the next 
several weeks, however, as the action of the masseter 
muscle may pull the zygoma and zygomatic arch 
downwards over time.  
 
Imaging 
 
After a careful examination of the midface, 
applying the knowledge and principles explained 
above, you should have a good idea of where the 
fractures are. Plain x-rays can supplement and 
confirm your suspicions and help you plan your 
surgical repair.  
 
A plain anteroposterior x-ray of the skull 
does not help much. The occipital bone overlaps with 
the areas of interest. The Waters View x-ray frames 
the maxilla and zygoma inside of the skull, removing 
any other structures from the picture.  
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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In the Waters view of the skull, the x-ray beam passes through 
the midface but not through the bones of the skull itself, 
allowing these structures to be seen individually. The patient is 
positioned such that a line between the meatus of the ear and 
the chin (meato-mental line, dotted Red line) is perpendicular 
to the x-ray plate. In this position, the nose is about 3-4cm from 
the x-ray plate; if both the chin and the nose are touching the 
x-ray plate, the view will be inadequate.  
 
 
Normal Waters View x-ray with superimposed buttresses shown 
in Red. Case courtesy of Dr Bálint Botz, From the case 
https://radiopaedia.org/cases/63083?lang=us  
 
 
Waters View x-ray shows a left Zygomaticomaxillary Complex 
fracture. A fracture is clearly seen involving both the inferior 
orbital rim and the zygomaticomaxillary buttress (Blue circle) 
with another fracture through the medial inferior orbital rim 
(Red circle.) Another fracture of the lateral orbital rim (Black 
circle) is also seen. The fluid-filled left maxillary sinus provides 
another clue that there is injury in this area- compare it with 
the clear, normal appearance of the right maxillary sinus. Case 
courtesy of Dr Derek Smith, From the case 
https://radiopaedia.org/cases/35549?lang=us  
 
Decision Making: 
There are two major indications for surgery 
on a maxillofacial fracture: restoration of function 
and improvement of cosmesis. The following 
principles arise out of these indications:  
• Retrobulbar hematoma is a surgical emergency 
that is usually diagnosed at CT scan. The 
treatment is lateral canthopexy and inferior 
canthotomy. As the operation is relatively minor, 
it should be done as soon as possible if you 
suspect this injury. The diagnosis and treatment 
are described in another chapter of this Manual.  
• Fractures causing entrapment of the periorbital 
fat should be repaired as soon as possible, within 
1-2 days. Extraocular muscles may also be 
entrapped and become damaged if not released.  
• All fractures of the mandible should be treated, 
even if nondisplaced: forces exerted on the 
mandible by the masseter and pterygoid muscles 
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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assure that all fractures will result in dental 
malocclusion. 
• All fractures of the maxilla causing malocclusion 
should be treated: if there is no significant 
midface deformity, it may be enough to perform 
open reduction of the fractures and then place the 
patient in intermaxillary fixation.  
• Patients in impoverished areas will often refuse 
surgery if they understand that it is only for 
“cosmetic” reasons. However, the deformities 
caused by LeFort 2, 3, and Zygomaticomaxillary 
Complex fractures are significant. These become 
apparent only after all the swelling has gone 
down and the resultant facial asymmetry and 
enophthalmos or exophthalmos are seen.  
 
 
Repair of maxillofacial fractures is never an 
emergency, except in case of proven or suspected 
retrobulbar hematoma. If a fracture can easily be 
repaired during closure of the laceration, you may do 
so. We have seen this only a few times: usually the 
fracture is so extensive that the best approach is to 
wash out and close the laceration during initial 
management of the patient. Facial fracture repair can 
be done up to two weeks later; the usual timing is 3-
5 days after trauma, to allow edema to subside. This 
interval also allows the patient to stabilize and other 
necessary investigations to be done.  
 
An inferior orbital rim fracture after reduction and fixation 
through a facial laceration. The infraorbital nerve is shown by 
the Black arrow. The laceration had been closed poorly, so the 
surgeon was able to redo the closure at the same setting. This 
patient had both a LeFort2 and Zygomaticomaxillary complex 
fracture.  
 
Not infrequently, a patient will have both 
maxillofacial fractures and severe head injury. When 
this occurs, it is reasonable to wait and see how much 
the patient will recover. Before two weeks have 
passed, it should be clearer whether the patient will 
recover- you can operate if they seem to be 
improving.  
Facial lacerations that have been closed can 
be re-opened during open reduction and internal 
fixation of facial fractures, if doing so allows the 
surgeon to avoid making other incisions on the face 
to access the fractures. These incisions are described 
in depth in the specific chapters on fracture repair.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
November 2024 
Approach to Maxillofacial Fractures Part 1: Midface 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Resource-Rich Settings 
Surgeons in resource-rich settings have a number of 
advantages, especially the ability to refer patients with facial 
fracture to specialists in this field. Other advantages include:  
• 
CT scan with 3-dimensional reconstruction allows 
preoperative 
planning, 
including 
calculating 
the 
postoperative volume of the orbit to minimize 
postoperative exophathalmos or enophthalmos  
• 
Titanium plates and miniplates, ultrathin titanium mesh, 
screws, and other material to assist in the reconstruction 
• 
3D printing of the skull as it will be after reconstruction, 
allowing 
preoperative 
cutting 
and 
bending 
of 
reconstructive plates to the exact dimensions needed. 
• 
Specialist dentists and prosthodontists to create dentures 
or implants to be used during and after the healing 
process.  
 
 
CT scanning with three-dimensional reconstruction makes it 
very easy to diagnose facial fractures. As a result, the 
diagnostic maneuvers described here are becoming a “lost 
art” in Resource-Rich settings. Source: Coronation Dental 
Specialty Group, CC BY 3.0 via Wikimedia Commons 
 
Without these advantages, and especially if you are self-taught 
in this field, your outcomes will not be as good as they would 
be in the hands of a specialist. But if you do nothing at all, the 
patient will be much worse off, possible unable to eat, see out 
of the affected eye, and with a very noticeable deformity.  
