15 fractures of middle third of face
TRANSCRIPT
Fractures of middle third of face
Instructor – Dr. Jesus George1
Boundaries of middle 1/3 of face
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Superiorly- a line drawn from zygomaticofrontal suture ,across frontonasal suture,frontomaxillary suture.
Inferiorly-occlusal plane of upper teeth. Posteriorly-sphenoethmoidal junction.
Nerve supply & blood supply
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Maxillary branch of trigeminal nerve Maxillary artery & its branches
Bones constituting middle1/3 of face
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2 maxillae 2 palatine bones 2 zygomatic bones 2 zygomatic processes of temporal bone 2 nasal bones 2 lacrimal bones Ethmoid bone 2 inferior conchae 2 pterigoid plates of sphenoid Vomer
Classification
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Lefort I Lefort II Lefort III
Lefort I #
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Also called horizontal # of maxilla or Guerin's # or floating # (separation of dentoalveolar part of maxilla
Fractured fragments are freely mobile Horizontal # line above the apices of teeth Line starts at the point on lateral margin of anterior
nasal aperture above the nasal floor, passes laterally above the canine fossa traverses lateral antral wall, dipping down below the zygomatic buttress across pterigomaxillary fissure & fractures pterigoid lamina at the junction of lower 1/3 & upper 2/3
Usually bilateral
Cont.
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Signs & symptoms Slight swelling & edema of lower part of face
with upper lip swelling Ecchymosis in labial & buccal vestibule Contusion of upper lip Laceration of upper lip & oral mucosa Bilateral epistaxis Mobility of dentoalveolar fragment of upper
jaw Disturbed occlusion Inability to masticate food
Cont.
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Pain while speaking & moving jaw In impacted # upward displacement of entire
fragment & Anterior open bite Percussion of upper teeth – dull cracked up
sound
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Lefort II #
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Pyramidal or subzygomatic # # line runs below the frontonasal suture
crossing the frontal process of maxilla, passes anteriorly across the lacrimal bones anterior to lacrimal canal, then passes downward, forward & laterally crossing inferior orbital margin in zygomatico maxillay suture, then it extends downward, forward & laterally to lateral wall of antrum medial to zygomatico maxillary suture line, then it passess beneath the zygomatic buttress fracturing pterigoid lamina at the midway
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Cont.
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Signs & symptoms Gross edema of middle 1/3 of face giving a moon’s
face appearance Bilateral circumorbital edema & ecchymosis ( black
eye) Bilateral subconjunctival hemorrhage Bridge of nose is depressed If impaction of fragments is there anterior open bite If there is downward & backward displacement of
fragments, elongation & lengthening of face & posterior gagging of occlusion with anterior open bite
Cont.
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Bilateral epistaxis Difficulty in mastication & speech Loss of occlusion Airway obstruction due to posterior
displacement of fragments CSF leak may be seen Step deformity in infraorbital margin Anesthesia or paresthesia of cheek
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Lefort III #
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Also known as high level # Force is in lateral direction Line starts near frontonasal suture, causing
dislocation of nasal bones & disruption of cribriform plate of ethmoid bone tearing dura mater & causing CSF rhinorrhea, then crosses through both nasal bones & frontal process of maxilla, then traverses upper limit of lacrimal bones, then it crosses thin orbital plate of ethmoid bone, it passes through medial orbital wall, then it reaches upper posterior aspect of maxilla & fractures pterigoid lamina at the base
Entire middle 1/3 is separated from cranial base
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Cont.
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Signs & symptoms Gross edema of face Bilateral circumorbital or periorbital ecchymosis Tenderness & separation at frontozyomatic
suture Dish face deformity Enophthalmos Diplopia Temporary blindness or impairment of vision Nasal septal deviation Epistaxis
Cont.
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CSF rhinorrhea
# of zygomatic complex
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Zygomatic bone is closely associated with maxilla, frontal & temporal bones – so they are known as zygomatic complex #
Signs & symptoms Flattening of cheek because of inward
displacement of fragments Unilateral epistaxis Circumorbital ecchymosis Subconjunctival hemorrhage Limitation of ocular movement
Cont.
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Anesthesia of cheek, nose, lip Edema of cheek & eyelids Step deformity in infraorbital margin Limitation of mandibular movement Ecchymosis & tenderness in upper buccal
sulcus Change in sensation of teeth & gum Enophthalmos
Treatment of midface #
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Manual reduction Arch bars are applied on teeth, lower jaw acts
as template In fresh # maxilla is held b/w index finger &
thumb & brought into normal occlusion Row’s disimpaction forceps (used in pairs) one
end in nasal floor & other in hard palate In split palate, Hayton william’s forceps is
applied to buccal aspect of alveolar process & medial compression until 2 jaws are approximated
Cont.
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Reduction by traction Used in delayed cases where the fragments
are not sufficiently mobile Intra oral elastic traction is given to restore
normal occlusion After getting correct occlusion IMF for 3-4
weeks If only slight mobility, & occlusion is not
disturbed progress of healing is supervised, patient is advised to avoid chewing for 2-3 weeks ( soft diet)
Cont.
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Open reduction Circumvestibular incision from 1st molar of one
side to the other side Mucoperiosteal flap is reflected Fragments are mobilized Disimpaction forceps is used & fragments are
brought into normal occlusion IMF is done & fragments are fixed under direct
vision by miniplates or intraosseous wiring
Treatment zygomatic #
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Keen’s approach Buccal vestibular incision is given in 1st & 2nd
molar region behind the zygomatic buttress Curved elevator is passed supraperiosteally
up beneath the zygomatic bone Depressed bone is elevated with upward,
forward & outward movement
Cont.
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If gross separation of zygomaticofrontal suture
Incision is made 1 cm above the outer canthus of eye
Holes are drilled 0.5cm from the fractured ends Intraosseous wiring or miniplates are given Wound is closed in layers Associated coronoid # If coronoid is completely detached & causing
limitaion of mouth opening, it can be excised through intraoral approach
Fractures of mandible
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Introduction
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Largest, heaviest & strongest bone of face Blood supply Inferior alveolar artery Nerve supply Inferior alveolar nerve
Classification
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Body # Condyle # Angle # Dentoalveolar # Symphysis # Ramus # Coronoid # Parasymphysis #
Management
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Closed reduction Presence of teeth provides guidance for reduction Dental wiring or arch bar is used to get the
occlusion IMF for 6 weeks In edentulous patients gunning splint is used Indications Nondisplaced # Grossly displaced # Atrophic edentulous mandible Lack of soft tissue over the # site
Cont.
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# in children with developing tooth buds Coronoid process # Open reduction Indications Displaced # Multiple # Associated midface # Associated condylar #
Cont.
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Contraindications If GA is not advisable Severe comminution or loss of soft tissue Severe infection
Symphysis & parasymphysis #
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Lip is everted & vestibular incision is made Periosteum is reflected & mental nerves are
identified Reduction & plate fixation is done Closure is done in layers Pressure dressing is given to prevent
hematoma
Body, angle & ramus #
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Mucosal incision is made 3-5 mm below mucogingival junction
Incision should not extend beyond mandibularocclusal plane to prevent herniation of buccal pad of fat
Periosteum is reflected & mandible is exposed Reduction & fixation is done Wound is closed in layers
Fractures of mandibular condyle
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Classification No displacement:-a crack is seen. Deviation :-simple angulation exists b/w
condylar neck & ramus. Displacement :-overlap exists b/w condylar
process & ramus. Dislocation :-condylar fragment is pulled
anteriorly & medially.
Cont.
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Clinical features Evidence of trauma in symphysis region. Pain & swelling in the region of tmj. Limitation of oral opening Deviation toawards the involved side on
opening mouth. Posterior open bite on contralateral side. Posterior cross bite on ipsilateral side Blood in external auditory canal. Pain on palpation on # site. Lack of condylar movement on palpation
Cont.
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Difficulty in lateral excursion & protrusion. Anterior openbite &posterior gagging of
occlusion in bilateral subcondylar #. Otorrhoea if there is #of middle cranial fossa. Treatment Nonsurgical management Condylar # without displacement or with min.
displacement, without much occlusal disturbance& functional range of motion-patient is asked to restrict movements & semisolid soft diet for 10 to 15 days
Cont.
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In case of deviation on oral opening without much occlusal discrepancy,simple muscle training
In case wherethe condylar fragment overriding is seen with altration in ramus height,producing malocclusion,initial elastic traction followed by imf is given for 2to3 weeks.
Early mobilization is advocated in young children to avoid ankylosis of tmj.
Cont.
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Surgical management Indications # dislocation in auditory canal or
intracranial fossa. Anterior dislocation with restricted mandibular
movement. Bilateral condylar # with craniofacial dysjunction Method of fixation Temporal region is shaved. The skin over the preauricular region is
prepared. Preauricular incision is made. Zygomatic arch is located.
Cont.
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Inverted L-shaped incision is made from lower boder of zygomatic arch to outer surface of ramus.
If condyle is displaced laterally, periostuem over the condyle is retracted & condylar retractor is inserted from posterior border medially to protect the vital structures.
A hole is drilled through the cortex, &a26 guage wire is passed through the hole.another hole is drilled on the ramus.
Miniplates can also be used. # is reduced & IMF is done. Wound is closed in layers. Immobilization for 15 to 20 days
Management of teeth retained in # line
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Antibiotic therapy Splinting of the tooth if mobile Endontic therapy if needed Immediate extraction # is infected Indication for removal of tooth in # line Longitudinal # involving crown & root Complete subluxation of tooth from the socket Pre –existing periapical pathology Grossly infected # line
Cont.
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Bad periodontal status Advanced caries Root stumps
Complications of maxillofacial injuries
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Anaesthesia Anaesthesia of lower lip because of the injury
to mandibular nerve. It may occur in # of body of mandible. It usually recovers in a few weeks. If infraorbital nerve is involved anaesthesia
occurs in lower eyelid,lateral part of nostril,upper lip in the affected side & anterior teeth
Cont.
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Malunion & deformities Deformities occur if reduction is not
satisfactory. In middle 1/3 injuries,improper reduction
result in flattening of face,anterior openbite with posterior gagging of occlusion.
Infection it occurs if root stumps are kept in # line or if
the general resistance of the patient is poor or if there is mobility at the # site.
Cont.
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Non -union & delayed union Occurs if tooth has retained in # line. - If the # is infected. - Inadequate immobilization. - Patients with systemic disease or
nutritional deficiencies. It can be treated by - Removing the cause(infection,teeth in #
line). - Freshening the ends & rewiring - If there is bone loss, grafing is done.
Cont.
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Derangement of occlusion Minor occlusal derangements are corrected as
the patient starts using the teeth. If there is persistance of traumatic occlusion it
can be corrected by selective grinding. If severe occlusal derangement, it is corrected
by refracturing the fragment & correction is done.
Cont.
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Ankylosis of TMJ It is more in young adults. It occurs in intra capsular #. Prolonged immobilization may cause
ankylosis. Other complications Diplopia Enophthalmos Strabismus Deviated nasal septum Epiphora Anosmia