midface fractures. midface fractures fractures of the middle third may be subdivided into:...
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MIDFACE FRACTURES
Midface fractures
Fractures of the middle third may be subdivided into:
Dento-alveolar fractures. Fractures of the maxilla. Fractures of the zygomatic bone & arch. Blow out fractures. Nasal-orbital-ethmoidal fractures.
Dento-alveolar fractures
It consists of fracture, subluxation, or avulsion of the teeth with or without an associated fracture of the alveolus, and they may occur as a clinical entity or in conjunction with any other type of fracture.
FRACTURES OF THE MAXILLA
Fractures of the maxillaClassification
The Le Fort classification defines the weakest areas of the midface complex when it is assaulted from a frontal directions at a different levels into :
Le Fort type I
Le Fort type II
Le Fort type III
LeFort Classification
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Le Forte type I fracture
Fracture lines
Le Fort type I
It results from a force delivered above the level of the teeth.
The fracture courses from the lateral border of the pyriform aperture
Le Fort type I
above the canine eminence lateral antral wall behind the maxillary tuberosity across the lower third of the ptergoid plate.
The nasal septum may be fractured
Le Fort type I fractures
* It may be unilateral or bilateral
* It may occur single or in conjunction of with Le Fort type II or III fractures.
*The clinical findings may be largely masked by more severe fractures.
* Caused by blow with a sharp object above the apices of the teeth.
Clinical findings in Le Forte I fractures
low level or Guerin type
Le Fort type I fractures
Clinical findings:
Extra-orally Swelling of the upper lip. Soft tissue laceration. Open mouth to accommodate the displaced
dento-alveolar portion. Epistaxis.
Le Fort type I fractures
Clinical findings:
Intra-orally Malocclusion.
Mobility of tooth bearing portion. Ecchymosis of the buccal sulcus. Dull sound on percussion.
Le Forte type II fractures
Fracture lines
Le Fort type II
It results from a force delivered at a level of the nasal bones.
The fracture line occurs along the nasofrontal suture lacrimal bone across the infra- orbital rim in the region of the zygomatico-maxillary suture
Le Fort type II
above the canine eminence inferiorly and distally along the lateral antral wall, but at a higher level than Le Fort type I across the pterygoid plate at its middle.
Clinical findings in Le Forte II fractures
Sub-zygomatic fracture
Pyramidal fracture
Le Fort type II fractures
Clinical Findings:
Extraorally
- Ballooning of the face.
- Lenghtenening of the face
- Circumorbital ecchymosis
- Subconjunctival Hg.- Epistaxis- Dipobia (cont)
Le Fort type II fractures
Clinical Findings: (cont)
Extraorally
- Enophthalmos- CSF rhinorrhoea- Step deformity in the
lower border of the orbit- Intact zygomatic bone &
arch
Le Fort type II fractures
Clinical Findings:
Intraorally- Malocclusion- Gagging of the posterior
teeth and anterior open bite
- Mobility of the maxilla- Ecchymosis of the
sulucs
Le Forte type III fractures
Fracture lines
Le Fort type III
The fracture is caused by a force at the orbital level , the resultant fracture is craniofacial dysjunction.
It is called :high level fracture or supra-zygomatic fracture
Le Fort type III
The fracture line courses through the zygoma-ticotemporal and zygomaticofrontal sutures lateral orbital wall inferior orbital fissure medially to the naso-frontal suture fractures the pterygoid plate at its base.
Clinical findings in Le Forte III fractures
Supra-zygomatic fracture
High level
Le Fort type III fractures
Clinical Findings
Extraorally
- Severe edema of the face “ballooning”
- Lengthening of the face
- Flattening of the cheek
- Circumorbital ecchymosis
- Subconjunctival Hg
Le Fort type III fractures
Clinical Findings (cont)
Extraorally- Epistaxis- Enophthalmos- CSF rhinorrhoea
Le Fort type III fractures
Clinical Findings Intraorally- Gagging of the posterior
teeth and anterior open bite
- Ecchymosis and Hg of the buccal sulcus
- Mobility of the maxilla- Mandibular interference
Radiology for maxillary fractures
Occipto-mental view CT scan
Occipto-mental view
Occipto-mental view
Computerized tomography
TYPES
* Axial scan
* Coronal scan
* 3/D CT
imaging
Axial scan
Computerized tomography
Axial scan
Computerized tomographyAxial scan
Coronal scan
Axial scan
Coronal scan Axial scan
3/D Computerized tomography
Treatment of the maxillary fractures
First aid treatment
Preliminary treatment
Definitive treatment
Treatment of the maxillary fractures
REDUCTION
IMMOBILIZATION
Treatment of the maxillary fractures
REDUCTION
* Digital pressure
* The use of Rowe’s
forceps , Hayton-
Wiliams disimpac-
tion forceps.
* Surgical
Rowe’s Desimpaction Forceps
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Maxillary fracturesImmobilization
Methods MMF Internal fixation Skeletal suspension Support External fixation
Maxillary fracturesImmobilization
Circumzygomatic suspension Obwegeser technique
Maxillary suspension
1- Frontal susp.
2- Pyriform fossa susp.
3- Infraorbital rim susp.
4- Circumzygomatic susp.
Antral support
Treatment of unilateral Le Fort type I fractures
A) Closed reduction & fixation
* Digital pressure.
* Arch bar tightened in the unfractured side and loose in the fractured side.
* Adjust occlusion, tighten the fractured side then secure MMF.
Treatment of unilateral Le Fort type I fractures
B) Open reduction & fixation
* Cases of unstable fractures.
* Arch bars are prepared
* Sulcus incision to expose the fracture site in canine & buttress regions
* Transosseous wiring or miniplates are used for fixation.
Transosseous wiring
Sulcus incision Fracture exposure Reduction Drilling wholes 24-26 guage wire is
used
Treatment of bilateral Le Fort type I fractures
Reduction closed or open Immobilization suspension or internal fixation
Treatment of Le Fort type Il fractures
Reduction closed or open Immobilization suspension or internal fixation
Treatment of Le Fort type Ill fractures
Reduction Immobilization suspension or internal fixation
Zygomatic complex fractures
Zygomatic complex fractures
Second most common fracture of the facial bones behind nasal bone fractures
Zygoma forms prominence of cheek which subsequently contributes to frequency of fractures
Major contact areas are with the maxilla and frontal bones
Also forms portion of lateral wall and floor of the orbit
ARTICULATIONS
Frontozygomatic Zygomaticotemporal Zygomaticomaxillary
Foramina
Foramen allows for passage of zygomaticofacial and zygomaticotemporal nerves of V2 that supply sensation to cheek and anterior temple
Infraorbital N. Of V2 courses the floor of the orbit and exits the infraorbital foramen or notch
COMMON FRACTURE SITES
Frontozygomatic suture Infraorbital rim Junction of the
zygomatic arch and temporal bones
Orbital floor Maxillary buttress
Classification of Zygomatic Fractures
Clinical features of Zygomatic Fractures
Clinical features of Zygomatic Fractures
Common clinical features: Edema Circumorbital ecchymosis Subconjunctival
hemorrage Malar depression Step defect at infraorbital
rim Step defect at
frontozygomatic suture Epistaxis
Clinical features of Zygomatic Fractures
Step defect at zygomatic buttress of maxilla intraorally
Ecchymosis at maxillary buttress region
V2/infraorbital nerve paraesthesia or anesthesia
Clinical features of Zygomatic Fractures
LESS COMMON FINDINGS Enopthalmos or Proptosis Diplopia (monocular vs. binocular) Decreased mobility of extraocular muscles -- upward gaze due to its
entrapment . Injury to globe itself -- ophtho. consultation should be obtained on all
midface fractures patients
Limitation of mandibular movement secondary to zygomatic arch impingement on the coronoid process
Crepitation from air emphysema
Unequal pupilary level
Clinical features of Zygomatic Fractures
Intra-oral inspection
Ecchymosis in the upper buccal sulcus in the region of zyg. Buttress.
Anesthesia of teeth and gum.
Intra-oral palpation
Tenderness over zyg. Buttress.
Crepitus may be felt.
RADIOGRAPHS
Water's view : a PA projection w/ the head positioned at 27 degree angle to the vertical with the chin resting on the cassette
Submentovertex : "jug handle" Caldwell view : PA projection w/ the face at
a 15 degree angle to the cassette CT Scan : for more detail usually obtain axial
and coronal 3-5mm cuts
Water's view
CT Scan
Zygomatic arch fractures
May exist alone or with zygomatic bone or other facial bone fractures.
Specific clinical findings:
* Visible depression over the zyg. arch area.
* Limitation of mandibular movements.
* Classified as a- triple or V-shaped fracture
b- comminuted fractures
Zygomatic fractures
Radiographic examination:
Subnemto-vertial view. Occipito-mental view. Ct scan , axial cuts
Subnemto-vertical view
Zygomatic arch fractures
Comminuted fracture
Triple fracture
Treatment of Zygomatic Fractures
Treatment of Zygomatic Fractures
Zygomatic bone requires reduction for the following reasons:.
Globe displacement - enophthaimus / exophthaimus / diplopia
Alteration in facial contour Muscle/Fat/Nerve entrapment Mechanical restriction of mandibular movement Cosmetic.
Treatment of Zygomatic Fractures
Methods: Reduction alone. Reduction & fixation.
Reduction of Zygomatic Fractures
Methods of reduction: Closed reduction using
- Bristow’s elevator
- Rowe’s zygomatic elevator
* Open reduction ( surgical )
GELLIIE’S APPROACH
NONFIXATION Isolated arch fractures/minimally
displaced ZMC fractures -- no direct visualization
2-3cm incision in hairline below and parallel to anterior branch of temporal artery
To and through superficial temporalis fascia
Bristow’s elevator is passed medial to arch for elevation in a sweeping upward and outward direction
OTHER INDIRECT APPROACHES
Towel Clip : applied directly
Treatment of Zygomatic Fractures
OPEN REDUCTION TECHNIQUES Lateral brow incision subcilliary (blepheroplasty) incision Infraorbital crease incision Bicoronal / Hemicoronal flap
Treatment of Zygomatic Fractures
DIRECT FIXATION TECHNIQUES Wiring - 24 - 30 gauge stainless steel wire Mini bone plates
Trans osseous wiring
Wiring - 24 - 30 gauge stainless steel wire
Open reduction and transosseous wire fixation
Mini bone plates
Blow-out fractures
The classic blow-out fracture implies an intact orbital rim and a disruption of one of walls of the orbit.
It may be caused by a blow to the orbit by an object larger than the outer structure of the orbit producing a momentary increase in intra orbital pressure.
Blow-out fractures
This causes the weakest point of the orbit to give away, usually the orbital wall of the ethmoid or the roof of the maxillary sinus.
This type of fracture acts as safety valve to spare the globe.
Blow-out fractures
Clinical symptoms Circumorbital edema. Circumorbital ecchymosis. Ophthalmoplagia. Diplopia , (upper & lateral gaze) Enophthalmos.
Orbital floor support
ORBITAL FLOOR RECONSTRUCTION
Autograft --rib, iliac crest, calvaria, as well as ear or nose cartilage
Allograft --lyophilized dura, rib, iliac crest, cartilage
Alloplast --Teflon, Silastic, Ti-Mesh, and Gelfilm have been described