Content : Anatomy and fracture of maxilla nasal bone fracture Naso- ethmoidal-orbital fracture

1. FRACTURE MIDDLE 3RD OF FACE

2. MIDDLE 3RD OF FACE
Consists of :
2 maxillae
2 zygomatic bones
2 zygomatic process of temporal bones
2 palatine bones
2 nasal bones
2 lacrimal bones
The vomer
The ethmoid
Pterygoid plates of sphenoid

3. ANATOMY OF THE MAXILLA
Forms the largest part of the middle 3rd of face
It is involved in the formation of the orbit, nose and palate, holds the
upper teeth
The body of each maxilla is hollowed by max sinus

4. ANATOMY OF MAXILLA
Frontal process
Palatine process
Alveolar process
Maxilla have 4 processes

5. ANATOMY OF MAXILLA
Mid face skeleton is made up of thin segments of bone which supported by a
more rigid frameworks of buttresses
It is absorbs and transmits forces applied to facial skeleton
It is :
vertical buttresses : nasomaxillary & zygomaticomaxillary & pterygomaxillary
Horizontal buttresses : frontal bar & orbital rims & zygomatic process of
temporal bone maxillary alveolus

6. FRACTURE OF MAXILLA
Radiographic examination
CT scan with 3D ( more diagnosed )
Water’s view
Caldwell view
Lateral view
Submentovertex view

7. CLASSIFICATION OF MAXILLARY FRACTURE
Le fort I
transverse fracture / floating maxilla
Occurs transversally across the maxilla above the level of the
teeth
The fracture segment contains the alveolar process , portions of
the wall of the maxillary sinus ,the palate and lower portion of the
pterygoid plates

8. CLASSIFICATION OF MAXILLARY FRACTURE
Le fort ll
pyramidal fracture
It involves the nasal bones and frontal process of maxilla and pass
laterally through the lacrimal bones ,the inferior rim of the orbit and
through the zygomaticomaxillay sutures
Then continue backward along the lateral wall of maxilla through
the pterygoid plates

9. CLASSIFICATION OF MAXILLARY FRACTURE
Le fort lll
craniofacial disjunction
Complete separation of the facial bones from their cranial
attachment
The fracture occurs through the zygomatico-frontal , maxillo-frontal
, naso-frontal sutures through orbital floor

10. CLASSIFICATION OF MAXILLARY FRACTURE
Alveolar fracture of the maxilla
This may involve bone containing one or more teeth
Vertical split fracture of the maxilla
Very rare that the maxilla splits along the sagittal plane

11. DIAGNOSIS OF MAXILLARY FRACTURE
History of trauma
Radiographic examination
Clinical examination :
>> Evidence of severe soft tissue injury in the facial region
>> Bleeding from the nose,periorbital ,edema and ecchymosis
>> Dish face deformity is a result of fractured and displaced middle
third
>> Malocclusion and open bite
>> Diploplopia

12. CLINICAL EXAMINATION

13. CLINICAL EXAMINATION

14. CLINICAL EXAMINATION

16. RADIOGRAPHIC EXAMINATION
Submentovertex viewWater view
C.t scanPanoramaOcclusal

17. TREATMENT OF MAXILLARY FRACTURE
Reduction
Early reduction is mandatory to avoid complications
Closed reduction manually is used in recent fracture when the
fragment are not impacted, if fragment are impacted ,a row
disimpaction forceps is used
Closed reduction by traction is used in delayed fractures
Open reduction is indicate when the traction is not effective

18. TREATMENT OF MAXILLARY FRACTURE

19. TREATMENT OF MAXILLARY FRACTURE
Fixation
Trans fixation wire used for fixation of comminuted unstable
midfacial fractures
suspension by wire adam wiring technique :A wire suspending the
midfacial fracture to intact bone in higher level than the fracture
fixation by miniplate
Open fixation technique by wire ostepsynthesis

20. TREATMENT OF MAXILLARY FRACTURE

21. NASAL BONE FRACTURE

22. INTRODUCTION
Nasal bone is the 3rd most commonly broken bone in the body
If not properly managed >>> long term func & cosmetic problems
(( foremost position
Managed easily in children more than adults ( more cartilaginous )

23. ANATOMY

24. TYPES
ACCORDING TO FORCE DIRECTION
Frontal direction
Sever flattening of nasal bones & septum
Widening of nasal width

25. Lateral direction
Depression of ipsilateral Nasal bone
Out fracture of contralateral nasal bone ( sever )
Twisting of the nose

26. Below direction
Fracture of septum
Quadrangular cartilage dislocation

27. SIGNS & SYMPTOMS
Pain
Edema
Nose deformation
Epistaxis
Rhinitis
Airway blockage
Crepitance
Ecchymosis around the eyes
Nasal septum deviation
Step deformity ( palpated )
CSF rhinorrhea ( salty taste )

28. MANAGEMENT
open
closed
reduction
intranasal
extranasal
fixation

29. CLOSED REDUCTION
Indications
unilateral or bilateral fracture of nasal bone
fracture of nasal septum with minimally deviated

30. CLOSED REDUCTION
may be done under local or general anesthesia
WALSHAM’S & ASCH’S septal forceps are used

32. OPEN REDUCTION
Indication
1- extensive fractures
2- deviation of nasal pyramid greater than on half width of nasal bridge
3- persistent deformity after closed reduction

33. OPEN REDUCTION
The septum may prevent proper reduction of nasal pyramid as the
septal fragments are interlocked
Be cautious when elevating the periosteum of the nasal bone
because the the fractured segments may become unstable ,
deviated or lost so that conservative approach is better

34. CONTRAINDICATIONS FOR REDUCTION
Some cases are contraindicated for TTT When :
1- The fragments are not displaced
2- Sever naso-ethmoid complex fractures ( precipitate or worsen CSF leak )

35. METHODS OF IMMOBILIZATION
INTRANASAL METHODS
ribbon gauze & stainless steel splint
Ribbon gauze is the most standard
12 – 15 cm length is inserted into the nose in layers beginning from above
downwards
NOTE >>>> DON’T OVERPACK THE NOSE TO AVOID DISPLACING
REDUCED FRACTURED SEGMENTS
DISADVANTGES :
1- Inadequate anteroposterior support
2- Difficulty in breathing through nose
3- Potential source of infection

36. ERTRANASAL METHODES
Plaster of Paris & lead splints
Not all cases require intranasal splinting
The plaster of Paris is most commonly used
The plaster of Paris is applied while it is still wet and moulded to the shape of
nose
The splint shouldn’t be extent to the soft part of the nose
This is left for about 1 week depending on the mobility of segments
antibiotics may be placed in each nostril for 1 – 5 days

37. When the segments is very mobile and can’t be stabilized with plaster of paris
:Lead plates can be used
It is consists of two holes and are fitted on each side of nose with help
of st st sutures which is passed into the holes and beneath the nasal
bones
This splint is left in place for a period of 3 weeks

38. NOTE
Certain fractures involving the nasal septum and ethmoid result in
loss of support to nasal bones
This fractures can’t be splinted by plaster or lead plates
It is recommended to be fixed with transosseous wiring of
frontonasal junction

39. NASO – ETHMOIDAL – ORBITAL FRACTURE

40. SURGICAL ANATOMY
NOE is situated In the central upper midface
the skeletal structure The nose … orbit …. Maxilla …. Cranium
The main structural buttress the frontal process of maxilla
the internal angular process of frontal bone

41. THE MEDIAL WALL OF ORBIT
Composed of
lacrimal bone anteriorly
Lamina papyracea of ethmoid bones posteriorly
THIS structure are susceptible to comminution and allowing for medial
displacement of orbital contents after blunt trauma
Thin ethmoid bones form part of the anterior skull base Superiorly
May result in dural injury and CSF leakage

42. Fracture or rupture of ant & post ethmoidal arteries >>>> orbital
haematoma
Optic canal is positioned posteriorly and local edema within it may cause
circulatory disturbance of pial plexus of optic nerve >>>>>> transient or
permanent blindness
High energy blunt trauma to NOE complex >>>> collapse of the
interorbital space and leading to injury to ant cranial contents or
intraorbital content

43. CLASSIFICATION OF NOE COMPLEX FRACTURE
Type I
In unilateral type I fractures, there is a single large NOE fragment
bearing the medial canthal tendon
Involvement of the nasal bone
The nasal bone may also be involved and, in cases of comminution,
may not provide adequate dorsal support to the nasal bridge.

44. CLASSIFICATION OF NOE COMPLEX FRACTURE
unilateral type II fractures
there is often comminution of the NOE area , but the canthal tendon
remains attached to a fragment of bone, allowing the canthus to be
stabilized with wires or a small plate on the fractured segment.
Involvement of the nasal bone
The nasal bone may also be involved and, in cases of comminution,
may not provide adequate dorsal support to the nasal bridge.

45. CLASSIFICATION OF NOE COMPLEX FRACTURE
Bilateral type II fracture with nasal bone involvement
In bilateral fractures the nasal bones are commonly involved. In
some instances, bone grafting of the nasal dorsum may be
necessary.

46. CLASSIFICATION OF NOE COMPLEX FRACTURE
Type III
Comminution within the central fragment allows fracture to extend
beneath the canthal insertion
The canthus is attached to bone fragments that are too small to
utilize in reconstruction

47. DIAGNOSIS
( CL EX + CT SCAN )
The patient often has swelling in the medial canthal area and pain and
crepitation with palpation.
Bilateral periorbital and subconjunctival haemorrhage
( limited to medial half of eye )
The nose can be retruded and impacted at the nasofrontal
suture area with lack of support for the nasal septum
and cartilages.
Epistaxis …… CSF leak
Flattening nasal dorsum

48. INTERCANTHAL DISTANCE TEST
There will be a lack of definition of the bony anatomy in the medial
canthal area and possible lateral splaying of the medial canthus
with increased intercanthal distance
(the normal distance varies depending on the ethnic group, e.g., in
Caucasians more than 35 mm intercanthal distance is considered
abnormal.)

49. BOW STRING TEST
grab the eyelid or use a forceps to grab the skin in the medial
canthal area and pull it laterally.
In the bow-string test the lid is pulled laterally while the tendon area
is palpated to detect movement of fracture segments.
A lack of resistance or movement of the underlying bone is
indicative of a fracture.

50. BIMANUAL PALPATION TEST
Another test is to place an instrument in the nose and push laterally
in the medial canthal area to test for instability and crepitation,
which suggests an unstable NOE fracture.

51. MANAGEMENT
Reduction and fixation of unstable fracture segment
to stable structures
The main goal :
Restoration of anatomic position of bony segments to esthetics and
functional baseline and prevents later complications

52. TYPE I
Reduction by hand or with penetrating towel clamp or other bone-
grasping inst. To prevent lateral migration of the segments
When the fracture involves the frontal process of max and inferior
orbital rim >>>>> small miniplates with self tapping screws applied
to each of these structures for fixation
If only small piece of lacrimal bone >>>> it may be wired to its
normal position using wires

53. TYPE II
Additional exposure of contralateral medial orbital wall is required
for fixation
Transnasal wiring provides a stable source of fixation
In addition to transnasal stabilization micro plates may be used to
fix the MCT bony fragment to adjacent stable bone

54. TYPE III
The most sever of the NOE fracture
Usually bilateral
Higher incidence of associated injuries to Dura , Skull base , Intra orbital
contents
After careful dissection of both medial orbital walls >>>> bilateral intercanthal
tendon fixation is performed
if the associated MCT bony segment is too small for drilling holes >>>>> the
wire may be passed through a thickened portion of MCT >>>>> both free
ends on the wire are then passed through the lacrimal defect on first side
through nasal septum and through the opposite lacrimal defect >>>>> use
the free ends to secure the opposite MCT and bony segment
The MCTs of both sides are pulled medially toward each other

55. COMPLICATIONS FOLLOWING SURGERY
Temporary or permanent paraesthesia
CSF leak
Meningitis
Sinus infection
Anosmia
Infection of implants
Osteomyelitis
enophthalamos
Extra ocular motion disfunc
Blindness
Possible need for additional surgery