Middle face fracture

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Middle face fracture

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Middle face fracture

  1. 1. • The middle third of the face consists of orbit,The middle third of the face consists of orbit,nose, maxilla, zygoma, and nasoethmoidnose, maxilla, zygoma, and nasoethmoidbone.bone.• In 1901, René LeFort used 32 cadaversIn 1901, René LeFort used 32 cadaversskulls and subjected them to various types ofskulls and subjected them to various types oftrauma, then he removed soft tissues andtrauma, then he removed soft tissues andexamined skulls:examined skulls:• He found that generally if the face wasHe found that generally if the face wasfractured, the skull was not.fractured, the skull was not.• He then stated that fractures occurredHe then stated that fractures occurredthrough three weak lines in the facial bonythrough three weak lines in the facial bonystructures that protect the cranial cavity andstructures that protect the cranial cavity andcircumscribe the midfacecircumscribe the midface
  2. 2. • Six buttresses are responsible forreinforcementSix buttresses are responsible forreinforcementof facial bones:of facial bones:A.A. V ERTC A L BU TTRES S ES :V ERTC A L BU TTRES S ES :1 .1 . Naso m axillaryNaso m axillary2.2. Zyg o m atico m axillaryZyg o m atico m axillary3.3. Pte ryg o m axillaryPte ryg o m axillary
  3. 3. B.B. HO RIZ O N TA L BU TTRES S ES :HO RIZ O N TA L BU TTRES S ES :1 .1 . Fro ntal barFro ntal bar2.2. Alve o lar Ridg eAlve o lar Ridg e3.3. Infrao rbitalrimInfrao rbitalrim
  4. 4. LeFort classification system1.1. LeFortLeFort I (horizontal or transversefracture) :I (horizontal or transversefracture) :• The fracture line extends above the rootThe fracture line extends above the rootapices from the piriform aperture of the nose.apices from the piriform aperture of the nose.• The fractured segment includes:The fractured segment includes: MaxillaryMaxillary teethteeth alveolar bone,alveolar bone, part of the basal bone,part of the basal bone, lowerthird of nasal septumlowerthird of nasal septum lowerthird of pterygoid plates posteriorly.lowerthird of pterygoid plates posteriorly.
  5. 5. LeFort I
  6. 6. 2.2. LeFortLeFort II:II:• It involves most of the nasal bone.It involves most of the nasal bone.• The fracture line extends from below theThe fracture line extends from below thenasofrontal suture, through the nasal bonenasofrontal suture, through the nasal bonealong the maxilla to the zygomatico-maxillaryalong the maxilla to the zygomatico-maxillarysuture (suture (below the zygoma which is intact)below the zygoma which is intact) andandinclude the medial inferior third of the orbit theninclude the medial inferior third of the orbit thenthe fracture continuous till the pterygoid platesthe fracture continuous till the pterygoid platesat a higher level thanat a higher level than lefort I.lefort I.
  7. 7. LeFort II
  8. 8. 3.3. LeFort III:LeFort III:• It separates the middle third from the cranium.It separates the middle third from the cranium.• It involves most of the orbital bone.It involves most of the orbital bone.• The fracture line extends from the nasofrontalThe fracture line extends from the nasofrontalsuture along the medial wall of the orbit throughsuture along the medial wall of the orbit throughthe superior orbital fissure.the superior orbital fissure.• It then extends along the inferior orbital fissuresIt then extends along the inferior orbital fissuresand the lateral orbital wall to theand the lateral orbital wall to the zygomatico-zygomatico-frontalfrontal suture; thesuture; the zygomatico-temporalzygomatico-temporal suture issuture isalso separated.also separated.• Then the fracture extend along the sphenoid boneThen the fracture extend along the sphenoid boneseparating the pterygoid plates.separating the pterygoid plates.
  9. 9. LeFort III
  10. 10. Clinical examination :A.A. E X T R A O R A L E X A M I N A T I O N :E X T R A O R A L E X A M I N A T I O N :• InspectionInspection Laceration of the skinLaceration of the skin.. Abrasion& ecchymosis areasAbrasion& ecchymosis areas.. Facial edemaFacial edema.. EpistaxisEpistaxis.. Cerebrospinal fluid leakageCerebrospinal fluid leakage.. Asymmetry of the noseAsymmetry of the nose.. Flat nasal bridgeFlat nasal bridge.. Dish-shaped faceDish-shaped face..• PalpationPalpation Bilateral palpation over the expected lines of fracture isBilateral palpation over the expected lines of fracture isperformed to feel bony steps or deformitiesperformed to feel bony steps or deformities• ..
  11. 11. • The level of fracture can be determined extraorally:The level of fracture can be determined extraorally: One hand holds the bridge of the nose while the otherOne hand holds the bridge of the nose while the othermanipulates the maxilla; movement at the alveolus suggestsmanipulates the maxilla; movement at the alveolus suggestsLefort ILefort I fracture.fracture. the first hand is placed over thethe first hand is placed over thefrontonasal suture while the otherfrontonasal suture while the otherone manipulates the maxilla;one manipulates the maxilla;movement at the frontonasal suturemovement at the frontonasal suturesuggestssuggests lefort II orlefort IIIlefort II orlefort III fractures.fractures.
  12. 12. B.B. I N T R A O R A L E X A M I N A T I O N :I N T R A O R A L E X A M I N A T I O N :• InspectionInspection Fractured teethFractured teeth.. Vestibular ecchymosis & edemaVestibular ecchymosis & edema.. Mucosal laceration & bleedingMucosal laceration & bleeding.. Steps or diastema in the maxillary teethSteps or diastema in the maxillary teeth.. MalocclusionMalocclusion..• PalpationPalpation Step deformity in the occlusal plane or theStep deformity in the occlusal plane or thealveolar ridge in case of edentulous patient.alveolar ridge in case of edentulous patient.
  13. 13. Imaging:1.1. Axial & coronal CT scan:Axial & coronal CT scan: The coronal CT scan is the best diagnostic radiographThe coronal CT scan is the best diagnostic radiographin case of suspected orbital floor fractures.in case of suspected orbital floor fractures. It can demonstrate soft tissue differences of hematomaIt can demonstrate soft tissue differences of hematoma.. it can demonstrate edema of subcutaneous tissue,it can demonstrate edema of subcutaneous tissue,muscle and fat.muscle and fat.2.2. Postero-anteriorviewPostero-anteriorview3.3. Waters viewWaters view4.4. Lateral viewLateral view5.5. Occipitomental viewOccipitomental view
  14. 14. TreatmentI.I. ReductionReduction ::• Rowe disimpaction forcepsRowe disimpaction forceps isisused to disimpact the maxillaused to disimpact the maxillain LeFort fracture .in LeFort fracture .• it consists of two forceps ( right &it consists of two forceps ( right &left ) acting togetherleft ) acting together• one of the forceps two arms hasone of the forceps two arms hashigh curvature to engage thehigh curvature to engage thepalate without injuring teeth.palate without injuring teeth.• The other arm of less curvatureThe other arm of less curvatureis inserted into the nostrils.is inserted into the nostrils.
  15. 15. II. Fixation :II. Fixation :1.1. Wire OsteosynthesisWire Osteosynthesis2.2. Rigid fixationRigid fixation3.3. Semi-rigid fixationSemi-rigid fixation4.4. Lag screwsLag screws
  16. 16. • It is an old but yet a successfully usedIt is an old but yet a successfully usedmethod.method.• Many designs are available:Many designs are available: One design includes drilling of four holes forOne design includes drilling of four holes forwiring.wiring. Another design use two holes onlyAnother design use two holes only Another design use two holes & circumscribe theAnother design use two holes & circumscribe thebony edge.bony edge.• The main disadvantage of wireThe main disadvantage of wireosteosynthesis is that it does not maintainosteosynthesis is that it does not maintainthree dimensional stability.three dimensional stability.11 Wire OsteosynthesisWire Osteosynthesis
  17. 17. • By m e ans o f arch bars o r wiringBy m e ans o f arch bars o r wiring to anto anintact m andibleintact m andible• It is the m o st re liable te chniq ueIt is the m o st re liable te chniq ue fo rfo re stablishing ante rio r pro je ctio n o f thee stablishing ante rio r pro je ctio n o f them andible .m andible . Intermaxillary fixationIntermaxillary fixation
  18. 18. • It had been introduced specifically for long boneIt had been introduced specifically for long bonefracture as it is cortical bone with decreasedfracture as it is cortical bone with decreasedamount of blood supply &amount of blood supply & subjected tosubjected to highhighstresses, so rigid fixation is needed to ensurestresses, so rigid fixation is needed to ensureintimate contact between fractured parts andintimate contact between fractured parts andenhance healing.enhance healing.• Types:Types:A.A. Dynamic compression platesDynamic compression platesB.B. Eccentric dynamic compression plateEccentric dynamic compression plate22 Rigid fixationRigid fixation
  19. 19. A. Dynamic compression plates :• Provided with oval holes.Provided with oval holes.• The pointed tip of the oval shape is directedThe pointed tip of the oval shape is directedoutward while the wide portion is directed towardoutward while the wide portion is directed towardthe midline of the plate.the midline of the plate.• When the screw is introduced into the thin portionWhen the screw is introduced into the thin portionof the hole it will escape toward the wide portionof the hole it will escape toward the wide portion(midline)(midline) pushing bony fragments toward thepushing bony fragments toward themidline.midline.• The action of screws on both sides helps toThe action of screws on both sides helps toapproximate bony fragments and enhances theirapproximate bony fragments and enhances theirunion.union.
  20. 20. • It had been proved that force affecting onIt had been proved that force affecting onbone will produce both tension andbone will produce both tension andcompression, and so; two plates are neededcompression, and so; two plates are neededone plate to resist compression and the otherone plate to resist compression and the otherto resist tension.to resist tension.• One plate can be used separately if placed inOne plate can be used separately if placed inthe neutral zonethe neutral zone
  21. 21. B. Eccentric dynamic compression plate• Holes are not directed perpendicular to bone,Holes are not directed perpendicular to bone,they have several angulations so the screwthey have several angulations so the screwwill take several directions and this willwill take several directions and this willeliminate the need of another plateeliminate the need of another plate (one plate(one platewill be enough)will be enough) as the screw is makingas the screw is makinganchorage at higher level to produce tensionanchorage at higher level to produce tensionrather than compressionrather than compression..
  22. 22. • Specific for maxillofacial region as maxillary bone isSpecific for maxillofacial region as maxillary bone isspongy and highly vascularspongy and highly vascular bone.bone.• Maxilla is not subjected to high stresses as in long bone soMaxilla is not subjected to high stresses as in long bone sosemi-rigid fixation may be used.semi-rigid fixation may be used.• Types of semi-rigid fixationTypes of semi-rigid fixationA.A. Miniplates:Miniplates: The most commonly used plates specially in theThe most commonly used plates specially in themandiblemandible (about 1.5 mmthickness)(about 1.5 mmthickness)A.A. Microplates:Microplates: used in very thin placesused in very thin places(about 0.6 mmthickness)(about 0.6 mmthickness)A.A. Resorbable plates:Resorbable plates: Recently introduced for treatment of fractures.Recently introduced for treatment of fractures.33 Semi Rigid fixationSemi Rigid fixation
  23. 23. • AdvantagesAdvantages :: Eliminate the need for another surgery as in youngEliminate the need for another surgery as in youngpatients (The plate may prevent growth of bone andpatients (The plate may prevent growth of bone andshould be removed after 6 months)should be removed after 6 months) Provide good esthetic appearanceProvide good esthetic appearance Prevent pain sensation at the site of plates specially inPrevent pain sensation at the site of plates specially incold environment and thin areas.cold environment and thin areas.• DisadvantagesDisadvantages ::ExpensiveExpensiveThickThick
  24. 24. • Used without plates.Used without plates.• A hole is drilled in the fractured bonyA hole is drilled in the fractured bonysegment, the screw is forced through thesegment, the screw is forced through thehole to penetrate the fixed segment , thehole to penetrate the fixed segment , thelarge diameter head of the screw willlarge diameter head of the screw willprevent its passage through the hole.prevent its passage through the hole.44 Lag Screws :Lag Screws :
  25. 25. Complications associated with maxillary fracture and theirrepair:• Infraorbital nerve paresthesia.Infraorbital nerve paresthesia.• Enophthalmos.Enophthalmos.• Infection.Infection.• Deviated septum.Deviated septum.• Nasal obstruction.Nasal obstruction.• Altered vision.Altered vision.• Nonunion.Nonunion.• Malunion or malocclusion.Malunion or malocclusion.• Epiphora.Epiphora.• Foreign body reaction.Foreign body reaction.• Scarring.Scarring.• Sinusitis.Sinusitis.
  26. 26. Thank You

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