Maxillary fractures presentation ih
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Maxillary fractures presentation ih
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Maxillary fractures presentation ih
- 2. Maxillary Fractures Presenter : Dr. Itrat Hussain
- 3. Applied anatomy of maxilla • The maxillary bones are paired pyramidal bones that in many ways serve as the cornerstones of the facial skeleton • Horse shoe shaped upper alveolus more delicate than mandible • Individual maxilla can be conceptualized as a 5-sided structure – orbital floor superiorly, – alveolar ridge inferiorly, – front wall of the maxillary sinus anteriorly, – anterior surface of the pterygopalatine fossa posterolaterally
- 4. Maxilla • Considered together Horse shoe shaped, • Lacks cortical margin (delicate) • But strength is conferred by the palatal shelves which unite the alveolar process all round
- 7. Favorable Characteristics • Complexity of facial skeleton • Fragility of bones • Concept of matchbox • Concept of pillars (buttresses) • Sloping of midfacial bones to the cranial base at an angle of about 45 degree’s
- 8. Complexity of mid facial bones POSTERIORLY & INFERIORLYPOSTERIORLY & INFERIORLY
- 9. Angulation of mid face to the cranial base
- 10. Matchbox concept
- 12. To resist the vertical forces of mastication • 3 paired vertical buttresses (from anteromedial to posterolateral): – the nasomaxillary buttress, – the zygomaticomaxillary buttress, – the pterygomaxillary buttress • additional unpaired midline support is the frontoethmoid- vomerine buttress • These pillars serve – to diffuse the vertical forces of mastication over the broad cranial base. – shock absorbers for a vertically oriented impact to the facial skeleton
- 13. • The nasomaxillary buttress transmits force from the maxillary canine area through the lateral pyriform rim and frontal process of the maxilla and to the superior orbital rim. • The zygomaticomaxillary buttress transmits forces from the zygomatico- alveolar crest through the zygoma to the posterior aspect of the superior orbital rim and temporal bone. • The pterygomaxillary buttress conducts force through the palatine bone to the pterygoid plates and sphenoid base
- 14. • Superior and inferior orbital rims and alveolar ridge constitute a group of weaker horizontal buttresses. • Horizontal buttresses have coronal and sagittal components. The sagittal buttresses are vital for facial projection • They can withstand much less force than the vertical buttresses • The skull base is at a 45° angle relative to the occlusal plane of the maxilla and can act as an axial buttress
- 15. ABILITY TO WITHSTAND FORCE • Better in inferio-superior direction • Transmit occlusal force through alveolar process to skull base around orbital & nasal cavities • Vulnerable to fracture if force is applied in perpendicular direction
- 16. Unfavorable Characteristics • Displacement of nasal complex • Exposure of the Para nasal sinuses • # of cribriform plate and dura tear – CSF rhinorrhoea – Infection
- 17. Divisions Of #’s • #’s of the Middle third facial skeleton may be divided into • CENTRAL MIDDLE THIRD – Includes, Dentoalveolar, naso-maxillary and naso- ethmoidal & Le Fort I, II, III & IV • LATERAL MIDDLE THIRD – Include zygomatico-maxillary #’s
- 18. PATHOPHYSIOLOGY • HIGH VELOCITY INJURIES – RTA – Dash board injuries – Acceleration deceleration • INTERPERSONAL VIOLENCE • SPORTS INJURIES
- 19. DASHBOARD INJURY
- 20. Etiology 1. Force from antero-posterior direction – Low level – le-fort I / Dentoalveolar – mid level – le fort II – High level – le fort III 2. Force from superior direction – High level – le fort III 3. Force from inferior direction – With mouth open – mid palatine split with Le fort II / III with fragmentation of upper anterior teeth 4. Force from lateral direction – Low level – le fort I / Dentoalveolar – mid level – le fort II – High level – le fort III with nasomaxillary complex #
- 21. Le Fort classification system • Rene Le Fort described the classic patterns of fracture in his 1901 work. • Le Fort's experiments consisted of using 32 cadavers that were either intact or decapitated. • Cadaver skulls were dropped from several stories or were struck with a wooden club. • He found 3 distinct fracture patterns, which he termed the linea minoros resistentiae
- 22. Shortcomings of Le fort system • It is deficient in addressing most midface fractures as most of them do not follow the simple Le Fort pattern of fracture rather, assume a combination of Le Fort fractures. • Most midface fractures have some degree of comminution and are complicated by fractures and displacement not addressed in the Le Fort system. • These midface fractures include palate, medial maxillary arch, dentoalveolar, and anterior maxillary fractures
- 23. Classification Fractures involving the occlusion • Dentoalveolar #’s Subzygomatic # - • Le-fort I # • Le-fort II # Suprazygomatic # - • Le-fort III # & • Le-fort IV #
- 24. Modified Le-fort classification Management of mid face fractures-R.D.Marciani;JOMS:1993
- 25. Frequency • Le Fort Fractures account for 10- 20% of all facial fractures. • They are result of a considerable amount of force, with motor vehicle accidents being the predominant cause and assaults and falls being additional etiologies • Overall incidence of midface fractures has decreased with usage of seat belts and air bags
- 26. Race, Sex, Age distribution • Klenk et al, 2003 revealed the average age of a facial fracture patient to be 26.5 years. – Males predominated at 83%. – motor vehicle accidents (59%), – falls (21%). – 33% had isolated midface fractures – 14% had a combination of midface fracture and mandibular fracture.
- 27. Dento-alveolar # • Laceration of the upper lip or • degloving of the alveolus • Fracture of anterior teeth
- 28. Le Fort I # (Guerin's #) • The fracture starts on the lateral margin of the anterior nasal aperture, passes above the nasal floor, above the canine fossa, traverses the lateral antral wall, dipping down below the zygomatic buttress and inclines upwards and posteriorly across the pterygomaxillary fissure to # the pterygoid lamina at junction of lower 3rd and upper 2/3rd ‘s
- 29. Signs and symptoms (Le-fort I) • Ecchymosis in labial / buccal sulcus • Contusion of skin of upper lip • Disturbed occlusion • Mobility of tooth bearing area • Damage to cusps of individual teeth • If impacted then open bite • Crackpot sound on percussion • Floating maxilla • Grating sound on attempted movement of upper jaw
- 31. Lefort II • Runs from thin middle area of nasal bone on either side crossing frontal process of maxilla into medial orbital wallcrosses lacrimal bone behind lacrima sac to cross infraorbital margin medial or thru infraorbital foramen • The # then extends downwards and backwards across the lateral wall of the antrum below the zygomatico-maxillary suture and divides the pterygoid laminae about halfway up. • Separation of the block from the base of the skull is completed via the nasal septum and may involve floor of ant. cranial fossa
- 32. Signs and symptoms (Le-fort II) • Gross edema (moon’s face) in short time • Step deformity at infra orbital margin • Mobility of midface at nasal bridge and infra orbital margin • Anesthesia or paraesthesia of cheek • Pupils tend to be level unless there is gross unilateral enophthalmos
- 33. • Step or hematoma at zygoamtic buttress • Subconjunctival ecccymosis towards medial side. • Dish face deformity • Abnormal mobility • Epistaxis • Surgical emphysema • Posterior gagging of occlusion • Diplopia may be present
- 35. Palatal Fractures • They are found in 8 % of Lefort fractures • Often associated with fractures of mid – face – 65% of palatal fractures – laceration of lip – 45% concurrently possessing both palatal and gingival mucosal disruption • Change in maxillomandibular relationship • Fragments displaced in anterior and lateral direction • CT in axial and coronal cuts indicated for diagnosis
- 36. Classification of palatal fractures Hendrickson M et al :1998;plast reconstr surg
- 39. Le-Fort III Fracture (suprazygomatic #) • The # runs from near the frontonasal suture transversely backwards, parallel with the base of the skull and involves the full depth of the ethmoid bone, including the cribriform plate. • Within the orbit, the # passes below the optic foramen into the posterior limit of the inferior orbital fissure. • From the base of the inferior orbital fissure the # line extends in 2 directions;
- 40. 1. Backwards across the pterygo- maxillary fissure to # the root of the pterygoid laminae and 2. Laterally across the lateral wall of the orbit separating the zygomatic bone from the frontal bone. The entire middle 3rd of the facial skeleton becomes detached from the cranial base.
- 41. Signs and symptoms (Le fort III) • Panda face with gross edema and black eyes • Tenderness and separation at fronto-zygomatic suture • Tenderness & deformity of zygomatic arches • Lengthening of face with disorganisation of nasal skeleton • Depression of ocular level / Hypoglobus • Enophthalmos • ‘Hooding’ of eyes
- 42. • Bilateral circumorbital oedema and ecchymosis (black eye) • Bilateral subconjunctival haemorrhage
- 43. • If impacted then open bite • Epistaxis • Orbital emphysema • Difficulty in mastication and speech • Mobility of whole skeleton as a single block • Tilting of occlusal plane with gagging at one side only • Lateral displacement of midline of upper jaw
- 44. • Retro positioning of maxillae • Gagging of posterior teeth • Difficulty in opening mouth • Inability to move the jaw • Mobility of the upper jaw • Haematoma of the palate • Cracked pot sound on tapping
- 45. Common signs and symptoms • Gross edema – moon face appearance
- 46. Panda face • Bilateral Periorbital Haematoma • Eye’s closed by swelling and bruising
- 47. Raccoon eye’s (skull base fractures) • Periorbital ecchymosis due to subgaleal bleeding from frontal trauma • Trauma from periorbital preseptal soft tissues
- 50. Battle’s sign (skull base fracture) • Mastoid Haematoma
- 51. Hooding of the eye If fracture occurs above whitnall’s tubercle Bone displaced downwards along with upper eyelid Physical sign - hooding of globe
- 52. Restriction of eye movements • Restriction of up gaze in the left eye due to inferior rectus entrapment • Secondary to orbital floor fracture
- 53. Chemosis
- 55. Telecanthus
- 56. Diplopia
- 57. Enophthalmos
- 58. Ptosis
- 59. Epiphora
- 61. CSF Rhinorrhoea Dural tear # cribriform plate Meningitis ?? Diagnosis Clinical - Tram track, halo effect Biochemical - Dipstick - glucose levels Radiological CT scan Radio opaque dye - sub arachnoid space
- 62. Guerin’s Sign
- 63. Infraorbital, arch and F-Z suture
- 64. Infraorbital and frontonasal and butress
- 65. Investigations • PNS view • Occipitomental view • CT scan • 3- dimensional reconstruction of Le fort fractures • Occlusal view • True lateral at 6 feet
- 66. CAMPBELL AND TRAPNELL LINES
- 68. Plain CT Axial CT section of Le fort II fracture
- 69. 3-D Scan reconstruction • 3 dimensional reconstruction of Le fort II fracture
- 70. Management • The management of maxillary fractures can be divided into 4 stages • 1. Emergency care and stabilization • 2. Initial assessment • 3. Definitive treatment • 4. Continuing care
- 71. PRIORITIES • Life saving treatment first • Management of fractures later
- 72. Emergency care • Important to evaluate the airway early to rule out – Intraoral hemorrhage – Edema – Loose teeth – Posteroinferior displacement of the maxilla • Establishment of a safe airway is a priority, • Tracheostomy may be needed if intubation proves to be not possible or unsafe • If the bleeding is severe enough, packing of the midface vessels and temporary reduction of the fracture may be necessary
- 73. 1) In a patient with Le-fort II, Le-fort III, & naso-ethmoid #, what is the choice of intubation? A. Oral B. Oral & nasal C. Nasal D. Submental Ans. (D) Submental •Surgical repair of maxillofacial trauma requires modification of the standard anesthesia technique. •Nasal endotracheal intubation is often contraindicated in the presence of fracture of base of the skull. •Comminuted midfacial fractures cause physical obstruction to the passage of nasotracheal tube. Further, the presence of nasotracheal tube can interfere with surgical reconstruction of fractures of the naso-orbital ethmoid (NOE) complex.
- 74. •Surgical reconstruction often involves maxillo-mandibular fixation in the intra operative period to restore patient’s dental occlusion. This precludes the use of oral endotracheal intubation in such cases. In these conditions tracheostomy may be indicated but it carries a significant morbidity. •Submental endotracheal intubation has been described as a useful alternative to tracheostomy •This technique provided a secure airway, an unobstructed intraoral surgical field and allowed maxillomandibular fixation while avoiding the drawbacks and complications of nasotracheal intubation and tracheostomy. •Nasotracheal intubation is not possible in the presence of fractures of nasal skeleton, skull base fractures and cerebrospinal fluid rhinorrhoea. •Any attempt towards nasotracheal intubation can lead to passage of tube into the cranium, meningitis, sepsis, sinusitis and epistaxis “Submental route of endotracheal intubation is a simple, safe and useful technique in maxillofacial trauma, where oral and nasal endotracheal intubation cannot be performed. It avoids the need for trachcostomy and its consequent morbidity” Indian J. Anaesth.. Further, the presence of nasotracheal tube can interfere with surgical reconstruction of the fractures of the naso – orbital ethmoid (NOE) complex.
- 75. SUPPORTIVE TREATMENT • Antibiotics • Analgesics • Immunization against tetanus DEFINITIVE MANAGEMENT • Disimpaction and reduction of maxilla • Fixation of maxilla
- 76. Treatment goals (1) Restoration of centric occlusion (2) Restoration of midfacial projection, (3) Restoration of midfacial height, (4) Stabilization of the maxillary buttresses (to prevent late sequelae of midfacial collapse and facial elongation)
- 77. DISIMPACTION AND REDUCTION OF MAXILLA I. OPEN REDUCTION CLOSED REDUCTION (WITH ROW’S DISIMPACTION FORCEPS, HAYTON-WILLIAM FORCEP) II. IMMEDIATE REDUCTION GRADUAL REDUCTION (BY BIRD CAGE TRACTION, TRACTION BY WEIGHT)
- 78. FIXATION OF MAXILLA I. INTERNAL FIXATION A. Direct osteosynthesis Bone plates Miniplates and screws Microplates 3-d plates Bioresorbable plates Interosseous wiring
- 79. B. Suspension wires • Frontal (central, lateral) • Circumzygomatic • Zygomatic • Infraorbital • Pyriform aperture • Peralveolar
- 80. Ii. EXTERNAL FIXATION A. Craniomandibular B. Craniomaxillary Supraorbital pins Zygomatic pins Haloframe Levant frame Iii. Transfixation with k-wire
- 81. Immediate reduction • Manual reduction • Arch bar application
- 83. Use of Rowe's disimpaction forceps
- 84. Use of Hayton William's forcep
- 85. Use of both the forceps together
- 87. Pulley extension for the reduction of midfacial fragments in vertical direction • Wassmund • (1927)
- 88. • Plaster headcap with attachment to extend the maxilla in a ventral direction (Stenzel bar). The elastic traction between the upper jaw and the attachment is indicated by an arrow
- 89. Box Frame
- 91. Royal Berkshire halo frame
- 92. Craniomaxillary fixation with POP head cap
- 93. Suspension wires • It is not a rigid method of fixation • Suspensory wires have to be placed superior to the fracture • 0.5 mm diameter soft stainless steel (prestretched 10 %) is recommended Frontal a. central b. lateral Lefort III & II (mandible unstable) (mandible stable) Circumzygomatic Lefort II & I Zygomatic Lefort I Infraorbital Lefort I Piriform aperture Lefort I Transnasal ‘Gunning type’ splint Peralveolar ‘Gunning type’ splint
- 95. Use of internal suspensions • William Milton Adams (1942) • DISADVANTAGES:- • Anatomical reconstruction not accurate • Midface shortening • Retrusion between the orbits & maxillary alveolus • 3 dimensional stability not present
- 97. Inferior orbital rim suspension
- 101. Obwegeser technique of circumzygomatic wiring
- 103. Open reduction & internal fixation • Use of mini plates and screws • Plating at frontonasal, fronto zygomatic, Nasomaxillary, infra orbital,zygomatic buttress region
- 107. Lower blepheroplasty / Subciliary incision
- 108. Degloving
- 110. Transconjunctival
- 111. Infraorbital
- 112. Eyebrow incision
- 113. Bicoronal incision
- 114. Splint in place using interdental wiring. Occlusion with a normally erupting lateral incisor at 8 weeks. Palatal displacement of the dentoalveolar segment with an infected buccal laceration. Preoperative occlusal discrepancy. Fabricated open-cap acrylic splint and wiring pattern
- 115. Gunning splint
Editor's Notes
- Anatomy The two maxillae are paired structures connected by a midline suture; the bones together compose a five-sided pyramid. The anterior surface slopes downward from its superior contact with the frontal and nasal bones at an angle of approximately 15°. The most prominent point at the anterior surface is the anterior nasal spine. A number of protuberances exist on the maxilla, formed by the alveolar base and origins of the small facial muscles. The lateral surface of the maxillae forms the infratemporal fossae and buccal vestibule and attaches to the zygoma.Most of the superior surface forms the majority of the orbital floor. The medial surface of each maxilla forms the midline suture and lateral nasal walls. This includes the nasal concha and sinus ostia. The ostium of the nasolacrimal duct is beneath the inferior concha. The ostia of the maxillary sinus and middle ethmoids, as well as the opening of the nasofrontal duct, lie beneath the middle concha. The inferior border composes the palatal vault and alveolus, which contain the teeth. The posterior border abuts the sphenoid bone and the pterygomaxillary suture. Within the maxilla is the maxillary sinus. This 34 × 33 × 25 mm air cavity is responsible for the weakness of the maxilla. The sinus is present at birth but does not pneumatize to its mature extent until the patient reaches 14 to 15 years of age. Minor changes in the sinus continue throughout life.17 The strong buttresses of the maxilla are the lateral piriform buttress, the zygomatic buttress, the greater palatine buttress, and the floor of the nose. The palatine bone is L shaped and abuts the posterior maxilla as a paired structure. These bones assist the maxilla in forming the posterior sinus, the posterior lateral nasal wall, and the pterygomaxillary suture. When joined to the maxilla the four bones represent one unit .The nasal bones are paired structures that abut the frontal bone superiorly, the maxilla laterally, the septum posteriorly and medially, and each other anteriorly and medially. The bones are thicker superiorly; therefore, fractures at the Le Fort II level may occur inferior to the nasofrontal suture. The nasal septum is a thin trapezoidal bone lying perpendicular to and joining the maxillae and palatine bones. The superior border is thick and articulates with the ethmoid bone. The ethmoid bone is cuboidal and extremely pneumatized; thus, it can be easily fractured and comminuted. The cribriform plate of the ethmoid composes the roof of the nasal cavity and communicates with the anterior cranial fossae through multiple foramina for the olfactory nerves. Lateral to the crista galli is a slit through which dura mater is exposed. Posterior and superior movements of the midface can easily comminute this bone, thus disrupting the dura mater and resulting in a cerebrospinal fluid leak. The zygoma abuts the frontal bone at the frontozygomatic suture and the temporal bone at the zygomaticotemporal suture. The maxilla and zygoma form twothirds of the orbital rim and, along with the palatine bone, one-third of the walls and floor of the orbit. The infraorbital nerve traverses the orbital floor and exits through the infraorbital foramen. The maxillary bone, along with the zygoma, forms the inferior orbital fissure. Through this fissure run the maxillary nerve, the infraorbital vessels, and the ascending branches of the pterygopalatine ganglion. The frontal process of the maxilla contains the lacrimal apparatus, which is housed between the medial canthal ligaments. The blood supply to the maxillae and palatine bones is through the periosteum, the incisive artery, and the greater and lesser palatine arteries. The internal maxillary artery, a source of potentially devastating hemorrhage, lies posterior to the maxillae and palatine bones and anterior to the pterygoid plates of the sphenoid. The blood supply to the nasal septum and the lateral nasal walls is provided by the anterior and posterior ethmoidal arteries, the sphenopalatine artery, and the greater palatine and superior labial arteries.
- The maxillæ are the largest bones of the face, excepting the mandible, and form, by their union, the whole of the upper jaw. Each assists in forming the boundaries of three cavities, viz., the roof of the mouth, the floor and lateral wall of the nose and the floor of the orbit; it also enters into the formation of two fossæ, the infratemporal and pterygopalatine, and two fissures, the inferior orbital and pterygomaxillary. 1 Each bone consists of a body and four processes—zygomatic, frontal, alveolar, and palatine. 2 The Body (corpus maxillæ).—The body is somewhat pyramidal in shape, and contains a large cavity, the maxillary sinus (antrum of Highmore). It has four surfaces—an anterior, a posterior or infratemporal, a superior or orbital, and a medial or nasal. 3 Surfaces.—The anterior surface (Fig. 157) is directed forward and lateralward. It presents at its lower part a series of eminences corresponding to the positions of the roots of the teeth. Just above those of the incisor teeth is a depression, the incisive fossa, which gives origin to the Depressor alæ nasi; to the alveolar border below the fossa is attached a slip of the Orbicularis oris; above and a little lateral to it, the Nasalis arises. Lateral to the incisive fossa is another depression, the canine fossa; it is larger and deeper than the incisive fossa, and is separated from it by a vertical ridge, the canine eminence, corresponding to the socket of the canine tooth; the canine fossa gives origin to the Caninus. Above the fossa is the infraorbital foramen, the end of the infraorbital canal; it transmits the infraorbital vessels and nerve. Above the foramen is the margin of the orbit, which affords attachment to part of the Quadratus labii superioris. Medially, the anterior surface is limited by a deep concavity, the nasal notch, the margin of which gives attachment to the Dilatator naris posterior and ends below in a pointed process, which with its fellow of the opposite side forms the anterior nasal spine.
- It is limited in front by part of the circumference of the orbit, which is continuous medially with the frontal process, and laterally with the zyogmatic process. Near the middle of the posterior part of the orbital surface is the infraorbital groove, for the passage of the infraorbital vessels and nerve. The groove begins at the middle of the posterior border, where it is continuous with that near the upper edge of the infratemporal surface, and, passing forward, ends in a canal, which subdivides into two branches. One of the canals, the infraorbital canal, opens just below the margin of the orbit; the other, which is smaller, runs downward in the substance of the anterior wall of the maxillary sinus, and transmits the anterior superior alveolar vessels and nerve to the front teeth of the maxilla. From the back part of the infraorbital canal, a second small canal is sometimes given off; it runs downward in the lateral wall of the sinus, and conveys the middle alveolar nerve to the premolar teeth. At the medial and forepart of the orbital surface just lateral to the lacrimal groove, is a depression, which gives origin to the Obliquus oculi inferior. 7 The nasal surface (Fig. 158) presents a large, irregular opening leading into the maxillary sinus. At the upper border of this aperture are some broken air cells, which, in the articulated skull, are closed in by the ethmoid and lacrimal bones. Below the aperture is a smooth concavity which forms part of the inferior meatus of the nasal cavity, and behind it is a rough surface for articulation with the perpendicular part of the palatine bone; this surface is traversed by a groove, commencing near the middle of the posterior border and running obliquely downward and forward; the groove is converted into a canal, the pterygopalatine canal, by the palatine bone. In front of the opening of the sinus is a deep groove, the lacrimal groove, which is converted into the nasolacrimal canal, by the lacrimal bone and inferior nasal concha; this canal opens into the inferior meatus of the nose and transmits the nasolacrimal duct. More anteriorly is an oblique ridge, the conchal crest, for articulation with the inferior nasal concha. The shallow concavity above this ridge forms part of the atrium of the middle meatus of the nose, and that below it, part of the inferior meatus.
- The palatine process, thick and strong, is horizontal and projects medialward from the nasal surface of the bone. It forms a considerable part of the floor of the nose and the roof of the mouth and is much thicker in front than behind. Its inferior surface (Fig. 160) is concave, rough and uneven, and forms, with the palatine process of the opposite bone, the anterior three-fourths of the hard plate. It is perforated by numerous foramina for the passage of the nutrient vessels; is channelled at the back part of its lateral border by a groove, sometimes a canal, for the transmission of the descending palatine vessels and the anterior palatine nerve from the spheno-palatine ganglion; and presents little depressions for the lodgement of the palatine glands. When the two maxillæ are articulated, a funnel-shaped opening, the incisive foramen, is seen in the middle line, immediately behind the incisor teeth. In this opening the orifices of two lateral canals are visible; they are named the incisive canals or foramina of Stenson; through each of them passes the terminal branch of the descending palatine artery and the nasopalatine nerve. Occasionally two additional canals are present in the middle line; they are termed the foramina of Scarpa, and when present transmit the nasopalatine nerves, the left passing through the anterior, and the right through the posterior canal. On the under surface of the palatine process, a delicate linear suture, well seen in young skulls, may sometimes be noticed extending lateralward and forward on either side from the incisive foramen to the interval between the lateral incisor and the canine tooth. The small part in front of this suture constitutes the premaxilla (os incisivum), which in most vertebrates forms an independent bone; it includes the whole thickness of the alveolus, the corresponding part of the floor of the nose and the anterior nasal spine, and contains the sockets of the incisor teeth. The upper surface of the palatine process is concave from side to side, smooth, and forms the greater part of the floor of the nasal cavity. It presents, close to its medial margin, the upper orifice of the incisive canal. The lateral border of the process is incorporated with the rest of the bone. The medial border is thicker in front than behind, and is raised above into a ridge, the nasal crest, which, with the corresponding ridge of the opposite bone, forms a groove for the reception of the vomer. The front part of this ridge rises to a considerable height, and is named the incisor crest; it is prolonged forward into a sharp process, which forms, together with a similar process of the opposite bone, the anterior nasal spine. The posterior border is serrated for articulation with the horizontal part of the palatine bone. 14
- SEVERE trauma produces communition of more superficial elements , particularly bones of nasoethmoidal complex and anterior maxillae it is this inward crushing that which produces dish face deformity rather than total posterior displacement . Composite structure of this complex of bones is so ordered that it will withstand forces of mastication from below and provide protection in certain areas for vital structures , notably the eye ..
- Frontal bone and body of sphenoid form an inclined plane which lies at an angle of 45 degree to occlusal plane . In lefort II and III downward and backward displacement of bones of middle third occurs along this inclined plane resulting in posterior gagging of the posterior teeth occassionally airway occluded, when tissues of soft palate meet the Tongue. Because of steep slope of base of the skull . The slight backward displacement causes posterior teeth of maxilla to push open the mandible causing lengthening of face
- Matchbox structure of midfacial skeleton cushions the effect of impact force B A force directly transmitted to brain causing severe injury C transmitted indirectly to cranial base via rigid structure of mandible thru temperomandibular articulation Boxers knock out punch. These physical differences important for survival after head injury .
- The bony pillars of middle third which remain after removal of thin connecting laminae of bone represented as an architectural conception of the essential skeletal reconstruction.
- The nasomaxillary buttress is formed by the lower maxilla, the frontal process of the maxilla, the lacrimal bone, and the nasal process of the frontal bone. The zygomaticomaxillary buttress is formed from the lateral portion of the maxilla, zygoma, and lateral portion of the frontal bone. The final buttress extends along the pterygoid plates to the skull base
- The horizontal buttresses are composed of the alveolus, hard palate, inferior orbital rim, and frontal bar. Horizontal buttresses have coronal and sagittal components. The sagittal buttresses are vital for facial projection. The midface is relatively deficient in sagittal buttresses. The skull base is at a 45° angle relative to the occlusal plane of the maxilla and can act as an axial buttress as well vertical impact tends to be better absorbed within the facial skeleton, which resists fracture, while horizontal impact tends to overcome the weaker horizontal buttresses and shear through the vertical pillars. In a surgical approach to maxillary fractures, attempts should be made to restore the continuity of these support buttresses
- Since energy is neither creatednor destroyed, the amount of energy (force) delivered to a given object is predicated on themagnitude and direction of that force, the impact characteristics of the two colliding bodies,and the ability of each to dissipate the energy. In a series of experiments by Nahum (1975),force tolerance ranges for the facial bones were determined and demonstrated to be in arelatively low range (150 to 300 pounds) for the maxilla, in comparison with the frontal bone(800 to 1600 pounds) and mandible (550 to 900 pounds anterior to posterior directed force).Tolerance values were found to be somewhat lower for females. When it is realized that a soft yielding surface absorbs energy (ie, a padded dashboard), whereas a rigid object (ie, a windshield or steering wheel) does not plastically deform and thereby dissipate energy well,it is not surprising that the most important mechanisms of fatal injury are represented by ejection from the vehicle, followed by impact on the steering assembly, instrument panel, and dashboard, respectively. Thus, knowledge of the position of the body, the direction of impact, and the use of restraints is helpful in predicting injury patterns.
- Sex Midface fractures predominantly affect males, who outnumber females by 5 to 1. Typically, these fractures affect younger males. See also Frequency, Internationally above. Age Compared with adults, children have a far lower incidence of midface fractures because of anatomic differences and the overall elasticity of their tissues
- occurring in roughly 35 to 55 per cent of most reported series (Dawson and Fordyce, 1953; Kuepper and Harrigan, 1977; Steidler and colleagues, 1980), and like LeFort I fractures are usually the result of horizontally directed impacts.
- Type I – alveolar fracture:-2 types Ia – Anterior alveolus – contains only the incisor teeth and alveolus in that region Ib – posterolateral – contains premolars, molars, and alveolus in that region Type II – sagittal fracture – they occur as a midline split of palate. mostly seen in 2nd to 3rd decade because of lack of an ossified midline palatal suture
- Type III – Parasagittal fracture - most common in adults because of thinner palatal bone located parasagittally. They contain canine in addition to premolars and molars Type IV – paraalveolar fracture - found directly palatal to maxillary alveolus and also contains incisor dentition Type V – complex/communited fracture – multiple large obliquely oriented fracture fragments or gross communition
- Type VI – transverse – rarest , divides maxilla into coronal plane
- this type of fracture is not common, occurring in approximately 5 to 15 per cent of most reported series of maxillary fractures (Kuepper and Harrigan, 1977; Steidler and colleagues,1980). Unlike LeFort I and II fractures, LeFort III fractures are usually produced from impacts angled obliquely to the horizontal buttresses, and experimentally have been reproduced by impacts directed at 30 degrees above the Frankfort plane (Stanley and Nowak,1985).
- orbital emphysema by detected by the peculiar ‘crackling’ sensation imparted to finger tip, alternatively rolling two fingers gently over the tissue. # through a sinus wall with tearing of lining mucosa allows air to escape into facial soft tissue.The soft tissue of periorbital area, especially the eyelids, is prone to inflation with air owing to its loose areolar nature.
- Bilateral circumorbital ecchymosis Bilateral subconjunctival haemorrhage Obvious deformity of nose Bleeding from nose/clotted blood Cerebrospinal fluid rhinorrhoea Dish-face deformity/lengthening of face Limitation of ocular movement
- Trauma which is confined to the periorbital pre-septal soft tissues will present as a classical ‘black eye’ and oedema, Circumorbital ecchymosis subconjuctival haemorrhage will be present.
- SEVERE trauma produces communition of more superficial elements , particularly bones of nasoethmoidal complex and anterior maxillae it is this inward crushing that which produces dish face deformity rather than total posterior displacement . Composite structure of this complex of bones is so ordered that it will withstand forces of mastication from below and provide protection in certain areas for vital structures , notably the eye ..
- Frontal bone and body of sphenoid form an inclined plane which lies at an angle of 45 degree to occlusal plane . In lefort II and III downward and backward displacement of bones of middle third occurs along this inclined plane resulting in posterior gagging of the posterior teeth occassionally airway occluded, when tissues of soft palate meet the Tongue. Because of steep slope of base of the skull . The slight backward displacement causes posterior teeth of maxilla to push open the mandible causing lengthening of face Untreated Lefort fractures classically demonstrate mid face elongation and retrusion due to action of medial pterygoid muscle. IMF determines anatomical horizontal position of fractured segments , does not determine vertical postion. Classic suspension of maxillary fracture can result in midfacial shortening and retrusion of that component , resulting from overclosure
- Odema of conjunctiva frequently associated with periorbital hematoma . This causes swollen conjunctiva to bulge out between eyelids , a feature that becomes pronounced as eyelid swelling subsides
- Subconjuctival bleeding in such cases is localized and limited nature, whereas, in the case of orbital # , blood usually accumulates initially in the extraconal space and tracks anteriorly so that poster limit cannot be defined , variation in the nature of subconjuctival haemorrhage is helpful in differential diagnosis Initial absence of a subconjuctival haemorrhage does not exclude the possibility of #, reason for this is that some # do not tear the orbital periosteum and the blood accumulates slowly in the subperiosteal plane and may not appear for some days which tends to appear at periphery in the conjunctival fornices
- Medial palpebral ligament is more readily disturbed if the frontal process of maxilla is # and avulsion. Inferior displacement of the bone to which the ligament is attached will result in a mongoloid slant.detachment of medial canthal ligament associated with naso ethmoidal injuries can lead to traumatic telecanthus
- DIPLOPIA:- is due to the stimulation of non corresponding points of the two retinas by the same object. Name given to symptom of blurred vision. Two varieties-: 1. Monocular diplopia 2. Binocular diplopia Monocular diplopia :- Blurring of vision through one one eye with the other closed, require immediate attention of ophthalmologist since it usually indicates :- detached lens other traumatic injury to globe Binocular diplopia:- Blurring of vision occur only when patient looks through both eyes Diplopia results mainly from interfernce with the activity of extraocular muscles and results from odema and haemorrhage in and around these muscles
- Enophthalmos:- Is generally due to severe injury , in which the bones of floor of the orbit are # and soft tissue herniate , or to orbital cellulites followed by mechanical retraction by fibrous tissue. Causes of secondary enophthalmos include the following: Postnatal, inadequate, orbital cavity development Bone growth arrest (eg, ionizing radiation for retinoblastoma) Inadequate local tissue stimulation of orbital bone growth Intraorbital (eg, phthisis bulbi, anophthalmos, fat atrophy in childhood) Extraorbital (eg, maxillary bone growth problems) Orbital cavity expansion Outward fracture of orbital bones (frequency of fracture sites - floor > medial wall > lateral wall > roof) Surgical expansion of the orbit (as in thyroid orbitopathy) Silent sinus syndrome, ie, spontaneous, asymptomatic collapse of the maxillary sinus and orbital floor associated with negative sinus pressures Orbital varix with presumed slow bone erosion when the varix fills during recumbent position Volumetric loss of orbital contents Orbital fat atrophy Following concussive trauma Following severe inflammation or infection Following external beam irradiation Associated with wasting disorders (eg, Parry-Romberg hemifacial atrophy, linear scleroderma) Contraction of orbital fat - Scirrhous carcinomas (most commonly metastatic breast, but pulmonary, prostate, and gastrointestinal cancers may cause fat and globe retraction as well) Following surgery (as in resection of a mass lesion associated with local fat atrophy) Phthisis bulbi or prephthisis bulbi Pseudoenophthalmos Unilateral blepharoptosis Horner syndrome Contralateral exophthalmos Contralateral pseudoexophthalmos Contralateral high myopia Contralateral buphthalmos or megaloglobus Contralateral eyelid retraction
- Epiphora, or abnormal tearing, occurs because of blockage in the lacrimal drainage system, which impairs normal tear channeling into the nose. Recurrent infection may also occur as a result of the stagnation. The dacryocystorhinostomy operation, which involves fistulization of the lacrimal sac into the nasal cavity, may alleviate the symptoms.As normal access to the nose for the tears is impaired, a neopassage is defined from the lacrimal sac to the nose.EtiologyThe occurrence of symptoms may be related to congenital or acquired causes. Acquired causes include recurrent dacryocystitis and canaliculitis; dacryolithiasis; lacrimal system tumors; nasal pathology obstructing drainage; and trauma, which may be iatrogenic. An unidentifiable cause contributes to an idiopathic etiology.PathophysiologyAs a result of the blockage of the nasolacrimal duct, normal tear flow into the nose is impaired. This leads to epiphora. The stagnation of tears in the lacrimal sac and the adjacent conduits promotes infection and its accompanying sequelae.ClinicalPatients may present to an ophthalmologist with socially unacceptable unilateral or bilateral epiphora interfering with vision. Persistent neglect of the symptom may induce chronic dacryocystitis with purulent drainage from the canaliculi. Inflammation of the skin in the region of the medial canthus may occur with acute exacerbations.Relevant Anatomy The lacrimal punctum, which lies near the medial end of each lid margin, opens into a canaliculus. The upper and lower canaliculi lead to the lacrimal sac, which lies in the lacrimal fossa formed by the frontal process of the maxilla anteriorly and the lacrimal bone posteriorly. The nasolacrimal duct originates at the inferior end of the lacrimal sac and slopes caudolaterally to open in the inferior meatus of the nose. This opening is protected by several variable folds of mucous membrane that act as valves preventing retrograde air aspiration. The aqueous secretion of the lacrimal gland is covered by a film of mucus from the tarsal conjunctiva. This is further covered by a film of oily secretion from the meibomian glands. Evaporation is hence impeded, and the flow of tears occurs from lateral toward the lacus lacrimalis medially. The palpebral fibers of the orbicularis oculi trigger blinking, a reflex act. Blinking pumps the tears out of the conjunctival sac. During the act, the puncta are turned inward and dip into the lacus lacrimalis. At this time, the lacrimal sac is drawn open, and tears are sucked up through the canaliculi. When the muscle relaxes, the lacrimal sac retracts to its original volume and the tears are pushed down the nasolacrimal duct DCR (Dacryocystorhinostomy)Tears are made primarily by the lacrimal gland, which is anatomically located in the upper lateral aspect of the upper eyelid. With each blink, however, tears are drained from the eye through the tear drainage system, into the nose. There are normally two openings to the tear drainage system; one in the upper eyelid and one in the lower eyelid. These tiny orifices are situated along the margin of the eyelid, closest to the nose, and are known as puncta. The puncta lead to tiny ducts known as canaliculi which lead to the lacrimal sac, situated just along the inside corner of the eye, on the side of the bridge of the nose. Tears are carried from the lacrimal sac down the nasolacrimal duct into the nose. It is usually toward the bottom of the nasolacrimal duct that obstructions of this passageway occur.
- Cerebrospinal fluid rhinorrhea is indicative of a fracture in the region of the cribriform plate of the ethmoid, sphenoid or frontal bones together with a tear in the overlying dura and usually occurs within 24 to 48 hours of injury. The diagnosis is usually obvious from the clinical history and the typical appearance of a thin, glairy, sero-sanguinous nasal discharge that tends to form “tram lines” on the facial skin as it evaporates and dries. If there is any doubt in the diagnosis fluid should be sent for quantitative glucose analysis. Glucose levels greater than 30 mg/100ml are indicative of CSF not nasal secretions. Glucose oxidize reagent strips should not be relied on as they not infrequently produce false negative results. Nasogastric tubes must not be inserted into patients with CSF rhinorrhea, as cannulation of the anterior cranial fossa via a disrupted cribriform plate is not unknown 20 – 25 % cases of mid face fractures are associated with CSF rhinorrhea
- Obstruction of nasal and oral airways by blood clot,saliva, bone teeth, parts of denture Inhalation of any of above Occlussion by downward and backward displacement of maxilla Obstruction of nasal and oral airways by tongue fall in symphysis fractures.
- The paired forceps are placed with the fat end in the nose and the bowed end on the palate. The surgeon stands over the patient’s head and in an inferior-anterior movement disimpacts the maxilla. Further assistance may be provided with hayton- Williams forceps used in conjunction with the Rowe disimpaction forceps
- Rigid form of craniomandibular fixation with help of supraorbital pins and 2 others inserted in mandible 1 cm above lower border in canine region . Suitable in absence of cap splints . Disadvantage – emergency release of fixation in post operative period is more difficult while pt. is still in anesthesia.
- Simple rigid skeletal craniomaxillary suspension between supra orbital rim and the maxilla connected by a central maxillary rod attached at lower end by means of cap or acryli splints Central vertical rod attached by 2 universal joints 30 degree bends medial to pin connections making rotation about horizontal axis impossible
- Indicated in supraorbital ridge fractures. Encircles three quarters of skull and leaves the occiput free.its attached to cap splint and reduction achieved
- Indicated in middle third fractures with extensive fractures of cranial vault.GA not recquired if stabilized with cap splints.LA is preferred
- Use of different type of internal wire suspension
- Wire passed bilaterally in first bicuspid region kelsey fry type peralveolar awl . Holes predrilled in denture passage to allow passage of awl Maxillary denture modified with stout continuous loops and sutured to maxilla with a nasal spine wire and lateral perialveolar wires Maxillary denture with embedded arch bar secured to maxilla with zygomatic buttress wires and nasal spine wires
- Three concentric circles used as guide for reduction of multiple facial fractures .bones crossed by line of outer circle are reduced and immobilized first .those within middle ring are next repositioned finally nasal complex represented by inner circle is treated
- Initial restoration of FZ and arch – outer facial frame with exact anteroposterior projection and transverse facial width.inner facial frame – infraorbital rim and naso ethmoid region within this frame Lower facial repair after IMF and completing repair at 2 anterior maxillary buttresses
- Management of an Unusual Maxillary Dentoalveolar Fracture: A Case Report A.R. Prabhakar, MDS David P. Tauro, MDS A.B. Shubha, BDS(J Dent Child 2006;73:112-115)