CASE PRESENTATION IN MAXILLOFACIAL AND ORAL SURGERY

1. Presented by – Dr. ABHIJEET KAMBLE
PG year 2

2. CASE History
◦ A/H/O Fall at ground level while the patient was returning after donating blood at IGMC, Shimla on 09-02-
2023 at around 9:30 am.

3. CASE History
◦ Date of Reporting : 09-02-2023
◦ Cr no : 2022014593
◦ Name : Sabreen
◦ Age : 24 years
◦ Sex : female Adult
◦ Occupation : Homemaker
◦ Address : TOWN – MOHALA KASHMIRI , P.O & TEH – CHAMBA , DISTRICT -
CHAMBA
◦ CONTACT NUMBER: - 9816530098, 9857934242
◦ CHIEF COMPLAINT : PAIN AND SWELLING WRT RIGHT EYE REGION SINCE 10 DAYS
◦ HISTORY OF PRESENTING ILLNESS : H/O FALL AT GROUND LEVEL WHILE DONATING BLOOD

4. CASE History
◦ Past medical history: Xn
◦ Past dental history: Xn
◦ Family history: Married
◦ Personal history: vegetarian diet

5. GENERAL
EXAMINATION
◦ Pallor: Absent
◦ Icterus: Absent
◦ Cynosis: Absent
◦ Clubbing: Absent
◦ CNS: Well oriented GCS: 15/51
◦ CVS: NAD
◦ Respiratory system: NAD

6. Extra oral examination
◦ Facial symmetry: Asymmetrical, Diffuse swelling + wrt right side face region
◦ Eye movements: WNL, No diplopia, No blurring of vision
◦ Mouth opening: Adequate
◦ Mandibular movements: WNL
◦ Tenderness on palpation: + wrt right lateral wall of orbit
◦ Step Deformity: + wrt right orbit lateral wall
Front view

7. Intra oral examination
◦ Maximum interincisal opening: 25 mm
◦ Occlusion: Intact
◦ No bony tenderness
◦ No step deformity
Intact occlusion

8. Pre operative Radiographs
PNS View NCCT Axial view

9. Radiographic examinations comprised of orthopantomogram and computerized tomography that
revealed a Displaced Fracture of lateral wall of Right Orbit .
Based on these findings, a diagnosis of Comminuted Displaced Fracture of lateral wall of right Orbit.

10. Treatment planning: Open reductio internalfixationwas planned for the patient Under GA.
COMMINUTED DISPLACED FRACTURE OF LATERAL WALL
OF RIGHT ORBIT
Lateral eyebrow incision Two 3 hole mini plate fixation done