This document provides an overview of fractures of the middle third of the facial skeleton. It begins with an introduction defining this region and the bones it includes. It then discusses the physical characteristics, areas of weakness and strength, and classification of fractures. The document focuses on Le Fort fracture patterns, describing the clinical features and treatment approaches for each. It also covers diagnosing injuries, reducing fractures, treatment modalities including internal fixation techniques, surgical approaches, and considerations for combined fractures.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
Maxillofacial Surgery
Dental Students Fifth Year First semester
Lecture Name maxillofacial trauma part 2
Al Azhar University Gaza Palestine
Dr. Lama El Banna
Area between a superior plane drawn through the FZ sutures tangential to the skull base and inferior plane at the level of maxillary occlusal surface
Triangular region with widest dimension facing anterior
Definition:
Middle third of the facial skeleton may be defined as that area bounded superiorly by a transverse line connecting the 2 zygomaticofrontal sutures & inferiorly by occlusal plane of the maxillary teeth, or alveolar ridge in edentulous patient.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Mandibular angle fractures account for 23% to 42% of all facial fractures. Fracture of mandibular angle can be classified as (A) Vertical favorable or unfavorable, (B) Horizontally favorable of unfavorable. Traditionally, mandibular angle fractures have been treated with either closed reduction and inter-maxillary fixation or open reduction and internal fixation with or without inter-maxillary fixation. Patients treated with inter-maxillary fixation have a restricted airway and loose excess weight. Rigid internal fixation and early return to function have eliminated the use of wire osteosenthysis and prolonged use of inter-maxillary fixation. The principal of rigid fixation, however, have inherent set of disadvantages including damage to the inferior alveolar nerve and the marginal mandibular branch of facial nerve. Postoperative malocclusion rates are also high. With the introduction of semi-rigid technique fracture of the mandibular angle could be treated according to Champy’s Ideal lines of osteosenthysis. The technique involves placement of a single monocortial miniplate on the superior border of the mandible. However, some studies suggested using a second miniplate along the inferior border. Wether one or two miniplates should be used is still debatable. The application of 3D plates may provide additional stability in 3 dimension and good resistance against torque forces.
Maxillofacial Surgery
Dental Students Fifth Year First semester
Lecture Name maxillofacial trauma part 2
Al Azhar University Gaza Palestine
Dr. Lama El Banna
Area between a superior plane drawn through the FZ sutures tangential to the skull base and inferior plane at the level of maxillary occlusal surface
Triangular region with widest dimension facing anterior
Definition:
Middle third of the facial skeleton may be defined as that area bounded superiorly by a transverse line connecting the 2 zygomaticofrontal sutures & inferiorly by occlusal plane of the maxillary teeth, or alveolar ridge in edentulous patient.
Its a Clinical Presentation of Midface fractures-specifically, Lefort fractures. Classification, Anatomical Landmarks, Clinical Features, Diagnosis & Management protocols are discussed.
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Description:
Hi. This is Dr. Amit T. Suryawanshi. Dentist in Kolhapur (MDS) Oral & Maxillofacial surgeon from Kolhapur, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
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Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
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1. Define an electrocardiogram (ECG) and electrocardiography
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3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
7. fractures of middle third of facial skeleton
1. (Department of Oral & Maxillofacial Surgery)
FRACTURE OF MIDDLE THIRD OF
FACIAL SKELETON
Presented By:
Dr. Samarth Johari
2. CONTENTS
Introduction
Articulation with skull base
Physical characteristics of the midfacial
skeleton
Areas of weakness
Areas of strength
Classification
Le Fort I
Le Fort II
Le Fort III
Diagnosing a maxillofacial injury
Reduction of mid face fractures
Treatment modalities
Surgical approaches
Plate systems & techniques for rigid
internal fixation
First mandible, second maxilla in
combined fractures
Sinus drainage
Referrences
3. INTRODUCTION
• Defined as: an area bounded
superiorly by a line drawn across skull
from zygomaticofrontal suture across
frontonasal & frontomaxillary sutures
to the zygomaticofrontal suture on the
opposite side & inferiorly by the
occlusal plane of upper teeth (or by
alveolar ridge if patient is edentulous)
4. • Following bones constitute the middle third of the face:
i. Two maxillae
ii. Two zygomatic bones
iii. Two zygomatic processes of temporal bones
iv. Two palatine bones
v. Two nasal bones
vi. Two lacrimal bones
vii. Vomer
viii.Ethmoid & its attached conchae
ix. Two inferior conchae
x. Pterygoid plates of sphenoid
Frontal bone, body;
greater & lesser wings of
sphenoid bone are
protected by the
cushioning effect achieved
when fracturing forces
crush weaker bones of
middle third of face
7. PHYSICAL CHARACTERISTICS OF
THE MIDFACIAL SKELETON
• Made up of considerable number of bones – rarely fractured in isolation
• All the bones are comparatively fragile, articulate in a most complex fashion
• Greatest portion is maxilla:
i. Capable to absorb force and transmit to the adjacent articulating bones
ii. Acts as a cushion for the trauma directed to the cranium
• Middle third is anatomically complicated – Generally comminuted fractures
8. AREAS OF WEAKNESS
• Developmental Sutures
• Air filled spaces
• Neurovascular bundle
9. AREAS OF STRENGTH
• Described by Sicher & Tandler in 1928
• Thickened Bones that transmit chewing forces to supporting regions of
skull
• Analogus to architectural concepts of support
10. Horizontal Buttresses:
i. Supra-Orbital Rims with Frontal bones
ii. Infra-Orbital Rims
iii. Zygomas
iv. Alveolar Process
11. Vertical Buttresses:
i. Medial / Nasomaxillary
pillars
ii. Lateral / Zygomatico-
maxillary pillars
iii. Posterior/ Pterygomaxillary
pillars
12. EFFECTS OF MID FACE FRACTURES
• Involvement of brain &
cranial nerves:
i. Communition of
ethmoid
occurs with Le Forte II &
III fractures & severe
nasal fractures
13. ii. Damage to infraorbital & zygomatic nerves
Occur with zygomatic & Le Forte II fractures
iii. Damage to cranial nerves within orbit
Occur in Zygomatic, Le Forte II & III fractures
14. CLASSIFICATION
• Based on cadaveric studies conducted by Rene Le Fort in 1901
Le Fort I (low-level fracture)
Le Fort II (pyramidal or subzygomatic fracture)
Le Fort III (high transverse or suprazygomatic fracture)
15. • According to Rowe & Williams, 1985:
A. Fractures not involving the occlusion
1. Central region-
a. Fractures of nasal bones &/or nasal septum
i. Lateral nasal injuries
ii. Anterior nasal injuries
b. Fractures of frontal process of maxilla
c. Fractures of type (a.) & (b.) which extend into the ethmoid bone (naso-
ethmoid)
d. Fractures of type (a.), (b.) and (c.) which extend into frontal bone (fronto-
orbito-nasal dislocation)
16. 2. Lateral region-
Fractures involving the zygomatic bone, arch & maxilla (zygomatic
complex)excluding the dentoalveolar component
A. Fractures involving the occlusion
1. Dentoalveolar
2. Subzygomatic
a. Le Fort I (low level or Guerin)
b. Le Fort II (pyramidal)
3. Suprazygomatic
a. Le Fort III (high level or craniofacial dysjunction)
17. • Along with Le Fort fractures nasal septum & palate may also be fractured
• Palatal fractures - classified by Hendrickson and colleagues based on
fracture pattern:
Type I: alveolar
Type II: sagittal
Type III: parasagittal
Type IV: para-alveolar
Type V: comminuted/complex
Type VI: transverse
• Type III fractures are the most encountered pattern as the parasagittal bone
of the palate is thinner than the mid sagittal buttress
18. • Modified lefort classifications by Marciani Rd 1993:
Lefort I – Low Maxillary Fractures
I a _ Low maxillary Fracture /Multiple Segments
Lefort II- Pyramidal Fracture
II a - Pyramidal and nasal Fractures
II b - Pyramidal and naso Orbito ethmoidal (NOE) Fracture
19. Lefort III - Craniofacial Dysjunction
III a- Craniofacial Dysjunction and Nasal Fracture
III b- Craniofacial Dysjunction and NOE
Lefort IV - Lefort II or III fracture and cranial base fracture
IV a- Supra orbital fracture
IV b – Anterior Cranial Fossa and Supra Orbital Rim Fracture
IV c - Anterior Cranial Fossa and Orbital wall fracture
20. Le Fort I
• Also known as low level fracture, Guerin
fracture, floating fracture, horizontal fracture,
pterygomaxillary dysjunction, subzygomatic
fracture
• Above nasal floor
• Lateral margin of anterior nasal aperture
• Zygomatic buttress
• Lower third of pterygoid laminae
• Lateral wall of nose
• Lower third of nasal septum
• Joins lateral frature behind tuberosity
21. CLINICAL FEATURES:
Swelling of the upper lip
Ecchymosis present in the buccal sulcus beneath
each zygomatic arch
Anterior open bite
Deranged occlusion
Midline split of the palate
Subluxation of teeth
22. The impacted Le Fort I fracture (Telescoping
fracture) –difficult to diagnose – ‘grating sound’
Percussion - ‘cracked pot’ sound
Haemorrhage in the maxillary sinuses
23. Le Fort II
• Also known as pyramidal or subzygomatic fracture
24. Clinical features
No alteration of pupillary level
Haematoma in the upper buccal sulcus
Step deformity : infra orbital margins
Classic raccoon sign : caused by bilateral periorbital edema &
ecchymosis
25. Limitation of orbital movement with
diplopia and enophthalmos
CSF rhinorrhea : due to dural tear
Anaesthesia or Paraesthesia of the
cheek
Gagging of occlusion and retro-
positioning of the maxilla
On manipulation: movement being
detected at the infra orbital margins
and nasal bridge
26. Le Fort III
• Also known as high transverse or suprazygomatic fracture
27. Clinical features
Lenghtening of the face
Classic dish shaped deformity
Alteration of the occular level
unilateral or bilateral hooding of the eye
# of the zygomatic arch :
flattening of the zygomatic complex
Tenderness and deformity over the zygomatic arch
28. Disruption of the cribriform
plate :CSF rhinnorhoea
Telecanthus
Epiphora
Tenderness and separation at
the F-Z suture
Mobility of the whole facial
skeleton as a single block
Gagging of occlusion in the
molar area
31. Local clinical examination
Extra oral examination
On inspection check for:
Lacerations or injury over head
Check for edema, ecchymosis (periorbital,
conjunctival, scleral) and soft tissue lacerations
Any obvious bony deformities, haemorrhage,
epistaxis or otorrhoea, rhinorrhea
occular involvement
32. On Palpation:
It should begin at the back of the neck and cranium,
Upper face,the zygomatic arch, bone and orbit
Ares of tenderness, deformities are to be noted
Step deformity, subcutaneous, emphysema
Mobility of maxilla
Eyelids separated and vision tested, check for
diplopia, light reflex
Check for Paraesthesia
33.
34.
35. Intra oral examination
Derangement of occlusion, gagging of
occlusion, lacerations, ecchymosis
Palpation
Areas of tenderness, bony irregularities, crepitus
mobility of teeth noted
Examination of teeth
Pharynx evaluated for laceration & bleeding
39. Most important step.
Universal rule of mechanics
Reduction:
Manual reduction / Hand manipulation
For fresh #, Non impacted
Special instruments
For old, Grossly displace or impacted
REDUCTION OF MIDFACE
FRACTURES
44. Le Fort II & III –
When inadequate alignment results,
individual segments are reduced
separately.
Direct reduction: Elevator, bone hook or
wire inserted through the fragment.
Traction using elastic bands applied to
maxillary and mandibular arch bar can be
used for reducing fracture.
45. TREATMENT
MODALITIES• Changes in treatment strategy:
Before introduction to O.R.I.F external fixators & plaster head caps were used
With introduction to corrosion resistant & saliva resistant cheap steel, intra-
oral tooth-borne wiring techniques were used
Tissue inert steel wires – internal wire suspension techniques
Disappointing results – specially in higher Le Fort levels
Reason: tooth borne appliances – no complete control over bone
46. Improvement in antibiotics & anaesthesia management
Open reduction techniques became popular
Introduction to micro-screws & plates – even small fragments were preserved for
exact anatomical reduction & fixation
47. • Timing of surgical intervention:
Best results – immediately after trauma
In presence of soft tissue lacerations – surgical treatment within 8 hrs after
trauma
Late interventions – difficult (due to enormous swelling of soft tissues)
Go for intramaxillary fixation & wait for few days, but not more than 12 to 14
days – because bony consolidation occurs rapidly
48. • Closed reduction & internal fixation by Intermaxillary Fixation:
I.M.F can be continued for 2-3 weeks until fractures are bridged with woven
Bell et al in 1975 conducted a study on monkeys & demonstrated that after Le
Fort I osteotomy, without bony fixation, I.M.F for 3-4 weeks resulted in a healed
maxilla in correct position
Disadvantages-
• Tooth borne ligatures control fracture only on occlusal level
• No satisfactory result in case of severe displacements in region of facial
buttresses
• Breathing difficulty – due to nasal pack or feeding tube
50. • Wire suspension in combination with closed or open reduction:
Mobile maxillary part is suspended to fixed
point on non fractured skull
Common techniques:
i. Frontomalar suspension
ii. Suspension on glabella
iii. Piriform aperture wiring
iv. Infraorbital wiring
v. Circumzygomatic wiring
Removed after 6 weeks
51. • Open reduction & internal fixation by interosseous wiring:
Introduced for midfacial fractures by
Adams in 1942 & refined by Manson et al
Gruss & Mackinnon in 1986 emphasized
on importance of immediate bone
grafting to stabilize buttresses
Requires additional 2-3 weeks of I.M.F
52. • Open reduction & internal fixation by miniplates, microplates & screws:
Champy et al – method of monocortical plate fixation in mandible.
Miniaturized plates were applied to midfacial fractures by Harle & Duker in 1975
by Luhr in 1979
53. SURGICAL APPROACHES
• Intra-oral approach by gingivobuccal sulcus (sublabial) incision or by
marginal gingival (sulcular) incision:
63. MAXILLARY SINUS DRAINAGE
• Usually unnecessary
• Drainage usually occurs spontaneously by the fractured lateral wall and
lacerated mucosal lining
• Infection is rarely seen
• When occurs, is most likely to be because of loose screws, plates or
necrotic bone fragments
• Infection subsides when the loose structures are removed
64. REFERRENCES
• Maxillofacial surgery by Peter Ward Booth
• Killey’s fractures of middle third of facial skeleton
• Maxillofacial injuries by Rowe & Williams, volume 1
• Fonseca Oral and Maxillofacial Surgery, fourth edition
• Surgical approaches to the facial skeleton by Edward Ellis III