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
â orbital floor superiorly,
â alveolar ridge inferiorly,
â front wall of the maxillary sinus anteriorly,
â anterior surface of the pterygopalatine fossa posterolaterally
7. To resist the vertical forces of mastication
⢠3 paired vertical buttresses (from anteromedial to
posterolateral):
â the nasomaxillary buttress,
â the zygomaticomaxillary buttress,
â the pterygomaxillary buttress
⢠additional unpaired midline support is the frontoethmoid-
vomerine buttress
⢠These pillars serve
â to diffuse the vertical forces of mastication over the
broad cranial base.
â shock absorbers for a vertically oriented impact to the
facial skeleton
8. ⢠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
9. ⢠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
10. Divisions Of #âs
⢠#âs of the Middle third facial skeleton may be divided into
⢠CENTRAL MIDDLE THIRD
â Includes, Dentoalveolar, naso-maxillary and naso-
ethmoidal & Le Fort I, II, III & IV
⢠LATERAL MIDDLE THIRD
â Include zygomatico-maxillary #âs
13. 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
14. 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
15. Classification
Fractures involving the occlusion
⢠Dentoalveolar #âs
Subzygomatic # -
⢠Le-fort I #
⢠Le-fort II #
Suprazygomatic # -
⢠Le-fort III # &
⢠Le-fort IV #
17. 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
18. 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
âs
19. 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
21. 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
22. Signs and symptoms (Le-fort II)
⢠Gross edema (moonâs 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
23. ⢠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
24.
25. 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;
26. 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.
27. 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
⢠âHoodingâ of eyes
29. ⢠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
30. ⢠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
31. Common signs and symptoms
⢠Gross edema â moon face appearance
33. Raccoon eyeâs (skull base fractures)
⢠Periorbital ecchymosis
due to subgaleal bleeding
from frontal trauma
⢠Trauma from periorbital
preseptal soft tissues
37. Hooding of the eye
ďą If fracture occurs above
whitnallâs tubercle
ďą Bone displaced downwards
along with upper eyelid
ďą Physical sign - hooding of
globe
38. Restriction of eye movements
⢠Restriction of up gaze
in the left eye due to
inferior rectus
entrapment
⢠Secondary to orbital
floor fracture
53. 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
55. Emergency care
⢠Important to evaluate the airway early to rule out
â Intraoral hemorrhage
â Edema
â Loose teeth
â 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
56. 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
â˘Surgical repair of maxillofacial trauma requires modification of the standard
anesthesia technique.
â˘Nasal endotracheal intubation is often contraindicated in the presence of fracture of
base of the skull.
â˘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.
57. â˘Surgical reconstruction often involves maxillo-mandibular fixation in the intra
operative period to restore patientâs 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.
â˘Submental endotracheal intubation has been described as a useful alternative to
tracheostomy
â˘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.
â˘Nasotracheal intubation is not possible in the presence of fractures of nasal
skeleton, skull base fractures and cerebrospinal fluid rhinorrhoea.
â˘Any attempt towards nasotracheal intubation can lead to passage of tube into
the cranium, meningitis, sepsis, sinusitis and epistaxis
âSubmental 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 morbidityâ Indian J. Anaesth..
Further, the presence of nasotracheal tube can interfere with surgical
reconstruction of the fractures of the naso â orbital ethmoid (NOE) complex.
58. 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)
59. DISIMPACTION AND
REDUCTION OF MAXILLA
I. OPEN REDUCTION
CLOSED REDUCTION
(WITH ROWâS DISIMPACTION FORCEPS,
HAYTON-WILLIAM FORCEP)
II. IMMEDIATE REDUCTION
GRADUAL REDUCTION (BY BIRD CAGE
TRACTION, TRACTION BY WEIGHT)
60. FIXATION OF MAXILLA
I. INTERNAL FIXATION
A. Direct osteosynthesis
Bone plates
Miniplates and screws
Microplates
3-d plates
Bioresorbable plates
Interosseous wiring
62. Ii. EXTERNAL FIXATION
A. Craniomandibular
B. Craniomaxillary
Supraorbital pins
Zygomatic pins
Haloframe
Levant frame
Iii. Transfixation with k-wire
68. Pulley extension for the reduction of
midfacial fragments in vertical direction
⢠Wassmund
⢠(1927)
69. ⢠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
74. 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 âGunning typeâ splint
Peralveolar âGunning typeâ splint
75.
76. 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
84. Open reduction & internal
fixation
⢠Use of mini plates and screws
⢠Plating at frontonasal, fronto zygomatic,
Nasomaxillary, infra orbital,zygomatic
buttress region
94. 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
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 Ă 33 Ă 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 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 maxillÌ 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
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 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.
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.
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 âcracklingâ 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 âblack eyeâ 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
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 âtram linesâ 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 â 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 patientâs 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 â 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 â outer facial frame with exact anteroposterior projection and transverse facial width.inner facial frame â 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)