Rabu, 02 November 2011

Management of facial trauma-Mid-face Injury-Oral and Maxillofacial Surgery

The area between a superior plane drawn through the zygomatico-frontal sutures tangential to the base of the skull and inferior plane at the level of the maxillary dental occlussal surface.

Structures connection
(structures in relation)
  • Orbit
  • Maxillary sinus
  • Nasal bone
  • Naso-orbital ethmoid (NOE) complex
  • Zygomatic complex
  • Frontal bone and sinus
  • Vertical and horizontal pillars

Area of strength
  • Vertical and horizontal pillars
  • Muscular attachment
Area of weakness
  • Sutures
  • Lining tissues and air-filled cavities
Pattern of fractures of mid-face skeleton
  • Alveolar fracture and dental fracture
  • Le Fort ‘s fracture (french surgeon Rane Le Fort 1901)
  • Naso-orbital ethmoid fracture
  • Zygomatic complex and arch fracture
  • Frontal sinus and bone fracture
Alveolar bone fracture
Involve block of alveolar bone with or without
  • Intrusion of teeth
  • Extrusion of teeth
  • Luxation of teeth
  • Fracture of teeth

Le Fort’s fractures
  • Le Fort I (low level or Guerian fracture)
  • Unilateral/ bilateral
  • Horizontal fracture through the maxilla above the level of the nasasl floor and alveolar process
  • Piriform rims
  • Anterior maxilla
  • Zygomatic buttresses
  • Ptrygoid laminae
Signs and symptoms
  1. Slight swelling of upper lip
  2. Ecchymosis in upper lip sulcus
  3. Hematoma intra-orally over zygoma and in palate
  4. Disturbed occlusion
  5. Mobility of teeth of the involved segment of maxilla
  6. Combination of soft tissue laceration
  7. Exposure of nares and the maxillary antra in case of gross injury
  8. Impacted type of fracture is oftenly not mobile and teeth cusps may be damaged
  9. Cracked-pot percussion of upper teeth
Le Fort II (pyramidal or subzygomatic)

Separation of NF suture, medial orbital walls (lacrimal bone), inferior orbital floor and rim (adjacent to infrorbital canal and foramen), anterior maxilla below zygomatic buttress and ptrygoid laminae about halfway up.
Separation of the block from the base of skull is completed via the nasal septum and may involve the floor of the anterior cranial fossa

LeFort III (cranifacial dysjunction, high transverse, suprazygomatic)
Separation of NF suture, medial orbital walls (involve the depth of the ethmoid bone and cribriform plate, pass below optic foramen and cross the inferior orbital fissur), inferior orbital floor, lateral orbital wall, ZF suture, zygomatic arch, suprazygomatic to the root of ptrygoid plate.
Signs and symptoms
although it is possible to distinguish between le fort II and III, the signs and symptoms are almost similar
  • Gross edema of soft tissue
  • Bilateral circumorbital ecchymosis
  • Bilateral subconjunctival hemorrahge
  • Obvious deformity of the nose
  • Nasal bleeding and obstruction
  • CSF leak rhinorrhea
  • Dish-face deformity
  • Limitation of ocular movement
  • Possible diplopia and enophthalmous
  • Retropostioning of the maxilla with anterior open bite
  • Lengthening of the face
  • Difficulty in mouth opening
  • Mobility of the upper jaw
  • Occusional hematoma of the palate
  • Cracked-pot sound on percussion
  • Step deformity at infra-orbiatal margin
  • Anasthesia of midface
  • Nasal bone moves with mid-face as a whole
  • Tenderness and sepration at FZ suture
  • Tenderness and deformity of zygomatic arch
  • Depression of occular level and pseudoptosis

Bowerman classification of midface-fracture (1994)
Fracture not involving the occlusion

Central region
  • Nasal bone/ septum (lateral, anterior injuries)
  • Frontal process of the maxilla
  • Nasoethmoid
  • Fronto-orbito-nasal dislocation
Lateral region (zygomatic complex EX dento alveolar frcature

Fracture involving the occlusion
  • Dento alveolar
  • Subzygomatic:
    • Le Fort’s (I, II)
  • Supra zygomatic:
    • Le Fort III
These fractures may occur unilaterally or bilaterally, with separation of maxillary midline  and or extension to frontal or temporal bone

Prevalence of mid-face fractures

Extra-oral (e.g. swelling, deformity, asymmetryc Leaks)
Intra-oral (e.g. hematoma, occlusion)
  • Step deformity, criptation, cracked pot sound, mobility
  • Radiographical investigations
Radiographical examination
Plain radiograph
Occipitomental (10 or 30 degree)
Search line (Campbell’s line 1977)

Water’s view
Suitable for isolated orbital fracture

Lateral skull view
Occlusal view of the maxilla

Perapical views of damaged teeth

CT scan
3-D CT imaging
Coronal sections

Axial sections

  1. Whenever intracranial damage and frontal sinus are suspected
  2. Extensive fracture that involves nasoethmoid complex or orbital region
  3. Orbital trauma to evaluate the degree of orbital injury and enophthalmos

Indications for treatment
  • Physical signs of a fracture of the maxilla.
  • Evidence of a fractured maxilla on imaging.
  • Disruption of the occlusion of the teeth.
  • Displacement of the maxilla.
  • Post traumatic facial deformity.
  • Indications for treatment
  • Fractured or displaced teeth.
  • Cerebrospinal fluid leak.
  • Abnormal eye movement or restriction of eye movement.
  • Occlusion of the nasolacrimal duct.
  • Sensory or motor nerve deficit.
  • Other evidence of loss of function
Aims of treatment
  • Relieve pain
  • Restore function.
  • Restore bone anatomy.
  • Prevent infection
  • Restore the dental occlusion
  • Restore jaw movement at the earliest possible stage
  • Restore normal nerve function
Factors affecting the risk
  • Association with multiple injuries.
  • Presence of uncontrolled haemorrhage
  • Impairment of the airway.
  • Presence of bone comminution
  • Association with a dural tear.
  • Association with a base of skull fracture.
  • Presence of a pre-existing dentofacial deformity.
  • Time elapsed since the injury.
  • Presence of a medical or surgical factor which would delay general anesthesia
  • Presence of any factor which would delay healing. (eg nutritional deficiency or alcoholism) 
  • Stage of dental development (deciduous, mixed or permanent dentition)
  • Presence of fractured teeth.
  • Total absence of teeth (edentulous)
  • Inability of the patient to co-operate with treatment.
  • Association with fractures of the mandible especially bilateral fractures of the condyles.
Principles of treatment
Closed reduction may be appropriate in cases
  • Simple uncomplicated fractures
  • Complex or comminuted fractures
  • Medical or surgical contraindications to open reduction
  • Maxillary fractures in children
Open reduction may be appropriate where
  • Immediate or early jaw function is desirable
  • Difficulty is encountered in reducing the
  • Fracture by a closed method
  • The fracture is unstable
Definitive treatment
  • Manual manipulation
  • Use of dis-impaction forceps
Fixation and immobilization
Extraoral fixation
  • Craniomandibular fixation
  • Box-frame (pin fixation)
  • Halo-frame
  • Plaster of paries headcap
Craniomaxillary fixation
  1. Supra-orbital pins
  2. Zygomatic pins
  3. Halo-frame

Immobilization within the tissue
  • Direct fixation
  • Transosseous wiring at fracture sites
  • Frontozygomatic sutures
  • Infrorbital margin
  • Midline of the palate

Internal-wire suspension
  • Circumzygomatico-mandibular
  • Infraorbital border-mandibular
  • Frontomandibular
  • Pyriform fossa-mandibular

Support via the maxillary sinus by filling materials
  • Ribbon gauze
  • Balloon
  • Folly catheter
  • Polyethylene material
Length of the hospital stay will depend on a number of factors including:
  • Presence of other injuries
  • Age and medical status of the patient
  • Severity of the injury
  • Technique employed in the reduction and fixation of the fracture
  • Presence or absence of medical or surgical complications
  • Social circumstances of the patient 

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