به نام خداوند بخشنده و مهربان. maxillary fractures
TRANSCRIPT
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به نام خداوند بخشنده و مهربان
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MAXILLARY FRACTURES
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LEFORT - AP VIEW
Midface FracturesMidface Fractures
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Le Fort’s fracturesLe 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 rimsAnterior maxillaZygomatic buttressesPtrygoid laminae
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Signs and symptoms
Slight swelling of upper lip
Ecchymosis in upper lip sulcus
Hematoma intra-orally over zygoma and in palate
Disturbed occlusion
Mobility of teeth of the involved segment of maxilla
Combination of soft tissue laceration
Impacted type of fracture is oftenly not mobile and teeth cusps may be damaged
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Lé Fort I
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Le Fort’s fractures
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
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Lé Fort II
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LeFort’s fractures
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.
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Le Fort 3 and mastication problem
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Signs and symptomsalthough 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
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Inspection
Palpation
Diagnostic Imaging
Plain films
CT
DIAGNOSIS OF MAXILLOFACIAL INJURIES
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INSPECTION
Sublingual ecchymosisSublingual ecchymosis Step defects, ridgediscontinuity, malocclusionStep defects, ridgediscontinuity, malocclusion
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PALPATION
“Step” Defect
Crepitus
Bony segments
Subcutaneous emphysema
Mobility
DIAGNOSIS OF MAXILLOFACIAL INJURIES
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FACIAL EXAMINATIONPALPATION OF MIDFACE/BRIDGE OF NOSE
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FACIAL EXAMINATIONORBITS EVALUATION
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FACIAL EXAMINATIONOrbits evaluated
Periorbital edema and ecchymosis
Gross visual acuity determined
Diplopia
Pupillary size & shape
Subconjunctival hemorrhage
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FACIAL EXAMINATION
Orbits evaluatedLid lacerations
Attachment of medial canthal tendon
Rounding of lacrimal lake
Increased intercanthal distance
Epiphora
Prompt Ophthamology consult
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FACIAL EXAMINATIONEvaluate mandibular
openingPalpation of buccal vestibule
Crepitus of lateral antral wallOcclusion evaluated
Absence and quality
of dentition notedEcchymosis common finding
Pharynx evaluated for laceration & bleeding
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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.
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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
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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
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Factors affecting the risk
Association with multiple injuries.
Presence of uncontrolled haemorrhage
Impairment of the airway.
Association with a dural tear.
Association with a base of skull fracture.
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Factors affecting the risk
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)
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Factors affecting the risk
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.
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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
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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
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Definitive treatment
Reduction
Manual manipulation
Use of dis-impaction forceps
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Fixation and immobilization
Extraoral fixation
Craniomandibular fixationBox-frame (pin fixation)Halo-framePlaster of paries headcap
Craniomaxillary fixationSupra-orbital pinsZygomatic pinsHalo-frame
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Cont: Management
Techniques
Plate Fixation (Miniplates) Interosseous Wire Fixation Bone Grafts
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Management by Le Fort Classification
Le Fort I: reduced digitally, MMF, fixation of ZM Le Fort II: stabilization of the ZM buttress, MMF , nasofrontal
process and inferior orbital rim.
Le Fort III: usually requires coronal flap for adequate exposure for exploration and miniplate fixation
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