midfacial fractures - oral surgery b.d.s

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BY CHIDAMBRA MAKKER

B.D.S FINAL YEAR

ROLL NO. 22

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DIRECT VIOLENCE

a. Fights

b. Metal rods,bricks

fist fight etc

c. Fall

d. Road traffic

accident

e. Occupational

hazards( atletic

injury)

f. Iatrogenic (during

dental treatment

INDIRECT VIOLENCE

a. Fall from a height

b. Excessive muscle contraction

Fractures of the middle third may be subdivided into:

Dento-alveolar fractures.

Fractures of the maxilla.

Fractures of the zygomatic bone & arch.

Blow out fractures.

Nasal-orbital-ethmoidal fractures.

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It consists of fracture, subluxation, or avulsion of the teeth with or without an associated fracture of the alveolus, and they may occur as a clinical entity or in conjunction with any other type of fracture.

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RENNE LE FORT CLASSIFIED MID-FACE FRACTURE INTO:

Le Fort type I

Le Fort type II

Le Fort type III

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MODIFIED LE FORT

CLASSIFICATION ( by marchiani 1993)Le fortI - low maxillary fracture

Ia- low maxillary fracture/multiple segments

Le fort II- pyramidal fracture

IIa- pyramidal and nasal fracture

IIb- pyramidal fracture with nasoethmoidal fracture

Le fort III- craniofacial dysfunction

IIIa- craniofacial disjunction with nasal fracture

IIIb – craniofacial disjunction with nasoethmoidal fracture

Le fort IV - le fort II and le fort III and cranial base fracture

IVa- le fort II and le fort III and cranial base fracture with supraorbital rim fracture

IVb - le fort II and III and cranial base fracture with anterior cranial fossa and

supraorbital rim fracture

IVc- le fort II and III and cranial base fracture with anterior cranial fossa and orbital

wall fracture

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Low level fracture

It results from a force delivered above the level of the teeth.

Le fort 1

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The fracture courses from the lateral border of the pyriform aperture above the canine eminence behind the maxillary tuberosity across the lower third of the pterygoid plate.

* It may be unilateral or bilateral

* It may occur single or in combination with Le Fort type II or III fractures.

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low level or Guerin type

Extra-orally

Swelling of the upper lip.

Soft tissue laceration.

Open mouth to accommodate the displaced dento-alveolar portion.

Epistaxis.

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Intra-orally

Malocclusion.

Mobility of tooth bearing portion

Ecchymosis in buccal sulcus beneath zygomaticarch

Percussion of upper teeth results in a distinctive cracked-pot sound

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Sub-zygomatic fracture

Pyramidal fracture

It results from a force delivered at a level of the nasal bones.

The fracture line occurs along the nasofrontal suture lacrimal bone across the infra- orbital rim in the region of the zygomatico-maxillary suture

above the canine eminence inferiorly and distally along the lateral antralwall, but at a higher level than Le Fort type I across the pterygoid plate at its middle.

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Extraorally

- Ballooning of the face.

- Lenghtenening of the face

- Circumorbital ecchymosis

- Subconjunctival Hemorrhage adjacent to those parts of orbit where fracture has occurred

- Diplopia and enophthalmous due to orbit damaged

-anesthesia or paranesthesia of cheeks

-diplopia-Chemosis- CSF rhinorrhoea(not

clinically detected)- Step deformity in the

lower border of the orbit

-Intact zygomatic bone & arch

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Intraorally

-Malocclusion

-Gagging of the posterior teeth and anterior open bite

-Mobility of the maxilla

-Ecchymosis of the sulcus

- ‘cracked pot’ sound on tapping teeth

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Supra-zygomatic fracture

High level

The fracture is caused by a force at the orbital level , the resultant fracture is craniofacial disjunction.

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The fracture line courses through the zygomaticotemporal and zygomaticofrontal sutures lateral orbital wallinferior orbital fissuremedially to the naso-frontal suture fractures the pterygoid plate at its base.

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Extraorally

- Severe edema of the face “ballooning”

- Lengthening of the face

- Flattening of the cheek

- Circumorbital ecchymosis

- Subconjunctival Hemorrhage

-Enophthalmos-CSF rhinorrhoea-Hooding of eyes-mobility of whole

facial skeleton as a single block

Intraorally

-Gagging of the posterior teeth and anterior open bite

-Ecchymosis and Hemorrhage of the buccal sulcus

-Mobility of the maxilla

-Mandibular interference

-displacement of midline of upper jaw

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Occipto-mental view

CT scan

TYPES

* Axial scan

* Coronal scan

* 3D CT23

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1. CABD 2. REDUCTION AND FIXATION

AND IMMOBILIZATION

REDUCTION

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CLOSED REDUCTION

OPEN REDUCTION

Is reduction of fracture segment to

previous anatomical and functional

position without direct visualisation

Is surgical reduction of fracture segments• Rowe’s disimpaction forceps can

be used to disimpact the fractured

maxilla and t bring it to occlusion

•Hayton william forceps used to

reduce midpalatal split maxilla

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Methods

Maxillo-mandibular fixation

Internal fixation

Skeletal suspension

Support

External fixation

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A) Closed reduction & fixation

* Digital pressure.

* Arch bar tightened in the unfractured side and loose in the fractured side.

* Adjust occlusion, tighten the fractured side then secure MMF.

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B) Open reduction & fixation

* Cases of unstable fractures.

* Arch bars are prepared

* Sulcus incision to expose the fracture site in canine & buttress regions

* Transosseous wiring or miniplates are used for fixation.

i) Essig’s wiring– Is used to stabilize dentoalveolar fractures in individual dental arches ,anchoring device for IMF and for stabilizing luxate teeth. 26 gauze wire is used.

The wire is passed around the necks of teeth, one end going from buccal to lingual and other end from lingual to buccal . Wire is twisted buccaly cut and placed interdentally. Atleast 3 teeth away fracture line taken

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ii)Gilmer’s wiring – intermaxillary fixation done. At least 1 anterior and 1 posterior teeth should be available for stabilization. 26 gauze wire. Both ends are brought together buccally n twisted.

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iii) risdon’s wiring– is method of horizontal wire fixation. 2nd molar on either side chosen for anchorage.

Wire passed around neck and brought bucally and twisted. Additional wire used to secure tooth.

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iv) Ivy eyelits wiring-- two teeth selected together

and wire passed from lingual to buccal

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v) col. Stout’s multiloop wiring– 4 posterior

quadrants used for wiring. 26 gauze wire used

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vi) Arch bars– are flat stainless steel metal strips.

Arch bars are fixed to the teeth bucally and 26 gauze

wire is passed mesial surface to lingual side and

back to buccal side from distal aspect of the tooth.

Is direct wiring across the fracture line.

Effective method of fixation and immobilization

It is done at- frontonasal suture, zygomatico-frontal suture,orbital rim,zygomatico-maxillary suture, zygomatic bone, alveolar bone

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Occurs due to direct trauma to the orbit with an object larger than globe size

Increase in hydraulic pressure within orbit so enophthalmous

Fracture gives way to maxillary sinus.

Sometimes muscle prolapse into sinus(hernia).

Diplopia

Diagnosis- fored duction test, hanging drop method in PA view, ct scan, water’s position radiograph

Treatment- sialstic bone sheet or bone graft

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Inadequate reduced fractures causes facial deformities

Obstruction of nasolacrimal duct due to le fort II fracture causes epiphora, dacryocystitis

Enophthalmous

Failure of recovery ofoculomotor nerve and abducent nerve causes strabismus, ptosis, diplopia

Fracture involving cribriform platemay cause anosmia

Malocclusion

Palatal fistula38

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