04/19/23 Professor Sameer Bafaqeeh 1

Fractures of the Middle Thirdof the Face

Fractures of the Middle Thirdof the Face

Maxillary Fracture

Can compromise the airway Commonly transverse Direct trauma to the face

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Le Fort Fractures SystemLe Fort Fractures System

• Le Fort 1: The upper alveolus is detached

• Le Fort 2: the entire upper jaw is detached

• Le Fort 3: the F.S. is separated from the S.B.

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Fractures of the Middle Thirdof the Face

• High-speed injuries (Motor vehicle accidents)• Seatbelt Laws

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Fractures of the Middle Thirdof the Face• Careful history &examination• Palpation around the facial

structures• Jaw movements &mobility• Eye & eye movements

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Types of Central Middle Third Fracture(Le Fort Classes I )

Types of Central Middle Third Fracture(Le Fort Classes I )

Maxillary FractureClinical presentation*Le Fort Class I – Low max. horizontal fractures – # the upper alveolus – Abnormal occlusion – Hematoma or fracture of the antral wall

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Types of Central Middle Third Fracture(Le Fort Classes II )

Types of Central Middle Third Fracture(Le Fort Classes II )

Maxillary FractureClinical presentation*Le Fort Class II – Pyramid fractures – # the upper jaw – The fracture passes – Dislocation and depression – Ethmoids, orbital, lacrimal involvement – Hypertelorism

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Types of Central Middle Third Fracture(Le Fort Classes III )

Types of Central Middle Third Fracture(Le Fort Classes III )

*Le Fort Class III – F. Sk. and SB are separated – The fracture line: zygomaticofrontal, maxillofrontal, and nasofrontal sutures – All the structures of the central part of the facial skeleton are involved – Massive depression of the middle third of the face – Multiple fractures of the bones (dish face) – Typical symptoms (shock, concussion, cerebral contusion)

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PathogenesisCentral Middle-third Fractures

# High-speed injuries

• Traffic accidents

• Occupational injuries

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Trauma of the Middle Third of the FaceDiagnosis

* History: Type, direction and force

* Inspection: – Skeletal (fracture, dislocations,depression) – Symmetry of middle and frontal areas – The nose – The orbit (hematoma, movement, & vision)

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Trauma of the Middle Third of the FaceDiagnosis (cont.)

Trauma of the Middle Third of the FaceDiagnosis (cont.)

* Palpation: Tenderness, upper jaw, facial contour, bony skeleton, orbital rim, trismus, nose root, mandible, occlusion, teeth.

* Sensory or motor innervation

* CSF Rhinorrhea* Brain tissue

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Trauma of the Middle Third of the FaceDiagnosis (cont.)

* Radiography: – Skull radiography (Radiopaque F.B.) – Angiography – C.T. scan – Olfactometry* Maxillofacial surgeon, an ophthalmologist a neurologist, a neurosurgeon, general and orthopedic surgeon are consulted.

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NOTE:

Rapid soft tissue swelling. Bloody effusion.

Soft tissue injuries.

Skeletal assymetryor deformity

Life-threateningskeletal injuries

concealed

concealed

}

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Treatment ofMiddle Third Injuries

Traumatologic ABC

A = Airway (the airway is secured and aspiration is prevented)

B = Bleeding (must be controlled)

C = Circulation (shock must be treated)

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Fracture Middle 1/3 Face

• Hospitalization: Traumatologic center

• Admission: Extent and type of the skull, thorax, abdomen & extremities

• Patient head injury: Special traumatologic teams

(A neurosurgeon, a rhinosurgeon, a maxillo- facial surgeon and an ophthalmic surgeon)

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Definitive Surgery ofMiddle Third Fractures

• Reconstitution (anatomy and function) - Debridement - Ventilation - Drainage• Rhinologic surgeon: I - Soft tissue injury, nose and sinuses II - Assessment of the base skull III- Correction of the F.Sk. and the B.O.• D.S. should be carried out quickly

Fracture Formationof callus

Rapidly heal in wrong position

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Fractures of the MandibleFractures of the Mandible

• Maintain the airway• Stop hemorrhage• Intracranial or other injury• Mouth deformity& malocclusion • Inferior dental nerve• Orthopantamogram [OPG]

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Mandible Fractures TreatmentMandible Fractures Treatment

• Undisplaced fractures: Analgesia & antibiotics .A simple fracture: Intermaxillary

fixation [eyelet wiring] .An irreducible fracture: Open reduction&fixation Wires or an AO Plate.

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Key Points:Key Points:

• 1.In orbital trauma, check the eye movements, palpate the bony orbital rim, and record visual acuity.

• 2.In patients with facial injury, always check the full range of jaw mov. &determine whether or not the upper jaw is mobile. fractures of the cheek bone [ zygoma ] are often overlooked.

• 3.Wear eye protection while playing racquet sports.

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Isolated Blowout Fracture Isolated Blowout Fracture

– Localized violence --> Orbital contents

– A blow (a fist, a tennis ball, a sq. ball,

a champagn bottle cork, etc )

– Fractures of the orbital bony floor

– Trapping of the orbital contents

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Blowout Fracture SymptomsBlowout Fracture Symptoms

– Enophthalmos

– Double vision

– Limitation of eye movement

– Infraorbital nerve sensation disorders

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Blowout FractureDiagnosis

Blowout FractureDiagnosis

• Radiographs “tear drop”

• Tomograms

• Ophthalmologic examination

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Blowout FractureTreatment

Blowout FractureTreatment

• The antral cavity must be explored: - The bony fragments are exposed - The prolapsed part is replaced - Bridging or stabilization (Lyophilized dura, cartilage or plastic prop)

• Alternative or supplementary measures: - Orbital access - Lyophilized dura, silicone sheet, or teflon - Autologous implant to correct enophthalmos

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Nasal trauma in ChildhoodNasal trauma in Childhood

• Child’s nose - less promineent

-more cartilaginous.Nonaccidental injury -[grotesque].# growth centers N.deformity.Surgical correction :conservative delay.Cart. : repositioned not resected

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Mucosal injuries of the MOUTH & Pharynx [ F.B. &

Trauma ]

• Good healing properties

• Mucosal suture in extensive injuries

• Antibiotic cover

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Penetrating soft tissue injuries of the Mouth and Pharynx

Penetrating soft tissue injuries of the Mouth and Pharynx

• Bullet, stab, and traffic accidents wounds.

• Mouth and Pharynx must be assessed with related soft and bony tissues

• Structures shoud be debrided, repositioned, fixed, and sutured in layers

• Antibiotic • Surgical emphysema

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Impalement injuries of the Palate and posterior

Pharyngeal wall• Children falling on pointed objects.• Expert examination• Suture of the wound

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Tongue Bites Heal spontaneously Penetrating bite require

suture Completely divided

tongue reimplanted :

-the time of reconstruction

-the condition of the wound

-the blood supply

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Insect Bites

• Swallowing a living insect [bees, etc.] .

• Edema of the pharynx respiratory obstruction

• I.V. high-dose steroids• Ice packs • Calcium &

tracheotomy