Upload
ravish-malhotra
View
294
Download
0
Tags:
Embed Size (px)
DESCRIPTION
hgjk
Citation preview
Maxillary fractures.
• Introduction
• Surgical anatomy
• Classification
• Signs and symptoms
• Assesment.
• Principles of management.
• Reduction
• Stabilization
• Fixation.
• Definitive treatment
• Conclusion
• References.
Introduction.
The maxilla, palatine bone and the nasal bones form the bulk of the
mid face. The maxillary bones help in the formation of three important
cavities of the face- the upper part of the oral cavity, the nasal cavity
and the orbital cavity. The maxillary sinus which is small at birth
assumes a larger and more inferior position in maxilla with maturity
until it forms a major bulk of mid face. This factor adds to the distinct
weakness of the region.
Skeleton of maxilla.
• Skeleton of mid facial region appears to transmit the powerful
forces of mastication as evenly as possible, as well as to absorb the
shocking effect of occluding teeth.
The strong horizontal elements in the maxilla, alveoli and hard palate
make up a foundation to support three paired vertical bony butreeses.
1. The naso maxillary butreess-extends from the dento
alveolar arch in the anterior maxilla superiorly along pyriform
margin to medial orbital rim and fronto maxillary suture.
2. The zygomatico maxillary buttress- from the region of first
molar to the body of zygoma and through this bone to the lateral
orbital wall to zygomatico maxillary suture.
3. The pterygo maxillary buttress- represented by the
attachment of maxillary tuberosity to Pterygoid plates and hence
to sphenoid bone.
Ideally surgical plates to be placed along the buttresses should
stabilize and reconstruct the load paths and the more screws placed on
either side of fracture line, more evenly the distribution force will be
applied along these paths.
• Blood supply and nerve supply
An understanding of the blood supply and the nerve supply to the
maxilla is important both in planning safe incisions foe the exposure of
an already damaged maxilla as well as in understanding of pattern of
numbness associated with maxillary fractures.
On each side via greater palatine canal, greater palatine nerve and
vessels supply all of bone and mucosa of soft palate.
Branches of maxillary artery and nerve enter posterior maxilla through
small foramina to become posterior superior alveolar artery and nerve.
These supply molar teeth through dental plexus.
Branches from infra orbital artery and nerve enters the anterior maxilla
from orbital floor and supply anterior teeth. Fracture of anterior maxilla
and orbit may result in numbness of anterior teeth. Fracture low in the
maxilla posterior to I st molar region may result in numbness of
posterior teeth.
Apart from above maxilla gains blood supply from gingival attachment
of the teeth and through its attachment to soft palate from pharyngeal
and palatine branches of facial artery and ascending pharyngeal
branches of external carotid artery.
Surgical anatomy
• # of maxilla are usually the result of direct force range from
simple alveolar # to extensive injuries of orbit, nose, palate and skull.
• Displacement is usually entirely the result of traumatic force.
Muscle contraction plays an unimportant role except in those
extending into the region of Pterygoid plates resulting in displacement
of maxilla in downward and posterior direction due to the action of
Pterygoid muscles.
• Lacrimal fossa is formed partially by maxilla and injuries to the
naso lacrimal duct may be associated with fractures of maxilla
resulting in epiphora.
• Damage to Infra orbital nerve results in anesthesia or
paresthesia of upper lip, cheek. Full recovery may take up to 2 years.
Anterior, middle, posterior superior alveolar nerve may be damaged
but patient seldom notices anesthesia of gingiva.
• Cranial nerve within the orbit may sustain damage. 6th nerve
damage is most frequently encountered. Sometimes contents of
superior orbital fissure are damaged resulting ophthalmoplegia,
dilation of pupil, and anesthesia within distribution of ophthalmic
branch.
• Optic foramen is a ring of dense compact bone; therefore
invariably fracture line gets deflected away from the foramen,
protecting optic nerve.
• # Involving orbital walls-may result in variation in the position of
globe. As the globe of the eye drops, upper lid follows it resulting in
hooding of eye.
• If orbital floor is fractured-herniation of orbital contents into the
sinus, resulting in restriction of eye movement and traumatic
enaphthalmus.
• Gross communition of antral walls can cause bleeding. The sinus
will be full of blood and appear hazy in radiographs resulting in
unilateral or bilateral epistaxis
.
• Mid palatine split of maxilla is only possible when there is injury
from a blow transmitted upward via the mandibular teeth with the jaw
open.
Classification.
• Broadly classified into-
A) Lefort I, II III
B) Erich’s 1942, as per the direction of fracture line.
Horizontal
Pyramidal
Transverse.
C) Depending on the relation of fracture line to zygomatic bone.
• Sub zygomatic
• Supra zygomatic
D) Depending on the level of fracture
Low level
Mid level
High level.
Most universally accepted classification is lefort’s I, II, III.
LEFORT I: - low level # Modification of Lefort’s classification.
BY MARCIANI 1943.
Ia: - low level # /multiple segments
LEFORT II: - pyramidal #
II a: - pyramidal # + nasal #
II b: - pyramidal # +NOE #
LEFORT III: - craniofacial dysjunction.
III a: -craniofacial dysjunction +Nasal #
III b: -craniofacial dysjunction. + NOE #
• Lefort IV: - LEFORT I +II+cranial base #
IV a: - + supra orbital rim #
IV b: - + supra orbital rim # anterior cranial fossa.
IV c: - anterior cranial fossa and orbital wall #.
Lefort’s I #(low level, sub zygomatic, guerin’s #, horizontal
#,floating #)
• Separation of entire dento alveolar segment.
• Violent force over a wide area above the level of teeth.
• May occur as a single entity or associated with lefort II and III.
• The typical Lefort I # is bilateral with # of lower 3rd of the
septum.
• Commences at a point on the lateral margin of anterior nasal
aperture passes above the nasal floor above canine fossa -lateral
antral wall dipping down below zygomatic buttress- pterygo maxillary
fissure to fracture Pterygoid laminae at lower 1/3rd.
Fracture also traverses along lateral wall of nose and subsequently
joins lateral line of fracture behind tuberosity.
Signs and symptoms.
• Slight swelling of upper lip. There is no massive edema as seen
in case of lefort II and III.
• Echymosis in the buccal sulcus.
• Mobile fragment which drops and the patient may have to keep
the mouth open to accommodate the vertical dimension of bite.
• Guerin sign- echymosis in the palate.
• Soft tissue laceration
• Impacted type of fracture-no mobility. When the maxillary teeth
are grasped and slight but firm pressure is given characteristic grating
sound is heard.
-Damage to the cusps of teeth.
Complete lefort # is associated with mid palatal split.
Lefort II(pyramidal, sub zygomatic)
Violent force usually from anterior direction, sustained by the central
region of mid face, over an area extending from glabella to alveolar
margin.
Commences-below the fronto-nasal suture-frontal process of maxilla-
across the lacrimal bone immediately anterior to naso lacrimal canal-
runs downward forward laterally crossing inferior orbital margin in
the region of zygomatico maxillary suture. It may or may not involve
infra orbital foramen. Now the fracture line extends downward and
forward to traverse lateral wall of antrum just medial to zygomatico
maxillary suture, passes beneath the buttress, to pterygo maxillary
fissure- Pterygoid laminae at mid one third.
Separation of entire pyramidal block form the base of skull is
completed via the septum.
Lefort III(transverse,supra zygomatic,high level)
• Trauma being inflicted over a wide area at the orbital level.
• Commences near fronto nasal suture causes dislocation of nasal
bones and disruption of cribriform plate of ethmoid bone. It crosses
both nasal bones and frontal process of maxilla, near the fronto nasal
and fronto maxillary sutures then traverses the upper limit of lacrimal
bone, crosses the thin orbital plate of ethmoid. As the optic foramen is
surrounded by dense ring of compact bone, fracture line tends to get
deflected downward and laterally to reach medial aspect of inferior
orbital fissure. It descends across the upper posterior aspect of maxilla
in the region of spheno palatine fossa – upper limit of pterygo maxillary
fissure and roots of Pterygoid laminae at its base.
The inferior orbital fissure constitutes a natural line of weakness and
from its anterior and lateral end on each side a further line of fracture
passes across the lateral wall of orbit, adjacent to the junction of
zygomatic bone with the greater wing of sphenoid. Fracture separates
zygomatic bone from frontal bone near the suture then inclines
laterally running abruptly downward across the infra temporal surface
joining the previous fracture. The entire middle third is thus detached
from cranial base. Fracture is completed by the # of zygomatic arch.
Signs and symptoms common to lefort II and III.
• Moon face.
• Bilateral circum orbital echymosis.
• Subconjunctival echymosis.
• Chemosis(edema of conjunctiva)
• Diplopia.
• Spreading inter canthal distance.
• CSF from nose.
• Retro positioning of maxilla-anterior open bite, posterior gagging.
• Cracked pot sound on percussion.
SIGNS AND SYMPTOMS ASSOCIATED WITH LEFORT II ALONE.
• Step deformity elicited at the inferior orbital margin.
• Anesthesia / paresthesia cheek.
• # in orbital floor-limitation of ocular movement.
• No alteration of pupil’s level.
• When the maxillary teeth are grasped, movement elicited at
infra orbital margin.
• Hematoma formation in the buccal sulcus.
• CSF rhinorrhea is not a constant finding.
Signs and symptoms of lefort III
• Tenderness and separation at fronto zygomatic suture..
• Tenderness and deformity of zygomatic arches.
• Lengthening of face.
• Depression of ocular levels
• Hooding of eyes.
• Lengthening and sometimes extreme disorganization of nasal
skeleton.
• Profuse CSF rhinorrhea.
• Mobility of whole facial skeleton as a single block.
Clinical assesment.
External inspection-
Cheek-edema bleeding,emphysema
If extends to orbit swelling and bruising of eyelids.
Intra oral-
Upper alveolar arch may be intact or split into fragments by a
longitudinal (para sagittal fracture) or mobile dental alveolar
segments may be seen.
• Disturbed occlusion may be evident-anterior open bite, cross-
bite.
• In typical fracture of upper jaw with an intact alveolar arch,
posterior and inferior displacement of occlusal surface will result in
anterior open bite. This is in part due to the inclination of the skull and
in part due to the vectors of force by medial Pterygoid. This movement
forces the mandible open leading to elongation of face.
Radiological assesment
• Provides back up evidence for clinical diagnosis.
• Plain AP, occipito mental x-ray –demonstrate fluid in maxillary
sinuses, displaced fracture line in the buttress, infra orbital rim or
pyriform margin.
• Most useful-CT.
• Axial cuts-fracture of posterior wall of antrum and of pterygoid
plates splits of hard palate and dento alveolar segmental fracture.
• Coronal CT-fracture of anterior maxilla, para sagittal fracture of
palate.
Mc gregor and Campbell (1950) described a system for examining the film by following
4 lines, which cover most of the sites of injury.
The first line runs across the zygomatico frontal suture the frontal sinuses and superior
margins of orbits. The second runs along the zygomatic arches the inferior margins of
orbits and nasal bones. The third crosses the mandibular condyles the coronoid process
and maxillary sinuses. the fourth runs along the occlusal surfaces of teeth and crosses
mandibular rami. Trapnell (1985) added a fifth line that runs along the inferior border of
mandible.
If this is done routinely it should reduce the chance of failing to detect a fracture.
PRINCIPLES OF MANAGEMENT.
• Management of these fracture depend in first place whether the
fracture is thought to be in need of surgical reduction and stabilization.
• Several clinical situations where the surgical reduction is contra
indicated are-
- Undisplaced fracture clinically and radiologically.
-In edentulous patient where there is only minor radiological
evidence of displacement and where # appears to be stable to
masticatory forces.
-Patients with severe brain injury who are not expected to survive.
Pre operative dental assesment.
• Impression of dental arch and teeth will be used to cast plaster
model.
• Cutting it at the site of vertical # through occlusion and then
mounting fragments on an articulator in the exact position of pre
traumatic occlusion. Acrylic bite wafer will then be constructed to use
in intra operative and postoperative period.
Close dental collaboration is more important with upper jaw fracture
than with lower jaw fracture. In the latter strong and solid form of
mandible ensures that anatomical reduction of fracture site is
relatively easy and occlusion is used as a secondary check for
correctness of reduction. In the fracture of upper jaw, the complex
fracture of the jawbone makes certainty of anatomical reduction of
fracture more difficult and dental relationships assume a high degree
of importance in establishing that reduction is achieved.
Where open reduction and rigid fixation are indicated in an edentulous
patient then gunning type of splint may be used temporarily.
Timing of definitive repair.
• Opinion regarding timing of definite repair has changed
significantly over last decade. The factors that are to be considered
are-
• Brain injury- may take some time to stabilize.
• Cardio vascular instability
• Unstable cervical spine injury
• Ocular injury.
• However early repair even in presence of intra cranial injury can
be carries out safely if the intra cranial pressure is maintained at < 25
mm of Hg. The chief argument behind this is early accurate bone
reconstruction will prevent development of soft tissue contractures
which will lead to post traumatic deformities.
Pre operative planning.
Certain essential decisions must be taken before surgery is
contemplated.
• 1. Need for tracheostomy.
Factors influencing decisions towards tracheostomy-
Degree of soft tissue swelling
Whether IMF is likely to be used.
• 2.open/closed method of reduction
• 3.The necessity for and type of IMF.
Disimpaction.
• When closed methods of reduction and fixation are used
reduction may be carried out using specially designed forceps
described by Rowe and Kelley. One end of the blade is inserted along
each nostril floor while other blade is placed via mouth over hard
palate mucosa. When both forceps are in position surgeon is able to
exert powerful levarage on upper jaw via hard palate, which is securely
gripped between the blades of forceps.
It can also be used in methods employing open exposure of maxillary
fractures, disimpaction and mobilization of upper jaw.
• Lefort I osteotomy to facilitate passive repositioning of maxilla
(JOMS 2004. )
In the normal sequence of treatment of mid facial # that involves
occlusion, maxilla is mobilized, then placed into proper occlusion
with intact mandible and maxillo mandibular fixation is carried out.
Even when this protocol is strictly followed, malocclusion can still
occur most frequent of which is anterior open bite and / or class III
tendency. The reason seems to be improper mobilization of maxilla.
The maxillo mandibular fixation may, make the occlusion look
normal during surgery, but in such cases mandibular condyle may be
posteriorly or inferiorly positioned within their fossa. When MMF is
released, condyles reseat themselves and mandible moves
anteriorly.
Fracture stabilization.
Various methods of stabilization available for maxillary fractures
include.
INTERNAL FIXATION .
Direct osteosynthesis.
Mini plates and screws
Wires.
Suspension wires.
EXTERNAL FIXATION.
Cranio-mandibular
Cranio-maxillary
Supra orbital pins
Zygomatic pins
Halo frame
Levant frame.
Mini plates and screws.-
Monocortical semirigid fixation with mini plates and screws eliminate
bony movement and allows primary healing to occur. They currently
represent the ideal form of fixation.
Stain less steel
• -First material used for semi rigid fixation.
• Susceptible to corrosion
• Difficult to bend
• Bulky.
• Titanium- excellent bio compatibility
-Resistant to corrosion
-Chemically inert.
-More malleable, easy contouring
Semi rigid fixation with plates and screws provides three-dimensional
stability. The placement of a plate with 2 screws on either side of #
resists both horizontal and rotational movement.
Rigid fixation.
• Superior cosmetic and functional result.
Very rigidity produced by these systems means that precise attention
to occlusion is mandatory, as elastic mandibulo-maxillary forces cannot
be used post operatively to correct minor occlusal problems.
Recent development –biodegradable plates and screws.
Inter osseous wiring.
• Soft stain less steel wiring-cheap, easy to use, well tolerated.
• Employed at suture sites-fronto nasal, maxillo zygomatic sutures.
• When a fracture involves palatal process of maxilla-mid palatal
split-direct wiring across the posterior free edge can be done.
Suspension wires
• Not a rigid fixation
• Superseded by mini plates and screws.
• Occasionally used in combination. Suspension wires have to be
placed superior to the fracture.
• Use of 0.5 mm-soft SLS (pre stretched 10%) can be employed.
• Frontal-
central -lefort II and III(mandible
unstable)
lateral –lefort II and III ( mandible stable).
• Circum zygomatic-lefort II and I
• Zygomatic-lefort I
• Infra orbital-lefort I
• Pyriform aperture-lefort I
• Trans nasal-gunning splint.
• Peralveolar-gunning splint.
Frontal suspension.
Lateral
• Incision is placed in the lateral 3rd of eyebrow to expose
zygomatic process of frontal bone just above fronto zygomatic suture.
• Bur hole 5 mm above the suture line and angulated to emerge
on the posterior or infra temporal fossa aspect.
A 40 cm long soft stain less steel wire is passed through this and bent
backwards so that an equal length protrudes on either side of bur hole.
Two ends of wire are threaded through the eye of Rowe’s zygomatic
awl and crimped.
Awl is passed downward behind the frontal process of zygomatic bone
(deep to arch) to pierce the oral mucosa in the upper buccal sulcus
adjacent to molar teeth. Wire ends are detached from the awl and
secured with heavy artery clip and awl is withdrawn. A 0.35 mm
diameter soft stainless steel is then threaded beneath the suspension
wire where is passes beneath the bone in the supra orbital region and
is twisted to form pull out wire. This facilitates cutting of suspension
wire prior to its removal through mouth without a subperiosteal
dissection of incision in the eyebrow.
Tension is applied to wire ends to take up the slack and then one end
is threaded through suitable loop of arch bar secured to teeth and two
ends are twisted together. Eyebrow incision is closed in layers.
• Central—
• Originally introduced by Kuffner.
Has little place since the introduction of plates.
• Bone screw to the anterior wall of the frontal sinus.
Circum zygomatic suspension.
• Rowe or obwegessor awl is passed through the Junction of
frontal and temporal process of zygomatic bone.
• Instrument pierces temporal fascia passes deep to the temporal
surface of buttress to emerge at upper buccal sulcus in Ist molar region.
• Wire attached, tip of awl withdrawn to just above the arch
without emerging from the skin, passed over the lateral aspect of arch
down ward and forward through original point of entry in buccal sulcus.
Wire is detached and point of awl is withdrawn.
• Theoretical disadvantage-introducing infection from mouth into
soft tissues.
Zygomatic suspension .
• 3 cm incision in upper buccal sulcus above premolar, molar
teeth.
• Expose base of buttress.
• Bur hole drilled posteriorly and laterally.
• 0.5 mm soft stain less steel is passed.
Two ends of wire are passed through suitable loop of arch bar.
• Deep aspect of periosteum should not be penetrated to prevent
herniation of buccal fat pad.
Trans nasal suspension.
• By Bowerman and Corroy 1981.
• For retention of surgical splint following maxillectomy,fixing
gunning splint.
• Superior retention and stability of splint as compared to
peralveolar and circum-zygomatic wires.
• Procedure-curved awl through the nasal aperture and backwards
along the floor of nose.withdrawn through soft palate to enter the oral
cavity through posterior edge of hard palate.
A 40 cm length 0.5 mm diameter soft stainless steel threaded through
the loop of heavy gauge wire incorporated into back edge of splint.
Free edges are threaded through awl and withdrawn from nasal cavity.
Point of awl is passed through mucosa of floor of nose immediately
anterior to piriform aperture to emerge at labial sulcus. Awl is
withdrawn.
One end through loop on anterior aspect of flange of split and two
ends are twisted together.
Repeated on contra lateral side.
Infra orbital suspension .
• 3 cm incision in upper buccal sulcus above canine tooth and
expose inferior orbital margin lateral to infra orbital foramen.
• Bur hole upwards and posteriorly.
• Pass stain less steel wire.
• Withdrawn into oral cavity.
• Attached to suitable loop on arch bar.
Pyriform aperture suspension.
• 2 cm incision in the upper buccal sulcus above lateral incisor.
• Expose the aperture.
• Nasal mucosa is elevated from the medial aspect to a depth of 2
cm.
• Bur hole-from lateral to medial side 1 cm from free margin. A 0.5
cm soft stain less steel wire is passed.
• Two ends are withdrawn into the mouth and attached to loop of
arch bar.
Peralveolar suspension.
Gunning type of splint is placed in situ and the position of holes placed
on the palatal aspect of splint are marked on the mucosa of hard
palate with bonney’s blue.
Per alveolar awl directed through the mucosa in the canine region and
driven through the alveolus from high up in the buccal sulcus.
Two ends are twisted over the splint.
It is repeated on the opposite side.
This method is largely been superseded by the use of circumferential
type of suspension.
External fixation
HALO frame.
• Crawford in1943.
Pre operatively the halo is adjusted to the contours of patient’s head to
allow correct alignment of screw pins.
• 2 anterior pins are sited on the temporal crest within the hair line
(taking care not to avoid temporal artery) and 2 posterior pins in the
region of mastoid process.
• At operation, halo is located and screw pins are adjusted until all
the four points touch the skin.
• Stab incision is placed to facilitate entry of screw pin through the
scalp.
Tighten the screw until they engage the outer table of skull.
Halo is linked to the anterior projection bar of silver cap splint or
gunning type of splint by standard stainless steel rods and universal
attachments.
It is necessary to use two or more connecting rods to obtain optimum
results.
Levant frame.
• Developed at Royal Melbourne Hospital.
Simple rigid skeletal cranio maxillary fixation between supra orbital
margin and maxilla connected by central cranio maxillary rod attached
at lower end either by cast metal silver cap splint or gunning splint.
Appliance-3 mm diameter stain less steel rod which is bent 30 0
towards each end of horizontal arm and a central U shaped
attachment.
Central attachment provides 2-point fixation of vertical cranio
maxillary rod preventing rotation in horizontal axis.
Technique- small horizontal incisions are made in each eyebrow at the
junction of supra orbital rim and temporal line of frontal bone (thickest
point of bony rim)
Hole is drilled barely to penetrate inner cortex of supra orbital rim.
Bone pins are inserted until firmly in place.
Once frame is attached facial fractures are reduced and central vertical
rod of 3 mm diameter is adapted to nasal contour.
It is attached to central attachment of head frame by two universal
joints and to cast silver cap splint with a further universal joint
attached to a central rod projecting from splint.
Definitive management.
• Aim of treatment- to return the displaced maxilla to its correct
relationship to intact mandible below and cranial base above.
Dento alveolar fracture.
Treatment of dento alveolar # should have same priority as treatment
of facial laceration fro two reasons.
• Injury to the vital teeth may cause severe pain.
• # Alveolus may interfere with occlusion.
Teeth without exposure of pulp-
• They are highly sensitive
• Fluoride desensitizer
• Sedative dressing
• Pulp testing + follow up.
With exposure of pulp
Pulp capping/ immediate pulp extirpation
Sub-luxated teeth.
• Slightly luxated teeth-left alone /splinted
• Follow up pulp testing and X ray.
• Severely luxated tooth-splinting+pulp extirpation.
• Completely avulsed tooth re implanted if within 30 mins of injury.
Alveolar fracture
• Tuberosity #
If completely detached from periosteum – dissected out and soft tissue
defect is sutured.
If tuberosity with/ without associated tooth-appears attached to
periosteum splinting of tooth attached to fragment and immobilizing
it to other standing teeth in maxilla for 1 month.
• # of alveolar floor of maxillary sinus- similar to the fracture
tuberosity.
• When there is an extensive fracture of alveolus with several
teeth attached-splinting the teeth and anchoring the splint to teeth
else where in the upper jaw.
Unilateral maxillary fracture
Closed reduction-
• If the fragment is mobile-digital pressure.
• Arch bar application+IMF.
Open reduction +rigid fixation.
Vestibular incision is placed.
If impacted- Rowe's disimpaction forceps is used to disimpact the
maxilla.
Arch bar application.
Inter maxillary Splint is secured to the maxillary arch and mandible is
passively guided into splint.
IMF.
Rigid fixation is done.
Lefort I fracture.
Reduction.
If occurs in isolation-
• Loose fracture- finger pressure
• Impacted fracture-Rowe’s disimpaction forceps.
• If firmly impacted-bilateral vestibular incision- mobilize using an
osteotome.
Closed reduction-
-Less ideal
-One month IMF.
Severe communition- 6 weeks IMF.
• Ideally open reduction and RIF should be done.
Bilateral incision in buccal vestibule from canine to first molar.
Buttress, lateral antral wall exposed, # line is followed using chisel to
Pterygoid plates.
Rowe and Hayton William forceps-reduction.
Rigid fixation is ideal in the absence of communition of antral wall and
buttress.
Determine the area, which contain sturdy bone for fixation.
Four-point fixation is minimal requirement-pyriform aperture and
zygomatic buttress.
For many years skeletal fixation and extra skeletal fixation were
effective for the patients-
• Who cannot undergo bone grafting.
• Cannot endure IMF for medical reasons.
Halo frame
Various suspensions.
Lefort II Fracture.
• Reduction-
• If it is in one piece-similar to above.
-Using Rowe’s disimpaction forceps.
-Should not be shaken indiscriminately because fracture line at times
involves the middle cranial fossa which should not be disturbed.
If there is co- existing lefort II-grasping at nasal septum with ashe’s or
walsham’s septal forceps and at the same time inserting the finger
of other hand up behind the soft palate and exerting forward
pressure.
STABILIZATION.
Atleast 3 point and preferably 4 point fixation is necessary.
Exposing the region of Zygomatico maxillary and fronto nasal suture.
In ideal situation where there is no # of orbital rim / floor – bilateral
intra oral exposure of ZMS-affords four point fixation.
For infra orbital rim and floor-four classic approaches.
• Infra orbital incision
• Sub ciliary incision
• Mid lower lid incision
• Trans conjunctival incision
• INCISONS FOR FRONTO NASAL SUTURE AREA.
Lefort III Fracture.
Often associated with lefort II and I.
The order at which reduction is carried out are -
-Frontal and zygomatic fractures.-coronal approach
Upper part of central mid facial fracture-same approach.
Naso ethmoidal complex reduction.
Stabilization-
A stable outer framework is established that is,
Reduction and immobilization of zygomatico temporal, zygomatico
frontal and fronto nasal sutures and reduction of maxilla inferiorly.
Once the outer framework has been established nasal skeleton floor of
orbit are constructed.
COMPLICATIONS.
MALOCCLUSION- 8-20%
• Improper occlusal reduction.
• Post operative relapse.
• Lack of correct passive repositioning of maxilla.
COSMETIC DEFORMITY.
• Over long face
• Dish face
LACRIMAL SYSTEM-
Epiphora
Dacrocystitis.
OPHTHALMIC COMPLICATION
• Diplopia
• Enophthalmos
• SOF syndrome.
OTHER NUEROLOGICAL COMPLICATIONS
Anosmia.
NON UNION
Uncommon
When there is communition or actual bone loss.
Palatal fractures.
• Accompany 8% of lefort fractures or may exist in isolation.
They divide the maxillary alveolus transversely/ sagittally, and
comminute the dentition, permit rotation of dental alveolar segments,
and increase the potential for mal alignment.
HENDRICKSON’S CLASSIFICATION (Plastic reconstructive surgery
2001)
• Depending on the pattern in axial and coronal CT.
• TYPE I: alveolar #
Of 2 general types.
Anterior-involving incisor teeth
Postero lateral-molar and bicuspid.
TYPE II: sagittal #
Commonest palatal # in children.
• Extends through anterior portion of pyriform aperture and
divides the palate longitudinally in the line of mid palatine suture.
TYPE III:para sagittal #.
• Seen in adults.
• The common sagittal fracture of maxilla usually divides the
palate anteriorly just off the mid line.
• Thinner bone just lateral to vomerine attachment of maxilla.
• TYPE IV: para alveolar #.
A variant of para sagittal #.
Just medial to maxillary alveolus.
Differs from postero lateral # in that fracture line extends anteriorly to
the incisor dentition.
TYPE V: complex #.
Dividing the palate obliquely,transversely, or comminuting palate and
alveolus.
• TYPE VI: Transverse palatal fracture
• Rarest
• Dividing the palate and maxilla transversely in coronal plane.
Management.
• Fractures of type II, III, IV are not comminuted and have large #
fragments. They can be reduced anatomically by exposure in the
palatal vault and at pyriform aperture with rigid fixation creating one-
piece maxilla, which can then be managed as an intact lower maxillary
fragment.
There is a general agreement that all fractures of palate are amenable
to open reduction and fixation at vertical maxillary buttresses. A few
surgeons prefer to add palatal vault stabilization.
Palatal vault stabilization-
Maintains palatal width.
Fractures selected for vault RIF should generally be antero posteriorly
oriented and must have large segments, which are not comminuted
or have missing bone.
Depends on the fracture edge inter-digitation to determine palatal
width alignment.
Either existing laceration or longitudinal incision is used.
Should not devascularize labial gingiva and palatal mucosa.
It is considered that mid 50% of palate is the safe area.
Sub periosteal dissection is carried out to reach the fracture segment.
• Three hole maxillary plates are best for stabilization.
• Mesh can sometimes be used.
• One plates anteriorly and one plate posteriorly.
Pyriform/ alveolar ridge stabilization.
• Rotation of palatal segment is prevented.
• After stabilization of palatal vault,IMF is done.
• Pyriform area, zygomatic buttress area exposed.
• Stabilization is done at the region of pyriform, alveolar and
zygomatic buttress area.
• In comminuted fracture, complex fracture.- splint is used.
• In postero lateral fracture of palate- either splint or stabilization
at buttress and pterygo maxillary buttress.
A new classification and algorithm to establish treatment plan.
( 2003 )
• Helps the surgeon to decide which fracture to open and how to
do so.
Is the closed reduction possible?
yes.
No
Is the stabilization of vault necessary?
yes no.
Is the fixation stable enough.
yes no.
CR type. AP type C type A type.
Conclusion
The maxillary fractures even though one of the common fractures to
encounter in the maxillofacial region. Though fractures confined to
isolated maxillary fractures are rare, it is associated with other fracture
of maxillofacial region. An understanding of various patterns of the
fracture line as well as different treatment modalities available is
extremely important to give the best possible treatment depending on
the clinical situation.
References.
• Maxillofacial trauma- Rowe and
Williams
• Maxillo facial trauma-Fonseca.
• Fractures of mid facial skeleton-Kelley and Kay.
• Cranio facial trauma-Churchill living stone
• JOMS 2004 Dec 62(12) 1477-1485.
• Plastic reconstructive surgery 2001-jun 107(7) 1669-1676.
• Plastic reconstructive surgery 2003 feb 101(2) 319-32.
CERTIFICATE
This is to certify the topic entitled Maxillary Fractures
is compiled, presented and submitted by Dr. VIDYA SHETTY
under my supervision, guidance and Satisfaction during her
postgraduate course.
Dr .B. H. SRIPATHI RAO.
Guide
Dr.B.H.SRIPATHI.RAO. Professor and H.O.D.Department of oral and maxillofacial surgery
Yenepoya dental college.Mangalore.
Place: MangaloreDate:
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
SEMINAR ON
MAXILLARY FRACTURES
PRESENTED BY,
DR. VIDYA. B. SHETTY