Mid Face Injury

8/10/2019 Mid Face Injury

1/38


2/38

2

Mid-faceDefinition:

The area betweena superior planedrawn through

the zygomatico-

frontal suturestangential to thebase of the skull

and inferior

plane at the levelof the maxillarydental occlussal

surface.


3/38

3

Structures connection(s t ru ctu res in re lat ion )

OrbitMaxillary sinusNasal boneNaso-orbitalethmoid (NOE)complex

ZygomaticcomplexFrontal bone andsinus


4/38

4

Vertical and horizontal pillars

Area of strengthVertical and horizontal pillarsMuscular attachment

Area of weaknessSutures

Lining tissues and air-filled cavities


5/38


6/38


7/38


8/38

8

Signs and symptomsSlight 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

Exposure of nares and the maxillary antra in case of

gross injury

Impacted type of fracture is oftenly not mobile andteeth cusps may be damaged

Cracked-pot percussion of upper teeth


9/38

9

Le Forts fractures

Le Fort II (pyramidal or subzygomatic)Separation of NF suture,medial orbital walls(lacrimal bone), inferior

orbital floor and rim(adjacent to infrorbitalcanal and foramen),anterior maxilla belowzygomatic buttress andptrygoid laminae abouthalfway up.

Separation of the block from the base of skull is completedvia the nasal septum and may involve the floor of the

anterior cranial fossa


10/38

10

LeForts fractures

LeFort III(cranifacial dysjunction, hightransverse, suprazygomatic)

Separation of NF suture,medial orbital walls (involve

the depth of the ethmoidbone and cribriform plate,pass below optic foramen

and cross the inferior orbitalfissur), inferior orbital floor,

lateral orbital wall, ZFsuture, zygomatic arch,

suprazygomatic to the rootof ptrygoid plate.


11/38

11

Signs and symptomsaltho ugh i t i s p os s ible to d is t ing uish between le for t II and III, thes igns and sy mp tom s a re almos t s imi lar

Gross edema of soft tissueBilateral circumorbitalecchymosisBilateral subconjunctivalhemorrahgeObvious deformity of thenoseNasal bleeding andobstructionCSF leak rhinorrheaDish-face deformityLimitation of ocular

movementPossible diplopia andenophthalmousRetropostioning of themaxilla with anterior openbiteLengthening of the face

Difficulty in mouth openingMobility of the upper jawOccusional hematoma ofthe palateCracked-pot sound onpercussionStep deformity at infra-orbiatal marginAnasthesia of midfaceNasal bone moves withmid-face as a wholeTenderness and sepration

at FZ sutureTenderness and deformityof zygomatic archDepression of occular leveland pseudoptosis


12/38

12

Bowerman classification of midface-fracture(1994)

Fracture not involving the occlusion Central region

Nasal bone/ septum (lateral, anterior injuries)Frontal process of the maxillaNasoethmoidFronto-orbito-nasal dislocation

Lateral region (zygomatic complex EX dento alveolarfrcature

Fracture involving the occlusion Dento alveolar

Subzygomatic: Le Forts (I, II)

Supra zygomatic:Le Fort III

These fractures may occur unilaterally or bilaterally, with separationof maxillary midline and or extension to frontal or temporal bone


13/38

13

Prevalence of mid-face fractures

Fracture Type Prevalence

Zygomaticomaxillary complex (tripod fracture) 40 %

LeFort I 15 % II 10 % III 10 %

Zygomatic arch 10 % Alveolar process of maxilla 5 % Smash fractures 5 % Other 5 %


14/38

14

Diagnosis

InspectionExtra-oral

(e.g. swelling, deformity, asymmetryLeaks)

Intra-oral(e.g. hematoma, occlusion)

PalpationStep deformity, criptation, cracked pot sound, mobility

Radiographical investigations


15/38

15

Radiographical examinationPlain radiograph

Occipitomental(10 or 30 degree)

Waters view Suitable for isolated orbital

fractureSearch line (Campbells line 1977)


16/38

16

Radiographical examination

Lateral skull viewOPGOcclusal view of the

maxillaPerapical views ofdamaged teeth


17/38

17

Radiographical examination

CT scan3-D CT imaging

Coronal sections Axial sections

1. Whenever intracranial damage andfrontal sinus are suspected

2. Extensive fracture that involvesnasoethmoid complex or orbitalregion

3. Orbital trauma to evaluate thedegree of orbital injury and

enophthalmos


18/38

18


19/38

19

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.


20/38

20

Indications for treatment

Fractured or displaced teeth.

Cerebrospinal fluid leak.

Abnormal eye movement or restriction ofeye movement.

Occlusion of the nasolacrimal duct.

Sensory or motor nerve deficit.

Other evidence of loss of function


21/38

21

Aims of treatmentRelieve pain

Restore function.

Restore bone anatomy.

Prevent infection

Restore the dental occlusion

Restore jaw movement at the earliestpossible stage

Restore normal nerve function


22/38

22

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.


23/38

23


Presence of a pre-existing dentofacialdeformity.

Time elapsed since the injury.

Presence of a medical or surgical factorwhich would delay general anesthesia

Presence of any factor which would delay

healing. (eg nutritional deficiency oralcoholism)

Stage of dental development (deciduous,mixed or permanent dentition)


24/38

24


Presence of fractured teeth.

Total absence of teeth (edentulous)

Inability of the patient to co-operate withtreatment.

Association with fractures of the mandibleespecially bilateral fractures of thecondyles.


25/38

25

Principles of treatment

Closed reduction may be appropriate incases

Simple uncomplicated fractures

Complex or comminuted fractures

Medical or surgical contraindications toopen reduction

Maxillary fractures in children


26/38

26

Open reduction may be appropriatewhere

Immediate or early jaw function isdesirable

Difficulty is encountered in reducing the

fracture by a closed method

The fracture is unstable


27/38

27

Definitive treatment

Reduction

Manual manipulation

Use of dis-impaction forceps


28/38

28

Fixation and immobilization

Extraoral fixation

Craniomandibular fixation

Box-frame (pin fixation)Halo-framePlaster of paries headcap

Craniomaxillary fixationSupra-orbital pinsZygomatic pinsHalo-frame
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/plastic/images/Large/937pla0480-08.jpg&template=izoom2http://www.srt-psc.com/aelfl.jpg


29/38


30/38

30

Immobilization within the tissue

Internal-wire suspension

Circumzygomatico-mandibular

Infraorbital border-mandibular

Frontomandibular

Pyriform fossa-mandibular


31/38

31

Immobilization within the tissue

Support via the maxillary sinus byfilling materials

Ribbon gauze Balloon Folly catheter

Polyethylene material


32/38

32

Length of the hospital stay will dependon 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 andfixation of the fracture

Presence or absence of medical orsurgical complications

Social circumstances of the patient


33/38

33


34/38

34


35/38

35


36/38

36


37/38


38/38

38

Documents

Mid Face Injury