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Le fort fractures

Le Fort fractures types, clinical features and various types of management

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Le fort fractures

  1. 1. Le Fort fractures and management Dr. G.P. Kumar.,Dr. G.P. Kumar., 11
  2. 2. SURGICAL ANATOMY Facial Skeleton roughlyFacial Skeleton roughly divided in todivided in to 3 Areas3 Areas 1.Upper Third1.Upper Third – Frontal– Frontal 2.Lower Third2.Lower Third _ Mandible_ Mandible 3.Middle Third3.Middle Third – In-– In- between Frontal bonebetween Frontal bone and Mandibleand Mandible Dr.GPK, OMFSDr.GPK, OMFS 22
  3. 3. Dr.GPK, OMFSDr.GPK, OMFS 33
  4. 4. Dr.GPK, OMFSDr.GPK, OMFS 44
  5. 5. Dr.GPK, OMFSDr.GPK, OMFS 55
  6. 6. Dr.GPK, OMFSDr.GPK, OMFS 66
  7. 7. Dr.GPK, OMFSDr.GPK, OMFS 77
  8. 8. MATCH BOXMATCH BOX Dr.GPK, OMFSDr.GPK, OMFS 88
  9. 9. SKELETAL ARCHITECTURE Dr.GPK, OMFSDr.GPK, OMFS 99
  10. 10. MIDDILE THIRD OF FACE The middle third of the face is the area bounded by : superiorly by a line drawn from the zygomaticofrontal suture across the frontonasal &frontomaxillary suture to the zygomaticofrontal suture at the opposite side. Inferiorly by the occlusal plane or the alveolar ridge, and Posteriorly as far as the frontal bone above and body of sphenoid below. Dr.GPK, OMFSDr.GPK, OMFS 1010
  11. 11. MIDDLE THIRD A. Central middle ThirdA. Central middle Third B. Lateral middle ThirdB. Lateral middle Third Dr.GPK, OMFSDr.GPK, OMFS 1111
  12. 12. BONES CONTRIBUTING MIDDLE 3BONES CONTRIBUTING MIDDLE 3rdrd OFOF THE FACETHE FACE PAIRED BONES 1. Two maxillae 2. Two Zygomatic bones 3. Two Zygomatic Processes of the Temporal Bones 4. Two Palatines Bones 5. Two nasal Bones 6. Two Lacrimal Bones UNPAIRED BONES 7. The vomer 8. The ethmoid and its attached conchae 9. The inferior conchae 10.The pterygoid plates of the sphenoid Dr.GPK, OMFSDr.GPK, OMFS 1212
  13. 13. Depending on the level of a fracture lineDepending on the level of a fracture line Low level fractureLow level fracture Mid level fractureMid level fracture High level fractureHigh level fracture Dr.GPK, OMFSDr.GPK, OMFS 1313
  14. 14. Erich’s classification (1942) Based on the direction of the facture line: Horizontal fracture Pyramidal fracture Transverse fracture Dr.GPK, OMFSDr.GPK, OMFS 1414
  15. 15. CLASSIFICATION OF MIDFACECLASSIFICATION OF MIDFACE FRACTURES BYFRACTURES BY RENE LEFORT 19011901 AA. Lefort I. Lefort I -Low level fracture (-Low level fracture (Guerin FractureGuerin Fracture)) B.B. Lefort IILefort II -Pyramidal or subzygomatic Fracture-Pyramidal or subzygomatic Fracture C.C. Lefort III –High Transverse or suprazygomatic fracture (Cranio–High Transverse or suprazygomatic fracture (Cranio Facial Dysjunction)Facial Dysjunction) LIMITATIONSLIMITATIONS 1.Inability to accurately predict reduction techniques1.Inability to accurately predict reduction techniques 2.Asymmetric fracture patterns2.Asymmetric fracture patterns Dr.GPK, OMFSDr.GPK, OMFS 1515
  16. 16. MODIFIED LEFORT CLASSIFICATIONS BY MARCIANI RD 1993 Lefort I – Low Maxillary Fractures I a _ Low maxillary Fracture /Multiple Segments Lefort II- Pyramidal Fracture II a - Pyramidal and nasal Fractures II b - Pyramidal and naso Orbito ethmoidal (NOE) Fracture Lefort III - Craniofacial Dysjunction Lefort III a- Craniofacial Dysjunction and Nasal Fracture Lefort III b- Craniofacial Dysjunction and NOE Lefort IV - Lefort II or III fracture and cranial base fracture Lefort IV a- Supra orbital fracture Lefort IV b – Anterior Cranial Fossa and Supra Orbital Rim Fracture Lefort IV c - Anterior Cranial Fossa and Orbital wall fracture Dr.GPK, OMFSDr.GPK, OMFS 1616
  17. 17. GENERAL CLINICAL FEATURES 1. Airway obstruction 2. Epistaxis 3. CSF Rhinorrhea 4. Facial oedema 5. Emphysema 6. Circumorbital echymosis 7. Subconjuctival haemorrhage 8. Occlusal disturbances 9. Facial disfigurement 10. Orbital symptoms 11. Abnormal opening of mouth 12. Oronasal openings Dr.GPK, OMFSDr.GPK, OMFS 1717
  18. 18. Le Fort fractures Le FortLe Fort IIIIII Le FortLe Fort IIII Le FortLe Fort II Dr.GPK, OMFSDr.GPK, OMFS 1818
  19. 19. Le Fort I Dr.GPK, OMFSDr.GPK, OMFS 1919
  20. 20. Le Fort fracture I Also called asAlso called as Horizontal fracture of the maxilla orHorizontal fracture of the maxilla or Guerin’s fractureGuerin’s fracture oror Floating fracture orFloating fracture or Low level fractureLow level fracture oror Pterygomaxillary dysjunctionPterygomaxillary dysjunction oror Subzygomatic fracture (Le Fort I & Le Fort II)Subzygomatic fracture (Le Fort I & Le Fort II) Dr.GPK, OMFSDr.GPK, OMFS 2020
  21. 21. Le Fort I fracture Violent force over a more extensive area above the level of the teeth will result in Le Fort I fracture Horizontal fracture line seen above the apices of the maxillary teeth, detaching the tooth bearing portion of the maxilla from the rest of the facial skeleton. The fractured fragment is freely mobile and displacement will depend on the direction of the force. Depending upon the displacement, a variety of occlusal disharmony can be seen in this type of Le Fort I fracture. Dr.GPK, OMFSDr.GPK, OMFS 2121
  22. 22. Le Fort I fracture The fracture line commences at the point on the lateral margin of the anterior nasal aperture, passes above the nasal floor, and it passes laterally above the canine fossa and traverses the lateral antral wall, dipping down below the zygomatic buttress and then inclines upward and posteriorly across the pterygomaxillary fissure to fracture the pterygoid laminae at the junction of their lower thrid and upper 2 /3rds. At the same time, from the same starting point, the fracture also passes along the lateral wall of the nose to join the lateral line of fracture behind the tuberosity. Dr.GPK, OMFSDr.GPK, OMFS 2222
  23. 23. LEFORT I Dr.GPK, OMFSDr.GPK, OMFS 2323
  24. 24. LEFORT I Dr.GPK, OMFSDr.GPK, OMFS 2424
  25. 25. Le Fort I fracture Mostly bilateral Sometimes unilateral depending upon the displacement, direction and severity of force May occur as single entity or with Le Fort I and II fractures. Dr.GPK, OMFSDr.GPK, OMFS 2525
  26. 26. SIGNS AND SYMPTOMS OF LEFORT ISIGNS AND SYMPTOMS OF LEFORT I FRACTUREFRACTURE EXTRAORALLYEXTRAORALLY Slight swelling and edema of the lower part of the mid face and the upper lip. Epistaxis may be observed. Pain and mobility . Air emphysema in some cases. Dr.GPK, OMFSDr.GPK, OMFS 2626
  27. 27. SIGNS AND SYMPTOMS OF LEFORT I FRACTURE INTRA ORALLYINTRA ORALLY Floating Maxilla Impacted or Telescopic fracture Anterior open bite Disturbed occlusion Echymosis CRACKED POT SOUND Midpalatal split in some cases Damaged or subluxed teeth. GUERIN’S SIGN Dr.GPK, OMFSDr.GPK, OMFS 2727
  28. 28. GUERIN’S SignGUERIN’S Sign Characterised by ecchymosis in the region of greaterCharacterised by ecchymosis in the region of greater palatine vesselspalatine vessels.. Dr.GPK, OMFSDr.GPK, OMFS 2828
  29. 29. Le Fort II Dr.GPK, OMFSDr.GPK, OMFS 2929
  30. 30. Le Fort II fracture Pyramidal or subzygomatic fracture Violent force in the central region extending from glabella to the alveolus results in pyramidal fracture Dr.GPK, OMFSDr.GPK, OMFS 3030
  31. 31. Le Fort II fracture The fracture line runs below the frontonasal suture from the thin middle area of the nasal bones down on either side, crossing the frontal process of the maxillae and passes anteriorly across the lacrimal bones anterior to nasolacrimal canal. From this point the fracture line passes downward, forward and laterally crossing the inferior orbital margin in the region of zygomaticomaxillary suture. May or may not involve the infra orbital foramen. The fracture line extends downward and forward and lateral to the transverse wall of the antrum, just medial to the zygomaticomaxillary suture line. Dr.GPK, OMFSDr.GPK, OMFS 3131
  32. 32. LEFORT II Dr.GPK, OMFSDr.GPK, OMFS 3232
  33. 33. SIGNS AND SYMPTOMS OF LEFORT II FRACTURE EXTRAORALLY BALOONING or MOON FACE Bilateral circumorbital edema and echymosis (Black eye) Subconjuctival echymosis Oedema of the conjunctiva or chemosis Detection of a step deformity in the bone of the Infra-orbital margin. (Most important in differentiating LEFORT III FRACTURE) Mobility of the midface Anaesthesia or parasthesia of cheek Posible Diplopia CSF Rhinorrhea NO tenderness over or disorganization and mobility of Zygomatic bones and arch. Elongation or lengthening of the face. Emphysema of soft tissues. Nasal disfigurement. Dr.GPK, OMFSDr.GPK, OMFS 3333
  34. 34. BALOONINGBALOONING OROR MOONMOON OROR FOOT BALLFOOT BALL FACEFACE Dr.GPK, OMFSDr.GPK, OMFS 3434
  35. 35. CSF RHINNORHEACSF RHINNORHEA Dr.GPK, OMFSDr.GPK, OMFS 3535
  36. 36. SIGNS AND SYMPTOMS OF LEFORT II FRACTURE INTRAORALLY Disturbed or Deranged Occlusion Posterior Gagging of occlusion with retro positioning of maxillae with Anterior open bite. Airway obstruction. Dr.GPK, OMFSDr.GPK, OMFS 3636
  37. 37. Le Fort III Dr.GPK, OMFSDr.GPK, OMFS 3737
  38. 38. Le Fort III fracture High level fracture Transverse fracture or Suprazygomatic fracture or Craniofacial dysjunction. Due to severe impact from the lateralDue to severe impact from the lateral surfacesurface Dr.GPK, OMFSDr.GPK, OMFS 3838
  39. 39. LEFORT IIILEFORT III Dr.GPK, OMFSDr.GPK, OMFS 3939
  40. 40. LEFORT IIILEFORT III Dr.GPK, OMFSDr.GPK, OMFS 4040
  41. 41. Le Fort III fracture The fracture line begins at the frontozygomatic suture along the lateral aspect of the internal orbit along the sphenozygomatic suture line to the inferior orbital fissure, extends medially across the floor of the orbit up the medial wall of the orbit towards the dorsum of the nose where it crosses and proceeds to the opposite side in the same manner. Various amounts of the pterygoid plates will usually remain attached to the posterior maxilla. Dr.GPK, OMFSDr.GPK, OMFS 4141
  42. 42. SIGNS AND SYMPTOMS OF LEFORT III FRACTURE EXTRAORALLY Tenderness and separation at FZ suture Lengthening of the face One or other Zygomatic complex fracture with Displacement Flattening and a step deformity at the Infra-orbital margin Movement of the entire facial skeleton as a single block. Enoptholmos HOODING of the eyes Profuse CSF Rhinorrhea and CSF Otorrhea PANDA FACIES DISH FACE deformity BATTLE’S SIGN Haemotympanum Orbital dystopia with associated Antimongoloid slant Flattening, widening and deviation of nasal bridge Dr.GPK, OMFSDr.GPK, OMFS 4242
  43. 43. Dr.GPK, OMFSDr.GPK, OMFS 4343
  44. 44. PERIORBITAL EDEMA AND ECHYMOSIS Dr.GPK, OMFSDr.GPK, OMFS 4444
  45. 45. SUBCONJUNCTIVAL HAEMORRHAGE AND CHEMOSIS Dr.GPK, OMFSDr.GPK, OMFS 4545
  46. 46. PANDA FACIESPANDA FACIES Raccoon eye/eyesRaccoon eye/eyes (also known in(also known in thethe United KingdomUnited Kingdom andand IrelandIreland asas panda eyespanda eyes,, though that termthough that term commonly refers to excess orcommonly refers to excess or smeared dark make-up around thesmeared dark make-up around the eyeseyes or to dark rings around theor to dark rings around the eyes) oreyes) or periorbital ecchymosisperiorbital ecchymosis isis aa signsign ofof basal skull fracturebasal skull fracture oror subgaleal hematomasubgaleal hematoma Dr.GPK, OMFSDr.GPK, OMFS 4646
  47. 47. BATTLE’S SIGN Battle's sign, also mastoid ecchymosis, is an indication of fracture of posterior cranial fossa of the skull, and may suggest underlying brain trauma. Dr.GPK, OMFSDr.GPK, OMFS 4747
  48. 48. HOODING OF THE EYE Dr.GPK, OMFSDr.GPK, OMFS 4848
  49. 49. DISH FACE Dr.GPK, OMFSDr.GPK, OMFS 4949
  50. 50. SIGNS AND SYMPTOMS OF LEFORT III FRACTURE INTRAORALLYINTRAORALLY Disturbed or Deranged OcclusionDisturbed or Deranged Occlusion Posterior Gagging of occlusion with retroPosterior Gagging of occlusion with retro positioning of maxillae with Anterior open bite.positioning of maxillae with Anterior open bite. Airway obstruction.Airway obstruction. SAGITTAL FRACTURE OF THE PALATE-SAGITTAL FRACTURE OF THE PALATE- aa variant of LEFORT III Fracturevariant of LEFORT III Fracture Dr.GPK, OMFSDr.GPK, OMFS 5050
  51. 51. LEFORT III Dr.GPK, OMFSDr.GPK, OMFS 5151
  52. 52. LEFORT III Dr.GPK, OMFSDr.GPK, OMFS 5252
  53. 53. DENTOALVEOLAR FRACTURES CLINICAL FEATURES  Anterior teeth injury associated with laceration of the upper lip or degloving of the alveolus.  Posterior tooth injury may include vertical splitting of one or more teeth  Mobility of teeth.  Teeth may be irretrievably damaged or avulsed  Fragments of teeth may become embedded in lip or tongue lacerations or they may be swallowed or rarely inhaled. Dr.GPK, OMFSDr.GPK, OMFS 5353
  54. 54. Immediate management of a patient with midfacial fractures 1. Maitenence of patent airway 2. Temporary cessation of haemorrhage 3. Blood fluid replacement 4. Antibiotic prophylaxis 5. Tetanus prophylaxis 6. Monitoring vitals 7. Assesing neurologic status(Glassgow coma scale) 8. Evaluation of cervical spine 9. Control of pain Dr.GPK, OMFSDr.GPK, OMFS 5454
  55. 55. GLASGOW COMA SCALEGLASGOW COMA SCALE Eye (E)Eye (E) 4 - open eyes spontaneously.4 - open eyes spontaneously. 3 - open eyes to voice.3 - open eyes to voice. 2 - open eyes to pain.2 - open eyes to pain. 1 - no eye opening.1 - no eye opening. Best Motor respose (M) 6 - Obeys commands.6 - Obeys commands. 5 - Localizes to pain.5 - Localizes to pain. 4 - Withdraws to pain.4 - Withdraws to pain. 3 - Abnormal flexion.3 - Abnormal flexion. 2 - Extension.2 - Extension. 1 - No response1 - No response Best Verbal response (V) 5 - Appropriate & oriented5 - Appropriate & oriented 4 - Confused conversation.4 - Confused conversation. 3 - in appropriate words.3 - in appropriate words. 2 - Incomprehensible sounds.2 - Incomprehensible sounds. 1 - No sounds.1 - No sounds. Dr.GPK, OMFSDr.GPK, OMFS 5555
  56. 56. Dr.GPK, OMFSDr.GPK, OMFS 5656
  57. 57. Dr.GPK, OMFSDr.GPK, OMFS 5757
  58. 58. GOLDEN HOURGOLDEN HOUR The vernacular term “golden hour” is widely attributed to R. Adams Cowley, founder of Baltimore’s Shock Trauma Institute. In a 1975 article, he stated, “the first hour after injury will largely determine a critically-injured person’s chances for survival.” Dr.GPK, OMFSDr.GPK, OMFS 5858
  59. 59. Management of midface fracture Maxillofacial Injuries Treatment divided into following phases – Emergency or initial care Early care Definitive care Secondary care or revision Dr.GPK, OMFSDr.GPK, OMFS 5959
  60. 60. Management of midface fracture Emergency treatment and stabilization of the patient. Definitive treatment with reduction and fixation Dr.GPK, OMFSDr.GPK, OMFS 6060
  61. 61. SOFT-TISSUE LACERATIONS The most common priority for patients with fractures of the middle third is repair of soft –tissue lacerations, particularly of the face. Ideally these should be sutured before too much oedema has occurred; that is within 1- 8 hours of injury. ASSESS THE GENERAL CONDITION OF THE PATIENT Dr.GPK, OMFSDr.GPK, OMFS 6161
  62. 62. Occlusion Teeth and occlusion are the key to Reconstruction. ItTeeth and occlusion are the key to Reconstruction. It provides the foundation upon which other facialprovides the foundation upon which other facial structures are builtstructures are built Dr.GPK, OMFSDr.GPK, OMFS 6262
  63. 63. Initial management The primary survey progresses in a logical manner based on the ABC’s & D,E. Airway maintenance with cervical spine control Breathing and adequate ventilation Circulation with control of hemorrhage The letters D and E have also been added: Degree of consciousness Exposure of the patient via complete undressing to avoid overlooking injuries camouflaged by clothing Dr.GPK, OMFSDr.GPK, OMFS 6363
  64. 64. Emergency care Preserve the airway Control of haemorrhage Prevent or control shock C Spine stabilization‐ Control of life threatening injuries‐ Head injuries, chest injuries, compound limb fractures, intra abdominal bleeding‐ Dr.GPK, OMFSDr.GPK, OMFS 6464
  65. 65. Evaluate the airway Existence & identification of obstruction Manually clear of fractured teeth, blood clots, dentures Endotracheal intubation & packing of oronasal airway Dr.GPK, OMFSDr.GPK, OMFS 6565
  66. 66. Airway ManagementAirway Management Maintain an intact airway Protect airway in jeopardy – Provide an airway(cricothyroidotomy/tracheotomy) C Spine injury may be present‐ Altered level of consciousness is the most common cause of upper airway obstruction Dr.GPK, OMFSDr.GPK, OMFS 6666
  67. 67. Airway management Chin lift to open intact airwayChin lift to open intact airway IntubationIntubation – Orotracheal: C spine injury absent on X-Ray‐– Orotracheal: C spine injury absent on X-Ray‐ Nasotracheal intubation: C spine injury suspected or‐Nasotracheal intubation: C spine injury suspected or‐ certaincertain Surgical AirwaySurgical Airway – Cricothyroidotomy – Tracheosotomy– Cricothyroidotomy – Tracheosotomy Dr.GPK, OMFSDr.GPK, OMFS 6767
  68. 68. Treatment of Blood Loss & Shock Extensive vascularity of head & neck may lead to massive blood loss Monitor vital signs closely – Intravenous infusion Penetrating injuries need to be explored – Arteriogram Esophagram Hemorrhage most common cause of shock after injury Multiple injury patients have hypovolemia Goal is to restore organ function & perfusion External bleeding controlled by direct pressure over bleeding site Gain prompt access to vascular system with IV catheters Fluid replacement – Ringer’s Lactate Normal saline – Transfusion Dr.GPK, OMFSDr.GPK, OMFS 6868
  69. 69. Stabilization of associated injuries C spine injury is primary concern with all maxillofacial‐ trauma victims Any patient with injury above clavicle or head injury resulting in unconscious state Any injury produced by high speed Signs/symptoms of C Spine injury‐ • Neurologic deficit • Neck pain Dr.GPK, OMFSDr.GPK, OMFS 6969
  70. 70. Early Care Emergency care has stabilized patient – Initial stabilization of fractures – Debridement & dressing of soft tissues – Elective tracheostomy Physical exam & history Laboratory tests Complete head & neck examination • Diagnosis of maxillofacial injuries Dr.GPK, OMFSDr.GPK, OMFS 7070
  71. 71. AFTER STABILIZING THE PATIENT---- (A) THOROUGH HISTORY(A) THOROUGH HISTORY Who? How? When? Where? What symptoms? What? LOC? Retrograde or anterograde amnesia Dr.GPK, OMFSDr.GPK, OMFS 7171
  72. 72. Positioning the patient Dr.GPK, OMFSDr.GPK, OMFS 7272
  73. 73. AFTER STABILIZING THE PATIENT---- (B) PHYSICAL EVALUATION 1.Eyes1.Eyes 2.Spine2.Spine 3.Limbs3.Limbs 4.Abdomen and chest4.Abdomen and chest 5.Pelvic areas5.Pelvic areas (C) Face and cranium for 1.Lacerations1.Lacerations 2.Abrasions2.Abrasions 3.Contusions3.Contusions 4.Edema or haematoma formation4.Edema or haematoma formation 5.Possible contour defects5.Possible contour defects 6.Vision6.Vision 7.Extraocular movements7.Extraocular movements 8.Pupillary reaction to light8.Pupillary reaction to light 9.Assessement of mobility of maxilla9.Assessement of mobility of maxilla 10.Medial intercanthal width10.Medial intercanthal width 11.Internal aspects of the nose11.Internal aspects of the nose Dr.GPK, OMFSDr.GPK, OMFS 7373
  74. 74. Facial Examination Evaluate mandibular opening Palpation of buccal vestibule Crepitus of lateral antral wall Occlusion evaluated Absence and quality of dentition noted Ecchymosis Pharynx evaluated for laceration & bleeding Dr.GPK, OMFSDr.GPK, OMFS 7474
  75. 75. Orbital ExaminationOrbital Examination Orbits evaluated Periorbital edema and ecchymosis Gross visual acuity determined Diplopia Pupillary size & shape Subconjunctival hemorrhage Funduscopic evaluation Dr.GPK, OMFSDr.GPK, OMFS 7575
  76. 76. Clinical examinationClinical examination Dr.GPK, OMFSDr.GPK, OMFS 7676
  77. 77. CLINICAL EXAMINATION Dr.GPK, OMFSDr.GPK, OMFS 7777
  78. 78. AFTER STABILIZING THE PATIENT---- INTRA ORALLY Mucosal laceration Echymosis Occlusion Teeth Dr.GPK, OMFSDr.GPK, OMFS 7878
  79. 79. AFTER STABILIZING THE PATIENT---- RADIOGRAPHIC EVALUATION Cervical spine(severe injuries) Water’s view Submentovertex view PA skull view Lateral skull view Dr.GPK, OMFSDr.GPK, OMFS 7979
  80. 80. Imaging 1- Occipitomental (standard ,10°, 15° and 30°)1- Occipitomental (standard ,10°, 15° and 30°) 2- True lateral2- True lateral 3- Soft tissue lateral3- Soft tissue lateral 4- Occlusal4- Occlusal 5- Intra orals5- Intra orals 6- Sub mento-vertex6- Sub mento-vertex 7- C.T Scan7- C.T Scan 8- 3D C.T Scan8- 3D C.T Scan 9- MRI(to detect CSF leaks and fistula)9- MRI(to detect CSF leaks and fistula) Dr.GPK, OMFSDr.GPK, OMFS 8080
  81. 81. CAMPBELL’S AND TRAPNELL’S LINES 1. First line across the zygomaticofrontal, the superior margin of the orbit and the frontal sinus 2. Second line across the zygomatic arch, zygomatic body, inferior orbital margin and nasal bone 3. Third line across the condyles, coronoid process and the maxillary sinus 4. Fourth line across the mandibular ramus, occlusal plane 5. Fifth line (trapnell's line) across the inferior border of the mandible from angle to angle Dr.GPK, OMFSDr.GPK, OMFS 8181
  82. 82. RADIOGRAPHIC EVALUATIONRADIOGRAPHIC EVALUATION The minimum radiographs required areThe minimum radiographs required are:: (A) FOR BONES OF THE MID-FACE(A) FOR BONES OF THE MID-FACE:: I . Occipitomental 10° and 30°I . Occipitomental 10° and 30° II . True lateral at 6 feetII . True lateral at 6 feet III. Soft tissue lateral at 6 feet.III. Soft tissue lateral at 6 feet. IV. Occlusal view of maxillaeIV. Occlusal view of maxillae V. Intra- oralV. Intra- oral Dr.GPK, OMFSDr.GPK, OMFS 8282
  83. 83. Radiographic evaluationRadiographic evaluation Lateral viewLateral view a) Occipitofrontal with tube angled 25 degree to the feet. b) Fronto-occipital( Townes projection) c) Isolated features of the orbital floor are diagnosed on a Waters view. d) Xeroradiographs and CT Dr.GPK, OMFSDr.GPK, OMFS 8383
  84. 84. X-RAY CERVICAL SPINE Dr.GPK, OMFSDr.GPK, OMFS 8484
  85. 85. Submentovertex viewSubmentovertex view Dr.GPK, OMFSDr.GPK, OMFS 8585
  86. 86. 30 Degree Occipitomental30 Degree Occipitomental Dr.GPK, OMFSDr.GPK, OMFS 8686
  87. 87. PA SKULLPA SKULL Dr.GPK, OMFSDr.GPK, OMFS 8787
  88. 88. REVERSE TOWNE’S PROJECTION Dr.GPK, OMFSDr.GPK, OMFS 8888
  89. 89. True lateral skull radiograph Dr.GPK, OMFSDr.GPK, OMFS 8989
  90. 90. Soft tissue lateralSoft tissue lateral Dr.GPK, OMFSDr.GPK, OMFS 9090
  91. 91. XERO RADIOGRAPHYXERO RADIOGRAPHY Dr.GPK, OMFSDr.GPK, OMFS 9191
  92. 92. INTRA-ORAL OCCLUSAL RADIOGRAPHINTRA-ORAL OCCLUSAL RADIOGRAPH Dr.GPK, OMFSDr.GPK, OMFS 9292
  93. 93. CT SCANCT SCAN Dr.GPK, OMFSDr.GPK, OMFS 9393
  94. 94. 3D CT3D CT Dr.GPK, OMFSDr.GPK, OMFS 9494
  95. 95. 3D CT3D CT Dr.GPK, OMFSDr.GPK, OMFS 9595
  96. 96. Stereo Lithographic model Dr.GPK, OMFSDr.GPK, OMFS 9696
  97. 97. SUMMARY OF RADIOGRAPHS INSUMMARY OF RADIOGRAPHS IN MIDFACE FRACTURESMIDFACE FRACTURES Dr.GPK, OMFSDr.GPK, OMFS 9797
  98. 98. Treatment for dentoalveolar fracturesTreatment for dentoalveolar fractures Fractured teeth without exposure of the pulp Fractured teeth with exposure of the pulp Subluxated teeth Fractures of the alveolus(tuberosity) Dr.GPK, OMFSDr.GPK, OMFS 9898
  99. 99. Treatment for Le Fort fracturesTreatment for Le Fort fractures Basic principlesBasic principles 1.1.ReductionReduction 2.2.FixationFixation 3.3.ImmobilizationImmobilization - for re-establishment of form, function and occlusion- for re-establishment of form, function and occlusion with minimum morbiditywith minimum morbidity Dr.GPK, OMFSDr.GPK, OMFS 9999
  100. 100. ReductionReduction Restoration of the fractured fragments to theirRestoration of the fractured fragments to their original anatomical positionoriginal anatomical position Two typesTwo types – Closed reductionClosed reduction – Open reductionOpen reduction Dr.GPK, OMFSDr.GPK, OMFS 100100
  101. 101. Closed reductionClosed reduction Alignment without visualization of the fracture lineAlignment without visualization of the fracture line i.i. Reduction by manipulationReduction by manipulation ii.ii. Reduction by traction.Reduction by traction. iii.iii. A.Intra-oral tractionA.Intra-oral traction B.Extra-oral tractionB.Extra-oral traction Open reductionOpen reduction Surgical reduction allows visual identification ofSurgical reduction allows visual identification of fractured fragmentsfractured fragments Dr.GPK, OMFSDr.GPK, OMFS 101101
  102. 102. Treatment of Le Fort I fractures Direct exposure of all involved fractures Reduction and anatomic realignment of the maxillary buttresses to re establish • Anterior projection • Transverse width • Occlusion Restoration of occlusion using IMF Internal fixation using miniplate fixation Dr.GPK, OMFSDr.GPK, OMFS 102102
  103. 103. Plating along the Buttress Dr.GPK, OMFSDr.GPK, OMFS 103103
  104. 104. Treatment of Le Fort II and III fractures Fractures should be treated as early as the generalFractures should be treated as early as the general condition of the patient allowscondition of the patient allows Team approach to treatmentTeam approach to treatment –– NeurosurgeryNeurosurgery –– OphthalmologyOphthalmology – Oral & Maxillofacial surgery– Oral & Maxillofacial surgery Dr.GPK, OMFSDr.GPK, OMFS 104104
  105. 105. –– Reestablishment of the correct intercanthal distanceReestablishment of the correct intercanthal distance –– Infraorbital rim fixatedInfraorbital rim fixated –– Orbit is reconstructedOrbit is reconstructed –– Occlusion unit with IMF is fixatedOcclusion unit with IMF is fixated Dr.GPK, OMFSDr.GPK, OMFS 105105 Treatment of Le Fort II and III fractures
  106. 106. Intubation must not interfere with ability to useIntubation must not interfere with ability to use IMFIMF Exposure & visualization of all fracturesExposure & visualization of all fractures Approaches to inferior rimApproaches to inferior rim •• InfraorbitalInfraorbital •• SubciliarySubciliary • Transconjunctival• Transconjunctival •• Mid lower lidMid lower lid Coronal approachCoronal approach Gingivobuccal incisionGingivobuccal incision Dr.GPK, OMFSDr.GPK, OMFS 106106
  107. 107. APPROACHES TO MID FACEAPPROACHES TO MID FACE Dr.GPK, OMFSDr.GPK, OMFS 107107
  108. 108. Vestibular approachVestibular approach Dr.GPK, OMFSDr.GPK, OMFS 108108
  109. 109. Lower eye lid approachLower eye lid approach Dr.GPK, OMFSDr.GPK, OMFS 109109
  110. 110. Subconjunctival approachSubconjunctival approach Dr.GPK, OMFSDr.GPK, OMFS 110110
  111. 111. Lateral Eyebrow approachLateral Eyebrow approach Dr.GPK, OMFSDr.GPK, OMFS 111111
  112. 112. Bicoronal/Coronal approach Dr.GPK, OMFSDr.GPK, OMFS 112112
  113. 113. Bicoronal degloving Dr.GPK, OMFSDr.GPK, OMFS 113113
  114. 114. ROWE’S DISIMPACTION FORCEPS Dr.GPK, OMFSDr.GPK, OMFS 114114
  115. 115. Methods of FixationMethods of Fixation 1.1. WiringWiring 2.2. Plates and screwsPlates and screws 3.3. IMF(intermaxillary fixation)IMF(intermaxillary fixation) 4.4. Internal suspension: e.g. circumzygomatic, infraorbitalInternal suspension: e.g. circumzygomatic, infraorbital 5.5. Craniofacial Suspension: e.g. supraorbital pins, boxCraniofacial Suspension: e.g. supraorbital pins, box frame, Halo frameframe, Halo frame Dr.GPK, OMFSDr.GPK, OMFS 115115
  116. 116. FixationFixation In this phase fractured fragments are fixed in theirIn this phase fractured fragments are fixed in their normal anatomical relationship to prevent displacementnormal anatomical relationship to prevent displacement and achieve proper approximationand achieve proper approximation TypesTypes – Direct skeletal fixationDirect skeletal fixation – Indirect skeletal fixation(can be intra-oral orIndirect skeletal fixation(can be intra-oral or extra oral)extra oral) Dr.GPK, OMFSDr.GPK, OMFS 116116
  117. 117. Direct skeletal fixationDirect skeletal fixation 1.1.ExternalExternal – device is outside the tissues but– device is outside the tissues but inserted into the boneinserted into the bone percutaneously.eg;Bone clamps and Pinspercutaneously.eg;Bone clamps and Pins 2.2.InternalInternal – devices are totally enclosed within– devices are totally enclosed within the tissues and uniting the bone ends bythe tissues and uniting the bone ends by direct approximation.eg;Transosseous wiringdirect approximation.eg;Transosseous wiring and plating system.and plating system. Dr.GPK, OMFSDr.GPK, OMFS 117117
  118. 118. INTERNAL FIXATION I. Direct Osteosynthesis : a) Tran osseous wiring at fracture sites: i)High level(frontozygomatic and frontonasal) ii)Mid level(orbital rim/zygomatic buttress) iii)Low level(alveolar / palatal) b) Miniplates c) Transfixation with kirschner wire or Steinmann pin: i) Transfacial ii) Zygomatic- -septal II. Suspension wires to mandible ia.. Frontalo -central or lateral b. Circumzygomatic c. Zygomatic d. Infra orbital e. Pyriform aperture Dr.GPK, OMFSDr.GPK, OMFS 118118
  119. 119. INTERNAL FIXATIONINTERNAL FIXATION III. SUPPORTIII. SUPPORT a. Antral packa. Antral pack b. Antral balloonb. Antral balloon Dr.GPK, OMFSDr.GPK, OMFS 119119
  120. 120. Circumzygomatic-mandibularCircumzygomatic-mandibular Dr.GPK, OMFSDr.GPK, OMFS 120120
  121. 121. Infra-orbital-mandibular internal suspension Dr.GPK, OMFSDr.GPK, OMFS 121121
  122. 122. Lateral frontomandibular internalLateral frontomandibular internal suspensionsuspension Dr.GPK, OMFSDr.GPK, OMFS 122122
  123. 123. PYRIFORM APERTUREPYRIFORM APERTURE Dr.GPK, OMFSDr.GPK, OMFS 123123
  124. 124. Plate fixationPlate fixation Dr.GPK, OMFSDr.GPK, OMFS 124124
  125. 125. External fixationExternal fixation 1. CRANIOMANDIBULAR1. CRANIOMANDIBULAR a. Box- framea. Box- frame b.Halo- frameb.Halo- frame c.Plaster of Paris head capc.Plaster of Paris head cap 2. CRANIOMAXILLARY2. CRANIOMAXILLARY a.Supraorbital pinsa.Supraorbital pins b.Zygomatic pinsb.Zygomatic pins c.Halo-framec.Halo-frame 3. Suspension by cheek wires from halo-frame3. Suspension by cheek wires from halo-frame or headcapor headcap Dr.GPK, OMFSDr.GPK, OMFS 125125
  126. 126. Box and Levant framesBox and Levant frames Dr.GPK, OMFSDr.GPK, OMFS 126126
  127. 127. THE ROYAL BERKSHIRE HALO FRAMETHE ROYAL BERKSHIRE HALO FRAME Dr.GPK, OMFSDr.GPK, OMFS 127127
  128. 128. Plaster of Paris head capPlaster of Paris head cap Dr.GPK, OMFSDr.GPK, OMFS 128128
  129. 129. Plaster of Paris head capPlaster of Paris head cap Dr.GPK, OMFSDr.GPK, OMFS 129129
  130. 130. TRACTIONTRACTION Dr.GPK, OMFSDr.GPK, OMFS 130130
  131. 131. Plates and ScrewsPlates and Screws Dr.GPK, OMFSDr.GPK, OMFS 131131
  132. 132. COMPLICATIONSCOMPLICATIONS Intraoperative complicationsIntraoperative complications Immediate post-operative complicationsImmediate post-operative complications Late post-operative complicationsLate post-operative complications Dr.GPK, OMFSDr.GPK, OMFS 132132
  133. 133. Post operative complications 1. Non- union 2. Delayed union 3. Malunion 4. Infection 5. Plate exposure 6. Occlusal derangement 7. Facial asymmetry 8. Meningitis 9. Injury to lacrimal system 10. Neurological complications Dr.GPK, OMFSDr.GPK, OMFS 133133
  134. 134. References R J Fonseca – Trauma 2 Vol. Peter Ward Booth - 1 Vol. Rowe And William - 2 Vol. Killey s Fractures Of The Middle Third Of The Facial‟ Skeleton Text book of Oral and Maxillofacial surgery – Neelima Anil Malik Dr.GPK, OMFSDr.GPK, OMFS 134134
  135. 135. Dr.GPK, OMFSDr.GPK, OMFS 135135

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