midfacial fractures - oral surgery b.d.s
TRANSCRIPT
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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
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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
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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
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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
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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
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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
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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.
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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.
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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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