Professional Documents
Culture Documents
Introduction
Surgical anatomy
Classification
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.
the dento
pterygo
maxillary
buttress-
represented
by
the
either side of fracture line, more evenly the distribution force will be
applied along these paths.
st
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
Damage
to
Infra
orbital
nerve
results
in
anesthesia
or
orbital
fissure
are
damaged resulting
ophthalmoplegia,
of globe. As the globe of the eye drops, upper lid follows it resulting in
hooding of eye.
sinus, resulting
and traumatic
enaphthalmus.
from a blow transmitted upward via the mandibular teeth with the jaw
open.
Classification.
A) Lefort I, II III
B) Erichs 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
Low level
Mid level
High level.
Most universally accepted classification is leforts I, II, III.
LEFORT I: - low level # Modification of Leforts 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 #
septum.
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.
Mobile fragment which drops and the patient may have to keep
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)
Moon face.
Subconjunctival echymosis.
Chemosis(edema of conjunctiva)
Diplopia.
Retro
positioning
of
maxilla-anterior
open
bite,
posterior
gagging.
LEFORT II ALONE.
orbital margin.
Lengthening of face.
Hooding of eyes.
skeleton.
Clinical assesment.
External inspectionCheek-edema bleeding,emphysema
If extends to orbit swelling and bruising of eyelids.
Intra oralUpper alveolar arch may be intact or split into fragments by a
longitudinal (para sagittal fracture) or mobile dental alveolar
segments may be seen.
bite.
Radiological assesment
Most useful-CT.
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.
model.
Opinion
regarding
timing
of
definite
repair
has
changed
Ocular injury.
essential
decisions
must
be
taken
before
contemplated.
Disimpaction.
surgery
is
(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.
Susceptible to corrosion
Difficult to bend
Bulky.
Employed
at
suture
sites-fronto
nasal,
maxillo
zygomatic
sutures.
Suspension wires
Zygomatic-lefort I
Infra orbital-lefort I
Pyriform aperture-lefort I
Peralveolar-gunning splint.
Frontal
suspension.
Lateral
Central
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.
soft tissues.
Zygomatic suspension.
teeth.
Two ends of wire are passed through suitable loop of arch bar.
gunning splint.
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.
cm.
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 bonneys 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.
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
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.
attachment
provides
2-point
fixation
of
vertical
cranio
Fluoride desensitizer
Sedative dressing
Sub-luxated teeth.
injury.
Alveolar fracture
Tuberosity #
tuberosity.
Lefort
fracture.
Reduction.
If occurs in isolation-
osteotome.
Closed reduction-Less ideal
-One month IMF.
Severe communition- 6 weeks IMF.
For many years skeletal fixation and extra skeletal fixation were
effective for the patients-
Halo frame
Various suspensions.
Lefort II Fracture.
Reduction-
forceps.
COSMETIC DEFORMITY.
Dish face
LACRIMAL SYSTEMEpiphora
Dacrocystitis.
OPHTHALMIC COMPLICATION
Diplopia
Enophthalmos
SOF syndrome.
NON UNION
Uncommon
When there is communition or actual bone loss.
Palatal fractures.
They divide
transversely/
sagittally, and
TYPE I: alveolar #
Of 2 general types.
Seen in adults.
Rarest
Management.
Fractures of type II, III, IV are not comminuted and have large
do so.
yes.
No
Is the stabilization of vault necessary?
yes
no.
yes
CR type.
AP type
no.
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
CERTIFICATE
SEMINAR ON
MAXILLARY FRACTURES
PRESENTED BY,
DR. VIDYA. B. SHETTY