Fractures of middle third of face

Instructor – Dr. Jesus George1

Boundaries of middle 1/3 of face

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Superiorly- a line drawn from zygomaticofrontal suture ,across frontonasal suture,frontomaxillary suture.

Inferiorly-occlusal plane of upper teeth. Posteriorly-sphenoethmoidal junction.

Nerve supply & blood supply

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Maxillary branch of trigeminal nerve Maxillary artery & its branches

Bones constituting middle1/3 of face

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2 maxillae 2 palatine bones 2 zygomatic bones 2 zygomatic processes of temporal bone 2 nasal bones 2 lacrimal bones Ethmoid bone 2 inferior conchae 2 pterigoid plates of sphenoid Vomer

Classification

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Lefort I Lefort II Lefort III

Lefort I #

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Also called horizontal # of maxilla or Guerin's # or floating # (separation of dentoalveolar part of maxilla

Fractured fragments are freely mobile Horizontal # line above the apices of teeth Line starts at the point on lateral margin of anterior

nasal aperture above the nasal floor, passes laterally above the canine fossa traverses lateral antral wall, dipping down below the zygomatic buttress across pterigomaxillary fissure & fractures pterigoid lamina at the junction of lower 1/3 & upper 2/3

Usually bilateral

Cont.

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Signs & symptoms Slight swelling & edema of lower part of face

with upper lip swelling Ecchymosis in labial & buccal vestibule Contusion of upper lip Laceration of upper lip & oral mucosa Bilateral epistaxis Mobility of dentoalveolar fragment of upper

jaw Disturbed occlusion Inability to masticate food

Cont.

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Pain while speaking & moving jaw In impacted # upward displacement of entire

fragment & Anterior open bite Percussion of upper teeth – dull cracked up

sound

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Lefort II #

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Pyramidal or subzygomatic # # line runs below the frontonasal suture

crossing the frontal process of maxilla, passes anteriorly across the lacrimal bones anterior to lacrimal canal, then passes downward, forward & laterally crossing inferior orbital margin in zygomatico maxillay suture, then it extends downward, forward & laterally to lateral wall of antrum medial to zygomatico maxillary suture line, then it passess beneath the zygomatic buttress fracturing pterigoid lamina at the midway

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Cont.

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Signs & symptoms Gross edema of middle 1/3 of face giving a moon’s

face appearance Bilateral circumorbital edema & ecchymosis ( black

eye) Bilateral subconjunctival hemorrhage Bridge of nose is depressed If impaction of fragments is there anterior open bite If there is downward & backward displacement of

fragments, elongation & lengthening of face & posterior gagging of occlusion with anterior open bite

Cont.

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Bilateral epistaxis Difficulty in mastication & speech Loss of occlusion Airway obstruction due to posterior

displacement of fragments CSF leak may be seen Step deformity in infraorbital margin Anesthesia or paresthesia of cheek

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Lefort III #

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Also known as high level # Force is in lateral direction Line starts near frontonasal suture, causing

dislocation of nasal bones & disruption of cribriform plate of ethmoid bone tearing dura mater & causing CSF rhinorrhea, then crosses through both nasal bones & frontal process of maxilla, then traverses upper limit of lacrimal bones, then it crosses thin orbital plate of ethmoid bone, it passes through medial orbital wall, then it reaches upper posterior aspect of maxilla & fractures pterigoid lamina at the base

Entire middle 1/3 is separated from cranial base

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Cont.

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Signs & symptoms Gross edema of face Bilateral circumorbital or periorbital ecchymosis Tenderness & separation at frontozyomatic

suture Dish face deformity Enophthalmos Diplopia Temporary blindness or impairment of vision Nasal septal deviation Epistaxis

Cont.

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CSF rhinorrhea

# of zygomatic complex

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Zygomatic bone is closely associated with maxilla, frontal & temporal bones – so they are known as zygomatic complex #

Signs & symptoms Flattening of cheek because of inward

displacement of fragments Unilateral epistaxis Circumorbital ecchymosis Subconjunctival hemorrhage Limitation of ocular movement

Cont.

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Anesthesia of cheek, nose, lip Edema of cheek & eyelids Step deformity in infraorbital margin Limitation of mandibular movement Ecchymosis & tenderness in upper buccal

sulcus Change in sensation of teeth & gum Enophthalmos

Treatment of midface #

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Manual reduction Arch bars are applied on teeth, lower jaw acts

as template In fresh # maxilla is held b/w index finger &

thumb & brought into normal occlusion Row’s disimpaction forceps (used in pairs) one

end in nasal floor & other in hard palate In split palate, Hayton william’s forceps is

applied to buccal aspect of alveolar process & medial compression until 2 jaws are approximated

Cont.

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Reduction by traction Used in delayed cases where the fragments

are not sufficiently mobile Intra oral elastic traction is given to restore

normal occlusion After getting correct occlusion IMF for 3-4

weeks If only slight mobility, & occlusion is not

disturbed progress of healing is supervised, patient is advised to avoid chewing for 2-3 weeks ( soft diet)

Cont.

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Open reduction Circumvestibular incision from 1st molar of one

side to the other side Mucoperiosteal flap is reflected Fragments are mobilized Disimpaction forceps is used & fragments are

brought into normal occlusion IMF is done & fragments are fixed under direct

vision by miniplates or intraosseous wiring

Treatment zygomatic #

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Keen’s approach Buccal vestibular incision is given in 1st & 2nd

molar region behind the zygomatic buttress Curved elevator is passed supraperiosteally

up beneath the zygomatic bone Depressed bone is elevated with upward,

forward & outward movement

Cont.

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If gross separation of zygomaticofrontal suture

Incision is made 1 cm above the outer canthus of eye

Holes are drilled 0.5cm from the fractured ends Intraosseous wiring or miniplates are given Wound is closed in layers Associated coronoid # If coronoid is completely detached & causing

limitaion of mouth opening, it can be excised through intraoral approach

Fractures of mandible

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Introduction

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Largest, heaviest & strongest bone of face Blood supply Inferior alveolar artery Nerve supply Inferior alveolar nerve

Classification

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Body # Condyle # Angle # Dentoalveolar # Symphysis # Ramus # Coronoid # Parasymphysis #

Management

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Closed reduction Presence of teeth provides guidance for reduction Dental wiring or arch bar is used to get the

occlusion IMF for 6 weeks In edentulous patients gunning splint is used Indications Nondisplaced # Grossly displaced # Atrophic edentulous mandible Lack of soft tissue over the # site

Cont.

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# in children with developing tooth buds Coronoid process # Open reduction Indications Displaced # Multiple # Associated midface # Associated condylar #

Cont.

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Contraindications If GA is not advisable Severe comminution or loss of soft tissue Severe infection

Symphysis & parasymphysis #

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Lip is everted & vestibular incision is made Periosteum is reflected & mental nerves are

identified Reduction & plate fixation is done Closure is done in layers Pressure dressing is given to prevent

hematoma

Body, angle & ramus #

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Mucosal incision is made 3-5 mm below mucogingival junction

Incision should not extend beyond mandibularocclusal plane to prevent herniation of buccal pad of fat

Periosteum is reflected & mandible is exposed Reduction & fixation is done Wound is closed in layers

Fractures of mandibular condyle

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Classification No displacement:-a crack is seen. Deviation :-simple angulation exists b/w

condylar neck & ramus. Displacement :-overlap exists b/w condylar

process & ramus. Dislocation :-condylar fragment is pulled

anteriorly & medially.

Cont.

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Clinical features Evidence of trauma in symphysis region. Pain & swelling in the region of tmj. Limitation of oral opening Deviation toawards the involved side on

opening mouth. Posterior open bite on contralateral side. Posterior cross bite on ipsilateral side Blood in external auditory canal. Pain on palpation on # site. Lack of condylar movement on palpation

Cont.

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Difficulty in lateral excursion & protrusion. Anterior openbite &posterior gagging of

occlusion in bilateral subcondylar #. Otorrhoea if there is #of middle cranial fossa. Treatment Nonsurgical management Condylar # without displacement or with min.

displacement, without much occlusal disturbance& functional range of motion-patient is asked to restrict movements & semisolid soft diet for 10 to 15 days

Cont.

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In case of deviation on oral opening without much occlusal discrepancy,simple muscle training

In case wherethe condylar fragment overriding is seen with altration in ramus height,producing malocclusion,initial elastic traction followed by imf is given for 2to3 weeks.

Early mobilization is advocated in young children to avoid ankylosis of tmj.

Cont.

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Surgical management Indications # dislocation in auditory canal or

intracranial fossa. Anterior dislocation with restricted mandibular

movement. Bilateral condylar # with craniofacial dysjunction Method of fixation Temporal region is shaved. The skin over the preauricular region is

prepared. Preauricular incision is made. Zygomatic arch is located.

Cont.

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Inverted L-shaped incision is made from lower boder of zygomatic arch to outer surface of ramus.

If condyle is displaced laterally, periostuem over the condyle is retracted & condylar retractor is inserted from posterior border medially to protect the vital structures.

A hole is drilled through the cortex, &a26 guage wire is passed through the hole.another hole is drilled on the ramus.

Miniplates can also be used. # is reduced & IMF is done. Wound is closed in layers. Immobilization for 15 to 20 days

Management of teeth retained in # line

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Antibiotic therapy Splinting of the tooth if mobile Endontic therapy if needed Immediate extraction # is infected Indication for removal of tooth in # line Longitudinal # involving crown & root Complete subluxation of tooth from the socket Pre –existing periapical pathology Grossly infected # line

Cont.

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Bad periodontal status Advanced caries Root stumps

Complications of maxillofacial injuries

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Anaesthesia Anaesthesia of lower lip because of the injury

to mandibular nerve. It may occur in # of body of mandible. It usually recovers in a few weeks. If infraorbital nerve is involved anaesthesia

occurs in lower eyelid,lateral part of nostril,upper lip in the affected side & anterior teeth

Cont.

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Malunion & deformities Deformities occur if reduction is not

satisfactory. In middle 1/3 injuries,improper reduction

result in flattening of face,anterior openbite with posterior gagging of occlusion.

Infection it occurs if root stumps are kept in # line or if

the general resistance of the patient is poor or if there is mobility at the # site.

Cont.

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Non -union & delayed union Occurs if tooth has retained in # line. - If the # is infected. - Inadequate immobilization. - Patients with systemic disease or

nutritional deficiencies. It can be treated by - Removing the cause(infection,teeth in #

line). - Freshening the ends & rewiring - If there is bone loss, grafing is done.

Cont.

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Derangement of occlusion Minor occlusal derangements are corrected as

the patient starts using the teeth. If there is persistance of traumatic occlusion it

can be corrected by selective grinding. If severe occlusal derangement, it is corrected

by refracturing the fragment & correction is done.

Cont.

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Ankylosis of TMJ It is more in young adults. It occurs in intra capsular #. Prolonged immobilization may cause

ankylosis. Other complications Diplopia Enophthalmos Strabismus Deviated nasal septum Epiphora Anosmia