Facial trauma and oroantral fistula

BRIG ANWAR UL HAQ

Trauma may involve◦ Soft tissues

◦ Bones

◦ Cartilages

General management

Soft tissue injuries and their management

Bony injuries and their management

Airway◦ Injuries

◦ Blood

◦ Secretions

Haemorrhage◦ Pressure

◦ Ligation

◦ Coagulation

Associated injuries◦ Head, chest, neck, larynx, cervical spine

Facial lacerations

Parotid gland and duct

Facial nerve

UPPER THIRD

MIDDLE THIRD

LOWER THIRD

Frontal Bone◦ Frontal Sinus

◦ Anterior wall

◦ Posterior wall

◦ Injury to nasofrontal duct

Supraorbital ridge

Frontal Bone

Anterior wall of Frontal Sinus

◦ Depressed deformity

◦ Reduction through the wound

◦ Elevation though eye brow incision

Posterior wall of Frontal Sinus

◦ Dural tear

◦ CSF Rhinorrhoea

◦ Temoralis Fascia Repair

◦ Obliteration of Sinus

Frontonasal Duct◦ Obstruction of Sinus

◦ Mucocele

◦ Surgical Obliteration of Sinus

MIDDLE THIRD

Nasal bone and septum

Naso orbital fractures



Fractures of zygoma

Fractures of zygomatic arch



Fractures of zygoma


Fractures of orbital floor



Fractures of zygoma



Fractures of maxilla

Most prominent part◦ More likely

Amount of injury◦ Magnitude of trauma

◦ Direction

Ant

lateral

Depressed

Angulated

Swelling

Periorbital echymosis

Tenderness

Crepitus

Nasal deformity

Epistaxis

Nasal obstruction

Lacerations◦ Internal

◦ external

Physical examination◦ Inspection

◦ Palpation - crepitus

X-Ray - +/-

Waters’ view

Lateral - Rt + Lt

No displacement - No treatment

Reduction◦ Closed

◦ Open

Timing◦ Immediately

◦ 5-7 days later

Children- early union - earlier reduction

Depressed fractures◦ Straight elevation

◦ Digital manipulation

Laterally displaced fractures◦ Digital manipulation

In opposite direction

Rarely required

Associated septal injuries

Late◦ Rhinoplasty

◦ Septorhinoplasty

Direct force over the Nasion◦ Fracture nasal bone

◦ Ethmoids

◦ Cribriform plate

◦ Medial orbital wall

◦ Frontal sinus

◦ Fronto-nasal duct

◦ Exra occular muscles

◦ Lacrimal apparatus

Telecanthus

Pig nose

Telecanthus

Pig nose

Peri-orbital echymosis

Peri-orbital haematoma

Telecanthus

Pig nose



Epistaxis

CSF rhinorrhoea

Telecanthus

Pig nose



Epistaxis

Csf rhinorrhoea

Displacement of eye ball

Squint (mal alignment of eyes)

Diplopia (Double Vision)

X rays◦ Various films

◦ Different angles

CT Scan ◦ Better option

Close reduction◦ Uncomplicated fractures

◦ Ashes’ forceps

◦ Fixation

Steel wire

Fixed over lead plates

Intra nasal packing

◦ Splinting - 10 days

Indications◦ Multiple communications

Nasal cavities

Frontal sinus

◦ Injuries

Lacrimal apparatus

Extra ocular muscles

Medial canthal ligaments

Frontal sinus

H shaped incision

Nasal bones reduced under vision

Medial canthal ligaments fixed with wire

Repair of lacrimal apparatus

Preference ◦ Medical canthal ligament

◦ Lacrimal apparatus

Nasal bridge and shape◦ Can be corrected later

Second most common

Direct trauma

Lower segment pushed medially posteriorly◦ Flattening of malar prominance

◦ Zygoma – fractured -separated

Zygomatico frontal

Zygomatico maxillary- orbital floor

Zygomatico temporal

Zygomatico frontalZygomatico temporalZygomatico maxillary - orbital floor

Zygomatico maxillary - orbital floorOrbital contents - herniates – maxillary sinus

Tear drop sign

Flattening of malar prominance

Step deformity of infra orbital margin

Trismus (inability to open mouth)

Oblique palpebral fissure◦ Displacement of LPL

Restriction of ocular movement – diplopia


Infra orbital anaesthesia

Waters’ view (Occipito-Mental View)

Blood in maxillary sinus - opaque

CT scan – more beneficial

Fracture of zygoma (Tripode fracture)

No displacemment - no treatment

Open reduction

Lateral brow incision

Reduction - putting elevator behind the zygoma

Fixation - wire

Transantral approach◦ Caldwell luc operation

◦ Intra nasal antrostomy

Zygomatic arch fractures in two segments

Fractures at both ends

Depressed fracture

Depression - Depressed fracture

Painful mastication

Clinical examination

X ray sub mento vertical view

Waters’ view

DiagnosisFractures of zygomatic arch

Incision - anterior to ear in the hair

Elevator◦ Deep to the temporalis fascia

Intra oral superior sulcus

Usually does not require fixation

TreatmentFractures of zygomatic arch

Accompanies◦ Zygomatic fractures

◦ Maxilla fracture Le Fort II

Isolated blow out fractures◦ Large blunt object strikes globe

◦ Orbital contents herniate in the maxillary antrum

Tear drop sign

Echymosis of lid, conjuctiva and sclera

Enophthalmos

Diplopia

Infra orbital anaesthesia

X ray PNS - Tear drop sign

CT Scan - 3D Reconstruction

Restricted eye movement◦ Inferior rectus

◦ Inf oblique

Cannot see up

Surgical◦ Enophthalmos

◦ Diplopia

Infra orbital approach

Transantral approach

Repair◦ Nasal septal cartilage

◦ Illiac crest

◦ Silicon plate


Malocclusion

Elongation of midface

Mobility of maxilla

CSF rhinorrhoea◦ Le fort II & Le fort III

X Ray◦Waters’ view

◦ Postro anterior view

◦ Lateral view

CT CSAN

Complex

General management

Interdental wiring

Intermaxillary wiring Open reduction and fixation

Wire slings◦ Frontal bone

◦ Zygoma

◦ Infra orbital rim

Mandible

Classified according to the location◦ Chondylar process

◦ Angle

◦ Body

◦ Symphysis

◦ Choronoid process

◦ Ramus

◦ Alveolar process

◦ Combination

If not displaced◦ Pain

◦ Trismus

Inability to open

◦ Tenderness

If displaced◦ Malocclusion

◦ Deviation

Palpation◦ Intraoral & extraoral

◦ Step deformity

Malocclusion

Tenderness

Crepitus

Echymosis of oral mucosa

X RAY PA VIEW

OBLIQUE VIEW- RT/LT

Panoramic view

Closed◦ Interdental wiring

◦ Inter maxillary fixation

◦ External pin fixation

• Open reduction

◦ Interosseous wiring – figure of 8

◦ Compression plates

◦ Immobalization – prolonged avoided

Communication◦ Oral cavity

◦ Maxillary Sinus

Location◦ Alveolus

◦ Gingivolabial Sulcus

Dental Extraction◦ Second premolar

◦ Molars

Failure to heal Cald well Luc incision

Erosion by carcinoma

Penetrating injuries of Maxilla

Osteitis of Maxilla

Syphilus

Malignant Granuloma

Regurgitation of food

Discharge

Inability to blow

Inability to suckNosesinus

Oralcavity

Probing the fistula

Conservative◦ Antibiotis

◦ Nasal Decongestants

Opturator

CaldWell Luc Operation

Antrostomy

Surgical repair◦ Labial Mucosal Flap

◦ Platal Falp

Facial trauma and oroantral fistula

Health & Medicine

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