Maxillary fractures.

• Introduction

• Surgical anatomy

• Classification

• Signs and symptoms

• 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.

• Skeleton of mid facial region appears to transmit the powerful

forces of mastication as evenly as possible, as well as to absorb the

shocking effect of occluding teeth.

The strong horizontal elements in the maxilla, alveoli and hard palate

make up a foundation to support three paired vertical bony butreeses.

1. The naso maxillary butreess-extends from the dento

alveolar arch in the anterior maxilla superiorly along pyriform

margin to medial orbital rim and fronto maxillary suture.

2. The zygomatico maxillary buttress- from the region of first

molar to the body of zygoma and through this bone to the lateral

orbital wall to zygomatico maxillary suture.

3. The pterygo maxillary buttress- represented by the

attachment of maxillary tuberosity to Pterygoid plates and hence

to sphenoid bone.

Ideally surgical plates to be placed along the buttresses should

stabilize and reconstruct the load paths and the more screws placed on

either side of fracture line, more evenly the distribution force will be

applied along these paths.

• Blood supply and nerve supply

An understanding of the blood supply and the nerve supply to the

maxilla is important both in planning safe incisions foe the exposure of

an already damaged maxilla as well as in understanding of pattern of

numbness associated with maxillary fractures.

On each side via greater palatine canal, greater palatine nerve and

vessels supply all of bone and mucosa of soft palate.

Branches of maxillary artery and nerve enter posterior maxilla through

small foramina to become posterior superior alveolar artery and nerve.

These supply molar teeth through dental plexus.

Branches from infra orbital artery and nerve enters the anterior maxilla

from orbital floor and supply anterior teeth. Fracture of anterior maxilla

and orbit may result in numbness of anterior teeth. Fracture low in the

maxilla posterior to I st molar region may result in numbness 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

• # of maxilla are usually the result of direct force range from

simple alveolar # to extensive injuries of orbit, nose, palate and skull.

• Displacement is usually entirely the result of traumatic force.

Muscle contraction plays an unimportant role except in those

extending into the region of Pterygoid plates resulting in displacement

of maxilla in downward and posterior direction due to the action of

Pterygoid muscles.

• Lacrimal fossa is formed partially by maxilla and injuries to the

naso lacrimal duct may be associated with fractures of maxilla

resulting in epiphora.

• Damage to Infra orbital nerve results in anesthesia or

paresthesia of upper lip, cheek. Full recovery may take up to 2 years.

Anterior, middle, posterior superior alveolar nerve may be damaged

but patient seldom notices anesthesia of gingiva.

• Cranial nerve within the orbit may sustain damage. 6th nerve

damage is most frequently encountered. Sometimes contents of

superior orbital fissure are damaged resulting ophthalmoplegia,

dilation of pupil, and anesthesia within distribution of ophthalmic

branch.

• Optic foramen is a ring of dense compact bone; therefore

invariably fracture line gets deflected away from the foramen,

protecting optic nerve.

• # Involving orbital walls-may result in variation in the position of

globe. As the globe of the eye drops, upper lid follows it resulting in

hooding of eye.

• If orbital floor is fractured-herniation of orbital contents into the

sinus, resulting in restriction of eye movement and traumatic

enaphthalmus.

• Gross communition of antral walls can cause bleeding. The sinus

will be full of blood and appear hazy in radiographs resulting in

unilateral or bilateral epistaxis

.

• Mid palatine split of maxilla is only possible when there is injury

from a blow transmitted upward via the mandibular teeth with the jaw

open.

Classification.

• Broadly classified into-

A) Lefort I, II III

B) Erich’s 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

D) Depending on the level of fracture

Low level

Mid level

High level.

Most universally accepted classification is lefort’s I, II, III.

LEFORT I: - low level # Modification of Lefort’s 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 #

• Lefort IV: - LEFORT I +II+cranial base #

IV a: - + supra orbital rim #

IV b: - + supra orbital rim # anterior cranial fossa.

IV c: - anterior cranial fossa and orbital wall #.

Lefort’s I #(low level, sub zygomatic, guerin’s #, horizontal

#,floating #)

• Separation of entire dento alveolar segment.

• Violent force over a wide area above the level of teeth.

• May occur as a single entity or associated with lefort II and III.

• The typical Lefort I # is bilateral with # of lower 3rd of the

septum.

• Commences at a point on the lateral margin of anterior nasal

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.

Signs and symptoms.

• Slight swelling of upper lip. There is no massive edema as seen

in case of lefort II and III.

• Echymosis in the buccal sulcus.

• Mobile fragment which drops and the patient may have to keep

the mouth open to accommodate the vertical dimension of bite.

• Guerin sign- echymosis in the palate.

• Soft tissue laceration

• Impacted type of fracture-no mobility. When the maxillary teeth

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)

Violent force usually from anterior direction, sustained by the central

region of mid face, over an area extending from glabella to alveolar

margin.

Commences-below the fronto-nasal suture-frontal process of maxilla-

across the lacrimal bone immediately anterior to naso lacrimal canal-

runs downward forward laterally crossing inferior orbital margin in

the region of zygomatico maxillary suture. It may or may not involve

infra orbital foramen. Now the fracture line extends downward and

forward to traverse lateral wall of antrum just medial to zygomatico

maxillary suture, passes beneath the buttress, to pterygo maxillary

fissure- Pterygoid laminae at mid one third.

Separation of entire pyramidal block form the base of skull is

completed via the septum.

Lefort III(transverse,supra zygomatic,high level)

• Trauma being inflicted over a wide area at the orbital level.

• Commences near fronto nasal suture causes dislocation of nasal

bones and disruption of cribriform plate of ethmoid bone. It crosses

both nasal bones and frontal process of maxilla, near the fronto nasal

and fronto maxillary sutures then traverses the upper limit of lacrimal

bone, crosses the thin orbital plate of ethmoid. As the optic foramen is

surrounded by dense ring of compact bone, fracture line tends to get

deflected downward and laterally to reach medial aspect of inferior

orbital fissure. It descends across the upper posterior aspect of maxilla

in the region of spheno palatine fossa – upper limit of pterygo maxillary

fissure and roots of Pterygoid laminae at its base.

The inferior orbital fissure constitutes a natural line of weakness and

from its anterior and lateral end on each side a further line of fracture

passes across the lateral wall of orbit, adjacent to the junction of

zygomatic bone with the greater wing of sphenoid. Fracture separates

zygomatic bone from frontal bone near the suture then inclines

laterally running abruptly downward across the infra temporal surface

joining the previous fracture. The entire middle third is thus detached

from cranial base. Fracture is completed by the # of zygomatic arch.

Signs and symptoms common to lefort II and III.

• Moon face.

• Bilateral circum orbital echymosis.

• Subconjunctival echymosis.

• Chemosis(edema of conjunctiva)

• Diplopia.

• Spreading inter canthal distance.

• CSF from nose.

• Retro positioning of maxilla-anterior open bite, posterior gagging.

• Cracked pot sound on percussion.

SIGNS AND SYMPTOMS ASSOCIATED WITH LEFORT II ALONE.

• Step deformity elicited at the inferior orbital margin.

• Anesthesia / paresthesia cheek.

• # in orbital floor-limitation of ocular movement.

• No alteration of pupil’s level.

• When the maxillary teeth are grasped, movement elicited at

infra orbital margin.

• Hematoma formation in the buccal sulcus.

• CSF rhinorrhea is not a constant finding.

Signs and symptoms of lefort III

• Tenderness and separation at fronto zygomatic suture..

• Tenderness and deformity of zygomatic arches.

• Lengthening of face.

• Depression of ocular levels

• Hooding of eyes.

• Lengthening and sometimes extreme disorganization of nasal

skeleton.

• Profuse CSF rhinorrhea.

• Mobility of whole facial skeleton as a single block.

Clinical assesment.

External inspection-

Cheek-edema bleeding,emphysema

If extends to orbit swelling and bruising of eyelids.

Intra oral-

Upper alveolar arch may be intact or split into fragments by a

longitudinal (para sagittal fracture) or mobile dental alveolar

segments may be seen.

• Disturbed occlusion may be evident-anterior open bite, cross-

bite.

• In typical fracture of upper jaw with an intact alveolar arch,

posterior and inferior displacement of occlusal surface will result in

anterior open bite. This is in part due to the inclination of the skull and

in part due to the vectors of force by medial Pterygoid. This movement

forces the mandible open leading to elongation of face.

Radiological assesment

• Provides back up evidence for clinical diagnosis.

• Plain AP, occipito mental x-ray –demonstrate fluid in maxillary

sinuses, displaced fracture line in the buttress, infra orbital rim or

pyriform margin.

• Most useful-CT.

• Axial cuts-fracture of posterior wall of antrum and of pterygoid

plates splits of hard palate and dento alveolar segmental fracture.

• Coronal CT-fracture of anterior maxilla, para sagittal fracture of

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.

• Management of these fracture depend in first place whether the

fracture is thought to be in need of surgical reduction and stabilization.

• Several clinical situations where the surgical reduction is contra

indicated are-

- Undisplaced fracture clinically and radiologically.

-In edentulous patient where there is only minor radiological

evidence of displacement and where # appears to be stable to

masticatory forces.

-Patients with severe brain injury who are not expected to survive.

Pre operative dental assesment.

• Impression of dental arch and teeth will be used to cast plaster

model.

• Cutting it at the site of vertical # through occlusion and then

mounting fragments on an articulator in the exact position of pre

traumatic occlusion. Acrylic bite wafer will then be constructed to use

in intra operative and postoperative period.

Close dental collaboration is more important with upper jaw fracture

than with lower jaw fracture. In the latter strong and solid form of

mandible ensures that anatomical reduction of fracture site is

relatively easy and occlusion is used as a secondary check for

correctness of reduction. In the fracture of upper jaw, the complex

fracture of the jawbone makes certainty of anatomical reduction of

fracture more difficult and dental relationships assume a high degree

of importance in establishing that reduction is achieved.

Where open reduction and rigid fixation are indicated in an edentulous

patient then gunning type of splint may be used temporarily.

Timing of definitive repair.

• Opinion regarding timing of definite repair has changed

significantly over last decade. The factors that are to be considered

are-

• Brain injury- may take some time to stabilize.

• Cardio vascular instability

• Unstable cervical spine injury

• Ocular injury.

• However early repair even in presence of intra cranial injury can

be carries out safely if the intra cranial pressure is maintained at < 25

mm of Hg. The chief argument behind this is early accurate bone

reconstruction will prevent development of soft tissue contractures

which will lead to post traumatic deformities.

Pre operative planning.

Certain essential decisions must be taken before surgery is

contemplated.

• 1. Need for tracheostomy.

Factors influencing decisions towards tracheostomy-

Degree of soft tissue swelling

Whether IMF is likely to be used.

• 2.open/closed method of reduction

• 3.The necessity for and type of IMF.

Disimpaction.

• When closed methods of reduction and fixation are used

reduction may be carried out using specially designed forceps

described by Rowe and Kelley. One end of the blade is inserted along

each nostril floor while other blade is placed via mouth over hard

palate mucosa. When both forceps are in position surgeon is able to

exert powerful levarage on upper jaw via hard palate, which is securely

gripped between the blades of forceps.

It can also be used in methods employing open exposure of maxillary

fractures, disimpaction and mobilization of upper jaw.

• Lefort I osteotomy to facilitate passive repositioning of maxilla

(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.

Stain less steel

• -First material used for semi rigid fixation.

• Susceptible to corrosion

• Difficult to bend

• Bulky.

• Titanium- excellent bio compatibility

-Resistant to corrosion

-Chemically inert.

-More malleable, easy contouring

Semi rigid fixation with plates and screws provides three-dimensional

stability. The placement of a plate with 2 screws on either side of #

resists both horizontal and rotational movement.

Rigid fixation.

• Superior cosmetic and functional result.

Very rigidity produced by these systems means that precise attention

to occlusion is mandatory, as elastic mandibulo-maxillary forces cannot

be used post operatively to correct minor occlusal problems.

Recent development –biodegradable plates and screws.

Inter osseous wiring.

• Soft stain less steel wiring-cheap, easy to use, well tolerated.

• Employed at suture sites-fronto nasal, maxillo zygomatic sutures.

• When a fracture involves palatal process of maxilla-mid palatal

split-direct wiring across the posterior free edge can be done.

Suspension wires

• Not a rigid fixation

• Superseded by mini plates and screws.

• Occasionally used in combination. Suspension wires have to be

placed superior to the fracture.

• Use of 0.5 mm-soft SLS (pre stretched 10%) can be employed.

• Frontal-

central -lefort II and III(mandible

unstable)

lateral –lefort II and III ( mandible stable).

• Circum zygomatic-lefort II and I

• Zygomatic-lefort I

• Infra orbital-lefort I

• Pyriform aperture-lefort I

• Trans nasal-gunning splint.

• Peralveolar-gunning splint.

Frontal suspension.

Lateral

• Incision is placed in the lateral 3rd of eyebrow to expose

zygomatic process of frontal bone just above fronto zygomatic suture.

• Bur hole 5 mm above the suture line and angulated to emerge

on the posterior or infra temporal fossa aspect.

A 40 cm long soft stain less steel wire is passed through this and bent

backwards so that an equal length protrudes on either side of bur hole.

Two ends of wire are threaded through the eye of Rowe’s zygomatic

awl and crimped.

Awl is passed downward behind the frontal process of zygomatic bone

(deep to arch) to pierce the oral mucosa in the upper buccal sulcus

adjacent to molar teeth. Wire ends are detached from the awl and

secured with heavy artery clip and awl is withdrawn. A 0.35 mm

diameter soft stainless steel is then threaded beneath the suspension

wire where is passes beneath the bone in the supra orbital region and

is twisted to form pull out wire. This facilitates cutting of suspension

wire prior to its removal through mouth without a subperiosteal

dissection of incision in the eyebrow.

Tension is applied to wire ends to take up the slack and then one end

is threaded through suitable loop of arch bar secured to teeth and two

ends are twisted together. Eyebrow incision is closed in layers.

• Central—

• Originally introduced by Kuffner.

Has little place since the introduction of plates.

• Bone screw to the anterior wall of the frontal sinus.

Circum zygomatic suspension.

• Rowe or obwegessor awl is passed through the Junction of

frontal and temporal process of zygomatic bone.

• Instrument pierces temporal fascia passes deep to the temporal

surface of buttress to emerge at upper buccal sulcus in Ist molar region.

• Wire attached, tip of awl withdrawn to just above the arch

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.

• Theoretical disadvantage-introducing infection from mouth into

soft tissues.

Zygomatic suspension .

• 3 cm incision in upper buccal sulcus above premolar, molar

teeth.

• Expose base of buttress.

• Bur hole drilled posteriorly and laterally.

• 0.5 mm soft stain less steel is passed.

Two ends of wire are passed through suitable loop of arch bar.

• Deep aspect of periosteum should not be penetrated to prevent

herniation of buccal fat pad.

Trans nasal suspension.

• By Bowerman and Corroy 1981.

• For retention of surgical splint following maxillectomy,fixing

gunning splint.

• Superior retention and stability of splint as compared to

peralveolar and circum-zygomatic wires.

• Procedure-curved awl through the nasal aperture and backwards

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 .

• 3 cm incision in upper buccal sulcus above canine tooth and

expose inferior orbital margin lateral to infra orbital foramen.

• Bur hole upwards and posteriorly.

• Pass stain less steel wire.

• Withdrawn into oral cavity.

• Attached to suitable loop on arch bar.

Pyriform aperture suspension.

• 2 cm incision in the upper buccal sulcus above lateral incisor.

• Expose the aperture.

• Nasal mucosa is elevated from the medial aspect to a depth of 2

cm.

• Bur hole-from lateral to medial side 1 cm from free margin. A 0.5

cm soft stain less steel wire is passed.

• 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 bonney’s 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.

Pre operatively the halo is adjusted to the contours of patient’s head to

allow correct alignment of screw pins.

• 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

the four points touch the skin.

• Stab incision is placed to facilitate entry of screw pin through the

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.

• Developed at Royal Melbourne Hospital.

Simple rigid skeletal cranio maxillary fixation between supra orbital

margin and maxilla connected by central cranio maxillary rod attached

at lower end either by cast metal silver cap splint or gunning splint.

Appliance-3 mm diameter stain less steel rod which is bent 30 0

towards each end of horizontal arm and a central U shaped

attachment.

Central attachment provides 2-point fixation of vertical cranio

maxillary rod preventing rotation in horizontal axis.

Technique- small horizontal incisions are made in each eyebrow at the

junction of supra orbital rim and temporal line of frontal bone (thickest

point of bony rim)

Hole is drilled barely to penetrate inner cortex of supra orbital rim.

Bone pins are inserted until firmly in place.

Once frame is attached facial fractures are reduced and central vertical

rod of 3 mm diameter is adapted to nasal contour.

It is attached to central attachment of head frame by two universal

joints and to cast silver cap splint with a further universal joint

attached to a central rod projecting from splint.

Definitive management.

• Aim of treatment- to return the displaced maxilla to its correct

relationship to intact mandible below and cranial base above.

Dento alveolar fracture.

Treatment of dento alveolar # should have same priority as treatment

of facial laceration fro two reasons.

• Injury to the vital teeth may cause severe pain.

• # Alveolus may interfere with occlusion.

Teeth without exposure of pulp-

• They are highly sensitive

• Fluoride desensitizer

• Sedative dressing

• Pulp testing + follow up.

With exposure of pulp

Pulp capping/ immediate pulp extirpation

Sub-luxated teeth.

• Slightly luxated teeth-left alone /splinted

• Follow up pulp testing and X ray.

• Severely luxated tooth-splinting+pulp extirpation.

• Completely avulsed tooth re implanted if within 30 mins of injury.

Alveolar fracture

• Tuberosity #

If completely detached from periosteum – dissected out and soft tissue

defect is sutured.

If tuberosity with/ without associated tooth-appears attached to

periosteum splinting of tooth attached to fragment and immobilizing

it to other standing teeth in maxilla for 1 month.

• # of alveolar floor of maxillary sinus- similar to the fracture

tuberosity.

• When there is an extensive fracture of alveolus with several

teeth attached-splinting the teeth and anchoring the splint to teeth

else where in the upper jaw.

Unilateral maxillary fracture

Closed reduction-

• If the fragment is mobile-digital pressure.

• Arch bar application+IMF.

Open reduction +rigid fixation.

Vestibular incision is placed.

If impacted- Rowe's disimpaction forceps is used to disimpact the

maxilla.

Arch bar application.

Inter maxillary Splint is secured to the maxillary arch and mandible is

passively guided into splint.

IMF.

Rigid fixation is done.

Lefort I fracture.

Reduction.

If occurs in isolation-

• Loose fracture- finger pressure

• Impacted fracture-Rowe’s disimpaction forceps.

• If firmly impacted-bilateral vestibular incision- mobilize using an

osteotome.

Closed reduction-

-Less ideal

-One month IMF.

Severe communition- 6 weeks IMF.

• Ideally open reduction and RIF should be done.

Bilateral incision in buccal vestibule from canine to first molar.

Buttress, lateral antral wall exposed, # line is followed using chisel to

Pterygoid plates.

Rowe and Hayton William forceps-reduction.

Rigid fixation is ideal in the absence of communition of antral wall and

buttress.

Determine the area, which contain sturdy bone for fixation.

Four-point fixation is minimal requirement-pyriform aperture and

zygomatic buttress.

For many years skeletal fixation and extra skeletal fixation were

effective for the patients-

• Who cannot undergo bone grafting.

• Cannot endure IMF for medical reasons.

Halo frame

Various suspensions.

Lefort II Fracture.

• Reduction-

• If it is in one piece-similar to above.

-Using Rowe’s disimpaction forceps.

-Should not be shaken indiscriminately because fracture line at times

involves the middle cranial fossa which should not be disturbed.

If there is co- existing lefort II-grasping at nasal septum with ashe’s or

walsham’s septal forceps and at the same time inserting the finger

of other hand up behind the soft palate and exerting forward

pressure.

STABILIZATION.

Atleast 3 point and preferably 4 point fixation is necessary.

Exposing the region of Zygomatico maxillary and fronto nasal suture.

In ideal situation where there is no # of orbital rim / floor – bilateral

intra oral exposure of ZMS-affords four point fixation.

For infra orbital rim and floor-four classic approaches.

• Infra orbital incision

• Sub ciliary incision

• Mid lower lid incision

• Trans conjunctival incision

• INCISONS FOR FRONTO NASAL SUTURE AREA.

Lefort III Fracture.

Often associated with lefort II and I.

The order at which reduction is carried out are -

-Frontal and zygomatic fractures.-coronal approach

Upper part of central mid facial fracture-same approach.

Naso ethmoidal complex reduction.

Stabilization-

A stable outer framework is established that is,

Reduction and immobilization of zygomatico temporal, zygomatico

frontal and fronto nasal sutures and reduction of maxilla inferiorly.

Once the outer framework has been established nasal skeleton floor of

orbit are constructed.

COMPLICATIONS.

MALOCCLUSION- 8-20%

• Improper occlusal reduction.

• Post operative relapse.

• Lack of correct passive repositioning of maxilla.

COSMETIC DEFORMITY.

• Over long face

• Dish face

LACRIMAL SYSTEM-

Epiphora

Dacrocystitis.

OPHTHALMIC COMPLICATION

• Diplopia

• Enophthalmos

• SOF syndrome.

OTHER NUEROLOGICAL COMPLICATIONS

Anosmia.

NON UNION

Uncommon

When there is communition or actual bone loss.

Palatal fractures.

• Accompany 8% of lefort fractures or may exist in isolation.

They divide the maxillary alveolus transversely/ sagittally, and

comminute the dentition, permit rotation of dental alveolar segments,

and increase the potential for mal alignment.

HENDRICKSON’S CLASSIFICATION (Plastic reconstructive surgery

2001)

• Depending on the pattern in axial and coronal CT.

• TYPE I: alveolar #

Of 2 general types.

Anterior-involving incisor teeth

Postero lateral-molar and bicuspid.

TYPE II: sagittal #

Commonest palatal # in children.

• Extends through anterior portion of pyriform aperture and

divides the palate longitudinally in the line of mid palatine suture.

TYPE III:para sagittal #.

• Seen in adults.

• The common sagittal fracture of maxilla usually divides the

palate anteriorly just off the mid line.

• Thinner bone just lateral to vomerine attachment of maxilla.

• TYPE IV: para alveolar #.

A variant of para sagittal #.

Just medial to maxillary alveolus.

Differs from postero lateral # in that fracture line extends anteriorly to

the incisor dentition.

TYPE V: complex #.

Dividing the palate obliquely,transversely, or comminuting palate and

alveolus.

• TYPE VI: Transverse palatal fracture

• Rarest

• Dividing the palate and maxilla transversely in coronal plane.

Management.

• Fractures of type II, III, IV are not comminuted and have large #

fragments. They can be reduced anatomically by exposure in the

palatal vault and at pyriform aperture with rigid fixation creating one-

piece maxilla, which can then be managed as an intact lower maxillary

fragment.

There is a general agreement that all fractures of palate are amenable

to open reduction and fixation at vertical maxillary buttresses. A few

surgeons prefer to add palatal vault stabilization.

Palatal vault stabilization-

Maintains palatal width.

Fractures selected for vault RIF should generally be antero posteriorly

oriented and must have large segments, which are not comminuted

or have missing bone.

Depends on the fracture edge inter-digitation to determine palatal

width alignment.

Either existing laceration or longitudinal incision is used.

Should not devascularize labial gingiva and palatal mucosa.

It is considered that mid 50% of palate is the safe area.

Sub periosteal dissection is carried out to reach the fracture segment.

• Three hole maxillary plates are best for stabilization.

• Mesh can sometimes be used.

• One plates anteriorly and one plate posteriorly.

Pyriform/ alveolar ridge stabilization.

• Rotation of palatal segment is prevented.

• After stabilization of palatal vault,IMF is done.

• Pyriform area, zygomatic buttress area exposed.

• Stabilization is done at the region of pyriform, alveolar and

zygomatic buttress area.

• In comminuted fracture, complex fracture.- splint is used.

• In postero lateral fracture of palate- either splint or stabilization

at buttress and pterygo maxillary buttress.

A new classification and algorithm to establish treatment plan.

( 2003 )

• Helps the surgeon to decide which fracture to open and how to

do so.

Is the closed reduction possible?

yes.

No

Is the stabilization of vault necessary?

yes no.

Is the fixation stable enough.

yes no.

CR type. AP type 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

• Maxillo facial trauma-Fonseca.

• Fractures of mid facial skeleton-Kelley and Kay.

• Cranio facial trauma-Churchill living stone

• JOMS 2004 Dec 62(12) 1477-1485.

• Plastic reconstructive surgery 2001-jun 107(7) 1669-1676.

• Plastic reconstructive surgery 2003 feb 101(2) 319-32.

CERTIFICATE

This is to certify the topic entitled Maxillary Fractures

is compiled, presented and submitted by Dr. VIDYA SHETTY

under my supervision, guidance and Satisfaction during her

postgraduate course.

Dr .B. H. SRIPATHI RAO.

Guide

Dr.B.H.SRIPATHI.RAO. Professor and H.O.D.Department of oral and maxillofacial surgery

Yenepoya dental college.Mangalore.

Place: MangaloreDate:

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

SEMINAR ON

MAXILLARY FRACTURES

PRESENTED BY,

DR. VIDYA. B. SHETTY