Maxillofacial trauma 2

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  1. 1. Maxillofacial Trauma [Type text] Page 1 Maxillofacial trauma Dr. Firas kassab
  2. 2. Maxillofacial Trauma Dr. Firas Kassab Page 2 Outline Scope, problems, priorities Diagnosis Types of Fractures Bone Anatomy Bone Fracture Bone Healing Nasal Bone Fractures Mandibular Fractures Zygomatic and Orbital Fractures Maxillary Fractures Nasoethmoidal fractures
  3. 3. Maxillofacial Trauma Dr. Firas Kassab Page 3 OBJECTIVES Identify the causes of CMF injuries Discuss the initial management of CMF trauma Discuss the bone and fracture biology Discuss the principles of internal fixation Discuss the different CMF fractures INTRODUCTION Maxillofacial fractures usually occur as the result of massive facial trauma. There is extensive facial swelling, midface mobility of the underlying bone on palpation, malocclusion of the teeth with anterior open bite, and possibly leakage of cerebrospinal fluid (cerebrospinal rhinorrhea) secondary to fracture of the cribriform plate of the ethmoid bone. Double vision (diplopia) may be present, owing to orbital wall damage. Involvement of the infraorbital nerve with anesthesia or paresthesia of the skin of the cheek and upper gum may occur in fractures of the body of the maxilla. Nose bleeding may also occur in maxillary fractures. Blood enters the maxillary air sinus and then leaks into the nasal cavity. SCOPE For this morning were going to talk about maxillofacial trauma. The principles will be the same probably if you have trauma of the bones in other parts of the body. And of course if you have trauma you will be learning the same principles as of dealing with other traumas of the body. Were going to deal more with the trauma of the facial skeleton which includes:
  4. 4. Maxillofacial Trauma Dr. Firas Kassab Page 4 Mandible Zygoma Orbital Maxilla Nasal bone Naso-orbitoethmoidal Craniofacial defects CAUSES Assault Motor Vehicle Accidents Sports injuries Falls especially among elderly patients Work-related Pathological fractures Automobile accidents, fisticuffs, and falls are common causes of facial fractures. Fortunately, the upper part of the skull is developed from membrane (whereas the remainder is developed from cartilage); therefore, this part of the skull in children is relatively flexible and can absorb considerable force without resulting in a fracture. PROBLEMS Airway o Swelling of the soft tissues o Hemorrhage o Fractures
  5. 5. Maxillofacial Trauma Dr. Firas Kassab Page 5 You will be asked to handle the airway. You will have a lot of swelling, hemorrhage and fractures which will obstruct the airway such that when confronted with this situation, you come up with the ABCs.(see below in first aid) Shock Hypovolemia Pain Consciousness- associated CNS injuries Cervical vertebral injuries PRIORITIES : For the ABCs, number one is airway then breathing and circulation .It is the same for other types of trauma. If the patient is stable with good airway, breathing and circulation, then you can address the other problems/injuries. First Aid Airway Breathing Circulation Resuscitation Exclusion of other injuries DIAGNOSIS : diagnose your patients with trauma. History For craniomaxillary fractures, this will probably be one of the shortest histories you will get. Why? Because youre just going to ask for the following: Nature of injury (NOI)
  6. 6. Maxillofacial Trauma Dr. Firas Kassab Page 6 Place of injury (POI) Date of injury (DOI) Time of injury (TOI) Why do you need these things? Because probably this is a medico-legal case. Aside from the four, you just get: Direction of the force Kind of force applied to the patient Examination Then you can now do your PE which focuses on inspection, palpation and auscultation Inspection Palpation Auscultation When you do your physical exam, you also look for these: Deformity- changes in the patients facial shape Bleeding/hematoma Trismus- inability of the patient to open his mouth; If youre able to open your mouth for 2 cms, you are normal. Anything below that would be abnormal. Tenderness- if you palpate and there is pain Dental Problems fractures of the tooth, loosening of the teeth Movement of the Face sometimes you have patients with flattening of the cheeks, and if you hold on to the cheeks and try to move them, they will have some crepitation or movement if the face, that is a sign of a fracture Ophthalmologic findings especially enophthalmos and exophthalmos Enophthalmos- eye goes inward Exophthalmos- eye/contents of orbit move out of the orbit Hypertelorism- both eyes are beyond the normal horizontal plane; one eye moves laterally Signs of fractures of the facial bones include deformity, ocular displacement, or abnormal movement accompanied by crepitation and malocclusion of the teeth.
  7. 7. Maxillofacial Trauma Dr. Firas Kassab Page 7 Anesthesia or paresthesia of the facial skin will follow fracture of bones through which branches of the trigeminal nerve pass to the skin. Then you might have to do several or special tests. Types Of Fractures What are types of fractures? This is just an overview. Complete- total loss of continuity; Imagine this microphone, if you have cortex on top, medulla on middle and cortex again on the bottom. In a complete fracture, you have fracture on all these 3. But for example, you only have fracture on the cortex and medulla but not on the other cortex, then that is an incomplete fracture. Incomplete- with continuity Simple- consists of 2 pieces or fragments, overlying mucosa and skin are intact Comminuted- consists of 3 or more fragments Compound- with an open wound Complex- involving a long fracture line; its like when you break it on the proximal side and moves along the longitudinal plane up to the other side. Complicated- involves both the maxilla and mandible (Panfacial Fracture); so here you have two areas involved. Greenstick- involves one cortical plate; here, you are mainly talking about pediatric fractures.
  8. 8. Maxillofacial Trauma Dr. Firas Kassab Page 8 FACIAL BONE Your facial bone is a Dynamic tissue- it constantly undergoes resorption and remodelling Structure determined by Material properties Mechanical and metabolic function The shape of the head is spherical and it is made as such that when the skull is hit, it is hit tangentially. ANATOMY Architecture of bone
  9. 9. Maxillofacial Trauma Dr. Firas Kassab Page 9 Cortex- compact osseous tissue: hard part of the bone Medulla- cancellous or spongy bone Bone Cells Osteoblasts- associated with formation of osseous tissue; appears on surface of bone undergoing development Osteocytes- osteoblasts which has become embedded within the bone matrix; are the ones that produce bone materials Osteoclast- multinucleated giant cell; derived from the stromal cells of the bone marrow; are the ones regulating formation of the bone. If there is more bone in one area, the osteoclast will try to resorb that bone By the action of all these 3 bone cells, your bone becomes dynamic. By dynamic, we mean that once it becomes fractured, it will heal by itself. Other Bone Structures Haversian Canals - cylindrical, branching and anastomosing canals; Contain blood vessels with small amount of connective tissues Volkmanns Canals- connect Haversian canals with each other, and external surface of the bone and bone marrow cavity Periosteum at the edge Bone Marrow would be in the middle which is a part of your cancellous bone (not compact with a lot of cells embedded in them) Endosteum- thin connective tissue layer lining the walls of the bone cavity, filled with bone marrow Haversian System (OSTEON) Unit structure of compact bone Irregular cylindrical, branching and anastomosing structure with thick walls and a narrow lumen (Haversian Canal) and your haversian canal forms your haversian system. Surrounded by concentrically arranged lamella of bone Directed/move along the long axis of the bone
  10. 10. Maxillofacial Trauma Dr. Firas Kassab Page 10 This is an example of your haversian system. In the middle, it moves longitudinally. BONE FRACTURE Now if you have a fracture, imagine a long bone with a discontinuity along that bone and the force is transmitted along that bone and a break in that bone happens, then theres fracture already. Continuity is destroyed and normal force transmission is absent Leads to rupture of blood vessels with hematoma formation Localized avascularity of the fragment ends Thrombosis of vessels within haversian and Volkmanns canals No treatment until function is impaired Imagine your mandible, if you have a fracture in your mandible but the patient is still able to chew and chewing is the major function of your mandible then no treatment is necessary. Main aim: Re-establish function If you are asked in the exam what is the treatment of choice when a mandible is fractured but the patient is still able to chew, probably the answer is to just leave it as is because it can still function anyway. Bone Healing
  11. 11. Maxillofacial Trauma Dr. Firas Kassab Page 11 The fracture wont stay as it is, of course youll have bone healing. And you have two types of bone healing: Indirect bone-healing Aka: secondary osseous and soft tissue healing Occurs via pluripotential cells: bone, periosteum and soft tissue Direct Bone healing Aka: Primary osseous healing Two types: Contact healing Gap healing Indirect Bone-Healing : Occurs via pluripotential cells bone, periosteum and soft tissue Results from mechanical instability of the fracture leading to resorption of fracture ends Callus formation (which happens later in the process) This is one statement that we need to understand. You have indirect bone healing because there Is mechanical instability of the fracture. If you have a fracture in the radius and the patient still moves his arm/elbow and there is instability, even if you splint it or if you put a cast, the arm will still be able to move. Meaning there is still mechanical instability. And because the fracture ends move against each other, this will lead to resorption of fracture ends. Healing will still take place and formation of callus happens. stages of callus formation o Deposition of granulation tissue Hematoma formation Periosteum stripped away from bone surface Migration of Neutrophils and Macrophages into hematoma- this is because of the open blood vessels
  12. 12. Maxillofacial Trauma Dr. Firas Kassab Page 12 Phagocytosis of hematoma and necrotic debris Ingrowth of capillaries and fibroblasts o Osteoid synthesis. Transformation of granulation tissue into interfragmentary connective tissue The next stage is the transformation of that granulation tissue into interfragmentary connective tissue. You have development of new osteoprogenitor cells, production of osteoid. Osteoid synthesis proceeds to produce a connective tissue between the fracture ends. The newly formed osteoid will be arranged in a haphazard manner in a woven-bone pattern. o Remodelling into fibrocartilage Osteoid is layed in a haphazard manner producing woven bone pattern. This becomes your fibrocartilage. And this becomes your callus. There are two: External Callus- which is found on the side; outside the axis of the bone Internal Calluswhich is found in the center; in between your bone fragments o Mineralization Once bone ends are closely apposed, ossification between fracture ends occurs. There is changing into bone already. 3rd week: callus well established but mechanically weak (woven bone) o Haversian remodelling Your haversian system/osteons will move from one fracture segment into the other. You should understand that your osteons are the basic structure of your bone. And they will have to move from one fracture end to another for that bone to be fully healed. This happens within the next few months Osteoclastic erosion and organized osteoblastic osteoid synthesis takes place Replace woven bone with compact, organized lamellar bone In the next few months, the Haversian system (osteons) will replace your woven bone. It will later become a compact, lamellized bone This transformation happens after 6 weeks. It will remodel
  13. 13. Maxillofacial Trauma Dr. Firas Kassab Page 13 Direct Bone Healing Aka Primary osseous healing It happens only if you have perfect anatomic repositioning of fractured segments back to their normal position and stable fixation Lack of callus formation: stage 1,2,3,4 will not undergo callus formation Disappearance of the fracture lines: happens immediately after direct bone healing So how do we achieve that? Synergism between contact and gap healing Close apposition of segments provides mechanical stability Osteons are in direct contact Allowing transverse bridging of the haversian system with no intervening callus formation 2 types Contact healing Gap healing Direct or primary healing only occurs when there is no motion across the fracture line.
  14. 14. Maxillofacial Trauma Dr. Firas Kassab Page 14 Contact Healing Seen after stable anatomic repositioning Contact healing only happens when there is perfect anatomic repositioning of your fracture ends and stable fixation. There is no callus formation. Immediately after direct bone healing, there is disappearance of suture lines. This happens when there is a synergism between contact healing and gap healing. There should be close apposition of segments and there should be mechanical stability. Your osteons/haversian systems are in direct contact allowing transverse bridging of your haversian system with no callus formation. o Perfect interfragmentary contact o No possibility for any cellular or vascular ingrowth o Cutting cones (haversian system) are able to cross this interface from one fragment to the other by remodelling the haversion canal.. o Only seen directly beneath the mini plate. Gap Healing Takes place in gaps with a width greater than 200 um Osteoblasts deposit osteoid on the fragment ends. This space is very small such that the cones will be able to traverse without any problem. Seen on the inner side of the mandible Seen on the inner side of the mandible Undergoes several stages as well Stages of Haversian remodelling o Gaps are filled with transversely-oriented lamellar bone completed within 4-6 weeks o Replacement by axially-oriented osteons. In 10 weeks, you have newly re- constructed cortical bone. Contact healing and gap healing are seen especially when you put your implants.
  15. 15. Maxillofacial Trauma Dr. Firas Kassab Page 15 It appears that the bridging of a bony gap by bone can only occur in the absence of motion across that gap. The more motion is present, the greater the amount of callus will be needed to stabilize the fragments so that healing by bone can eventually occur. Conversely, the more stable a repair is (and thus less motion is present), the less callus will form and the greater the likelihood that bone will directly bridge fracture and heal the injury. It of course follows that when callus is unable to stabilize a fracture, bone will never form; the fracture remains bridged by fibrous tissue, thus forming a fibrous union (alternately known as a non-union, a fibrous non-union, or a pseudoarthrosis. To accomplish a stable repair, it is necessary to understand the biomechanics of the facial skeleton, and even more important, it is critical to use this understanding when applying fixation. Otherwise, motion will tend to occur when the repair is loaded in function, and complications are then more likely to occur. Delayed Healing Factors detrimental to bone healing Poor blood supply Poor general nutritional status Poor apposition in the fracture ends Foreign bodies in the fractures Infection Corticosteroid intake Successful Healing Minimum Requirements For Successful Bone Healing Biological Requirement o You need functioning cells that participate in the various phases of the healing process.
  16. 16. Maxillofacial Trauma Dr. Firas Kassab Page 16 These functioning cells should be able to reach the site of repair Adequate nutritional supply is needed Good blood supply is a primary prerequisite Mechanical Requirement o Immobilization- You need to immobilize the fractures for that to heal. o Interfragmentary Motion Tissues are continuously torn and squeezed. Tolerance o Connective tissue 100% o Cartilage 10-15% o Bone 2% Let us look at the different tissues in the body. If you have a break in your skin, that skin will still heal even if you move the skin. The skin, or any other connective tissue, will be able to tolerate that 100%. If there is movement in your cartilage, only 10-15 % will tolerate that and will heal. If there is movement in your bone, the bone will not be able to tolerate that and will not heal. Such that, if there is still movement in your bone, you will not achieve bone healing. OPERATIVE TREATMENT OF FRACTURES Aim: o Rapid recovery of form and function o Relief of pain o Avoidance of late complications o Short hospitalization time o Early return to work Optimal, not maximal, stability is required.
  17. 17. Maxillofacial Trauma Dr. Firas Kassab Page 17 Nasal Bone Fractures Nasal Bone Anatomy Anatomy: The two nasal bones form the bridge of the nose. Their lower borders, with the maxillae, make the anterior nasal aperture. The nasal cavity is divided into two by the bony nasal septum, which is largely formed by the vomer. The superior and middle conchae are shelves of bone that project into the nasal cavity from the ethmoid on each side; the inferior conchae are separate bones. The nasal bone is the most frequently traumatized bone. It is very prominent in the face, and would probably be the first to be injured when there is trauma o It is most predisposed to fractures is at the junction of the thin, broad and lower portions of the nasal bone o It is intimately related to the nasal septum o Nasal septal fracture or dislocation may co-exist with nasal bone fractures. Fractures of the nasal bones, because of the prominence of the nose, are the most common facial fractures. Because the bones are lined with mucoperiosteum, the fracture is considered open; the overlying skin may also be lacerated. Although most are simple fractures and are reduced under local anesthesia, some are associated with severe injuries to the nasal septum and require careful treatment under general anesthesia. Signs
  18. 18. Maxillofacial Trauma Dr. Firas Kassab Page 18 Stepdown deformity- If you touch nasal bridge, you feel that there is a sudden downward deformity. Nasal Fracture Stepdown Deformity o Epistaxis o Nasal obstruction secondary to fracture o Septal deviation o Mucus and blood clots o Crepitations (sound heard or felt during palpation of the nose) o All external manifestations may be masked by severe soft tissue edema especially in a patient seen a few hours after injury. Especially if there is swelling. Management The most appropriate treatment for a nasal injury is the least invasive one that will fully correct the deformity without long-term complications or relapse. Non-displaced fractures that do not result in any defects are best managed with observation alone . 1. Closed reduction Indications: Fractures which are non-comminuted Mild to moderate Recent fractures Use Ashe forceps/hemostat Should be done within 7-10 days in adults, 2-4 days in children Closed nasal reduction is best for simple injuries such as an isolated, unilateral nasal bone fracture with medial displacement. One of the most important reasons for failure of closed nasal reduction is concurrent nasal septal fracture.
  19. 19. Maxillofacial Trauma Dr. Firas Kassab Page 19 Closed reduction We just get the fractured bone and elevate that. Pull that upward and that will actually replace the bone back to its original anatomic position. Most of the time, we put the patient into general anesthesia because it is painful. Some of the indigent patients would prefer to have this done under local anesthesia. We introduce anesthetics in the infraorbital rim, inside the nose and the lip. Instruments needed for reduction of simple nasal fractures o fiber optic headlight o intranasal specula o scalpel knife o Ashe forceps - for displaced septum o Walsham forceps - for impacted nasal bones o nasal splint o tape and bandage 2. Open reduction For more severe trauma (e.g. bilateral, depressed fracture with septal and cartilaginous involvement), an open approach is the best means of producing a satisfactory outcome. Disadvantages of using open reduction for majority of nasal fractures are the higher treatment costs and the increased risk of surgical complications. Open reduction should be limited to those cases in which it would yield significantly better results than more conservative measures to justify the drawbacks. Indications include: o Bilateral fractures with dislocation of the nasal dorsum and significant septal pathologic changes o Bilateral fractures with major dislocation with or without significant septal pathologic states o Infrastructure of the nasal dorsum o Fractures of the cartilaginous pyramid without dislocation of the upper lateral cartilages. 3. Alternative Reduction Methods
  20. 20. Maxillofacial Trauma Dr. Firas Kassab Page 20 External compression plating Percutaneous wire fixation Complications of Nasal Fractures o Subperichondrial fibrosis with partial obstruction o Synechiae o Obstruction of the nasal vestibule o Osteitis o Malunion of the nasal fractures with deviation MANDIBULAR FRACTURES Anatomy The mandible (lower jaw) is a U-shaped structure with several areas: Symphysis found in the middle in between middle incisors. Any fracture in this area is called a symphyseal fracture. Parasymphysis Between lateral incisors and canine, make an imaginary line going down to the inferior border of the mandible. Any fracture there is considered parasymphyseal. Body from lateral incisors to 3rd molar; between angle and parasymphysis. Angle - junction of ramus and body of mandible.
  21. 21. Maxillofacial Trauma Dr. Firas Kassab Page 21 Alveolar area tooth bearing portion Condyle attached to glenoid fossa Coronoid process Ramus- From the angle going up The mandible or lower jaw is the largest and strongest bone of the face, and it articulates with the skull at the temporomandibular joint. The mandible consists of a horseshoe-shaped body and a pair of rami. The body of the mandible meets the ramus on each side at the angle of the mandible. Traumatic impact is transmitted around the ring, causing a single fracture or multiple fractures of the mandible, often far removed from the point of impact. Signs And Symptoms Malocclusion patient is unable to close the mouth and appose the teeth normally. When the patient has an abnormal bite. Hyposthesia of lower lip and gingiva due to damaged inferior alveolar nerve Sublingual hematoma Mucosal disruption Pain and tenderness over fracture Tooth loosening Trismus- inability of the mouth to open more than 2 cm Facial deformation/Swelling Investigation Of Mandibular Fractures Imaging Studies o Radiology Panorex (Panoramic X-ray) Mandible series (frontal, lateral, oblique Study models
  22. 22. Maxillofacial Trauma Dr. Firas Kassab Page 22 Photography- compare it with pretrauma pictures of the patient For the mandible, most surgeons prefer plain x-rays, or more commonly panoramic topography, and often both as the imaging techniques of choice. Management Of Mandibular Fractures : In the dentate mandible, the first priority is reestablishment of the proper occlusal relationship of teeth. As discussed earlier, we require immobilization for the fractures to heal. You may either use splinting or compression. Splinting o Application of a more or less stiff device to the fractured bone. o But this does not completely abolish fracture mobility. 2 types of Splinting: External splinting Reduce fractures without surgical intervention May be fixed to teeth, or applied to mucosal or skin covered surfaces In your long bone, the splint will be the cast. You apply that to your skin. Even with the cast, the patient will still be able to move his hand and move the fracture ends. So it does not completely abolish fracture mobility Internal Splinting o The stabilizing devices are fixed directly to the fracture segments o Some interfragmentary motion o Interfragmentary wire sutures and flexible plates. Even if you put these directly to the bone, you will still have some interfragmentary motion Compression/ Internal fixation Excludes interfragmentary motion Consists of pressing together 2 surfaces, either bone to bone or implant to bone. You compress the bone together. This is achieved only by using your implants. Biological advantages:
  23. 23. Maxillofacial Trauma Dr. Firas Kassab Page 23 When you compress, there is undisturbed healing because it guarantees absolute stability even under conditions of function. If you compress the mandible, even if the patient uses his mandible, the fractured ends will not move against each other. Immobilization is the key to healing. Allows load sharing between the bone and the implant. Provides maximum strength with minimum fixation material. A load-sharing repair depends on the integrity of the underlying bone, and the fixation appliance is positioned so as to ensure that the forces in function are borne by bone itself. A small plate across the tension zone will ensure the solid bone is pushed together in function so that it shares the load with the fixation appliance. Miniplate fixation, compression plate fixation, and lag screw fixation all represent load-sharing repairs and require adequate bone contact to succeed. Closed Reduction Bartons Bandage an internal splint
  24. 24. Maxillofacial Trauma Dr. Firas Kassab Page 24 Intermaxillary fixation (IMF) for 6 weeks There are rubber bands applied to the teeth. The patient will be unable to move the mouth. There will still be some interfragmentary motion. Intermaxillary Fixation. This is another example of an internal splint. If you have Bartons bandage of Intermaxillary fixation, the fractures will heal but it will take 6 weeks before it heals. He will not be able to eat for 6 weeks and so he needs an NGT. Imagine how discomforting this is. Eyelet wires Arch bars A good arch bar will re-establish proper occlusal relationship of teeth and will also provide a good tension band across the alveolar portion of the fracture. NGT Liquid feedings Open Reduction o Direct visual access to the fracture. You open up the skin or the mucosa to visualize the fracture. o Anatomical reduction of bone fragments o Fixation Wire osteosynthesis The wires are pliable .They will not be able to totally abolish fracture mobility. Although they are applied directly to the bone, this is still considered as internal splint. Not compression. Interosseous Wiring :
  25. 25. Maxillofacial Trauma Dr. Firas Kassab Page 25 Screw Fixation- compression/ internal fixation Plate Fixation- compression/ internal fixation Miniplates Reconstruction Plates
  26. 26. Maxillofacial Trauma Dr. Firas Kassab Page 26 Plates and Screws. It is only if you have internal fixation, that you can totally abolish fracture mobility and go through direct bone healing, and achieve healing faster compared to indirect bone healing. Post Operative Care Airway o Avoidance of IMF in post op period o Nasopharyngeal airway o Tracheostomy Analgesia Antibiotics Fluids and diet
  27. 27. Maxillofacial Trauma Dr. Firas Kassab Page 27 ZYGOMATIC FRACTURES AND ORBITAL FRACTURES Anatomy The zygomatic bones (cheek bones, malar bones), forming the prominences of the cheeks, lie on the inferolateral sides of the orbits and rest on the maxillae. The anterolateral rims, walls, floor, and much of the infraorbital margins of the orbits are formed by these quadrilateral bones. The zygomatic bones articulate with the frontal, sphenoid, and temporal bones and the maxillae. Inferior to the nasal bones is the pear-shaped piriform aperture, the anterior nasal opening in the cranium The zygomatic arch is formed by the union of the temporal process of the zygomatic bone and the zygomatic process of the temporal bone Bones of the Orbit Frontal Greater wing of sphenoid Lesser wing of sphenoid Ethmoid Lacrimal Zygomatic Superior Orbital Fissure Located between the greater and lesser wings, it communicates with the orbit and transmits the ophthalmic veins and nerves (CN III, CN IV, CN V1, CN VI, and sympathetic fibers) entering the orbit. Contains:
  28. 28. Maxillofacial Trauma Dr. Firas Kassab Page 28 Superior and inferior division of oculomotor n. Trochlear n. ophthalmic n. - lacrimal and nasociliary branches superior and inferior divisions of ophthalmic rim (vein) sympathetic fibers of cavernous sinus Inferior Orbital Fissure Contains: zygomatic branch of the maxillary nerve ascending branch of pterygopalatine ganglion inferior orbital fissure separates the mandible from sphenoids Signs of Zygomatic/Orbital Fracture: Black eye Lateral subconjuctival hemorrhage Swollen or flattened cheek Diplopia/Restricted Eye Movements Hypoesthesia of the cheek Trismus Proptosis Enophthalmos: imagine your orbit as a glass of water, and you put a ping pong ball on top and if you break the glass, the ping pong ball will actually go downward and that is what we call enophthalmos Tripod Fracture involves the zygomatico-frontal, zygomatico-maxillary and zygomatico- temporal suture lines (due to inherent weakness) tripod fractures they usually begin with pre-injury weakness of the facial bone and foramen
  29. 29. Maxillofacial Trauma Dr. Firas Kassab Page 29 Principles Of Treatment Restore the patient to pre-injury facial configuration Prevent cosmetic deformity Prevent delayed visual disturbances Repair within 5-7 days allows edema to decrease and avoids shortening of masseter with lateral and inferior rotation Treatment 1- Closed Reduction Gillies Temporal Approach incise at hairline (temporal area), insert a metal rod going towards maxilla and pull out zygoma Your tripod fracture will cause a portion of the cheek to move either medially or laterally. If t move medially, we make a small incision by the hairline get a piece of metal rod, insert that rod, then push the cheek out
  30. 30. Maxillofacial Trauma Dr. Firas Kassab Page 30 Cheek Hook get a hook, pull out the bone so it will return to the normal configuration Transbuccal hook approach make a small incision inside oral cavity, insert the hook and pull zygoma out 2- Open Reduction Perform a coronal incision and expose the fracture and then plate the fracture Frontozygomatic Inferior orbital Oral Bitemporal Fixation Miniplate osteosynthesis 1 mm thin plate Microplate osteosynthesis mm thin plate Resorbable materials BLOWOUT FRACTURES Compression of orbital contents deforms the orbital floor, walls, and roof. Open door or trap door deformity Your globe will move inward, X-rays will show a TEARDROP SHAPE SIGN
  31. 31. Maxillofacial Trauma Dr. Firas Kassab Page 31 Types Of Blowout Fracture Pure Blowout Fracture No involvement of the orbital rim, only the floor is involved With entrapment of EOMs Must be differentiated from simple orbital floor fractures Impure Blowout Fracture Orbital rim involved Often associated with malar, NOE, Le Fort and Frontal Sinus fractures Signs And Symptoms Diplopia Restricted eye movements Enophthalmos Superior Orbital Fissure Syndrome Symptoms of Superior Orbital Fissure Syndrome Diplopia Paralysis of EOMs Exopthalmos Ptosis Blindness (apex)
  32. 32. Maxillofacial Trauma Dr. Firas Kassab Page 32 Usual mechanism is a blow to the eye whereby the diameter of the causative force is usually bigger than the diameter of the orbit This forces the orbit downward since the orbital space is limited posteriorly and the orbital floor has least resistance. Lamina papyracea: thinnest portion of the orbital bone Usually the orbit herniates through the fracture Presence of continuity between the sinus and the orbit Orbital emphysema: air in radiograph Tear drop sign: represents the herniated orbital contents, periorbital fat and inferior rectus muscle CT scan provides better evaluation since it can detect the fracture and hemorrhage in different planes
  33. 33. Maxillofacial Trauma Dr. Firas Kassab Page 33 Treatment Open Reduction Internal Fixation (ORIF) Orbital Defect Reconstruction Plates Silicone implants Autologous Bone If the patient cannot afford the titanium implant, we just get a piece p bone from the calvarium, one cortical level, then we lay that on the defect. Titanium mesh(implants) MAXILLARY FRACTURES Buttresses Of The Facial Skeleton Nasomaxillary Zygomaticomaxillary Pterygomaxillary What are your buttresses? They are preformed structures in the face which are stronger than the other areas of the face. These are the structures that hold the maxilla together. If you have fractures and disruption of the buttresses, these are the areas you have to compress or plate for you to be able to achieve correct treatment of your maxillary fractures. You have to manage all of these buttresses first. will not be able to withstand the forces of occlusion Reconstruction is made either through wires or plates.
  34. 34. Maxillofacial Trauma Dr. Firas Kassab Page 34 The buttresses are strong because of your bite; the pressure of biting is transverse to the buttresses. If the buttresses are fractured, the maxilla and mandible will collapse. Imaging Radiographs Occipitomental Lateral CT MR Angiography Photography Study models Anatomical Classication Le Fort I Le Fort II Le Fort III The Le Fort classification describes various midfacial fracture patterns ranging from isolated detachment of the alveolar process (Le Fort I) to separation of the midfacial bones from the anterior skull base (Le Fort III).
  35. 35. Maxillofacial Trauma Dr. Firas Kassab Page 35 Le Fort Type I (Transverse Maxillary Fracture) Le Fort Type II (Pyramidal Fracture) Le Fort Type III (Craniofacial Dysjunction) Broken pterygoid plates + fracture that runs horizontally above the anterior maxillary alveolar process Broken pterygoid plates + fracture that runs along maxillary sinus, inferior orbital rim, orbital floor, medial orbital wall, & nasofrontal suture Broken pterygoid plates + zygomatic arch fracture + craniofacial separation LE FORT I Low level fracture Often mobile Mild swelling Disturbed occlusion Deviated midline If you have patient with a history of facial trauma, when you hold the teeth and you pull that out, the alveolus (tooth-bearing structure) will move anteriorly, that is your anterior drawer sign. Only the tooth bearing segment moves, then that is a sign of your Le Fort I fracture. LE FORT II Sub-zygomatic pyramidal Gross swelling Immobile Anterior Open Bite Altered Sensation
  36. 36. Maxillofacial Trauma Dr. Firas Kassab Page 36 Long faced appearance CSF rhinorrhea When you pull anteriorly, even the nasal bridge will move anteriorly, the drawer sign will include the whole nasal bridge. Be careful because the infraorbital may already be affected hence increased sensation to pain. LE FORT III Suprazygomatic craniofacial dysjunction Gross swelling Immobile Altered occlusion Long face Flattened cheek CSF rhinorrhea The whole face is disjoint from the skull. When you pull, even the cheeks and the inferior orbital rim will move anteriorly.
  37. 37. Maxillofacial Trauma Dr. Firas Kassab Page 37 Treatment Conservative Closed Reduction Open Reduction External Fixation Internal Fixation Wires: again wires are not internal fixation, just internal splints Suspension Osteosynthesis Summary of Anterior Drawer Sign Le Fort I Alveolus moves anteriorly Le Fort II Alveolus and nasal bridge moves anteriorly Le Fort III Alveolus, nasal bridge, cheeks and inferior orbital rim move anteriorly
  38. 38. Maxillofacial Trauma Dr. Firas Kassab Page 38 Screws Plates Internal Fixation NASOETHMOIDAL INJURIES Trauma to central midface Traumatic telecanthus or hypertelorism Telecanthus the canthal ligament has moved laterally during traumatic injuries.
  39. 39. Maxillofacial Trauma Dr. Firas Kassab Page 39 Nasal deformity Orbital wall involvement Enophthalmos Diplopia The main structural buttress of the nasoethmoid: Frontal process of the Maxilla Contains insertion of the medial canthal ligament o TYPE I NOE Fracture Has a large central fragment represent a single noncomminuted central fragment without medial canthal tendon disruption o TYPE II NOE Fracture Involve comminution of the central fragment, but the medial canthal tendon remains firmly attached to a definable segment of bone.
  40. 40. Maxillofacial Trauma Dr. Firas Kassab Page 40 o TYPE III NOE Fracture Are uncommon and result in severe central fragment comminution with disruption and detachment of the medial canthal tendon insertion. TREATMENT The objectives of definitive surgical treatment of NOE fractures are reduction and fixation of unstable fracture segments to stable structures SUMMARY Initial management of craniomaxillaryfacial trauma involves the ABCs of emergency Successful bone healing requires immobilization Internal fixation abolishes inter=fragmentary motion