Fracture maxilla

fracture maxilla

1. FRACTURE MAXILLA DR SHAMEEJ MUHAMED KV SENIOR RESIDENT DEPARTMENT OF NEUROSURGERY , GMC CALICUT

2. INTRODUCTION 2 nd l argest bone of face 2 m axil l ae f o r m s w h ole of u p per j aw Each m axil l a co n trib u t e s in f o r m a t ion of 1. Face 2. N o se 3. Mo u th 4. O r bit 5. I n f r a t e m p o r al f o ssa 6. Pter y g o pala t i ne f o ssa

3. FEATURES OF MAXILLA Each maxilla has – 1. A bo d y 2. 4 processes – frontal zygomatic alveolar palatine

4. BODY OF MAXILLA Shape – pyramidal It has – 1. Base – directed medially at nasal surface 2. Apex - directed laterally at zygomatic process 3 . 4 surfaces – anterior / facial posterior / infratemporal medial / nasal superior / orbital Encloses a cavity – maxillary sinus

5. ANTERIOR / FACIAL SURFACE Directs laterally Incisive fossa -depressor septi Nasalis – superolateral , along nasal notch

6. Canine fossa – levator anguli oris Infraorbital foramen levator labii superioris Medially – the nasal notch & anterior nasal spine

7. POSTERIOR / INFRATEMPORAL SURFACE  Concave  Directed – backward & laterally  Forms – anterior wall of infratemporal fossa  Separated from anterior surface by zygomatic process & zygomatico maxillary ridge  Posteroinferiorly – maxillary tuberosity & superficial head of medial pterygoid muscle

8. SUPERIOR / ORBITAL SURFACE Smooth, triangular & slightly concave Forms – Greater Part Of Floor Of Orbit Anterior border forms – part of inferior orbital margin continues with lacrymal crest of frontal process

9. Posterior border – smooth & rounded Forms most anterior margin of inferior orbital fissure In middle – infraorbital groove Medial border – Anteriorly lacrymal notch, converted into nasolacrimal canal Behind the notch, articulation with – Lacrymal Labrynth of ethmoid Orbital process of palatine bone

10. THE MEDIAL /NASAL SURFACE  Part of lateral wall of nose  Posterosuperiorly – maxillary hiatus  Above the hiatus – air sinuses  Below the hiatus – anterior part of inferior meatus  Behind the hiatus – articulates with perpendicular plate of palatine bone & encloses greater & lesser palatine canals

11. Infront of the hiatus – nasolacrymal groove articulates with descending process of lacrymal bone & lacrymal process of inferior nasal concha to forms nasolacrymal canal More anteriorly – conchal creast for articulation with inferior nasal concha. Above the conchal crest – atrium of middle meatus.

12. PROCESSES OF MAXILLA 1. FRONTAL 2. ZYGOMATIC 3. ALVEOLAR 4. PALATINE

13. FRONTAL PROCESS Projects upward & backwards to articulate above – nasal margin of frontal bone infront – nasal bone behind – lacrymal bone Lateral surface – divided by anterior lacrymal crest into anterior smooth & posterior grooved A nterior lacrymal crest gives attachment to lacrymal fascia & medial palpebral ligament

14. Medial surface – forms lateral wall of nose from above downwards – - Uppermost roughened area for articulation with ethmoid -2. Ethmoidal crest – a horizontal ridge, articulates with middle nasal concha - Below the ethmoidal crest- atrium of middle meatus

15. ZYGOMATIC PROCESS  Pyramidal lateral projection  Anterior, posterior & superior surfaces converge here  Superiorly – rough, to articulate with zygomatic bone

16. ALVEOLAR PROCESS Forms half of alveolar arch  Bears socket for maxillary teeth  In adults = 8 sockets

17. PALATINE PROCESS Thick horizontal plate Projecting medially Forms largest part of roof & floor Inferior surface – concave & forms anterior 3/4 th of bony hard palate. Posterolaterally –greater & lesser palatine foremen Superior surface – concave from side to side & forms floor of nasal cavity.

18. ARTICULATIONS OF MAXILLA Superiorly – 3 bones 1. Frontal 2. Nasal 3. Lacrymal Laterally – 1 bone 1. Zygomatic bone

19. Medially – 5 bones 1. Ethmoid 2. Inferior nasal concha 3. Vomer 4. Palatine 5. Opposite maxilla

20. D Orbit, medial wall E orbit , lateral wall F Suture between sphenoid and zygomatic bones Nasomaxillary suture 1 Globe 2 Ethmoid sinus 3 Sphenoid sinus 4 Nasal bone 5 Maxilla , frontal process 6 Orbit, lateral rim 7 Sphenoid bone 8 Optic foramen

21. F Groove for infraorbital nerve G Maxillary sinus, posterolateral wall 5 Maxilla , frontal process 9 Maxillary sinus 10 Zygomatic arch 11 Pterygoid bone 12 Nasolacrimal duct 13 Mandible, condyle Clear maxillary sinuses can almost rules out certain fractures such as LeFort , blowout fractures,zmc #

22. H Maxillary sinus, anterior wall I Maxillary sinus, medial wall J Medial pterygoid plate K Lateral pterygoid plate 9 Maxillary sinus 14 Mandible , ramus Fracture of the pterygoid plates may represent LeFort fracture

23. Buttresses of Maxillofacial Force that are applied to the face are absorbed and transmitted by buttress system , mainly of two types Vertical Horizontal

24. Horizontal Buttresses 1 . Frontal Bar 2 . orbital rims 3 . Maxillary Alveolar 4 . Mandibular alveolar 5 . Inferior border of mandible

25. Vertical buttress 1 . Nasomaxillary , 2. Zygomaticomaxillary 3 . Pterygomaxillary 4. mandibular

26. Classification of Fracture of maxilla • Rene Le Fort classification (1901) Le Fort I Le Fort II Le Fort III

27. Marciani modification of Le Fort Le Fort I - Low maxillary fracture Ia - Low maxillary fracture/multiple segments Le Fort II - Pyramidal fracture IIa - Pyramidal and nasal fracture IIb - Pyramidal and NOE fracture • Le Fort III - Craniofacial disjunction IIIa - Craniofacial disjunction and nasal fracture IIIb - Craniofacial disjunction and NOE fracture.

28. Le Fort IV - LeFort II or III fracture & cranial base fracture IV a - + Supraorbital rim fracture IV b - + Anterior cranial fossa & supraorbital rim fracture IV c - + Anterior cranial fossa & orbital wall fracture

29. LE FORT FRACTURES Among the most severe fractures seen in face and associated with high-energy trauma Named after René LeFort , a French physician, who studied facial fractures in cadavers. Result was published in 1901 Key facts - In each type, there is a partial or complete separation of maxilla from the remainder of the facial skeleton All LeFort fractures must extend through posterior face, transects the pterygoid processes Any combination of LeFort I, II, and III patterns can occur

30. ETIOLOGY &EPIDEMIOLOGY Road traffic accidents (most common) -40% • Industrial accidents - 10 % • Assault -15% • Sports - 25 % • Fall - 10 % Most maxillary fractures occur in young men aged between 16 to 40 years. • Peak age- 21 - 25 years • Male : Female - 4:1

31. Le Fort I : Guérin fractures OR Low Level Result from a force of injury directed low on the maxillary alveolar rim in a downward direction Escapes diagnosis

32. MOI--- Direct horizontal or angular blow at the level of upper teeth but below the anterior nasal spine = Le Fort I or horizontal maxillary fracture

33. LE FORT I Fracture line passes fron nasal septum to the lateral pyriform rims , travels horizontally above the teeth apices, crosses below the z ygomaticomaxillary junction , and traverses the pterygomaxillary junction to interrupt the pterygoid plates Alsp known as floating palate- seprates teeth from upper face

34. Sign and symptom Swelling of upper lip and cheek •Ecchymosis–maxillary buccal sulcus •Nasal block –oral breathing •Eye or ocular sign are usually absent • Guerin sign – Echymosis in palate –greater palatine foramen bilaterally

35. Occlusion – Undisplaced incomplete fracture –no disturbance to occlussion – Displaced occlusion • Anterior open bite : backward and downward distraction of posterior maxilla –traction from medial pterygoid muscle • Posterior gagging of occlusion –threat to airway

36. Teeth fracture Damage to the cusp of individual teeth due to impact from opposite teeth Palatal fracture • 8–15% of Le Fort fractures • follow a sagittal or parasagittal direction , splitting the maxilla longitudinally close to the midline • exit anteriorly between the central incisors, or between the lateral incisor and the canine tooth

37. Bilateral epistaxis or nasal bleeding may be observed •Pain while speaking and moving the jaw • Cracked pot sound •Floating maxilla •Palpation Step deformity along the piriform aperture , buccal sulcus and tuberosity region

38. Le Fort II/Pyramidal fracture Starts from nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, • Infero laterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen , and inferiorly through the anterior wall of the maxillary sinus ; • It then travels under the zygoma , across the pterygomaxillary fissure , and through the pterygoid plates

39. Horizontal impacts along the Frankfort plane = Le Fort II fracture pyramidal fracture

40. Sign and symptom gross edema of the middle third of the face known as ballooning or moon face • bilateral circumorbital edema and ecchymosis( Black eye ) • Bilateral subconjunctival hemorrhage -medial half • Bridge of the nose will be depressed (flat face) • Anterior open bite -impaction of the fragment • Gross downward and backward displacement of the fragment Posterior gagging of the occlusion with -anterior open bite ( Dish shaped face )

41. Pseudotelecanthus : swelling over the nasal bridge illusion of telecanthus , true telecanthus on the involvement of NOE complex • Bilateral epistaxis • Difficulty in mastication, and speech • Loss of occlusion may be seen • CSF leak may be present • Step deformity at the infraorbital margins • Anesthesia or paresthesia of the cheek is noted

42. LE FORT III Craniofacial Dysjunctions This fracture separates calvaria (skull) from the facial bones. Most severe of all LeFort fractures • Anteriorly: nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones . • The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. • Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues supero -laterally through the lateral orbital wall , through the zygomaticofrontal junction and the zygomatic arch . From this point , fracture descends across the upper posterior aspect of maxillae in the region of sphenopalatine fossa and upper limit of pterygomaxillary fissures and fractures the roots of pterygoid laminae at its base. • Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid , through the vomer , and through the interface of the pterygoidplates to the base of the sphenoid.

43. Impact on the nasion at 30-60 degree above the horizontal = Le Fort III fracture (craniofacial disjunction )

44. FEATURES high level fracture •Lateral direction with a severe impact •Clinically this fracture appears similar to the LeFortII fracture, but close examination will demonstrate a more serious condition. •After stabilizing the head and then gripping of the maxillary teeth with one hand and simple manipulation, will confirm complete movement of the middle third of the face. •Mobility of whole skeleton as a single block can be felt

45. Sign and symptom Gross edema of the face, ballooning,“Panda facies ” within 24 to 48 hours •Bilateral circumorbital / periorbital ecchymosis and gross edema ’ Racoon eye •Gross circumorbital edema will prevent eyes from opening •Bilateral subconjunctival hemorrhage •tenderness and separation at the frontozygomatic sutures .

46. Characteristic ‘dish face’ deformity • enophthalmos • diplopia or • impairment of vision, temporary blindness, • Flattening and widening, deviation of the nasal bridge. • Epistaxis CSF rhinorrhea

47. INVESTIGATION CT-scan is best option for studying mid-facial fracture but plain radiograph may be help full too . •Radiographic examination –Water’s view: PA view with cephalad angulation –Caldwell view : PA view –Lateral view – Submentovertex view :

48. CT scan (coronal view) documenting a Le Fort I fracture

49. LE FORT II CT scan, axial view of a Le Fort II fracture, shows the fracture line through anterior and posterior maxillary sinus CT scan, axial view of a Le Fort II fracture, shows the fracture line through both infraorbital rims and zygomatic arch on the right

50. LE FORT III

51. MANAGEMENT Timings of surgery emergencies involving panfacial fractures require immediate surgery If no such medical emergencies surgery may be delayed Delayed repair (7-14 days) • manipulation of bones and soft tissue easier –suppression of edema. • risk of fibrosis and healing is there

52. Principles of management REDUCTION FIXATION IMMOBILIZATION

53. DEFENITIVE MANAGEMENT – LE FORT I FRACTURE SURGICAL APPROACH- MAXILLARY VESTIBULAR REDUCTION - ROWE OR HAYTON WILLIAMS FORCEP

54. FIXATION - 4-point fixation with MINIPLATE. I MMOBILISATION - MAXILLOMANDIBULAR FIXATION(MMF)

55. LE FORT II SURGICAL APPROACH Coronal Approach A– Subciliary incision B – Sub tarsal incision C - Infraorbital incision D - Extension of Subciliary

56. REDUCTION - ROWE OR HAYTON WILLIAMS FORCEP FIXATION - 3-POINT fixation

57. LE FORT III CORONAL APPROACH PREAURICULAR APPROACH

58. A . LATERAL EYEBROW APPROACH B. UPPER-EYELID APPROACH GLABELLA APPROACH

59. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP FIXATION- 3-point fixation IMMOBILISATION- Maxillomandibular Fixation if required

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