Mid facial fractures and their management

midfacial fractures and their management

1. Mid-facial fractures and their management DDS5

2. Layout Introduction Causes Midfacial bones Facial Buttresses Nerve supply of Midfacial region Important blood vessels History and examination Types of Midfacial fractures LeFort I,II,III and management Zygomatic fractures and management Orbital blow out and management Nasal fractures and management 3/12/2016 2

3. Abbreviations CSF – Cerebrospinal fluid NOE – Nasoorbital Ethmoid CT - Computerized tomography 3/12/2016 3

4. Introduction 3/12/2016 4

5. Introduction Middle third of the facial skeleton is an area bounded Superiorly by a line drawn across the skull from the zygomaticofrontal suture of one side, across the frontonasal and frontomaxillary sutures to the zygomaticofrontal suture on the opposite side Inferiorly by the occlusal plane of the upper teeth, or, if the patient is edentulous, by the upper alveolar ridge. 3/12/2016 5

6. Posteriorly , the region is demarcated by the sphenoethmoidal junction, but includes the free margin of the pterygoid laminae of the sphenoid bone inferiorly. 3/12/2016 6

7. Causes of facial fractures Motor vehicle accidents Assault/Domestic violence Falls Sports- related incidents Pathological Work- related incidents Warfare 3/12/2016 7

8. Midfacial bones 3/12/2016 8 Sphenoid (1) Ethmoid (1)

9. The frontal bone, the sphenoid body and greater and lesser wings are not usually fractured. In fact, they are protected to a considerable extent by the cushioning effect achieved as the fracturing force will crush the relatively weaker bones comprising the middle third of the facial skeleton. 3/12/2016 9 WHICH LEADS US TO TALK OF BUTTRESSES

10. Facial buttresses The central midface has many fragile bones that could easily be crushed when subjected to strong forces. They are surrounded by thicker bones of facial buttress system lending it some strength and stability. 3/12/2016 10

11. Midface buttresses are composed of: Frontal bone Maxillary bones Zygomatic bones Sphenoid bone AND THEIR ATTACHMENTS TO ONE ANOTHER  3/12/2016 11

12. 2 Components of Buttress system: Vertical buttresses Horizontal buttresses 3/12/2016 12

13. Vertical buttresses:   1. Nasomaxillary 2. Zygomaticomaxillary 3. Pterygomaxillary 4. Vertical mandible Resist occlusal load. 3/12/2016 13

14. Horizontal buttresses: 1. Frontal bar 2. Infraorbital rim & nasal bones 3. Hard palate & maxillary alveolus Interconnect and provide support for the vertical buttresses.  3/12/2016 14

15. Nerve Supply The middle third of the face supplied by 2 nd division of the Trigeminal nerve. 3/12/2016 15

16. Maxillary nerve branches 3/12/2016 16

17. The infraorbital nerve passes through the infraorbital canal below the floor of the orbit to innervate the soft tissues of the lower lid, the cheek and the lateral aspect of the nose and the upper lip. 3/12/2016 17

18. The palatine branches innervate the mucosa of the palate. The nasopalatine nerve passes anteriorly in the mucosa of the nasal septum bilaterally and through the incisive foramen to innervate the mucosa of the anterior palatine area. 3/12/2016 18

19. Blood supply The facial region is supplied by branches of external carotid artery . 3/12/2016 19

20. Branches of external carotid artery 3/12/2016 20

21. Important blood vessels The third part of the maxillary artery and its terminal branches are closely associated with the fractures of the middle third of the face. Occasionally the artery or its greater palatine branch is torn in the region of the pterygomaxillary fissure or pterygopalatine canal resulting in severe life threatening hemorrhage into the nasopharynx . 3/12/2016 21

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23. History taking 3/12/2016 23

24. Take AMPLE history A - Allergies M - Medications (Anticoagulants, insulin and cardiovascular medications especially) P – Previous medical/surgical history L – Last meal (time) E – Events/Environment surrounding the injury (Exactly what happened) 3/12/2016 24

25. History taking How did the accident occur? When did the accident occur ? Time since injury. What are the specifics of the injury, including the type of object contacted , the direction from which contact was made? 3/12/2016 25

26. Did loss of consciousness, vomiting, bleeding occur? What symptoms are now being experienced by the patient, including pain, altered sensation, visual changes, and change in bite? 3/12/2016 26

27. Physical examination 3/12/2016 27

28. Primary Survey: ABCDE Airway maintenance with cervical spine control Breathing and adequate ventilation Circulation with control of haemorrhage Degree of consciousness Exposure of the patient via complete undressing to avoid overlooking injuries camouflaged by clothing 3/12/2016 28

29. Physical examination Evaluate soft tissues for wounds. Palpate bony landmarks beginning with the: Supraorbital and lateral orbital rims Infraorbital rims Malar eminences Zygomatic arches Nasal bones. 3/12/2016 29

30. Physical examination Any steps or irregularities along the bony margin are suggestive of a fracture. Numbness over the area of distribution of the trigeminal nerve is usually noted with fractures of the facial skeleton. Inspect oral cavity for lost teeth, lacerations, occlusal alterations, step deformities. 3/12/2016 30

31. 3/12/2016 31

32. Types of Midfacial fractures 3/12/2016 32

33. Types of Midfacial fractures LeFort I, II, III Zygomatic complex fractures Zygomatic arch fractures Orbital blow out Nasal fractures NOE ( Naso Orbital Ethmoid ) fractures MAY BE ISOLATED OR OCCUR IN COMBINATION 3/12/2016 33 Rene LeFort 1901

34. Classifications Helps for communication purpose and to plan treatment. Rene LeFort : LeFort I, LeFort II and LeFort III . However there were other classifications also.. 3/12/2016 34

35. Erich’s (1942)- direction of the fracture line. 3/12/2016 35

36. Another classification based on relationship of the fracture line to the zygomatic bone - Below the zygomatic bone - Subzygomatic fractures Above or including the zygomatic bone - Suprazygomatic fracture 3/12/2016 36

37. Another classification depending on the level of a fracture line Low level fracture Mid level fracture High level fracture The most universally used classification is LeFort’s classification. 3/12/2016 37

38. LeFort I fracture Results from a horizontal force delivered above the level of the teeth (to the maxilla). The fracture courses from the lateral border of the pyriform aperture above the canine eminence  lateral antral wall  behind the maxillary tuberosity  across the lower third of the pterygoid plate. 3/12/2016 38

39. Almost always involves the pterygoid process of the sphenoid bone. The fracture separates the maxilla from the pterygoid plates and nasal and zygomatic structures. 3/12/2016 39

40. This type of trauma may separate the maxilla in one piece from other structures, split the palate, or fragment the maxilla. May involve the maxillary sinuses. The resultant “floating” component is the lower part of the maxilla and its teeth. 3/12/2016 40

41. The nasal septum may be fractured also. Le Fort I fracture may be unilateral or bilateral. It may occur on its own or in combination with other midfacial fractures. 3/12/2016 41

42. Clinical findings of LeFort I: Extra-orally Swelling of the upper lip. Soft tissue laceration. Open mouth to accommodate the displaced dentoalveolar portion. Epistaxis . 3/12/2016 42

43. Intra-orally Malocclusion. Mobility of tooth bearing portion. Dull sound on percussion. Ecchymosis of the maxillary buccal sulcus . 3/12/2016 43

44. LeFort II fracture R esults from a force delivered at a level of the nasal bones in superior direction. The fracture line occurs along the nasofrontal suture  lacrimal bone  across the infra- orbital rim in the region of the zygomatico -maxillary suture  above the canine eminence  inferiorly and distally along the lateral antral wall, but at a higher level than Le Fort type I  across the pterygoid plate at its middle. 3/12/2016 44

45. Separation of the maxilla and the attached nasal complex from the orbital and zygomatic structures. 3/12/2016 45

46. Clinical Findings of LeFort II Extraorally Ballooning of the face Lengthenening of the face Circumorbital ecchymosis Subconjunctival Haemorrhage Epistaxis Diplopia 3/12/2016 46

47. Enophthalmos CSF rhinorrhoea Step deformity in the lower border of the orbit Intact zygomatic bone and arch Intraorally Malocclusion Gagging of the posterior teeth and anterior open bite Mobility of the maxilla Ecchymosis of the sulcus 3/12/2016 47

48. LeFort III R esults when horizontal forces are applied at a level superior enough (at orbital level) to separate the NOE) complex, the zygomas , and the maxilla from the cranial base (Craniofacial separation/ dysjunction ). 3/12/2016 48

49. The fracture line courses through the zygomaticotemporal and zygomaticofrontal sutures  lateral orbital wall inferior orbital fissure medially to the naso -frontal suture  fractures the pterygoid plate at its base. 3/12/2016 49

50. Most severe of the LeFort fractures. Often associated with extensive soft tissue injury. Large force needed to cause this type of fracture. The resultant “floating” component is almost the entire face. 3/12/2016 50

51. Clinical Findings of LeFort III Extraorally Severe edema of the face “ballooning” Lengthening of the face Flattening of the cheek Circumorbital ecchymosis Subconjunctival Haemorrhage Epistaxis Enophthalmos CSF rhinorrhoea 3/12/2016 51

52. Intraorally Gagging of the posterior teeth and anterior open bite Ecchymosis and Haemorrhage of the buccal sulcus Mobility of the maxilla Mandibular interference 3/12/2016 52

53. Obstructed airway – soft palate rest on posterior dorsum of tongue 3/12/2016 53

54. Bilateral circumorbital ecchymoses – panda facies , or racoon eyes Bilateral subconjunctival ecchymosis 3/12/2016 54

55. Diplopia due to: Edema and hematoma Restrictive motility disorder (mechanical) Cranial nerve injury ( neurogenic ) 3/12/2016 55

56. Radiographs needed Occipito -mental view (Water’s View) CT scan Axial scan Coronal scan Sagittal 3 dimensional 3/12/2016 56

57. Treatment for LeFort fractures First aid and Preliminary treatment Definitive treatment Reduction Immobilization 3/12/2016 57

58. The principles of definitive treatment of LeFort fractures consist of reduction and fixation of the fractured bones to one another and to the skull achieved by either conservative or operative methods. 3/12/2016 58

59. The sooner the treatment is carried out, the better the prognosis. Restoration of the occlusion is a must. The bony framework and buttresses of the midface must also be repositioned or restored and fixed. 3/12/2016 59

60. Methods of reduction for LeFort fractures Manual reduction Simple manipulation by hand Dental compound on impression tray Gauze or rubber catheters Special instruments Reduction by traction Conservative treatment Supervised spontaneous healing Open reduction 3/12/2016 60

61. Manual reduction Carried out in all fresh fractures where the fragments are not impacted. As a rule, arch bars are first applied to the teeth. The lower jaw serves as a template , so that the occlusion can be checked. 3/12/2016 61

62. Simple manipulation by hand is possible in fresh fractures, maxilla is held between the index finger and thumb and brought into normal occlusion. Another method is to fix two double wires encircling the first and second maxillary molars and twisting them individually on either sides. 3/12/2016 62

63. Both the twisted wire ends are held by means of wire holders or hemostats and simultaneously downward movement of the maxilla will help to achieve the normal occlusion. 3/12/2016 63

64. Dental compound loaded into impression tray was suggested by Dingman and Harding in 1951, for mobilizing the fractured fragment of maxilla. This can be used, where some amount of fibrosis has set in because of delayed treatment. 3/12/2016 64

65. When the impression compound sets, then the firm grip can be taken on the maxillary arch and the handle of the tray is used for rocking the maxilla. 3/12/2016 65

66. Propescu and Burlibasa in 1966, have described reduction by rubber dam sheets or by means of long ribbon/strip gauze or rubber catheters. Whenever the maxilla is impacted and simple manual mobilization is not possible , then this method can be tried, if sophisticated instruments are not available. 3/12/2016 66

67. The rubber catheter’s end is passed from the nostril into the oropharynx and it is grasped with the help of hemostat and brought out of the oral cavity. 3/12/2016 67

68. So, you have one end coming out from nostril and other end through the oral cavity, same procedure is repeated on the other side through the nostril. After grasping all four ends of the catheter and stabilizing the head, maxilla can be rocked into the normal occlusion. 3/12/2016 68

69. Reduction by using special instruments—Specially constructed disimpaction forceps can be used to take firm grasp of the maxilla and reduce it into the position. 3/12/2016 69

70. Rowe’s maxillary disimpaction forceps : Available as right and left forceps. Always used in pairs . These are two pronged (divided) forceps, where one prong fits into the nasal floor and another one on the hard palate . 3/12/2016 70

71. Rowe’s Disimpaction Forceps 3/12/2016 71

72. Anterior traction in the case of a split palate, may be facilitated by the use of the special forceps devised by Hayton Williams. 3/12/2016 72

73. Applied to the buccal aspect of the alveolar process and medial compression exerted until the two halves of the upper jaw are approximated . 3/12/2016 73

74. A screw top is adjusted to prevent crushing of the bone. Can be combined with Rowe’s maxillary disimpaction forceps. The stabilized maxillary block may then be disimpacted and drawn forward. 3/12/2016 74

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76. Reduction by traction Repositioning the fractures that are already in a state of partial fusion OR when attempted manual reduction is met with failure , then reduction by elastic traction is tried to interdigitate the fractured fragments. 3/12/2016 76

77. Mainly used in delayed cases, where the fracture is 10 to 14 days old and no longer sufficiently mobile. Intraoral elastic traction. Extraoral elastic traction with appropriate extension bars and side bars. Intraoral intermaxillary elastic traction may be used in an appropriate direction to restore normal occlusion then replaced by IMF. 3/12/2016 77

78. Conservative Treatment Reduction and fixation of the fractured midface is indicated in cases, where surgery is not possible due to poor general condition of the patient or where there is extensive comminution with tissue loss, making internal skeletal fixation impossible. Also used as a supplementary measure with the surgical treatment of midfacial fracture. 3/12/2016 78

79. Supervised Spontaneous Healing Where mobility at the fractured maxilla is only slight , and occlusion is not disturbed. Progress of healing is merely supervised . The patient should avoid chewing during the first 2 to 3 weeks and should take a liquid/semisolid diet. 3/12/2016 79

80. Monomaxillary fixation: This method used when tooth bearing section of the maxilla is not fractured and therefore can serve as fixation point. The arch bar or palatal acrylic plates can be used. This can be used for unilateral fractures of maxilla or higher fractures without occlusal discrepancies. Maintained for 6 weeks . 3/12/2016 80

81. Intermaxillary fixation (IMF): Maintained for 3 to 4 weeks and at the end of this period IMF wires and the lower arch bars are removed. 3/12/2016 81

82. Internal skeletal wire suspension: Many times in addition to IMF, additional support is required for immobilization of the jaws. Craniomaxillary or craniomandibular suspension can be carried out using the stable point above the fracture line. The selection of the site for suspension wire will be dependent on the level of fracture line. 3/12/2016 82

83. The procedure for internal skeletal wire suspension is done through a minor surgery . Application of arch bars Reduction of fracture by closed method - occlusion is checked Fixation of the midface to the base of the skull by means of suspension wires. 3/12/2016 83

84. Fixation of the midface by tightening the suspensory wires and intermaxillary fixation. For edentulous patients, available prosthesis or Gunning splint is used. 3/12/2016 84

85. LeFort I fracture: Intermaxillary fixation by zygomatic arch suspension, if necessary additional suspension at the piriform aperture. 3/12/2016 85

86. LeFort II : Zygomatic arch suspension or frontal bone suspension. Intraosseous wiring may be done at infraorbital margins. 3/12/2016 86

87. LeFort III: Intraosseous wiring at zygomaticofrontal sutures and bilateral frontomalar suspension is used after the application of arch bars. Intraosseous wiring may be done at the infraorbital margin, if step deformity exists 3/12/2016 87

88. Maxillary suspension 3/12/2016 88

89. Open Reduction Carried out under endotracheal anesthesia with nasal intubation. Intraoral vestibular incision is taken from first molar to first molar region on either side. Mucoperiosteal flap is reflected to expose the fracture line. After identifying the fracture line, in old fractures, an osteotome is inserted to mobilize the fragment. 3/12/2016 89

90. Disimpaction forceps can be used and the fragment is brought into normal occlusion by manipulation. Temporary IMF is carried out and fracture fragments are fixed under direct vision by intraosseous wiring or minibone plates with screws. 3/12/2016 90

91. For extensive high level fractures of the midface bicoronal incision can be taken. 3/12/2016 91

92. Various skeletal incisions for exposure of midface skeleton are follows: Supraorbital eyebrow incison Subciliary incision Median lower eyelid incision Infraorbital incision Transconjunctival incision Zygomatic arch incision Transverse nasal incision Vertical nasal incision Medial orbital incision. 3/12/2016 92

93. Circumzygomatic suspension Obwegeser technique 3/12/2016 93

94. Zygomatic fractures 3/12/2016 94

95. Anatomy of Zygomatic bone 4 processes which articulate with: Maxillary bone Frontal bone Temporal bone Sphenoid bone 3/12/2016 95

96. Foramina of the Zygoma Foramen allows for passage of zygomaticofacial and zygomaticotemporal nerves of Maxillary branch of Trigeminal nerve that supply sensation to cheek and anterior temple . Infraorbital nerve courses the floor of the orbit and exits the infraorbital foramen. 3/12/2016 96

97. Zygomatic fracture It is unusual for the zygomatic bone itself to be fractured, but in extreme violence, the bone may be comminuted or split across. The isolated zygomatic arch fracture may occur without displacement of the zygomatic bone. 3/12/2016 97

98. Types of zygomatic fracture Zygomatic complex fracture – separate of zygoma from its 4 articulations Zygomatic arch fracture – fracture of zygomatic arch in isolation 3/12/2016 98

99. Classification of zygomatic fractures (Henderson, 1973) Type 1 – Undisplaced fracture Type 2 – Arch fracture only Type 3 – Tripod malar fracture ( Fronto-Zygomatic suture intact) Type 4 – Tripod malar fracture ( Fronto-Zygomatic suture distracted) Type 5 – Pure blowout fracture Type 6 – Orbital rim fracture Type 7 – Comminuted and other fractures 3/12/2016 99

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101. In 1985, Rowe changed his 1968 classification and gave more clinical significance by dividing fractures into stable and unstable varieties. 3/12/2016 101

102. Group A: Stable fracture—showing minimal or no displacement and requires no intervention. Group B: Unstable fracture—with great displacement and disruption at the frontozygomatic suture and comminuted fractures. Requires reduction as well as fixation. Group C: Stable fracture—other types of zygomatic fractures, which require reduction, but no fixation. 3/12/2016 102

103. Early clinical features of Zygomatic fracture Swelling and bruising over cheek Depressed cheek prominence Trismus and restricted lateral mandibular movements Ecchymosis at maxillary buttress region Step deformity along infraorbital margins and possibly along lateral orbital margin and zygomatic buttress Diplopia Enophthalmos Epistaxis on side of fracture 3/12/2016 103

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107. Late clinical features of Zygomatic fracture Flat cheek Enophthalmos Altered pupillary level Infraorbital paraesthesia Diplopia 3/12/2016 107

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109. Anaesthesia or paraesthesia of infraorbital and anterior superior alveolar nerve, may take 5-9 months for full recovery. Proximal part of nerve recovers first ie . Cheek before upper lip. After 1 year 10% still complain of paraesthesia . 3/12/2016 109

110. Radiographs needed Water's view: Submentovertex - "jug handle" Caldwell view CT Scan 3/12/2016 110

111. Treatment In majority of cases, early operation is advisable, provided that there are no ophthalmic or cranial complications. Whenever there is a gross periorbital edema and ecchymosis , postponement of the operation for 3 to 5 days can be done, but it should not be prolonged more than two weeks. 3/12/2016 111

112. Stable fractures: Simple elevation will be sufficient, because of high degree of stability due to integrity of temporal fascia and the interdigitation of the fracture lines. No additional fixation is required after reduction. Type 1 : No treatment Type 2 : Unless vertically displaced Type 3 : and Type 4 (a): Open reduction may be required and transosseous wiring is advisable. 3/12/2016 112

113. Unstable fractures: Require open reduction and transosseous wiring or bone plating. Type 4 (b) Types 5, 6, and 7, 8 3/12/2016 113

114. Operative technique: The approach of Gillies , Kilner and Stone (1927) is popular for reduction of fractures of zygoma 3/12/2016 114

115. Methods of reduction : Closed reduction ( Gillies temporal approach) using: - Bristow’s elevator - Rowe’s zygomatic elevator Open reduction ( surgical ) 3/12/2016 115

116. Gillies Temporal Approach The temporal fascia is attached to the zygomatic arch and the temporal muscle passes downward medial to the fascia to be attached to the coronoid process. Between these two structures a natural anatomical space exists into which an instrument can be inserted and it can be utilized to elevate the displaced zygoma or its arch into position. 3/12/2016 116

117. Technique: The hair is shaved from the temporal region of the scalp. The external auditory meatus is plugged with cotton to prevent any fluid or blood getting inside. An incision about 2 to 2.5 cm in length is made, inclined forward at an angle of 45 degrees to the zygomatic arch, well in the temporal region. Care is taken to avoid injury to the superficial temporal vessels. 3/12/2016 117

118. The temporal fascia is exposed which can be identified as white glistening structure. The incision is taken into the fascia and the fibers of temporalis muscles will be seen. Long Bristow’s periosteal elevator is passed below the fascia and above the muscle. 3/12/2016 118

119. Once this correct plane is identified and instrument is inserted through it, downward and forward, the tip of the instrument is adjusted medially to the displaced fragment. A thick gauze pad is kept on the lateral aspect of the skull to protect it from the pressure of elevator while reduction is going on. 3/12/2016 119

120. The operator has to grasp the handle of the elevator with both hands and assistant has to stabilize the head of the patient. (During elevation procedure care should be taken that pressure is not exerted on the lateral surface of the skull to end up with depressed fracture of the skull). 3/12/2016 120

121. The tip of the elevator is manipulated upward, forward and outward. The snap sound will be heard as soon as reduction procedure is complete. Wound is closed in layers after withdrawing the elevator. 3/12/2016 121

122. Care is taken that after surgery at least for 5 to 7 days, no pressure is exerted on the area till the bone consolidates. Patient is instructed to sleep in supine position or not to sleep on the operated side. 3/12/2016 122

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125. Intraoral procedure Keen’s approach (1909): Introral buccal vestibular incision is taken in first and second molar region behind the zygomatic buttress. A pointed curved elevator (Monks’ pattern) is passed supraperiosteally up beneath the zygomatic bone. The depressed bone is then elevated with an upward, forward and outward movement. 3/12/2016 125

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127. In 3/12/2016 127 Intraoral reduction of zygomatic bone fracture by Keen’s Approach Stabilization of reduced fracture by using balloon catheter

128. Alternate methods like intranasal elevation via intra nasal antrostomy or oroantral elevations were suggested. Direct extraoral elevation can be done by inserting a sharp curved hook directly through the skin below and above the prominence of the zygomatic bone. Manipulation of the hook reduces the fracture 3/12/2016 128

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130. Gross separation of the zygomaticofrontal suture (Type 4(a), 4(b), 5(a),(b) and (c): Extraoral incision is taken in the wrinkles, one centimeter above the outer canthus or in the line of the outer aspect of the eyebrow. Holes are drilled approximately 0.5 cm away from the fracture ends of the frontal and zygomatic bones. 3/12/2016 130

131. A periosteal elevator is placed on the medial aspect to protect the eye. The 26 gauge double wire is passed and twisted after passing through both the holes and approximation of the fragments. Instead of wire, 2 hole miniplates can also be used for direct fixation. Wound is closed in layers 3/12/2016 131

132. Comminution of the orbital floor (Type 6(a)): Use of antral pack or balloon catheter can be done which is previously described. Comminution and displacement of the orbital rim (Type 7): Direct figure of eight intraosseous wiring can be done through extraoral infraorbital incision or semilunar orbital bone plate can be fixed 3/12/2016 132

133. Associated coronoid fractures: No separate treatment is indicated. But if coronoid process is completely detached and causing limitation of the oral opening after reduction then it should be excised through intraoral incision. 3/12/2016 133

134. Other indirect approaches Towel Clip : applied directly 3/12/2016 134

135. Open reduction techniques: Lateral brow incision Subcilliary ( blepheroplasty ) incision Infraorbital crease incision Bicoronal / Hemicoronal flap 3/12/2016 135

136. Trans osseous wiring: Wiring - 24 - 30 gauge stainless steel wire 3/12/2016 136

137. Mini bone plates 3/12/2016 137

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139. Malunion of the Zygomaticomaxillary Complex It will show following signs and symptoms: 1. Cosmetic 2. Neurological 3. Antral 4. Masticatory 5. Ophthalmic 3/12/2016 139

140. Cosmetic: Loss of contour or prominence of cheek will be seen. Correction may be done either by surgical refracturing or camouflaging the deformity by means of onlay bone grafting or alloplastic material like hydroxylapatite blocks. 3/12/2016 140

141. Neurological: The paresthesia , dysesthesia or anesthesia may be present. Observation for recovery of infra orbital nerve should be done for 6 to 12 months, otherwise surgical exploration of the nerve can be done. 3/12/2016 141

142. Antral : Persistent sinusitis may be due to the presence of loose necrotic bone pieces or a foreign body, which should be removed via Caldwell Luc operation. 3/12/2016 142

143. Masticatory : Depressed zygomatic arch fracture impinges on the coronoid process bringing about limitation of the mandibular movements and opening. In extensive fracture, via coronal incision the arch should be exposed, refractured and stabilized by direct fixation method. Osteotomy and bone grafting can be done if required. 3/12/2016 143

144. Ophthalmic: Change of the ocular level, diplopia , enophthalmos , occulorotatory restriction are the residual deformities which are difficult to correct secondarily. Exploration and surgical correction can be attempted. 3/12/2016 144

145. Fracture of the Floor of the Orbit (Blow-out Fracture) 3/12/2016 145

146. Fracture of the Floor of the Orbit (Blow-out Fracture) True blowout fracture occurs as a result of direct trauma to the orbit with an object larger than the globe size (cricket ball injury). Here primarily there is an increase in hydraulic pressure within the orbit resulting from compression of the orbital contents. 3/12/2016 146

147. In addition, forces acting on the bone play a part. The fractured orbital floor gives way into the maxillary sinus. At the same time, orbital fatty tissue and sometimes muscles, (inferior rectus and inferior oblique) prolapse into the sinus like a hernia. 3/12/2016 147

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150. Clinical symptoms: Circumorbital edema Circumorbital ecchymosis Ophthalmoplagia Diplopia (upper & lateral gaze) Enophthalmos 3/12/2016 150

151. Diagnosis can be confirmed by: Forced duction test Hanging drop appearance in PA view, Water’s position radiograph or by CT scan 3/12/2016 151

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153. 3/12/2016 153 Figure

154. Forced duction test: Here a small tissue holding forceps is used to grasp the tendon of the inferior rectus muscle through the conjunctiva of the inferior fornix and the patient is asked for the entire range of motion. An inability to rotate the globe superiorly signifies entrapment of the muscles in the orbital floor 3/12/2016 154

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157. Treatment Surgical exploration of orbital floor and reconstruction of the orbital floor by silastic sheet or bone graft, whenever necessary. Otherwise balloon support or ribbon gauze packing can be used in the maxillary sinus. 3/12/2016 157

158. Antral support 3/12/2016 158

159. Orbital floor reconstruction Autograft --rib, iliac crest, calvaria , as well as ear or nose cartilage Allograft --lyophilized dura , rib, iliac crest, cartilage Alloplast --Teflon, Silastic , Ti-Mesh, and Gelfilm have been described 3/12/2016 159

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161. Nasal bone fracture 3/12/2016 161

162. Fractures of Nasal bone High Incidence because of prominence of nose. Usually due to direct injury; can occur as an isolated fracture or it may be combined with other facial fractures. 3/12/2016 162

163. Leads to cosmetic deformity and functional disturbance. 3/12/2016 163

164. Nasal fractures in children should be generally treated conservatively with closed reduction, because of the growth potential. 3/12/2016 164

165. Often overlooked in multiple facial injuries. Nasal symmetry, proper appearance and adequate airway through the nose is important. 3/12/2016 165

166. Anterior injuries: Direct, violent, and/or anterior force may result in smash fractures of the nasal bones, the frontal process of the maxilla, the lacrimal bones and the septum. Comminuted fragments may be driven laterally into the orbit or upward into the ethmoid region. 3/12/2016 166

167. Splayed nasal fractures may be associated with damage to the nasolacrimal ducts, the perpendicular plate of the ethmoid , the ethmoid sinuses, the cribriform plate and the orbital parts of the frontal bone. Widening of the intercanthal distance is known as traumatic telecanthus . Buckling of the nasal septum may be seen. 3/12/2016 167

168. Lateral injuries: Force applied from the side, may involve only one nasal bone with medial displacement, but most commonly in adults, a violent blow from the side results in fractures of both nasal bones and fracture of nasal septum with lateral shifting of the entire bony framework. 3/12/2016 168

169. This is known as ‘open book’ fracture - Nasal septum collapsed and nasal bones splayed out. In most severe injuries, the septum may be fractured or displaced from the maxillary crest, from the vomerine groove or from its attachment at the anterior nasal spine of the maxilla, with displacement into the adjacent airway. Fractures of the septum occur in the vertical plane. There may be telescoping or overlapping seen. 3/12/2016 169

170. Diagnosis History Careful clinical examination Radiographs 3/12/2016 170

171. History: History of previous nasal deformity, trauma, surgery or breathing difficulty should be asked for. Nature and direction of the trauma also should be asked. Patient’s chief complaints are usually nasal bleeding, pain, swelling and difficulty in breathing through the nose. Sense of smell also may be lost or diminished. 3/12/2016 171

172. Clinical features: Depressed bridge of the nose Flattening or deviation of the nasal bone Hematoma Subconjunctival haemorrhage Nasal obstruction may be caused by: edema, blood clots, swelling of nasal mucosa, dislocated bone, cartilage 3/12/2016 172

173. Subcutaneous emphysema may be present because of patient’s repeated attempts to blow nose Circumorbital ecchymosis Cerebrospinal fluid (CSF) rhinorrhoea Crepitation and tenderness Active bleeding or epistaxis should be taken care immediately. 3/12/2016 173

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175. Radiographs Occipitomental Lateral views of the nasal bones A lateral view taken with a small dental film against the side of the nose also provides an excellent detailed study. Computed Tomography (CT) scan is helpful for higher level fractures of the nose. 3/12/2016 175

176. Management Closed reduction is the treatment of choice for most nasal bone and/or septal fractures. These fractures should be repaired within 7 to 10 days. Closed reduction can be done under LA with or with out sedation or general anesthesia. 3/12/2016 176

177. It should never be conducted under intravenous sedation alone. As reduction procedure will provoke bleeding, the trickling of the blood near glottis may provoke a dangerous laryngeal spasm. 3/12/2016 177

178. If the local anesthesia and sedation are used, it is important to protect the airway by packing ribbon or strip gauze soaked with local anesthetic agent plus vasoconstrictor for hemostasis . The pack is placed in the posterior aspect of the nose with suture attached to it for retrieval. Local anesthetic agent is then injected with vasoconstrictor intranasally . 3/12/2016 178

179. The two specially designed instruments that are used for repositioning the nasal bones are Asche’s and Walsham’s forceps. In general, bony fractures should be reduced first, followed by reduction of septal fractures or its dislocation from the maxillary groove. 3/12/2016 179

180. The reduction can be done by using a long, flat, narrow instrument such as Howarth’s periosteal elevator. Inferiorly or medially displaced nasal bones are lifted upward and laterally, by using Howarth’s elevator intonormal position. The laterally displaced nasal bones are brought into normal position by using Walsham’s forceps or digital pressure. 3/12/2016 180

181. Walsham‘s forceps are used with unpadded blade inside the nasal cavity deep to the nasal bones and the other padded blade externally on the skin over the fractured nasal bones. The bones are manipulated between the blades until adequate mobility is achieved. 3/12/2016 181

182. Anterior traction and medial rotation followed by lateral rotation to reposition the fragments is done. Operator will constantly check the external nasal contour with his palpating fingers. 3/12/2016 182

183. Asche’s septal forceps are then introduced on either side of the septum along the floor of the nose and used to realign the septal cartilage in the groove in the vomer and having ironed out any deflection in the perpendicular plate of ethmoid or the vomer are slowly brought upward and forward to elevate the nasal bridge anteriorly . 3/12/2016 183

184. At the end of the reduction, previous nasal pack with the suture is removed. Following complete reduction, internal stabilization is done with nasal packing using half inch ribbon gauze saturated with antibiotic ointment. 3/12/2016 184

185. The pack is placed under direct vision in the superior nasal vault first and then packed inferiorly. Both the nostrils should be packed to support the nasal septum. The pack is removed after 3 to 4 days. 3/12/2016 185

186. The external dressing consists of padding the area with cotton wool or gauze pieces and stabilizing it with adhesive tape in a ‘butterfly’ manner secured to the forehead and crossing over the nasal bridge on either side. External splints that may be used include dental impression compound mould, plaster of Paris, metal splints, lead plates or acrylic or prefabricated splints such as Denver splint. 3/12/2016 186

187. The external splints are usually left in place for 5 to 7 days after reduction. The splint provides support for the nasal bones as well prevents hematoma and edema of the nasal structures. 3/12/2016 187

188. Nasal fractures associated with maxillofacial injuries should be treated after stabilizing other fractures with miniplate system, so that IMF is not required and airway can be maintained through the oral route as the nostrils will be packed for 3 to 4 days postoperatively. 3/12/2016 188

189. In extensive unstable fractures open reduction can be opted for. Open sky or bicoronal approach can be used and bone grafting, direct fixation of the fragments can be planned. 3/12/2016 189

190. References Contemporary Oral and Maxillofacial Surgery 6 th Edition – Hupp , James (Chapter 25 Management of facial fractures) Maxillofacial injuries – A synopsis of Basic Principles, Diagnosis and Management - George Dimitroulis , Brian Avery (Chapter 6 ). https://sites.google.com/site/drtbalusotolaryngology/rhinology/buttress-system-of-midface ‘Buttress system of midface ’. Accessed on 14.2.2016. Textbook of Oral and Maxillofacial Surgery 3 rd Edition – Neelima Anil Malik (Chapter 29 + 30). 3/12/2016 190

191. Thank you for listening  3/12/2016 191