panfacial fractures- anatomy, clinical features, radiology.pptx

Power point presentation on facial fracture and its management

1. PAN FACIAL FRACTURES Dr. Gautam Kalra Senior Resident Plastic & Reconstructive surgery AFMC

2. Introduction Clinical anatomy Fracture patterns & clinical features Radiology

3. Introduction Definition : Complex facial fractures concurrently involving upper, middle and lower one-third of face. In practice- two out of three. Incidence: 4-10% * * Panfacial fractures- An approach to management-William Curtis et.al- Oral & Maxillofacial Surgery Clinics, Vol-25, Issue-4, 649-660

4. Introduction Etiology * 1)Assault (36%) 2) Road traffic accidents (32%) 3) Fall (18%) 4) Sports (11%) 5) Occupational (3%) 6) Gunshot wounds (2%) * Erdmann D, Follmar KE, Debruijn M, et.al. A retrospective analysis of facial fracture etiologies. Ann Plast Surg. 2008 Apr. 60(4): 398-403

5. Introduction Involved bones Frontal bones Zygomatico -maxillary complex Naso-orbitoethmoid region Maxilla & mandible

6. Clinical Anatomy Facial buttress Areas of relative increased bone thickness that support the functional units of the face (muscles, eyes, dental occlusion, airway) in an optimal relation and define the form of face by projecting the overlying soft tissue envelope. Structural support to facial skeletal complex. Function: transmission of forces to the cranium

7. Clinical Anatomy Vertical buttress Nasomaxillary Zygomaticomaxillary Pterygomaxillary Vertical mandible Horizontal buttress Frontal bar Infraorbital rim & nasal bones Hard palate & maxillary alveolus

8. Clinical Anatomy Vertical buttress Manson et.al 3-D projection of midface Mastication- Vertical force- well developed vertical buttress Transmit forces along a vertically oriented vector. Horizontal buttress Interconnect and support vertical buttress Lateral stability to facial skeleton.

9. Clinical Anatomy Significance of buttress * Accommodate metal screw fixation. Linked directly or indirectly through another buttress to cranium/ cranial base as a stable reference point. Horizontal buttress reduction- facial profile, width Vertical buttress reduction- facial height. Buttress reduction- functional support for teeth, globe. Precise reduction of buttresses against stable cranial base/ mandible restores 3-D shape of face. * Diagnosis of midface fractures with CT: What the surgeon needs to know. Richard A Hopper, Radiographics 2006; 26: 783-793

10. Clinical Anatomy Key landmarks 1) Dental arches 2) Mandible 3) Sphenozygomatic suture 4) Intercanthal region

11. Clinical Anatomy Dental arches Intact dental arch- guide to dental width Maxillary arch- semiellipse A-B(short axis): 57-62mm C-D(half long axis): 50-50mm Mandibular arch- parabola A-B(distance b/n mesiobuccal cusps of lower 3 rd molars): 55-60mm C-D: 48-52mm

12. Clinical Anatomy- Dental Arches Clinical scenario : Mid-palatal split + fracture-tooth bearing mandible + condylar fracture Expose palatal fracture, reduction & rigid fixation, reestablish maxillary width. Fabricate dental models simulated surgery on upper and lower arch fabricate surgical splint Reconstruct mandible first. MINIPLATE

13. Clinical Anatomy 2 ) The Mandible Reduction of lingual & buccal cortical surfaces yields better results Bilateral subcondylar fractures- reduction necessary to restore posterior facial height & facial width

14. Clinical Anatomy 3) Sphenozygomatic suture Key landmark for reduction & fixation of ZMC, provided roof and lateral orbital wall are intact. Gross bone loss- primary bone grafting Exposed along the internal surface of lateral orbital wall.

15. Clinical Anatomy 4) Intercanthal region : (30-35mm) Used to re-establish mid-facial width if nasoorbitoethmoid (NOE) complex is not severely comminuted.

16. Fracture patterns Complex midfacial fractures- 5 midface subunits Nasoseptal fractures Naso-orbito-ethmoid complex(NOE) fractures Orbital fractures Zygomaticomaxillary complex(ZMC) fractures Occlusion bearing maxillary fracture - alveolar process fractures Other clinically significant facial fractures - frontal sinus fractures - paranasal sinus fractures - mandibular fractures

17. Fracture patterns Nasoseptal fractures -Most common facial #(45%) - Mechanism: Lateral impact : Head on impact - Associated injuries: Septal hematoma Orbital blow out fracture Frontal process of maxilla fracture

18. Fracture patterns Xrays : Lateral view Water’s view- nasal arch Presentation: Epistaxis Deformity Nasal airway obstruction Infraorbital ecchymosis

19. Fracture patterns ii) NOE complex fracture Central upper midface Mechanism: high impact force to anterior nose, transmitted posteriorly through ethmoid bone. Associated injuries: Medial canthal tendon injury- telecanthus NLD disruption- frontal mucocele formation Exophthalmos - reduced intraorbital volume Cribriform plate #- CSF rhinorrhea

20. Fracture patterns Markowitz & Manson classification Type-I: Medial canthal tendon intact, connected to a single large fracture segment Type-II: Comminuted fracture, medial canthal tendon connected to a single bone fragment Type-III: comminution extends to the medial canthal tendon insertion site on the anterior medial orbital wall at the level of the lacrimal fossa , with resultant avulsion of the tendon

21. Fracture patterns NOE fractures Clinical features: - Telecanthus , hypertelorism - Periorbital ecchymosis & edema - Epistaxis , CSF rhinorrhea - Upturned nasal tip- pig snout - Epiphora , anosmia - Decreased dorsal nasal projection

22. Fracture pattern X-ray- can be missed hazy maxillary & ethmoid sinuses CT- thin cut(1.5mm) axial & coronal

23. Fracture Pattern iii) Orbital wall fractures Anterior- orbital rim Posterior- roof, floor, medial, lateral walls Blow out Direction of force Blow in Non-contrast CT: 1.5mm or 2mm axial, sagittal and coronal cuts

24. Fracture pattern Classification - Manson – based on CT High energy: extreme displacement, comminution of the articulations, and segmentation of bones. Moderate energy : displacement with involvement of all sutures. Low energy: displacement but without comminution of articulations.

25. Fracture pattern Clinical features Diplopia Restricted ocular movements Enopthalmos Vision loss Hypoesthesia- infraorbital nerve distribution

26. Fracture Pattern iv) Zygomaticomaxillary complex fractures( ZMC) 2 nd most common facial fractures. Causes : assault, RTA Significance : impairment of ocular & mandibular function Anteromedial Inferior orbital fissure Superolateral (key landmark) Inferior Sphenozygomatic suture: for reduction

27. Fracture Pattern 1 st fracture line Anteromedial , along orbital floor, orbital process of maxilla upto infraorbital rim 2 nd fracture line Posteriorly through infratemporal aspect , joins fracture from anterior maxilla 3 rd fracture line Superiorly along lateral orbital wall separating zygomaticoshpenoid suture 3 1 2

28. Fracture Pattern Clinical features Periorbital ecchymosis , -Step deformity- orbital margin edema - Trismus Flattening of malar - Infraorbital nerve parasthesia prominence - Depression of lateral canthus Flattening of zygomatic - Enophthalmos arch Maxillary buccal sulcus ecchymosis

29. Fracture pattern Le Fort classification of midface fractures Type-I Fracture line passes through alveolar ridge , lateral nose and inferior wall of maxillary sinus Horizontal maxillary fracture separating teeth from upper face Rene Lefort-1901

30. Fracture pattern Type-II Fracture line passes through posterior alveolar ridge, lateral walls of maxillary sinus, inferior orbital rim and nasal bones . Pyramidal fracture- base-teeth, apex- nasofrontal suture.

31. Fracture pattern Type-III Transverse fracture line passes through nasofrontal suture, maxillofrontal suture, orbital wall and zygomatic arch/ zygomaticofrontal suture. Craniofacial dysjunction

32. Fracture pattern Le Fort I: ‘floating palate’ Le Fort II: ‘floating maxilla’ Le Fort III: ‘floating face’ Intact anterolateral margin of nasal fossa : excludes Lefort -I Intact inferior orbital rim: excludes Lefort -II Intact zygomatic arch: excludes Lefort -III

33. Fracture patterns Frontal sinus fracture 5-12% of all facial fractures Stanley’s modification of Gonty’s classification Type-I: Anterior table fracture Type-II: Anterior and posterior table fracture Type-III: posterior table fracture Type-IV: through and through fracture Associated injuries: NOE fractures

34. Fracture patterns Clinical presentation: Forehead swelling, pain Forehead parasthesia Xray : Sinus opacification bony step-off CT: 1.5mm coronal and axial cuts

35. Radiology X-ray Standard X-ray projections Lateral cephalic Caldwell’s view Water’s view Submentovertex (SMV) view Towne’s view

36. Radiology Lateral cephalic view Evaluation of airway, retropharyngeal soft tissue Anterior & posterior maxillary antral walls Anterior alveolar ridge Midface fractures- Lefort & nasal

37. Radiology Caldwell’s view- Entire orbital rim esp superomedial Ethmoid sinus Orbital fracture, posterior facial fractures Nasofrontal & vertical segments of zygomatic buttress, nasal fossa , mandible

38. Radiology Water’s view Fractures of orbital rims, zygomatic arches, anterior facial fractures

39. Radiology Towne’s view Subcondylar mandible fracture- lateral/medial angulation Inferior orbital fissure Maxillary sinus & inferior orbital rim- post op evaluation after repair.

40. Radiology Submentovertex view Zygomatic arch & midface fractures Zygomatic arch fracture

41. Radiology Orthopantomogram (OPG) Evaluation of mandibular fractures Occlusal fims : dentoalveolar injuries

42. Radiology Trapnell’s line Pattern of 5 lines Systematic examination of all parts of facial skeleton and likely fracture sites. 1 st line: zygomaticofrontal suture, superior margin of orbit & frontal sinus 2 nd line: zygomatic arch, zygomatic body, inferior orbital margin, nasal bone 3 rd line: across condyles , coronoid process, maxillary sinus 4 th line: across mandibular ramus , occlusal plane 5 th line: Trapnell’s line- across the inferior border of mandible from angle to angle

43. Radiology Dolan et.al Evaluation of occipitomental projection Orbital line Zygomatic line Maxillary line

44. Clinical Anatomy- Related arteries