MIDFACE FRACTURES

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MIDFACE FRACTURES:

MIDFACE FRACTURES Prepared by- DR PARTH RAVAL P.G. 2nd yr Oral Surgery

Slide 2:

God has given you one face, and you make yourself another. William Shakespeare The face is intimately related to self image. It gives us identity in the society. It is the region responsible for our senses of smell and vision and for providing our voice and resonance through the presence of air sinus

MID-FACE:

3 MID-FACE Definition: The area between a superior plane drawn through the zygomatico -frontal sutures tangential to the base of the skull and inferior plane at the level of the maxillary dental occlussal surface. Posteriorly the region is demarcated by the sphenoethmoidal junction, but includes the free margin of pterygoid laminae of the sphenoid bone inferiorly.

SURGICAL ANATOMY OF MIDAFCE:

SURGICAL ANATOMY OF MIDAFCE Bony architecture The bones contributing to midface ; 2 maxillae 2 palatine bones 2 zygomatic bones and their temporal process 2 zygomatic process of temporal bone 2 lacrimal bones Vomer Ethmoid bone and its attached conchae Body , greater and lesser wings of sphenoid 2 nasal bones

Slide 5:

Developmental sutures between these structures represent potential areas of weakness and are often the sites of fracture. Common sutural fracture sites are the Frontozygomatic suture, Zygomaticomaxillary suture, Zygomaticosphenoid suture, Nasofrontal suture, Maxillofrontal suture, Nasomaxillary suture, Midpalatal suture.

Slide 6:

The two maxillae are paired structures connected by a midline suture; the bones together compose a five-sided pyramid. The anterior surface slopes downward from its superior contact with the frontal and nasal bones at an angle of approximately 15°. The lateral surface of the maxillae forms the infratemporal fossae and buccal vestibule and attaches to the zygoma . Most of the superior surface forms the majority of the orbital floor.

Slide 7:

The medial surface of each maxilla forms the midline suture and lateral nasal walls. This includes the nasal concha and sinus ostia . The ostium of the nasolacrimal duct is beneath the inferior concha . The ostia of the maxillary sinus and middle ethmoids , as well as the opening of the nasofrontal duct, lie beneath the middle concha

Slide 8:

The inferior border composes the palatal vault and alveolus, which contain the teeth. The posterior border abuts the sphenoid bone and the pterygomaxillary suture. Within the maxilla is the maxillary sinus. This 34 × 33 × 25 mm air cavity is responsible for the weakness of the maxilla.

Slide 10:

The palatine bone is L shaped and abuts the posterior maxilla as a paired structure. These bones assist the maxilla in forming the posterior sinus, the posterior lateral nasal wall, and the pterygomaxillary suture. When joined to the maxilla the four bones represent one unit

Slide 11:

The nasal bones are paired structures that abut the frontal bone superiorly, the maxilla laterally, the septum posteriorly and medially, and each other anteriorly and medially. The bones are thicker superiorly therefore, fractures at the Le Fort II level may occur inferior to the nasofrontal suture.

Slide 12:

The nasal septum is a thin trapezoidal bone lying perpendicular to and joining the maxillae and palatine bones. The superior border is thick and articulates with the ethmoid bone.

Slide 13:

The ethmoid bone is cuboidal and extremely pneumatized ; thus, it can be easily fractured and comminuted . The cribriform plate of the ethmoid composes the roof of the nasal cavity and communicates with the anterior cranial fossae through multiple foramina for the olfactory nerves. Lateral to the crista galli is a slit through which dura mater is exposed. Posterior and superior movements of the midface can easily comminute this bone, thus disrupting the dura mater and resulting in a cerebrospinal fluid leak.

Slide 14:

The zygoma abuts the frontal bone at the frontozygomatic suture and the temporal bone at the zygomaticotemporal suture. The maxilla and zygoma form two-thirds of the orbital rim and, along with the palatine bone, one-third of the walls and floor of the orbit. The infraorbital nerve traverses the orbital floor and exits through the infraorbital foramen. The maxillary bone, along with the zygoma , forms the inferior orbital fissure. Through this fissure run the maxillary nerve, the infraorbital vessels, and the ascending branches of the ptery - gopalatine ganglion.

Slide 15:

The frontal process of the maxilla contains the lacrimal apparatus, which is housed between the medial canthal ligaments. The blood supply to the maxillae and palatine bones is through the periosteum, the incisive artery, and the greater and lesser palatine arteries. The internal maxillary artery, a source of potentially devastating hemorrhage , lies posterior to the maxillae and palatine bones and anterior to the pterygoid plates of the sphenoid. The blood supply to the nasal septum and the lateral nasal walls is provided by the anterior and posterior ethmoidal arteries, the sphenopalatine artery, and the greater palatine and superior labial arteries

Physical characteristics of midfacial skeleton:

Physical characteristics of midfacial skeleton Numerous bones which are rarely #d in isolation Bones of maxilla are fragile and they aritculate in complex fashion. Maxilla is attached to cranium and is supported by vertical and horizontal buttress. Midface is like a matchbox sitting below a hard shell containing brain. So forces are absorbed by it and it provides protection to brain and spinal cord.

Vertical and horizontal buttresses of face:

Vertical and horizontal buttresses of face

Slide 18:

The fractures of midface are generally comminuted esp bones of nasoethmoid and anterior maxilla creating typical dish face deformity. The forces from below upwards are well tolerated and distributed along the buttresses of the face but lateral and horizontal forces invariably leads to fracture of maxilla.

Slide 19:

If the bones comprising the middle third are removed from the skull, it will seen that frontal bone and body of sphenoid form an inclined plane of 45degree of frontal bone to occlusal level of upper teeth

Slide 20:

Maxillary fractures often tend to displace the elements of nasal septum and nasal bones and expose paranasal sinuses to possibility of infection. At times comminution of the bone of orbital floor and medial wall of orbit occurs leading to varying degree of diplopia due to detachment of medial or lateral attachments of L ockwood or due to entrapment of muscle in the fracture line.

Slide 21:

A shearing stress applied to ethmoidal region results in comminution of the cribriform plate of ethmoid bone leading to CSF rhinorhoea . The maxillary, palatine, ethmoid , vomer , lacrimal and body of sphenoid bones are enclosed in the mucosa covering the large areas of their surfaces, hence the blood supply of any part of midfacial skeleton is never compromised.

Etiology of Midfacial Injuries:

Typical causes: direct violence indirect violence Crush injuries Automobile accidents RTA Air crash Mining accidents High velocity missiles Central middle third injuries are caused by road traffic accidents, Zygomatic fractures commonly result from urban violence, sports injuries or falls. Etiology of Midfacial Injuries

Slide 23:

For convenience fractures of middle third of facial skeleton may be divided into lateral middle third ( zygomatico maxillary) central middle third LeFort I Transverse Maxillary Lefort II Pyramidal Lefort III Craniofacial Dysjunction Orbital Floor Nasal Fractures Naso -orbital/ Ethmoid

Classification of middle third fractures :

Classification of middle third fractures Broadly classified A). Lefort I II III B).Erich`s in 1942,as per the direction of fracture line. Horizontal , Pyramidal, Transverse. C).Depending on the relation of fracture line to zygomatic bone. sub zygomatic, supra zygomatic D) Depending on the level of fracture Low level, Mid level, High level.

Slide 25:

It was not until 1901 that René Le Fort published his landmark works, a three-part experiment using 32 cadavers that were either intact or decapitated. The heads of the cadavers were subjected to various types of trauma; the soft tissue was then removed and the bones were examined. Le Fort noted that, generally, if the face was fractured, the skull was not.

Slide 26:

He then stated that fractures occurred through three weak lines in the facial bony structure: those that protect the cranial cavity, those that circumscribe the midface , and those that cut across the face. From these three lines the Le Fort classification system was developed

Le Fort I (Low-level Fracture / Guerin / Floating Fracture) :

This is a horizontal fracture above the level of the nasal floor. The fracture line extends backwards from the lateral margin of the anterior nasal aperture below the zygomatic buttress to cross the lower third of the pterygoid laminae . The fracture also passes along the lateral wall of the nose and the lower third of the nasal septum to join the lateral fracture behind the tuberosity . Le Fort I (Low-level Fracture / Guerin / Floating Fracture)

Le Fort II (Pyramidal or Sub zygomatic Fracture) :

This fracture runs from the thin middle area of the nasal bones down either side, crossing the frontal processes of the maxillae into the medial wall of each orbit. Within the orbit, the fracture line crosses the lacrimal bone behind the Lacrimal sac, before turning forward to cross the infra-orbital margin slightly medial to or through the infra-orbital foramen. The fracture now extends downwards and backwards across the lateral wall of the antrum below the zygomaticomaxillary suture and divides the pterygoid laminae about halfway up. Separation of the block from the base of the skull is completed via the nasal septum and may involve the floor of the anterior cranial fossa. Le Fort II (Pyramidal or Sub zygomatic Fracture)

LE FORT III (HIGH TRANSVERSE OR SUPRAZYGOMATIC FRACTURE / CRANIO FACIAL DYSJUNCTION) :

The fracture runs from near the frontonasal suture transversely backwards, parallel with the base of the skull and involves the full depth of the ethmoid bone, including the cribriform plate. Within the orbit, the fracture passes below the optic foramen into the posterior limit of the inferior orbital fissure. From the base of the inferior orbital fissure the fracture line extends in two directions; backwards -across the pterygo -maxillary fissure to fracture the roots of the pterygoid laminae laterally -across the lateral wall of the orbit separating the zygomatic bone from the frontal bone. In this way the entire middle third of the facial skeleton becomes detached from the cranial base. LE FORT III (HIGH TRANSVERSE OR SUPRAZYGOMATIC FRACTURE / CRANIO FACIAL DYSJUNCTION)

Slide 30:

E)Modification of Lefort`s classification, BY MARCIANI 1993. Lefort I :-Low level # Ia:Low maxillary# /multiple segments Lefort II:-Pyramidal # IIa:pyramidal #+Nasal# IIb : Pyramidal #+NOE# Lefort III :-Craniofacial dysjunction IIIa:Craniofacial dysjunction+Nasal # IIIb:Craniofacial dysjunction+NOE # Lefort IV:-LEFORT II OR III+Cranial base# IVa : -+Supra orbital rim # IVb : -+Supra orbital rim #+ant cranial fossa . IVc : -+ant cranial fossa and orbital wall#

Slide 31:

F)ROWE & WILLIAM`S Classification I. Fractures not Involving the Occlusion. 1. Central Region a. Fractures of the nasal bones and/or nasal septum. i . Lateral nasal injuries ii. Anterior nasal injuries b. Fractures of the frontal process of the maxilla c. Fractures of type (a) and (b) which extend into the ethmoid bone ( naso-ethmoid ) d. Fractures of types (a), (b) and (c) which extend into the frontal bone ( fronto - orbito -nasal dislocation). 2. Lateral Region Fractures involving the zygomatic bone the zygomatic arch and the maxilla (zygomatic complex) excluding the dento -alveolar component.

Slide 32:

II. Fractures Involving the Occlusion 1. Dento -alveolar 2. Subzygomatic a. Le Fort I (low level or Guerin) b. Le Fort II (pyramidal) 3. Suprazygomatic a. Le Fort III (high level or cranio -facial dysjunction )

SIGNS AND SYMPTOMS:

SIGNS AND SYMPTOMS

Signs and Symptoms:

LEFORT I Extraoral - Swelling of upper lip+/- laceration Increase in Vertical dimension of face Epistaxis Pain during speech and mastication Intra-oral Ecchymosis in buccal sulcus in zygomatic buttress region Laceration in labial mucosa Anterior open bite Posterior gagging of occlusion Tenderness over zygomatic buttress and nasal aperture. Mobility of the Maxilla felt at the anterior nasal spine. Percussion of upper teeth gives a dull “cracked pot sound” Signs and Symptoms

Signs and Symptoms:

LEFORT - II Extraoral Gross facial edema, giving `moon face appearance`. Increased vertical dimension with dish face deformity. Bilateral circumorbital ecchymosis (`raccoons eye`) and edema. Subconjunctival haemorrhage . Widening of the intercanthal distance Depression in the nasal region Epistaxis CSF rhinorrhoea may be present Infraorbital nerve parasthesia . Surgical emphysema from air of maxillary sinus Signs and Symptoms

Signs and Symptoms:

Intra-oral Retropositioning of the maxilla Laceration of the hard and soft palate seen if there is fracture in midpalatine region. Echymosis in buccal vestibule Percussion gives cracked pot sound Mobility elicited at infraorbital ridge. Signs and Symptoms

Signs and Symptoms:

LEFORT-III Gross oedema of the face, ballooning ‘ Panda facies ’ Bilateral circumorbital echymosis and gross edema ‘ Racoon eyes’. Gross circumorbital edema prevent eyes from opening. Bilateral subconjunctival hemorrhage with or without posterior limit. Tenderness and seperation of F-Z sutures producing lengthening of the face and lowering of the occular level. Unilateral or bilateral hooding of the eyes. Charecteristic dish face deformity is present Enopthalmos , diplopia or impairment of vision, temproray blindness. Flattening and widening, devation of nasal bridge Epsitaxis , CSF rhinorrhoea. Signs and Symptoms

Emergency care:

Emergency care Airway is immediately evaluated for the existence of and identification of an obstruction Oral cavity is cleared of debris, secretions, fractured teeth, dentures, blood clot. Position- Lateral decubitus and mild trendlenberg . Oral and nasal bleeding should be controlled locally or if unmanageable should be packed with gauze followed by placement of endotracheal tube. Possibility of cervical spine fractures- endotracheal intubation should not be attempted

Slide 40:

In case of suspected cervical fractures- cervical collar should be fitted. In conscious patient cervical # is diagnosed by presence of pain, paresis, loss of sensation in upper or lower limbs, or combinations In case of upper airway obstruction in association of fractured cervical spine- tracheostomy or cricothyroidotomy is performed. In lower airway obstruction – clear indication of tracheostomy

Slide 41:

After airway is controlled patient’s blood volume is ascertained. Vital’s are monitored and in case patient is hypovolaemic ,2 IV lines are established one in upper extremity and one in lower and Normal saline or RL should be infused to maintain Blood pressure and later after blood grouping is done, crossmatched blood should be transfused according to the requirement. Wound that have penetrated the platysma should be explored and an arteriogram and esophagus obtained.

FACIAL EXAMINATION :

FACIAL EXAMINATION After stabilization of the patient's condition, a complete facial examination is performed. Face should be examined for any Lacerations Obvious depressions on skull Facial asymmetry, swelling. Nasal discharge, CSF rhinorrhoea

Slide 44:

NASAL SECRETIONS/ BLOOD CEREBROSPINAL FLUID It will stiffen handkerchief Will not salty Sweet, metallic High protien content in blood Low protein content Less sugar content More sugar content More mucin No mucin In case of blood it will be found on periphery in ring test While CSF is clooected in centre

Slide 46:

Facial skeleton is palpated in systematic manner to rule out fractures.

Slide 47:

Orbits should be evaluated for Periorbital edema Peri orbital echymosis Proptosis Gross visual acuity Diplopia - binoccular , horizontal and vertical Pupilary size and shape Strabismus Location and extent of subconjunctival hemmorhage Fundospoic examination for intraoccular hemmorhage Lid lacerations Crepitation percieved on palpation is indicative of orbital emphysema( most commonly caused due to communication with ethmoidal sinus and maxillary sinus) Loss of vision Attachment of medial canthal ligament

Slide 49:

INTRAORAL EXAMINATION INSPECTION Restriction of opening ,gagging, lacerations, ecchymosis & damage to teeth, disturbed occlusion. PALPATION Buccal & lingual sulci-tenderness,contour,crepitus,mobility of teeth. To assess the maxillary mobility,pts head should be stabilized using pressure over forehead with one hand.

Radiologic evaluation:

Radiologic evaluation Once patient condition is fully stabilized, radiologic evaluation should be commenced A minimum following radiographs should be taken when using plain films Lateral skull view, water’s view, PA and AP views of skull OPG Towne’s view- zygomatic arches, vetical rami of mandible Occlusal radiograph for split palate.

Slide 52:

INVESTIGATIONS : Imaging studies : 1) Plain Radiographs : Standard views used are : a) Poster anterior oblique view (Water’s view or Ocipetomental view 15° & 30°) can visualize body of the zygoma, arches as well as sinus and infraorbital margin. b) Submentovertex (Bucket handle or Skull axial view) can visualize zygomatic arch c) Caldwell projection (PA view 15° angulation of face to cassette) orbital floor and zygomatic process can be visualized. d) Other views  Lateral skull and anteroposterior views may also be used.

CT SCAN is preferred radiologic modality:

CT SCAN is preferred radiologic modality Clearly demonstrate damage to orbital structures. Delineate the extent of damage to NOE region. Location of CSF leak can also be demonstrated. Extent of edema and presence off foreign bodies can be visualized.

Management:

Stages of Treatment 1. Emergency care and stabilization 2. Initial assessment Definitive treatment Rehabilitation Continuing care Management

Emergency Care and Stabilization:

Immediate care of the injured patient has to be done to restore and maintain the upper airway. Oral cavity cleared of blood, debris, fractured teeth, dentures etc. Emergency cricothyrotomy / tracheostomy may be rarely required. Patient is placed in lateral decubitus or mild trendelenberg position to fecilitate drainage. The control of nasal or oral bleeding can be gained with anterior / posterior nasal packs and oral suturing . If theater treatment is necessitated, cleansing and suturing of soft tissue and impressions for dental study should be carried out. Laryngeal trauma and associated thoracic injuries must be identified and treated. The commonly associated head injury must be detected if present. The glasgow coma scale can be used to know the ultimate prognosis of such injuries. Emergency Care and Stabilization

Control of Epistaxis:

Control of Epistaxis

Initial assessment:

Initial assessment Once the condition of the patient is stable the initial assessment is started which includes History Clinical examination Radiological examination Special investigations Impressions are taken to fabricate study models, preformed arch bar or splints

Definitive treatment:

Goals of treatment of maxillary fractures: 1. Precise anatomical reduction to the cranial base above and to the mandible below 2. Stable fixation of the reduced fragments 3. Preservation of blood supply to the fractured site 4. Restoration function Definitive treatment

Slide 60:

Preoperative Planning Certain important decisions are to be taken prior to performing the surgery: 1. The need for tracheostomy as the airway is likely to be compromised in a maxillary fracture. 2. Whether open or closed method of reduction is to be employed. 3. The necessity for and the type of IMF to be employed if closed reduction is being done. 4. The type of osteosynthesis if open method of reduction is being done 5. The need for internal suspension in case of a comminuted fracture. 6. Timing of operative procedure

Definitive treatment:

Definitive treatment Initially all primary care required is to be delivered to patient at the time of admission which includes Tracheostomy Repair of facial lacerations Arrest of hemorrhage Taking impressions If medical status of patient is fine then simpler fractures can be reduced and internal fixation can be applied ( as in case of simple dentoalveolar fractue or uncomplicated Lefort I or II fracture)

Slide 62:

The optimum time for reduction of midface fractures is usually between the fifth to eighth post injury day . They can be satisfactorily reduced after this time but with each succeding day disimpaction becomes more difficult and open reduction more and more essential Definitive treatment

Operative procedure:

Operative procedure Tracheostomy Facial lacerations Reduction of associated mandibular fractures- Stable mandible is needed for correct positioning of upper jaw The occlusion- Teeth requiring extractions should be removed Associated alveolar # should be reduced and stabilized by means of arch bars, cap splints or plates Gunning splint should be wired to mandible in edentulous patients before

Operative procedure:

5. Zygomatic fractures- They are disimpacted first , particularly in case of Lefort –II fracture which is displaced posteriorly, allowing medial rotation of the zygomatic bone. In such case they are displaced laterally before disimpaction and forward movement of maxillae Operative procedure

Operative procedure:

Principle of treatment for Mid face #: CONSERVATIVE OPERATIVE/SURGICAL REDUCTION FIXATION Restoration of occlusion is must for correct reduction Fixation is maintained by external/internal skeletal fixation until consolidation is achieved. Immobilization for 6-8 weeks to stable segments IMF for 3-4 weeks Operative procedure

Operative procedure:

Indications for Closed Reduction: 1. Non displaced fracture 2. Grossly comminuted fractures 3. Fractures exposed by significant loss of over­lying soft tissues 4. Edentulous maxillary fractures 5. In children with developing dentition. Operative procedure

Slide 67:

Indications for open reduction: 1. Displaced fractures 2. Multiple fractures of the facial bones 3. Fractures of the edentulous maxilla with se­vere displacement 4. Edentulous maxillary fracture opposing an edentulous mandibular fracture 5. Delay of treatment and interposition of soft tissues between non-contacting displaced fracture segments 6. Specific systemic conditions contraindicating IMF.

Reduction of the Maxilla:

Manual reduction Reduction with wires Reduction using disimpaction forceps. Reduction by means of traction(elastics) Reduction of the Maxilla Operative procedure

Slide 69:

METHODS OF REDUCTION 1. manual/closed reduction 2.open reduction MANUAL/CLOSED REDUCTION: 1Simple manipulation by hand 2 Dingman and Harding in 1951 –dental impression compound 3 propescu and burlibasa in 1966 –rubber dam sheet/ribbon gauze/rubber catheters. 4 reduction by using special instruments- Disimpaction forceps ROWE`S MAXILLARY DISIMPACTION FORCEPS AND HAYTON WILLIAMS FORCEPS-I# FOR II# -ASCHE`S /WALSHAM`S SEPTAL FORCEPS

Disimpaction and reduction of maxillae:

Disimpaction and reduction of maxillae The smaller, straight unpadded blade is first introduced in the nasal floor and after it larger blade is entered into mouth and the forceps is closed to engage floor of nose and hard palate Movements- upwards- to effect disimpaction of pterygoid plates down Downwards- to mobilse the maxillae parallel to the inclined plane of cranial base Combination of forward traction with rocking and rotational movements in both horizontal and vertical axis In case of split palate Hayton williams forceps can be used along with the Rowe’s forceps Operative procedure

Alternative:

Alternative In case when operator feels cumbersome using 3 forceps at a time an alternative method is to grip the side opposite to palatal fracture with one pair of Rowe forceps and to grasp other maxilla with the pair of bone holding forceps. Judicious traction is applied on each side alternatively and on palatal side fracture the insertion of bone hook behind the maxillary tuberosity and the application of traction can assist with disimpaction and forward movement Operative procedure

Operative procedure:

7. Open reduction – any fracture sites which cannot be reduced with the help of closed reduction should be opened, reduced and stabilized with either trans osseous wiring or bone plates. At this stage concomitant NOE, Orbit and Zygomatic Fractures should also be reduced and fixed. 8. Skeletal fixation- Internal or external 9. Temporary IMF 10. Nasal Fracture- release temporary IMF and nasal intubation can be converted into oral intubation and nasal fracture is reduced with help of walsham and asches forceps and stabilised with help of plaster splint 11. Definitive IMF. Operative procedure

Immobilization of Lefort I, II & III Fractures :

Immobilization of Lefort I, II & III Fractures The fixation of a mobile fracture of the middle third of the facial skeleton presents a difficult problem as these is no easily available adjacent structure to which it can be immobilized.

Classification of Methods of Maxillary Fracture Fixation :

Classification of Methods of Maxillary Fracture Fixation A. Internal Fixation (Immobilization within the tissues) 1. Direct Osteosynthesis (preferred methods of treatment) a.Transosseous wiring at fracture sites i.High Level ( Frontozygomatic / Frontonasal ) ii.Mid Level (Orbital rim / zygomatic buttress) iii.Low level (alveolar / mid palatal) b.Miniplates c.Transifixation with Kirchner wire (or) steinmann pin i.Transfacial ii.Zygomatic - Septal 2. Suspension Wires to Mandible (ancillary methods of treatment) a.Frontal - central / laterally placed. b.Circumzygomatic c.Zygomatic d.Circumpalatal / Palatal screw e.Infra -orbital f.Piriform apenture g.Peralveolar 3. Support a.Antral pack b.Antral baloon

Slide 77:

B. EXTERNAL FIXATION (Less frequently used methods of treatment) 1. Craniomandibular a.Box -frame b.Halo -frame c.Plaster of Paris headcap . 2. Craniomaxillary a.Supra -orbital pins b.Zygomatic pins c.Levant frame 3. Suspension by Cheek Wires From Halo Frame or Head Cap.

Surgical Approaches to the Maxilla:

Intraoral buccal vestibular approach Infraorbital incisions Transconjunctival Subciliary Infraorbital Lateral Eyebrow Incision Bicoronal Incision Transverse Nasal Incision Vertical Nasal Incision Surgical Approaches to the Maxilla

Slide 79:

DIRECT OSTEOSYNTHESIS

Internal rigid fixation:

Internal rigid fixation Michelet first introduced minplate stabilization of facial fractures in 1972, plating of midface fractures has become the universal standard for patinet’s with these injuries. Selection of appropriate plates should be based on patient’s actual injuries and knowledge of midfacial biomechanics

Plate designs:

Plate designs Plating systems and other internal fixation devices vary according to severe parameters; The rigidity of plate Its width and shape Diameter and number of screws Type of metal- stainless steel, vitallium (alloy composed of cobalt chromium and molybednum ) and titanium.

Mini plates and screws :

Mini plates and screws Monocortical semiriged fixation-3 dimensional stability stainless steel Titanium Vitallium micro-plating system Biodegradable plates & screws.

Slide 83:

In general following types of rigid internal fixation devices are used; Miniplates - 0.6 to 1 mm Microplates - 0.5- 0.6 mm Mesh Three dimensional designs Thicker plates provide more rigid fixation but are aesthetically unpleasing due to thin overlying skin.

Slide 84:

“Increasing width provides more stabilization towards rotational forces.” Various designs are available in market which includes X, H, L, T, and Y types. Mesh and ladder shaped three dimensional plates also use this principle to augment rotational stability over fracture sites.

Factors affecting screw stabilization:

Factors affecting screw stabilization Bicortical screws are not used in midface region because of absence of significant plates In general a minimum of 2 screws is required in each bone segment to prevent rotation in the X and Y axis. Farther the point of stabilization more effective the device in counteracting rotation.

Slide 86:

Larger diameter screws are not used because of constraints imposed by particular anatomic site. All screw require adequate intervening bone between adjacent holes to preserve the integrity of the screw bone interface.

Resorbable bone plates and screws:

Resorbable bone plates and screws Composed of combinations of different biodegradable polymers ( polylactide - polgalactide ). Advantages Self resorbable so no need to remove over prominent areas. Thermoplastic so can be well contoured Theoretically if resorbable plates are placed over sutures they donot restrict the growth ath that site and instead it promoted fracture remodelling under functional loads in absence of stress shielding.

Location of fixation :

Location of fixation The precise location and number of plates and screws necessary to provide stabilization of midface are often determined by fracture pattern 1 st is positioned along vertical and horizontal pillars of the face. Fractures of lefort -I level are well stabilized with “L” plates placed at zygomatic buttress as well as curved plated placed at pyriform aperture.

Slide 90:

Three dimensional struts plates may be used to fixate buttress fractures. Lefort -II fractures may be stabilised with either a linear or a Y configuration plate at F-N junction, curved plates at infraorbital rims and L shaped plates at buttress.

Lefort III fracutures:

Lefort III fracutures

Palatal fractures :

Palatal fractures In most cases lateral and medial stabilization of maxilla with arch bars in combination with a palatal splint is sufficent . However if internal fixation is required it may be applied at anterior maxillary surface below the nasal spine and posterior junction of hard palate through small mucosal incision.

Microplate fixation:

Microplate fixation It is particularly used in NOE # where the fragments are small and loading forces are virtually absent. A Linear T, or Y shaped plate may be used at F-N junction, whereas long curve plates are used to suspend the frontal process of maxilla from the frontal bone.

Mesh fixation:

Mesh fixation Mesh fixation is used for retention and alignment of small fragments or bone grafts. Anterior and lateral walls of maxilla and anterior table of frontal bone are common sites for these application

Slide 95:

Internal suspension wiring

Internal Suspension Wiring:

Method of non-rigid fixation introduced by Adams in 1942. These suspension techniques involve connecting the lower jaw by wires within the tissues to areas of the facial skeleton above the fracture line, thus sandwiching the fractures position between the mandible and that part of the facial skeleton which is not involved in the fracture. Internal Suspension Wiring

Slide 97:

The wires are passed through the tissues with the aid of Long curved needles. Awls Cannulae In all these procedures, 0.5 mm diameter of stainless steel wire (pre-stretched 10%) is recommended. Type Use 1. Frontal a. Central Lefort III & II (Mandible Unstable) b. Lateral Lefort III & II (Mandible Stable) 2. Circumzygomatic Lefort II & I 3. Zygomatic Lefort I 4. Infraorbital Lefort I 5. Piriform apenture Lefort I 6. Trans nasal ‘Gunning - type’ splint 7. Peralveolar ‘Gunning - type’ splint Use of the different types of Internal Wire Suspension

Frontal suspension:

Frontal suspension Lateral Incision Exposure Bur hole is drilled 5 mm above the suture line and angulated to emerge on the posterior or infra temporal aspect. 40 cm long wire is passed through this and bent back so that equal length protrudes on each side of the hole Two ends are threaded through the eye of the Rowe’s zygomatic awl

Slide 100:

First the awl is passed downwards below the arch and it enter s the mouth through upper buccal sulcus . Pull out wire is passes beneath this suspension wire to facilitate its removal Alternative technique is to form the pull out wire as an integral part of suspension wire. Alternatively the lumbar puncture needle can also be used instead of awl and this technique is more atraumatic

Slide 101:

The suspension wire is then tied to arch bar or cap splint and twisted following reduction to facilitate stabilization. Wire can be attached to upper or lower teeth depending upon the type of suspension required ( cranio maxillary or cranio mandibular) Similarly this procedure is repeated on the other side and eyebrow incision is sutured in layers.

Removal :

Removal Can be removed under LA Wires around the cleat of splint or arch bar are untwisted and straightened The pull out wire is the clamped with heavy artery forceps and wire is removed from above or the pull out wire can be straightened or cut and then it can be removed intraorally from the traction below. This method produces less contamination than former. Incision over eyebrow can be given if necessary.

Frontal suspension:

Frontal suspension Central Method described by Kufner 2 cm incision made over skin of forehead above frontal sinus. Bone is exposed Hole is drilled by bur and Roger Anderson pin is inserted in oblique downward direction to engage the inner skull. 2cm subcutaneous tunnel is created below the pin for the passage wire and awl Awl is passed upwards through the soft tissues from the upper vestibule of the mouth in upper canine region and passing posterolaterally to the piriform aperture to reach the subcutaneous pocket .

Slide 105:

Two ends of wire are then threaded to awl and are withdrawn intraorally . Loop is passed over pin and traction is applied to the free ends to eliminate any slack.. The procedure is repeated on the other side. After reduction of the fractures the bilateral wires are secured to fixation appliances attached to either the maxillary or mandibular teeth. Grossman and Pogrel advocate the use of autopsy needle to pass wire from above downwards which reduces risk of infection

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Removal of the wires is done in local analgesia The pin is unscrewed and the wires are the n cut and pulled back into mouth. The scar is excised and primarily sutured.

Circumzygomatic:

Circumzygomatic The most direct method is to introduce the point of obwegesor awl as used for circum-mandibular wiring, extraorally at the junction of frontal and temporal process of zygomatic bone. The instrument then pierces the temporal fascia and keeping the point close to the deep or temporal aspect of the buttress, this is maneuvered so as to enter the upper buccal sulcus in first molar region.

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The wire is then threaded to awl and withdrawn to lie just above the arch without emerging from the skin. Now awl is passed laterally downwards and forwards to enter buccal sulcus . Wire is then detached and slack is removed it is tied to the arch bar or splint.

Alternative circumzygomatic :

Alternative circumzygomatic Four modified spinal needles are used. Their hubs are removed and stilettes are shortened by equal amount First needle is inserted in similar manner as described before. The stilette is then removed and 40 cm long wire of 0.5cm diameter is passed through the lumen of the needle which is then withdrawn from the mouth and discarded Another needle is inserted extraorally puncturing the skin passing laterally to the zygomatic bone and it enters the buccal vestibule. Again stilette is removed and the end of previous wire is passed through the lumen of the inserted spinal needle. The needle is then withdrawn from the mouth. To and fro movement of the wire is done to remove any soft tissue intervening between the wire and bone and wire are then tied to arch bar or splint.

Intra oral circumzygomatic:

Intra oral circumzygomatic Technique described by Lesney 1953 This is used in case extraoral technique is not possible eg in case where halo frame is present which obstructs the passage of the awl. The awl after piercing oral mucosa is directed upwards and backwards behind the frontal process of zygomatic bone deep to zygomatic arch, at which point the awl is rotated laterally through 90 degree to allow its point to penetrate the skin above the zygomatic arch.

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0.5cm wire is then tied to awl and withdrawn intraorally and then this procedure is repeated again but this time the awl is passed laterally to the zygoma in close proximity to avoid soft tissue damage and particulary facial nerve. The other end of wire is now withdrawn from the mouth. The loop is kept in contact with the bone and ends of wire are tied to arch bar or splints

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A sterile technique for threading and introducing wires utilizing long hypodermic needles was described by Edwards 1965. It was modified by Rowe and killey 1968. However the standard method of awl which has the theoretical disadvantage of introducing infection from mouth into the soft tissues, has proven to be quicker and simpler procedure.

Zygomatic suspension:

Zygomatic suspension Method was advocated by Guerman 1957 3 cm incision is made is upper buccal sulcus region , soft tissues are dissected subperiosteally and zygomatic buttress is exposed. A bur hole is drilled posteriorly and slightly laterally and soft SS wire is passed. Two ends are then attached to suitable loop or arch bar or cap splint. Care- Deep aspect of periosteum should not be penetrated so as to avoid herniation of BFP.

Circumpalatal suspension:

Circumpalatal suspension Method advocated by Bowerman and Conroy 1981 to facilitate retention of surgical splint following maxillectomy . Extremely useful for fixing upper gunning splint. Superior retention and stability Curved awl is passed through nasal aperture and floor of the nose. The point o the awl is then passed through the soft palate in order to enter oral cavity at posterior edge of hard palate. Loop is present at the back edge of gunning splint. 40cm 0.5 cm SS wire is threaded to this loop and then both the ends are engaged in the awl which is withdrawn from nasal cavity.

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The point of the awl is then passed through the mucosa of the floor of the nose immediately anterior to the piriform aperture to enter the mouth in the labial sulcus . Wires are then disengaged from the awl and tied to the loop sited in anterior buccal flange of the gunning type splint. In edentulous patient where there is extensive resorption of the alveolar ridge it may be possible to pass awl directly through buccal sulcus , nasal cavity and soft palate as one procedure. This procedure is then repeated on other contralateral side and this gives very rigid support for a gunning splint

Infraorbital suspension:

Infraorbital suspension A 3 cm incision is made in the upper buccal sulcus above the canine and soft tissues are dissected subperiosteally to expose the inferior orbital margin laterally to infra orbital foramen. A bur hole is drilled upwards and posteriorly and a soft SS wire is passed.

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During the drilling of the bur hole and threading of wire care is taken not to injure globe of eye so it is protected by blunt end of Howarth periosteal elevator. End of wires are then withdrawn inside the mouth and attached to archbar , or cleat of cap splint.

Piriform aperture suspension:

Piriform aperture suspension A transverse 2 cm incision os made in the upper buccal sulcus above the lateral incisor Subperiosteal dissection exposes the bony piriform aperture of the nose. Nasal mucosa is the elevated from the medial aspect to a depth of 2 cm and periosteal elevator is then left in postion to act as guard.

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Bur hole is drilled and wire is passed and withdrawn in side the mouth and tied to suitable loop, arch bar or cap splint. When accompanied with circummandibular wiring a very rigid and stable fixation can be achieved esp in children

Peralveolar suspension:

Peralveolar suspension The gunning splint is placed in situ and position of the holes located in palatal aspect of the splint are marked on underlying palatal mucosa with Methylene or Bonney’s Blue. The peralveolar awl or kelsey fry bone awl is then directed through the mucosa in the canine region and then driven through the alveolus from high up in buccal sulcus , piercing the palate at the point marked.

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SS wire is passed through the awl and then withdrawn via buccal sulcus . The 2 ends of wires are twisted together over the gunnnig splint and turned over. The procedure is repeated on the other side.

External Skeletal Fixation:

External Skeletal Fixation

External Skeletal fixation:

External Skeletal fixation The trend towards ORIF has been increased now a days as it is more efficacious in maintaining accurate reduction at the fracture site. External fixation is still advocated in some cases where there is “markedly depressed, posteriorly displaced midface fractures of the maxillae”.

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Principle- External appliances rely on sandwiching the midface between the base of the skull and mandible following disimpaction and closed manipulation. They produce satisfactory result when there is minimal displacement Lefort I and II levels. Primary indication for external skeletal fixation of midface is the presence of antero -posterior instability of facial skeleton.

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Four methods of External skeleton fixation which are in general use at present time Plaster of Paris head cap Halo frame Box frame Levant frame All the system uses external rods and universal joints to link base of skull via cranium to maxilla or mandible via cap splints

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One feature which is common is they provide “ anterior traction to the face” Disadvantages Cumbersome Conspicious Lengthen the period of hospitalisation Contraindicated in presence of mental confusion, cerebral irritation, epilepsy and alcoholism as such patients may dislodge the appliance and can hurt themselves.

POP head cap:

POP head cap

POP headcaps with metal frames:

POP headcaps with metal frames This method has been superseded by the halo frame but still can be used if later is not available in emergency condition. Disadvantage- Heavy Uncomfortable Unstable Indirect external skeletal fixation

Method of application:

Method of application Metal frame of 3mm diameter round german silver rod is adjusted to the shape of the forehead. A 7.5 cm POP bandage is then activated with water, excess is absorbed Head is engaged in 2 circumferential planes Maximum diameter of head obliquely above the forehead and down to external occipital protuberance Supra orbital rim in more horizontal plane Metal framework is then incorporated in the headcap during application of POP bandage.

REMOVAL :

REMOVAL

Halo frame:

Halo frame First metal frame was described by Crawford 1943 during second world war. It secured the metal framework directly to the skull by screw pins for treatment of upper jaw fractures United kingdom Royal Berkshire Hospital Pattern is generally favored because it is light, readily adjustable and having screw pins made up of titanium which is well tolerated by the tissues.

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Screw pins are engaged diametrically untill they engage the outer table of the skull. 2 anterior pins- temporal crest 2 posterior pins- behind the mastoid process. Care is taken to prevent tissue necrosis by electrolytic action around the screw pins by means of polymeric sleeves over the connecting rod, or by use of insulated universal joint which breaks the circuit. Skin sites around the screws pins are cleaned daily to prevent infection

BOX FRAME:

BOX FRAME Preferred method over POP head cap and HALO FRAMES. More stable and rigid. Other unstable fracture fragments can also be attached to the vertical rods ( eg fractured zygoma ) Four pins are attached into frontal bones and into mandible. Frontal pins are sited in lateral 1/3 rd of supra-orbital bony ridge. Point of insertion is about 1.5cm from the F-Z suture and 5 mm above the level of supra-orbital ridge.

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Similarly pins are placed inferior and anterior to the mental foramina in the mandible In case of intact zygomatic bones the pins may be inseted in bodies of zygoma instead of frontal bone

Levant frame:

Levant frame The levant frame developed at the Royal Melbourne hospital provides a simple, rigid, skeletal cranimaillary fixation between supra orbital rims and maxilla connected by central cranio -maxillary rod attached at lower end by means of either cast metal splints or acrylic splint.

Complications :

Complications Divided into; Immediate complications Late complications

Immediate complications following fixation:

Immediate complications following fixation Rare but not uncommon Airway- Fixation of bones may further induce embarrassment to airway. Tracheostomy may be done in emergency Nasal hemorrhage- Not uncommon and can be treated by nasal packing Ophthalmic- post reduction retrobulbar hemorrhage.

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Cerebral- Almost all patients with midface trauma may have sustained some degrre of violence to the brain. Care has to be taken by regular monitoring the patients for early detection of rise of ICP. CSF rhinorrhea - added risk of retrograde meningitis . leopard 1971 observed that avg duration of CSf leak after high midface # to be 4-5 days and most leak stopped spontaneously. If Leak persist more than 10 days elective neurosurgical care should be undertaken.

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Inaccurate reduction- may occur due to improper mobilization. Ensure that midline is correct Insecure fixation- Can occur due to improper technique. Circumzygomatic wires completely in soft tissues Capsplints not cemented properly Incorrectly applied halo frames Incorrectly applied miniplates .

Late complications:

Late complications Complications from the head injuries Postconcussional syndrome- headache, dizziness, insomnia, diplopia , intolerance to noise, changes in dispositon , intellectual impairment, intolerance to alcohol. Aerocele or cerbral abscess may develop within a few week. Meningitis

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Complications arising from fractures Bony deformity- due to inadequate reduction and fixation Flat zygomatic arch which may lead to cosmetic deformity, diplopia , restricted mouth opening Dish face deformity Posterior gagging, anterior open bite , and post traumatic defects in palate.

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The lacrimal system - Partial or complete obstruction of nasolacrimal duct cal lead to “ epiphora ” , patients may develop “infected mucocele ”, or condition termed “ Dacryocystitis ”

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Opthalmic complications- Diplopia - due to mechanical disturbance in movement of eye or muscles entrapped Enopthalmos - uncorrected expanded volume of eye Occulomotor nerve is vulnerable due to its long course so can lead to ptosis , strabismus, diplopia Superior orbital fissure syndrome Orbital apex syndrome Damage to globe itself may lead to resudual eye problem and visual disturbances

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Anaesthesia and paresthesia- infraorbital nerve and PSA Anosmia - due to # of cribriform palte of ethmoid NON UNION- In case of extensive communition or actual bone loss due to missile injurys

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