ohns finals lec#4 maxillofacial

7/29/2019 Ohns Finals Lec#4 Maxillofacial

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MAXILLOFACIAL TRAUMA

FEU-NRMF Medical Center

Department of Otolaryngology

Head and Neck Surgery


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Objectives:

Review head and neck soft tissue andskeletal anatomy

Discuss how to diagnose and identifycommon maxillofacial injuriesDiscuss the initial management of

maxillofacial injuriesDiscuss the principles of management of maxillofacial injuries


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ETIOLOGY

Vehicular Accidentsvs.

Physical Altercations


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PRIORITIES AirwayBreathingCirculation

DisabilityExposure


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Airway Management

EndotrachealIntubation

Tracheostomy


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SOFT TISSUE INJURIES

Contusion-Hematoma

AbrasionsLacerations

a. linear laceration

b. jagged laceration Avulsions


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Soft Tissue Swelling


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Contusion Hematoma


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Abrasions


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Lacerations


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Avulsion


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Facial laceration


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S/P Suturing of facial laceration


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Vertical Buttress


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Vertical Buttresses


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Horizontal Buttresses


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Horizontal Buttresses


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NASAL TRAUMANasal bone is most frequently

fractured facial boneHistory of blow to the face (nose)Related to nasal septum


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NASAL ANATOMY

External nose composed of bony & cartilaginousframework

Internal nose bounded by sphenoid, cribriformplate of the ethmoid, septum & maxillary bone


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Blood supply:ECA ( facial & internal maxillary)ICA ( ophthalmic & ethmoid )

Nerve supply:trigeminal

sphenopalatine ganglionolfactory nerves


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Nasal Bone FractureSigns and symptoms :Nasal deformityEdema / hematomaCrepitation / motion on palpationNasal obstruction

Epistaxis


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Nasal Bone Fractures

X-rays : Waters View Soft tissue lateral view


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Management of Nasal Bone Fracture

CLOSED REDUCTIONIndications:

Non-comminutedfracturesMild to moderatedisplacement

Recent fractures


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Asch forcep


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Closed Reduction of Nasal bonefracture should be done within:

7 - 10 days in Adults

2 - 4 days in Children


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MANDIBLE


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Mechanism of Injury

DIRECT BLOWBODY

Ipsilateral body Contralateral angle or subcondylar

SYMPHYSIS

Parasymphyseal Bilateral Condylar


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Types of Mandibular fracture

Favorablevs.

Unfavorable


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Favorable fracture

muscle forces tend to keepfragments together


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Unfavorable fracture

muscle forces tend to pullfragments apart


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Two Groups of Muscles Acting on

Fracture SegmentsPosterior Group Anterior Group

Masseter Lateral pterygoidMedial pterygoidTemporalis

GeniohyoidDigastricMylohyoidGenioglossus


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Mandibular Fracture

Favorable fracture: A and B

Unfavorable fracture: C and D


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Mandibular Trauma

Signs and symptoms :Malocclussion (open bite deformity)Hyposthesia of lower lip & gingivaMucosal disruptionTooth looseningTrismus


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Mandibular Fractures

Step Defect

CrepitusBony segmentsSubcutaneousemphysema

Abnormal mobility


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Mandibular Fractures

Sublingual ecchymosis Step defects


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Mandibular fractures

malocclusion ridge discontinuity


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Panorex

Radiographic Evaluation


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Goals of Management

Restore pre-injury occlusion

Immobilization to allow time for healing Maintain adequate nutrition Avoid infection, malunion or non-union


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Indications for Closed Reduction1. Minimally displaced fracture2. Favorable fracture3. Condylar fracture4. Alveolar fracture

5. For temporizing prior to definitivemanagement


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Maxillo-Mandibular Fixation (MMF)

4 6 weeks


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Indications for Open ReductionInternal Fixation (ORIF)

1. Unfavorable fracture

2. Incomplete or poor dentition3. Failure of closed reduction4. Multiple or comminuted5. Open wound (laceration near

fracture line)


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Post-op: ORIF of mandibular body fractureusing titanium plates


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Maxillary Trauma

- Direction of fracture displacementdepends on the degree, direction andpoint of impact of forces


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Maxillary Fracture

Weakest areas of midfacial complexwhen assaulted from a frontal directionat different levels

Rene Le Fort, 1901


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Le Fort I: above the level of teeth

Le Fort II: at level of nasal bonesLe Fort III: at orbital level


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Classification of Maxillary Fractures( Le Fort )

Le Fort I Guerin / T ransverse Maxillary

Le Fort II Pyramidal

Le Fort III Craniofacial Dysjunction


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Le Fort I Fracture Transverse Maxillary (Guerin Fracture)


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Le Fort II FracturePyramidal

Most common of Maxillary fractures


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Le Fort III FractureCraniofacial Dysjunction


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Signs and Symptoms1. Anterior Drawers sign 2. Open bite deformity/ Asymmetry3. Epistaxis4. Dishpan or Panface 5. Hypoesthesia

6. Swelling, tenderness & hematoma of midface7. CSF rhinorrhea


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Radiographic evaluation :Waters view Caldwell viewLateral view

Gold Standard: CT scan


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Diagnosis of Le Fort II and III

Clinical evaluation provides only a

rough impression since swelling hidesthe underlying bony structuresPlain film radiographs, axial and coronal

CT images are the basis for precisediagnosis & treatment plan


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Management of Maxillary Fractures

Le Fort I : interdental & intermaxillary for 4-6 weeks

Le Fort II : as above plus fixation fromzygomatic suture or orbital rim

Le Fort III : interdental & intermaxillaryfixation, suspension fromzygomatic suture & wiringfrom infraorbital rim


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ZYGOMATIC TRAUMAZygoma

very strong bonearticulates with frontal, maxillary and sphenoidbone

Most common cause of fracture is trauma


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Types of Zygomatic fracture

Simple Arch fractureTripod Fracture

-involves 3 suture lines


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ZYGOMATIC FRACTURES

Signs and Symptoms :Diplopia, unequal pupillary levelHyposthesia, cheek numbnessTrismusEpistaxisPeriorbital hematoma/ecchymosisDepressed cheek prominence


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Radiographic Findings

Submentovertex Axial CT scan


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Management of Zygomatic Fractures

Open Reduction

Lid or infraciliary incision Gilles approach


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Anatomy of Orbit

The orbit is a bony pyramid with the opticforamen at its apex

Floor - roof of maxillary sinusMedial wall - Lamina papyracea of ethmoid boneLateral wall- Zygoma and sphenoid bone (greater wing)Superior wall - Frontal bone (floor of frontal sinus and

anterior fossa)


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Blow-out fracture of the Orbit

An orbital floor fracture characterized bydehiscence of the bone, herniation of orbital contents & possible entrapment of orbital musclesResults from blunt trauma to globe


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ORBITAL BLOWOUTMechanism of Injury


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ORBITAL TRAUMA

Have an ophthalmologicevaluation

Orbital rim is intact inpure blow out fracture


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Signs & Symptoms of Blow-out fracturesDiplopia : (+) Forced Duction TestEnophthalmosInfraorbital hyposthesiaPeriorbital ecchymosis

Epistaxis


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Radiographic Evaluation

CT Scan 3D CT Waters x -ray


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Management of Blow-out fractures

Open Reduction via:- Low lid incision

- Caldwell-Luc approach


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FRONTAL SINUS ANATOMY

Anterior table - part of forehead and

supraorbital rimPosterior table - anterior wall of anterior

cranial fossa

Inferiorly, the nasofrontal duct drains thesinus into the nose


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FRONTAL SINUS TRAUMADirect blow to the frontal area

5 15% of all facial fractures

Least common


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Signs & Symptoms

HematomaSwelling over frontal sinus areaEcchymosisEpistaxis or CSF rhinorrheaAssociated nasal or skull fractures


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Neurosurgical consultation and co-management if necessaryRadiographs : Caldwell and Lateralprojections

CT scan

FRONTAL SINUS TRAUMA


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CSF rhinorrhea

Handkerchief testBenedicts test for glucose Beta 2 transferrin determination


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Frontal sinus obliterationExploration of frontal sinus via osteoplastic flap

Examine and repair dura if necessaryRemove all mucosa from the sinusFill the sinus with fat to prevent communication

with nose and reepithelialization


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THANK YOU!

ohns finals lec#4 maxillofacial

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