Mid-Continent Casualty Company v. Kipp Flores Architects - copyright advertising injury opinion.pdf
Mid Face Injury
Transcript of Mid Face Injury
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Mid-faceDefinition:
The area betweena superior planedrawn through
the zygomatico-
frontal suturestangential to thebase of the skull
and inferior
plane at the levelof the maxillarydental occlussal
surface.
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Structures connection(s t ru ctu res in re lat ion )
OrbitMaxillary sinusNasal boneNaso-orbitalethmoid (NOE)complex
ZygomaticcomplexFrontal bone andsinus
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Vertical and horizontal pillars
Area of strengthVertical and horizontal pillarsMuscular attachment
Area of weaknessSutures
Lining tissues and air-filled cavities
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Signs and symptomsSlight swelling of upper lip
Ecchymosis in upper lip sulcus
Hematoma intra-orally over zygoma and in palate
Disturbed occlusion
Mobility of teeth of the involved segment of maxilla
Combination of soft tissue laceration
Exposure of nares and the maxillary antra in case of
gross injury
Impacted type of fracture is oftenly not mobile andteeth cusps may be damaged
Cracked-pot percussion of upper teeth
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Le Forts fractures
Le Fort II (pyramidal or subzygomatic)Separation of NF suture,medial orbital walls(lacrimal bone), inferior
orbital floor and rim(adjacent to infrorbitalcanal and foramen),anterior maxilla belowzygomatic buttress andptrygoid laminae abouthalfway up.
Separation of the block from the base of skull is completedvia the nasal septum and may involve the floor of the
anterior cranial fossa
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LeForts fractures
LeFort III(cranifacial dysjunction, hightransverse, suprazygomatic)
Separation of NF suture,medial orbital walls (involve
the depth of the ethmoidbone and cribriform plate,pass below optic foramen
and cross the inferior orbitalfissur), inferior orbital floor,
lateral orbital wall, ZFsuture, zygomatic arch,
suprazygomatic to the rootof ptrygoid plate.
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Signs and symptomsaltho ugh i t i s p os s ible to d is t ing uish between le for t II and III, thes igns and sy mp tom s a re almos t s imi lar
Gross edema of soft tissueBilateral circumorbitalecchymosisBilateral subconjunctivalhemorrahgeObvious deformity of thenoseNasal bleeding andobstructionCSF leak rhinorrheaDish-face deformityLimitation of ocular
movementPossible diplopia andenophthalmousRetropostioning of themaxilla with anterior openbiteLengthening of the face
Difficulty in mouth openingMobility of the upper jawOccusional hematoma ofthe palateCracked-pot sound onpercussionStep deformity at infra-orbiatal marginAnasthesia of midfaceNasal bone moves withmid-face as a wholeTenderness and sepration
at FZ sutureTenderness and deformityof zygomatic archDepression of occular leveland pseudoptosis
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Bowerman classification of midface-fracture(1994)
Fracture not involving the occlusion Central region
Nasal bone/ septum (lateral, anterior injuries)Frontal process of the maxillaNasoethmoidFronto-orbito-nasal dislocation
Lateral region (zygomatic complex EX dento alveolarfrcature
Fracture involving the occlusion Dento alveolar
Subzygomatic: Le Forts (I, II)
Supra zygomatic:Le Fort III
These fractures may occur unilaterally or bilaterally, with separationof maxillary midline and or extension to frontal or temporal bone
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Prevalence of mid-face fractures
Fracture Type Prevalence
Zygomaticomaxillary complex (tripod fracture) 40 %
LeFort I 15 % II 10 % III 10 %
Zygomatic arch 10 % Alveolar process of maxilla 5 % Smash fractures 5 % Other 5 %
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Diagnosis
InspectionExtra-oral
(e.g. swelling, deformity, asymmetryLeaks)
Intra-oral(e.g. hematoma, occlusion)
PalpationStep deformity, criptation, cracked pot sound, mobility
Radiographical investigations
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Radiographical examinationPlain radiograph
Occipitomental(10 or 30 degree)
Waters view Suitable for isolated orbital
fractureSearch line (Campbells line 1977)
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Radiographical examination
Lateral skull viewOPGOcclusal view of the
maxillaPerapical views ofdamaged teeth
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Radiographical examination
CT scan3-D CT imaging
Coronal sections Axial sections
1. Whenever intracranial damage andfrontal sinus are suspected
2. Extensive fracture that involvesnasoethmoid complex or orbitalregion
3. Orbital trauma to evaluate thedegree of orbital injury and
enophthalmos
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Indications for treatment
Physical signs of a fracture of the maxilla.
Evidence of a fractured maxilla on imaging.
Disruption of the occlusion of the teeth.
Displacement of the maxilla.
Post traumatic facial deformity.
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Indications for treatment
Fractured or displaced teeth.
Cerebrospinal fluid leak.
Abnormal eye movement or restriction ofeye movement.
Occlusion of the nasolacrimal duct.
Sensory or motor nerve deficit.
Other evidence of loss of function
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Aims of treatmentRelieve pain
Restore function.
Restore bone anatomy.
Prevent infection
Restore the dental occlusion
Restore jaw movement at the earliestpossible stage
Restore normal nerve function
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Factors affecting the risk
Association with multiple injuries.
Presence of uncontrolled haemorrhage
Impairment of the airway.
Presence of bone comminution
Association with a dural tear.
Association with a base of skull fracture.
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Factors affecting the risk
Presence of a pre-existing dentofacialdeformity.
Time elapsed since the injury.
Presence of a medical or surgical factorwhich would delay general anesthesia
Presence of any factor which would delay
healing. (eg nutritional deficiency oralcoholism)
Stage of dental development (deciduous,mixed or permanent dentition)
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Factors affecting the risk
Presence of fractured teeth.
Total absence of teeth (edentulous)
Inability of the patient to co-operate withtreatment.
Association with fractures of the mandibleespecially bilateral fractures of thecondyles.
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Principles of treatment
Closed reduction may be appropriate incases
Simple uncomplicated fractures
Complex or comminuted fractures
Medical or surgical contraindications toopen reduction
Maxillary fractures in children
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Open reduction may be appropriatewhere
Immediate or early jaw function isdesirable
Difficulty is encountered in reducing the
fracture by a closed method
The fracture is unstable
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Definitive treatment
Reduction
Manual manipulation
Use of dis-impaction forceps
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Fixation and immobilization
Extraoral fixation
Craniomandibular fixation
Box-frame (pin fixation)Halo-framePlaster of paries headcap
Craniomaxillary fixationSupra-orbital pinsZygomatic pinsHalo-frame
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Immobilization within the tissue
Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular
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Immobilization within the tissue
Support via the maxillary sinus byfilling materials
Ribbon gauze Balloon Folly catheter
Polyethylene material
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Length of the hospital stay will dependon a number of factors including:
Presence of other injuries
Age and medical status of the patient
Severity of the injury
Technique employed in the reduction andfixation of the fracture
Presence or absence of medical orsurgical complications
Social circumstances of the patient
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