Ohns Finals Lec#4 Maxillofacial
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Transcript of 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!