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Questions and Answers
What is a characteristic of open (compound) fractures in the midface?
What is a characteristic of open (compound) fractures in the midface?
Which type of fracture is defined as not exposed to the external environment?
Which type of fracture is defined as not exposed to the external environment?
What causes immediate displacement of fractured segments in midface fractures?
What causes immediate displacement of fractured segments in midface fractures?
What is a potential outcome of severe backward displacement of the midface?
What is a potential outcome of severe backward displacement of the midface?
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Which anatomical feature is implicated in backward displacement of the maxilla?
Which anatomical feature is implicated in backward displacement of the maxilla?
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Which method is essential for addressing fractures of the middle third of the facial skeleton?
Which method is essential for addressing fractures of the middle third of the facial skeleton?
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What is the anatomical boundary for the superior region of the middle third of the facial skeleton?
What is the anatomical boundary for the superior region of the middle third of the facial skeleton?
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Which condition must be addressed in the treatment of compound fractures?
Which condition must be addressed in the treatment of compound fractures?
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What is a common clinical sign of a Le Fort II fracture?
What is a common clinical sign of a Le Fort II fracture?
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Which feature distinguishes a Le Fort III fracture from a Le Fort II fracture?
Which feature distinguishes a Le Fort III fracture from a Le Fort II fracture?
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Which of the following statements about the Le Fort fracture classification is accurate?
Which of the following statements about the Le Fort fracture classification is accurate?
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What type of mobility is typically noted during a physical examination of a Le Fort II fracture?
What type of mobility is typically noted during a physical examination of a Le Fort II fracture?
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Which radiological technique is most commonly used to diagnose midface fractures?
Which radiological technique is most commonly used to diagnose midface fractures?
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Which symptom is indicative of possible CSF rhinorrhea following a midface fracture?
Which symptom is indicative of possible CSF rhinorrhea following a midface fracture?
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What is a proper surgical treatment method for managing severe Le Fort fractures?
What is a proper surgical treatment method for managing severe Le Fort fractures?
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Which of the following is not a recognized sign of Le Fort II fractures?
Which of the following is not a recognized sign of Le Fort II fractures?
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What does the presence of the 'tramline' pattern indicate in a patient with a high level midface fracture?
What does the presence of the 'tramline' pattern indicate in a patient with a high level midface fracture?
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Which sign indicates a possible CSF leak when observing bloody fluid from the nose?
Which sign indicates a possible CSF leak when observing bloody fluid from the nose?
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In a midface fracture, which clinical sign would suggest diplopia?
In a midface fracture, which clinical sign would suggest diplopia?
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What is the role of measuring glucose in fluid coming from the nose during the diagnosis of CSF leak?
What is the role of measuring glucose in fluid coming from the nose during the diagnosis of CSF leak?
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Which statement about midface fractures is correct?
Which statement about midface fractures is correct?
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Which type of fracture classification is primarily focused on midface injuries?
Which type of fracture classification is primarily focused on midface injuries?
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Which diagnostic technique is essential to confirm the presence of beta-2-transferrin in nasal discharge?
Which diagnostic technique is essential to confirm the presence of beta-2-transferrin in nasal discharge?
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What surgical treatment method is most commonly indicated for high level midface fractures?
What surgical treatment method is most commonly indicated for high level midface fractures?
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Study Notes
Maxillofacial Traumatology: Fractures of the Middle Third of the Facial Skeleton
- The facial skeleton is traditionally divided into upper, middle, and lower thirds.
- The lower third is the mandible.
- The middle third is defined as the area between a line drawn across the skull (from the zygomaticofrontal suture on one side, across the frontonasal and frontomaxillary sutures to the zygomaticofrontal suture on the opposite side), and the occlusal plane of the upper teeth (or upper alveolar ridge if edentulous).
Types of Fractures
- Fractures are classified as either open (compound) or closed (simple).
- A simple fracture is not exposed to the outside.
- Compound fractures are exposed to the outside, increasing the risk of infection, requiring prophylactic antibiotics.
- Exposure can occur via the skin, periodontium, paranasal sinuses and/or nose.
- All fractures in tooth-bearing areas of the mandible, maxilla, nasoethmoidal complex, orbital floor and zygoma are considered compound fractures.
- Other maxillofacial fractures are considered simple if not exposed through the overlying skin.
Displacement of Fractured Segments
- Immediate displacement is caused by the impact.
- Later displacement may be caused by muscle pull.
- The base of the skull (where the frontal bone articulates with the sphenoid) angles approximately 45° to the occlusal plane of the upper teeth.
- Impacts with large force can displace mid-third of the facial skeleton posteriorly and downwards, following the slope of the sphenoid.
- Backward displacement allows posterior teeth to contact prematurely, creating an anterior open bite.
- This displacement may cause face lengthening.
- The pterygoids attach the posterior maxilla to the mandible.
- Contraction of these muscles may displace the maxilla downwards and backwards.
Treatment of Fractures
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Reduction: Correction of the fracture by returning the displaced segments to their anatomical positions.
- Open reduction: involves surgical access.
- Closed reduction: does not involve surgical access.
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Fixation: Holding the reduced segments fixed until healing is complete.
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Direct fixation: involves using plates and screws to stabilize the fractured bones directly.
- Miniplates provide stabilization with screws. The plates are secured along the buttresses. Transosseous wiring along the buttresses (lateral piriform rim and zygomaticomaxillary) and bone grafting across comminuted Le Fort I fractures are other direct fixation techniques.
- Miniplate fixation is used with bone grafts in situations where there is bone loss.
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Indirect fixation: involves placing stabilizing structures external to the bones to prevent further displacement.
- Maxillary suspension with frontal, infraorbital, pyriform fossa, and circumzygomatic suspensions.
- Intermaxillary fixation (IMF): using a device to place traction on the segments of maxilla to keep them in alignment. This aids in backward displacement prevention.
- External suspension: without IMF, hardware fixation only of the maxilla is employed.
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Direct fixation: involves using plates and screws to stabilize the fractured bones directly.
Surgical Anatomy
- Midface skeleton: a series of vertical and horizontal bones, the 'buttresses', surrounding the sinuses, eyes, and the upper parts of the respiratory tract. These 'buttresses' are joined by thin bones.
- The forces of mastication are distributed to the nasal airway, globes and paranasal sinuses.
- These structures are supported by the rigid skull base.
- Bones of the middle third: two maxillae, two palatine bones, two zygomatic bones, their temporal processes, and two zygomatic processes on the temporal bones.
- Other bones of the middle third include: two nasal bones, two lacrimal bones, the vomer, the ethmoid bone and its attached conchae, and the body and lesser/greater wings of the sphenoid bone (the pterygoid processes are commonly fractured in extensive fractures of the middle third).
- The midface articulates with the base of the skull.
- The dura and cranial nerves are involved, as are the blood vessels and paranasal sinuses.
Classification of Fractures (Anatomical Basis)
- Fractures can be classified based on whether the occlusion is involved.
- The Le Fort classification is used to categorize fractures based on the fracture line's location relative to the occlusion (teeth/gum line).
- Le Fort I: low-level (or Guerin) fracture, involves the lower third of the maxilla (above the teeth), and nasal septum.
- Le Fort II: Pyramidal fracture, extends from the nasal bone through the maxilla, inferior orbital floor, and the zygomatic bone
- Le Fort III: high-level (or craniofacial disjunction) fracture involves the maxilla and portions of the cranial structures (potentially impacting the optic canal/nerves).
Clinical Presentation
- Specific clinical presentation of each fracture type is outlined.
Radiology
- Plain radiography (occipitomental view, PA view), OPG, CT scan, and MRI are used to diagnose fractures.
Additional Points
- Symptoms (including, e.g., edema, ecchymosis, hematoma, crepitation, abnormal mobility, and neurological deficits) associated with each fracture type may be present.
- CSF rhinorrhea and retrograde or retrobulbar hemorrhages may also occur.
- Surgical emphysema (air seepage into the cranial cavity) is a complication that is possible.
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