Principles of Treatment of Midfacial Fractures PDF

Principles of Treatment of 30 Midfacial Fractures Chapter Outline ™ Methods of Reduction for Midface Fractures ™ Fractures of the Nasal Bone and Treatment ™ Treatment of Fractures of the Zygomatic Bone...

Principles of Treatment of 30 Midfacial Fractures Chapter Outline ™ Methods of Reduction for Midface Fractures ™ Fractures of the Nasal Bone and Treatment ™ Treatment of Fractures of the Zygomatic Bone
       
       
The principles of treatment of midfacial fracture consist of the reduction and fixation of the fractured bones to    
 one another and to the skull. Restoration of the occlusion               is a must for the correct reduction of the dentulous jaw segments. The bony framework and buttresses of the Manual reduction can be carried out in all fresh fractures midface must also be repositioned or restored and fixed. and where the fragments are not impacted. As a rule, arch Restoration of the form will also restore the function. bars are first applied to the teeth. The lower jaw serves as Reduction and fixation can be achieved by either conser- a template, so that the occlusion can be checked. vative or operative methods. It should be undertaken as i. Simple manipulation by hand is possible in fresh early as possible following injury. The sooner the treat- fractures, maxilla is held between the index finger ment is carried out, the greater the prospects for resto- and thumb and brought into normal occlusion. ration of normalcy. Another method is to fix two double wires encircling After the availability of mini-bone plate system, the the first and second maxillary molars and twisting conservative methods have largely been replaced by them individually on either sides. Both the twisted surgical methods. Common to both methods is splinting wire ends are held by means of wire holders or hemo- of both jaws in all cases, in which the alveolar process stats and simultaneously downward movement of of the maxilla is involved in the fracture. Fixation of the maxilla will help to achieve the normal occlusion. the midface must be maintained by external or internal ii. Dingman and Harding in 1951, suggested the use skeletal fixation until consolidation is achieved. The of dental compound loaded into impression tray for immobilization to stable skeletal segments of the skull mobilizing the fractured fragment of maxilla. This should be maintained for approximately six to eight can be used, where some amount of fibrosis has set weeks. IMF is maintained until occlusal disturbances in because of delayed treatment. When the impres- can no longer result, that is, three to four weeks. In case sion compound sets, then the firm grip can be taken miniplate osteosynthesis has been performed, then there on the maxillary arch and the handle of the tray is is no need for IMF. used for rocking the maxilla.  Chapter 30 ‹ Principles of Treatment of Midfacial Fractures                       iii. Propescu and Burlibasa in 1966, have described reduction by rubber dam sheets or by means of Repositioning the fractures that are already in a state of long ribbon/strip gauze or rubber catheters. When- partial consolidation or when attempted manual reduc- ever the maxilla is impacted and simple manual tion is met with failure, then reduction by elastic traction mobilization is not possible, then this method can be is tried to interdigitate the fractured fragments. This is tried, if sophisticated instruments are not available. mainly used in delayed cases, where the fracture is 10 to The rubber catheter’s end is passed from the nostril 14 days old and no longer sufficiently mobile. into the oropharynx and it is grasped with the help of i. Intraoral elastic traction. hemostat and brought out of the oral cavity. So, you ii. Extraoral elastic traction with appropriate extension have one end coming out from nostril and other end bars and side bars. through the oral cavity, same procedure is repeated Intraoral intermaxillary elastic traction may be used on the other side through the nostril. After grasping in an appropriate direction to restore normal occlusion. all four ends of the catheter and stabilizing the head, Once the satisfactory occlusion is achieved, it is replaced maxilla can be rocked into the normal occlusion. by IMF. iv. Reduction by using special instruments—specially con- structed disimpaction forceps can be used to take firm    ! " # $ % & # ! ' " ! $ % ( !  % grasp of the maxilla and reduce it into the position. Rowe’s maxillary disimpaction forceps—are available Reduction and fixation of the fractured midface is as right and left forceps. Always used in pairs. These indicated in cases, where surgery is not possible on are two pronged forceps, where one prong fits into the account of poor general condition of the patient or nasal floor and another one on the hard palate. Anterior where there is extensive comminution with tissue loss, traction in the case of a split palate, may be facilitated by making internal skeletal fixation impossible. It may be the use of the special forceps devised by Hayton Williams. used also as a supplementary measure with the surgical These are applied to the buccal aspect of the alveolar treatment of midfacial fracture. process and medial compression exerted until the two ) * + ! " # & ! , ) +   % $  !  * - ! $. &  / halves of the upper jaw are approximated. A screw top is adjusted to prevent crushing of the bone. It is possible to Fixation may be dispensed with, where mobility at combine the use of these forceps with Rowe’s maxillary the fractured maxilla is only slight, providing that the disimpaction forceps. The stabilized maxillary block occlusion is not disturbed. In such cases the progress of may then be disimpacted and drawn forward (Fig. 30.1). healing is merely supervised. The patient is advised to avoid chewing during the first 2 to 3 weeks and should remain on a liquid or semisolid diet. Monomaxillary fixation: This method is used when tooth bearing section of the maxilla is not fractured and there- fore can serve as fixation point. The arch bar or palatal acrylic plates can be used. This can be used for unilateral fractures of maxilla or higher fractures without occlusal discrepancies. As a rule monomaxillary fixation must be maintained for six weeks. Intermaxillary fixation (IMF): Intermaxillary fixation is maintained for 3 to 4 weeks and at the end of this period IMF wires and the lower arch bars are removed. Internal skeletal wire suspension: Many times in addition to IMF, additional support is required for immobiliza- tion of the jaws. Craniomaxillary or craniomandibular suspension can be carried out using the stable point above 0 1 2 3 4 5 3 6 7 8 9 : ; < = > ? @ ? A B C D > E E C F G A F C < = ; F 9 H I J K L 8 ? M 9 N H B C D > E E C F G the fracture line. The selection of the site for suspension wire will be dependent on the level of fracture line. The : > H > B O C < = > ? @ A ? F < 9 O H P J Q L R C G = ? @ S > E E > C B N H : > H > B O C < = > ? @ A ? F < 9 O H    T Section 5 ‹ Maxillofacial Trauma t u v 0 1 2 e 4 5 3 f g h i j 7 k E ? H 9 : F 9 : ; < = > ? @ M > = l > B B ? m > E > n C = > ? @ ? A A F C o B 9 @ = H ; H > @ o H ; H O 9 @ H ? F G M > F > @ o H C m ? p 9 = l 9 A F ? @ = ? n G o ? B C = > < H ; = ; F 9 H C @ : q r s procedure for internal skeletal wire suspension is done fragment. Disimpaction forceps can be used and the through a minor surgery. fragment is brought into normal occlusion by mani- Ŗ #RRNKECVKQPQHCTEJDCTU pulation. Temporary IMF is carried out and fracture Ŗ 4GFWEVKQPQHHTCEVWTGD[ENQUGFOGVJQFōQEENWUKQP fragments are fixed under direct vision by intraosseous is checked wiring or mini-bone plates with screws. Ŗ (KZCVKQP QH VJG OKFHCEG VQ VJG DCUG QH VJG UMWNN D[ For extensive high level fractures of the midface means of suspension wires. bicoronal incision can be taken. Various skeletal Ŗ (KZCVKQPQHVJGOKFHCEGD[VKIJVGPKPIVJGUWURGPUQT[ incisions for exposure of midface skeleton are follows wires and intermaxillary fixation (Fig. 30.7): Ŗ (QT GFGPVWNQWU RCVKGPVU CXCKNCDNG RTQUVJGUKU QT 1. Supraorbital eyebrow incison Gunning splint is used. 2. Subciliary incision LeFort I fracture: IMF fixation by zygomatic arch suspen- 3. Median lower eyelid incision sion, if necessary additional suspension at the piriform 4. Infraorbital incision aperture. 5. Transconjunctival incision 6. Zygomatic arch incision LeFort II: Zygomatic arch suspension or frontal bone sus- 7. Transverse nasal incision pension. Intraosseous wiring may be done at infraorbital 8. Vertical nasal incision margins. 9. Medial orbital incision. LeFort III: Intraosseous wiring at zygomaticofrontal Y " $ W % * " !  _ % ` ! Y.   "  _ % ` ! U " a & % sutures and bilateral frontomalar suspension is used after the application of arch bars. Intraosseous wiring may be X b.  c d  * % Y " $ W % * " ! ^ done at the infraorbital margin, if step deformity exists True blow-out fracture occurs as a result of direct trauma (Figs 30.2A to C). to the orbit with an object larger than the globe size U + !  V ! , * W % &   X Y & / Z [ \ Z %  Z [ \ ] ^ (cricket ball injury) (Fig. 30.8). Here primarily there is an increase in hydraulic pressure within the orbit resulting Open reduction is carried out under endotracheal an- from compression of the orbital contents. In addition, esthesia with nasal intubation. Intraoral vestibular forces acting on the bone play a part. The fractured incision is taken from first molar to first molar region orbital floor gives way into the maxillary sinus. At the on either side. Mucoperiosteal flap is reflected to expose same time, orbital fatty tissue and sometimes muscles, the fracture line. After identifying the fracture line, in (inferior rectus and inferior oblique) prolapse into the old fractures, an osteotome is inserted to mobilize the sinus like a hernia.  Chapter 30 ‹ Principles of Treatment of Midfacial Fractures   w t v u ~ 0 1 2 e 4 5 3 4 g h i x 7 J y L z 9 s ? F = q A F C < = ; F 9 M > = l B > : O C E C = C E H O E > = { ? < < E ; H C E : > H l C F B ? @ G P J | L q @ = F C ? F C E m ; < < C E p 9 H = > m ; E C F > @ < > H > ? @ = ? 9 D O ? H 9 = l 9 A F C < = ; F 9 E > @ 9 ? @ F > o l = H > : 9 P J k L z 9 A = H > : 9 H ; F o > < C E 9 D O ? H ; F 9 = ? 9 D O ? H 9 = l 9 A F C < = ; F 9 E > @ 9 C @ : m ? @ G : 9 A 9 < = > @ = l 9 C @ = 9 F ? E C = 9 F C E M C E E ? A = l 9 B C D > E E C F G H > @ ; H P J } L s F C < = ; F 9 F 9 : ; < = > ? @ : ? @ 9 = ? C < l > 9 p 9 H C = > H A C < = ? F G ? < < E ; H > ? @ t u v 0 1 2 e 4 5 3  g h i j 7 € } k  H < C @ z 9 s ? F = q q A F C < = ; F 9 M > = l 8 n G o ? B C C @ : C F < l A F C < = ; F 9 ‚ ƒ ? = 9 = l 9 C @ = 9 F > ? F ? O 9 @ m > = 9 : ; 9 = ? : ? M @ M C F : C @ : m C < „ M C F : : > H O E C < 9 B 9 @ = ? A B C D > E E C     Section 5 ‹ Maxillofacial Trauma v u t ~  Ž   ‘ ’ 0 1 2 e 4 5 3 g h i † 7 J y L s F ? @ = A C < 9 C A = 9 F = F C ; B C P J | L ‡ ; m < ? @ ˆ ; @ < = > p C E l 9 B ? F F l C o 9 M > = l < > F < ; B ? F m > = C E 9 < < l G B ? H > H P J k L } 9 F C @ o 9 : ? < < E ; H > ? @ P ' %RQHSODWH¿[DWLRQDIWHURSHQUHGXFWLRQDW/DQJOH ( %RQHSODWH¿[DWLRQDW/]\JRPDWLFEXWWUHVV ) ,QIUDRUELWDOULPIUDFWXUHH[SRVHGYLD H[WUDRUDOLQIUDRUELWDOLQFLVLRQ * %RQHSODWH¿[DWLRQDW/LQIUDRUELWDOULP + 6DWLVIDFWRU\RFFOXVLRQDIWHUUHGXFWLRQ , 3RVWRSHUDWLYHIURQWIDFH - 3RVWRSHUDWLYH3$YLHZPDQGLEOH v t ~ 0 1 2 3 4 5 3 “ 7 ” C F > ? ; H A C < > C E > @ < > H > ? @ H A ? F 9 D O ? H ; F 9 ? A B > : A C < > C E H „ 9 E 9 = ? @ The infraorbital rim remains intact. The fracture  u may go unnoticed due to the presence of orbital, 0 1 2 e 4 5 3 ‰ g h i Š 7 k  H < C @ ? A = l 9 O C = > 9 @ = H 9 9 @ > @ s > o ; F 9 € ‹ ‚ Œ J y C @ : | L € } k  H < C @ H l ? M > @ o z 9 s ? F = q q A F C < = ; F 9 M > = l z C @ o E 9 B C @ : > m E 9 A F C < = ; F 9 J y F F ? M H L P J k L R periorbital edema, hematoma and the clinically intact C n > @ 9 H H ? A z B C D > E E C F G H > @ ; H M > = l : > H F ; O = > ? @ ? A H > @ ; H M C E E H P 'DQG( *URVVGLVSODFHPHQWZLWKRYHUULGLQJRIIUDJPHQWVDW/DQJOH infraorbital ridge. Enophthalmos with restriction of the extraocular movements and at times diplopia may be B C @ : > m E 9