BDS10022 - Maxillofacial Trauma 2 (2020) PDF

BDS10022 Maxillofacial Trauma 2 Aims The aim of this lecture is to detail the clinical, diagnostic and management aspects of orbital and zygomatic trauma. Objectives On completion of this lecture, the student should be able to: Understand the clinical manifestations or orbital and/or zygomatic tr...

BDS10022 Maxillofacial Trauma 2 Aims The aim of this lecture is to detail the clinical, diagnostic and management aspects of orbital and zygomatic trauma. Objectives On completion of this lecture, the student should be able to: Understand the clinical manifestations or orbital and/or zygomatic traumatic injuries Understand the diagnostic processes for orbital and/or zygomatic traumatic injuries Understand the principles of management of orbital and/or zygomatic traumatic injuries Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity Etiology • Motor Vehicle Accidents (MVA) • Violence (12-68%) • Sport injury • Daily life activity Orbital Fractures • Internal orbital skeleton • Involve the orbital rim • Associated with other fractures • Orbital apex fractures Orbital Fractures • Internal orbital skeleton • Blow out • Blow in Orbital Fractures • Internal orbital skeleton • Blow out • Blow in Orbital Fractures • Internal orbital skeleton • Blow out • Blow in Orbital Fractures • Associated with other fractures of the facial skeleton • Zygomaticomaxilla ry complex fracture (ZMC) • Naso-orbitalethmoidal Fracture (NOE) • Le Fort fractures Orbital Fractures • Associated with other fractures of the facial skeleton • Zygomaticomaxillary complex fracture (ZMC) • Naso-orbital-ethmoidal Fracture (NOE) • Le Fort fractures Orbital Fractures • Associated with other fractures of the facial skeleton • Naso-orbitalethmoidal Fracture (NOE) • Zygomaticomaxilla ry complex fracture (ZMC) • Le Fort II or III Orbital Fractures • Associated with other fractures of the facial skeleton • Naso-orbitalethmoidal Fracture (NOE) • Zygomaticomaxilla ry complex fracture (ZMC) • Le Fort II or III Orbital Fractures • Orbital apex fractures • Optic canal injury • Superior orbital fissure syndrome Diagnosis of orbital fractures Diagnosis of orbital fractures • The initial ophthalmologic evaluation should include • Internal orbital injuries • Periorbital examination • visual acuity • ocular motility • pupillary responses • Visual fields • fundoscopic examination Diagnosis of orbital fractures • Inspection • Palpation • bony orbital rim should be palpated for steps, crepitus, and mobility. • Subjective findings • Nerve impairment, • Diplopia • Malocclusion Orbital Fractures • Periorbital edema and ecchymosis • Subconjunctival hemorrhage • Enophthalmos • Extraocular muscle entrapment Orbital Fractures • Periorbital edema and ecchymosis • Subconjunctival hemorrhage • Enophthalmos • Extraocular muscle entrapment Orbital Fractures • Periorbital edema and ecchymosis • Subconjunctival hemorrhage • Enophthalmos • Hertel exophthalmometer • Extraocular muscle entrapment Orbital Fractures • Periorbital edema and ecchymosis • Subconjunctival hemorrhage • Enophthalmos • Extraocular muscle entrapment Orbital Fractures • Periorbital edema and ecchymosis • Subconjunctival hemorrhage • Enophthalmos • Extraocular muscle entrapment • Forced duction test ZMC Fractures • Cosmetic deformities • flattening of the malar eminence • widening or depression of the arch • orbital dystopia • Enophthalmos ZMC Fractures • Functional disturbance • Trismus • Infraorbital nerve paresthesia • Diplopia Traumatic telecanthus Rounding of canthal angle (lake) Naso-orbitalethmoidal Fracture (NOE) Epiphora CSF leak Anosmia Bow-string test Kelly clamp NOE Fractures • Traumatic telecanthus • Normal intercanthal distance 28-34 mm • More than 35 is suggestive of NOE • More than 40 is diagnostic • Shortened palpebral fissure • Rounding of canthal angle (lake) • Bow-string test • Kelly clamp NOE Fractures • Traumatic telecanthus • Normally 28-34mm • More than 35 is suggestive of NOE • More than 40 is diagnostic • Rounding of canthal angle (lake) • Bow-string test (traction test) • Kelly clamp NOE Fractures • Traumatic telecanthus • Normally 28-34mm • More than 35 is suggestive of NOE • More than 40 is diagnostic • Rounding of canthal angle (lake) • Bow-string test • Kelly clamp NOE Fractures • Epiphora • CSF rhinorrhea • Anosmia • Epiphora • Jones lacrimal tests NOE Fractures • CSF rhinorrhea • Anosmia Diagnosis of orbital fractures • Le Fort I Diagnosis of orbital fractures • Le fort II Diagnosis of orbital fractures • Le fort III Diagnosis of orbital fractures • Imaging • 2D radiography • PA • Water’s view • Submentovertex view • Fine cut CT scan (1.0 mm slice thickness) Diagnosis of orbital fractures • CT findings • Herniation of orbital contents • Intraorbital &/or subcutaneous emphysema Principles of management Principle of management Objectives Restore functional disturbance • Extraocular muscle entrapment • Diplopia Correct cosmetic deformity Timing 2 weeks Immediate Treatment Planning Surgical approach Principle of management Reduction & Fixation/Reconstruction Follow up complications Management Medical Therapy Surgical Therapy avoid blowing the nose Transcutaneous Antibiotics transconjunctival, or Analgesics endoscopic (transmaxillary or transnasal) approaches Steroids Surgical Approaches Transcutaneous approaches Transconjunctival Transantral Orbital Floor Endoscopic endonasal transmaxillary Surgical Approaches • Transcutaneous approaches • Coronal Approach • Through existing laceration • Subciliary approach • Subtarsal approach • Infraorbital (skin crease) approach • Transconjunctival approach Surgical Approaches • Gillies approach • Kilner zygomatic arch elevator Surgical Approaches • Keen Approach Surgical Approaches • Transcutaneous approaches • Coronal Approach • Through existing laceration • Subciliary approach • Subtarsal approach • Infraorbital (skin crease) approach • Transconjunctival approach Surgical Approaches • Transconjunctival approach • Transantral orbital Floor repair • Endoscopic endonasal transmaxillary Surgical Approaches • Transconjunctival approach • Transantral orbital Floor repair • Endoscopic endonasal transmaxillary Reduction & fixation/Reconstruction • Internal orbital fractures • Reduction with no fixation required • Reduction with fixation • Orbital floor reconstruction • Medial wall reconstruction • Combined orbital floor and medial wall Reduction & fixation/Reconstruction • Internal orbital fractures • Reduction with no fixation required • Reduction with fixation • Orbital floor reconstruction • Medial wall reconstruction • Combined orbital floor and medial wall Reduction & fixation/Reconstruction • Internal orbital fractures • Reduction with no fixation required • Reduction with fixation • Orbital floor reconstruction • Medial wall reconstruction • Combined orbital floor and medial wall Reduction & fixation/Reconstruction • Internal orbital fractures • Reduction with no fixation required • Reduction with fixation • Orbital floor reconstruction • Medial wall reconstruction • Combined orbital floor and medial wall Reduction & fixation/Reconstruction • Internal orbital fractures • Reduction with no fixation required • Reduction with fixation • Orbital floor reconstruction • Medial wall reconstruction • Combined orbital floor and medial wall Reduction & fixation/Reconstruction • ZMC fractures • Closed reduction • Open reduction • NOE fractures • Le fort II, III Reduction & fixatioan/Reconstruction • ZMC fractures • Closed reduction • Open reduction • NOE fractures • Le fort II, III Reduction & fixation/Reconstruction • ZMC fractures • Closed reduction • Open reduction • NOE fractures • Le fort II, III Reduction & fixation/Reconstruction • ZMC fractures • Closed reduction • Open reduction • NOE fractures • Le fort II, III Complications Malunion Non-union Infection Orbital Fractures Enophthalmos Telecanthus Extraocular muscle entrapment Infraorbital paresthesia Persistent diplopia Traumatic optic neuropathy • Reading material: 1. Wray D et al; Textbook of General and Oral Surgery, Churchill Livingstone 2003 pp 89-102 2. Kerawala C, Newlands C. Oral and Maxillofacial Surgery. Oxford University Press, 2010 pp 32-56 3. Brennan et al. Maxillofacial Surgery Volume 1. Elsevier 2017 pp 93-132 TO SUM IT UP : • Diagnosis of conditions that require immediate interventions and conditions that contraindicate surgery is mandatory • Excellent communication between the ophthalmologist and the maxillofacial surgeon is essential • Strict adherence to systematic diagnostic protocol ensures a complete record of all the findings • The zygomatic fractures are the most common type of midfacial fractures (62%) followed by le fort II fractures (22%) Aims The aim of this lecture is to detail the clinical, diagnostic and management aspects of orbital and zygomatic trauma. Objectives On completion of this lecture, the student should be able to: Understand the clinical manifestations or orbital and/or zygomatic traumatic injuries Understand the diagnostic processes for orbital and/or zygomatic traumatic injuries Understand the principles of management of orbital and/or zygomatic traumatic injuries Thank you