PLASTICS 2

SUBSPEC
DR KHO
OCTOBER 6 2016

MAXILLOFACIAL INJURIES FACE

Trauma patients facial series
ABCS
Maintain that airway is patent WATERS VIEW
Maintain breathing
Aspiration precaution
No matter how horrible it looks it it is the least of the
worries
Have to stabilize patients first
Always look for other injuries
Get a cervical spine C1-C7 (very important)
postero- antero view with cephalad angulation
aka occipitomental view
DIVIDE FACE INTO 3 AREAS
most comprehensive view
Upper face
see upper third of the face
o Frontal bone in the sinus
EXCELLELENT VIEW OF:
Very hard need a high force
o Maxilla and maxillary sinuses
energy to cause injury to this
area o Zygoma and zygomatic arches
o Rims and orbits especially floor
Mid face
o Nasal bones
o Upper midface
3 lines of DOLAN
Cheekbone
Nose
Ethmoid
Maxilla
-Dont need a high force (low impact)
energy can cause injury
o Lower midface
Maxillary alveolus
Teeth
Palate o do frontal Xrays- compare suspected site to
Lower face the contralateral site
o Mandible ELEPHANTS OF ROGER
-need high impact energy to cause injury o 2nd and 3rd lines

DIAGNOSIS CALDWELL VIEW

Inspection- suspect areas with lacerations ecchymosis
to outline deformity to appreciate
PALPATION- facial asymmetry
o divide the face in the middle
o 2 rights and 2 lefts
o RULE: the more symmetrical you are the
more attractive you are
o Pain- suspect
PA view
o Bones should not be moved if moves-
Occipitofrontal view
FRACTURED
o Step off in bone- should be smooth For facial symmetry
Indicative of break in continuity Upper third of the face
o Paresthesia- injured nerve EXCELLENT VIEW OF:
o Check oral mucosa o Entire rim of the orbit especially the
o Ask patient to bite to check for superomedial rim
MALOCCLUSION o Frontal and ethmoid sinuses

DIAGNOSTIC IMAGING LATERAL VIEW

1. XRAY Profile view
Advantage: check for the structures found further
o Fast o sphenoid sinuses
o Not expensive o antero posterior tables of the frontal sinus
o Can identify or differentiate to nearby o lateral orbit
structures o palate of the mandible
o Can be found anywhere
Disadvantage BASE VIEW
o Radiation exposure- soft tissue cant be submental vertex view
appreciated much visualize:
o Projection Limited to antero posterior or o used for the zygomatic arches
postero- anterior o any impingement upon the coronoid
process

MANDIBULAR SERIES
lateral oblique view
townes view
orthopantogram or panorex

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LATERAL OBLIQUE VIEW ANATOMY:
see the entire half mandible
need to order at least 2 the right and the left
key structures:
o R- TMJ

o Symphysis- central incisors

o Prasymphysis- canine
o Body
Tooth baring portion
o Angle
3rd molar
o Ramus
o Condyle
o Coronoid process
TOWNES VIEW Under zygomatic arch
Excellent view of Most frequent region of fractures
o Mandibular condyles and condyle necks o Condyle
Ear view Lack of support thin structure
o Middle ear o Body
o Mastoid Molar region
o Cochlea Presence of the teeth
Roots extending to the body
ORTHOPANTOGRAM OR PANOREX area porrous
o Angle
PRINCIPLE OF MULTIPLICITY
o Fractures are frequently multiple
o Seldom are fractures solo
o Ipsilateral body and contralateral
subcondylar tracture
o Symphyeal fracture and bilateral
subcondylar fracture
*can have 3 fracture- one in the symphysis and
See the entire mandible in one shot bilateral subcondylar fractures
Usually seen in dental clinics Muscles of the mandible- play an important tool in the
Most effective screening management of fractures
See both sides o ELEVATORS- muscles which pull the
mandible upward
2. CT SCAN Masseter
Most accurate Pterygoid (medial)
can see the exact area and extent of the fractures Temporal muscle (anterior part)
ADVANTAGES o PROTRUSOR
o 3D lateral pterygoid
o Provides depth information o FRACTURE- tend to pull apart
o Improved soft tissue contrast
o Fast and simple
DISADVANTAGES
o Ionizing radiation
o Risk of solid malignancies
o More expensive
3 views *if fractures are in the opposite direction- muscles are
o FRONTAL touch and go helping keeping fractures opposed to prevent separation
Anterior and posterior *symphysis- fractures- tend to separate because
o SAGITTAL PLANE- right and left tendency is that the pressure should pull segments downwards
o TRANSVERSE o RETRACTORS
Upper and lower half Posterior part of the temporal
muscle
CORONAL VIEW Deep part of the masseter
muscle
o DEPRESSOR- RETRACTORS
Digastric muscles
Geniohyoid muscles

*cuts- important- if the cuts are too far- might miss a DENTAL OCCLUSION
fracture in between cuts Relationship of the midface and mandible in fractures
Want very small cuts to prevent missing
fractures in between EDWARD ANGLE
SAGITTAL CUT Dentist
o Right and left Relationship of maxillary teeth to mandibular teeth
o Depends on the cut upper first molar and lower 1st molar
CLASS 1
MANDIBULAR FRACTURES
Mauling or by accident
Frequent
2nd most commonly injured facial bone o Centric occlusion
Most common: NOSE o Mesiobuccal cusp of the maxillary first
Increased incidence in NASAL FRACTURES molar is in the intercuspal groove of the
Common mandibular first molar
Mandibles prominence and relative lack of support o NORMAL RELATIONSHIP

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 3 steps in doing mandibular fracture
CLASS 2 o TMJ- make sure that condyle is in the
glenoid mucosa
o Put in a fixation before trying to reduce the
fracture-
o Anterior (mesial) positioning of the MOLARS-used as guide (wear
maxillary teeth and tear of the molar surface)
o Orthognathic (underbite) like a jigsaw puzzle
o Small mandible compared to the maxilla o Fracture
CLASS 3 Incisions- as much as possible incisions are hidden
o oral incisions- harder but will not be seen
o extraoral incisions- if lacerations are
present
o Posterior (distal) positioning of the o try to put incisions in areas that cant be
maxillary teeth seen
o Retrignathic(overbite) below the mandible
o Have either a large mandible or a small subciliary
maxilla near the eye
Importance of the angle:
o Find out patients class TYPES OF MANDIBULAR FRACTURES
o Once treating- dont change the bite of the
patient
o Class on the start should still be the class
upon finish
o Class 2 or 3- change to class 1 can be done
(different procedure)
o Trauma patients- need to bring back the
original angle of the patient

PANOREX
Panoramic radiography (orthopantography)
Need patient in upright position

ANGLE AND BODY FRACTURES

o ORIF f displaced
Increased = right ramus of the mandible (red arrows) o Almost all fractures of angle unfavorable
Increased- subtle second site of fracture is at the left
body
ORBITAL FRACTURES
CT SCAN Always check the visual acuity first- if there is an
Can be done even if patient is toxic impairment it might be an emergency
Shows all mandibular fractures and other facial To rule out injury that might be an emergency
function including position and alignment of fragments
Associated soft tissue injuries ANATOMY OF THE ORBIT
Easy to perform in multi-trauma patients

TREATMENT OF MANIBULAR FRACTURES

Non surgical treatment
o Minimal to no displacement
o Preserved pretraumatic occlusive
relationship
o Normal ROM
MAXILLOMANDIBULAR FIXATION
o Aka intermaxillary fixation
o Conservative approach- looks like braces
Can be done for minimal
displacement
For children Roof- part of the frontal bone
o Simplest method to reduce and fix fracture MIDDLE WALL- lamina papiracea of the ethmoid
o Minimize stripping periosteum Lateral wall- zygoma and sphenoid bone
o given
Children BLOWOUT FRACTURE
2-4 weeks Most common orbital fracture
Adults Orbital floor blowout fracture
4-6 weeks History is a blow hitting the eye
o Requirements Mechanism wherein eye is protected transient
Conscious patients increase in the intraorbital pressure and if there is
Patent nasal airway nothing that one will give the globe will rupture
No seizure disorder
Protective mechanism- floor will give instead of the
o Feeding- by straw
globe
All blenderized
Thinnest area areas that will give
o Need to go to the dentist weekly
o Median floor
SURGICAL TREATMENT
o Inferior medial wall
o Goals:
o Intermediate wall
Resoration of pretraumatic
Indications for surgery
dental occlusion
o Large rupture
Reduction of stable fixation of
o Enopthalmos- sinking of the globe
the fracture
Repair of soft tissue

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 o Diplopia more than 2 weeks- because of the ____ ETHMOIDAL FRACTURES
inferior rectus forceful blow from the front
Inferior rectus- very important usually have other injuries
for the movement of the eye important- MEDIAL CANTHAL TENDON
IR- if stuck in the floor- diplopia o All structures come from the medial canthal
can happen tendon
Put local aneasthetic and try to o 13mm between the middle canthus- normal
moves eyes in all directions Greater- telecanthus
o Rupture of the floor- will have a bigger TELECANTHUS-
orbital column globe can sink downward o Can have if middle canthal tendon is
backward inferiorly bpound to one side or on both sides
o IMPORTANCE OF CUTS (CT SCAN) o Increased distance of more than 13 mm
o Can look normal on the outside but o PE
damaged on the inside Bimanual palpation test
TREATMENT Give direct pressure and notice a
o Replace the contents fracture
o Repair the floor or the opening Not only functional but also a cosmetic deformity
o Use plates and screw TYPE 1
COMPLICATIONS o Large ___ fracture- middle canthal tendon
o Persistence of the double vision is intact
o Enopthalmos Type 2
o Enthropion o Comminuted
o Endropion o Several pieces but tendon is still attached
Type 3
LATERAL INTRAORBITAL LIMB FRACTURES o Worst
Usually part of zygomatic complex fractures o Comminuted but detached middle canthal
tendon
COMPLICATIONS AFTER ORBITAL FRACTURE TREATMENT
Superior orbital fissure syndrome (SOF) Reduce all the fractures and stabilize
o Compression of the structures in the SOF Using pins and screws and bone grafting if needed
o CN 3 4 6 Frontal sinus fractures are sometimes managed by
o Ophthalmic neurosurgeons
o s\sx Sinus- weak fracture
ptosis Treatment would depend on the fracture
proctosis
paralysis of the EOM because of FRONTAL SINUS- In between the anterior and posterior tables
CN 6
Anterior table- responsible for the contour of the
aneasthesia of the 1st branch of
forehead
trigeminal (opthalmic)
o Frontal sinus- behind anterior table
Orbital apex syndrome(OAS) o Posterior table- behind frontal sinus
o Same but including CN 2
Posterior table- separates the sinus from the dura
*both considered emergencies and not common
o Of missing
Frontal sinusitis involving the
ZYGOMATIC FRACTURES
sinus
Zygoma Can easily affect the dura of the
Orbits brain
Articulations (4) o 2\3rds of the fractures that are seen are
o Sphenoid bone- laterally combined
o Frontal bone- superiorly Fracture of the anterior and
o Maxilla- medially posterior table
o Temporal bone- arch o 1\3rd- fracture on the anterior table
o Seldom see fractures of the posterior tables
2 types of zygomatic fractures without the anterior table involved
1) Isolated zygomatic arch
2) Zygomatic complex fractures- which include the body TREATMENT
Anterior table- if no treatment is given there would be
For non displaced fractures- observe a bad contour of the anterior forehead
Displaced: Posterior table
o Put rullers if displaced request for CT scan o Dangerous
o Infection of the frontal sinus- can easily go
SURGERY to the brain
Temporal approach o 2 options
Or can do it through transoral approach inside the Have to destroy the frontal sinus
mouth Obliteration of the nasofrontal
COMPLEX duct frontal sinus will cease
Foor direct visualization acting like a sinus

ZYGOMATICO MAXILLARY COMPLEX NASAL FRACTURE

Entire body Most common
Not a tripod fracture Upper portion
Fracture segment will rotate laterally inferiorly o Upper third of the nose
Flattened cheekbone Middle portion
s\sx o Upper cartilage
o intraorbital ___ numbness Lower 3rd portion
o conjunctival hematoma o Lateral cartilage
Check the nose inside for presence of hematoma
TREATMENT o Very important
not displaced no treatment o Have to drain- if not the cartilage (nasal
displaced- ORIF septum) will collapse pressure necrosis
End up with a saddle nose

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 DIAGNOSTIC IMAGING
o To rule out other injuries
Treatment
o Want to reduce fracture ASAP
o A lot easier if treatment is done within 1
week
o NEGLECTED FRACTURE- need to refracture

MIDFACE FRACTURES
Link between cranium and occlusant plane between
the maxilla and the mandible
Responsible for the AP facial projection
Most severe facial fractures
Need a high energy drug

3 types LEFORT

1) Transverse or leport 1 fracture

Fractures are above the images of the teeth
retinal line
Separates the lower maxilla hard palate
maxillary plates and the remainder of the
skull
low transverse fracture that crosses the
floor of the nose, pyriform aperture, canine
fossa, and lateral wall from the maxilla,
resulting in separation of the palate from
the maxilla
low septal fracture

2) Lefort 2
Pyramidal fractures
Shape of a pyramid
Separates the nose and lower maxilla from
the pinofacial skeleton
crosses the nasal bones on the ascending
process of the maxilla and lacrimal bone
and crosses the orbital rim
Only the Le Fort II fracture violates the
orbital rim.
Because of this proximity to the infraorbital
foramen, type II fractures are associated
with the highest incidence of infraorbital
nerve hypesthesias.
extends posteriorly to the pterygoid plates
at the base of the skull
high septal fracture
3) Lefort 3
Craniofacial disjunction
Separates the entire midface from the
cranium
Fractures are across the zygomaticofrontal
suture
traverses the frontal process of the maxilla,
the lacrimal bone, the lamina papyracea,
and the orbital floor
. This fracture often involves the posterior
plate of the ethmoid.
Because of their location, Le Fort III
fractures are associated with the highest
rate of cerebrospinal fluid (CSF) leaks
Can have 2 leports in 1 patient
*can have leport 3 on one side and leport 2 on the other

TREATMENT
Reestablish the normal features

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