Fracture maxilla
- 1. FRACTURE MAXILLA DR SHAMEEJ MUHAMED KV SENIOR RESIDENT DEPARTMENT OF NEUROSURGERY , GMC CALICUT
- 2. INTRODUCTION • 2nd largest bone of face • 2 maxillae forms whole of upper jaw • Each maxilla contributes in formation of 1. Face 2. Nose 3. Mouth 4. Orbit 5. Infratemporal fossa 6. Pterygopalatine fossa
- 3. FEATURES OF MAXILLA Each maxilla has – 1. Abody 2. 4 processes – frontal zygomatic alveolar palatine
- 4. BODY OF MAXILLA • Shape – pyramidal • It has – • 1. Base – directed medially at nasal surface • 2. Apex - directed laterally at zygomatic process • 3. 4 surfaces – anterior / facial posterior / infratemporal medial / nasal superior / orbital • Encloses a cavity – maxillary sinus
- 5. ANTERIOR / FACIAL SURFACE • Directs laterally • Incisive fossa -depressor septi • Nasalis – superolateral, along nasal notch
- 6. • Canine fossa – levator anguli oris • Infraorbital foramen • levator labii superioris • Medially – the nasal notch & anterior nasal spine
- 7. POSTERIOR / INFRATEMPORAL SURFACE Concave Directed – backward & laterally Forms – anterior wall of infratemporal fossa Separated from anterior surface by zygomatic process & zygomatico maxillary ridge Posteroinferiorly – maxillary tuberosity & superficial head of medial pterygoid muscle
- 8. SUPERIOR / ORBITAL SURFACE • Smooth, triangular & slightly concave • Forms – Greater Part Of Floor Of Orbit • Anterior border forms – part of inferior orbital margin • continues with lacrymal crest of frontal process
- 9. Posterior border – smooth & rounded • Forms most anterior margin of inferior orbital fissure • In middle – infraorbital groove Medial border – Anteriorly lacrymal notch, converted into nasolacrimal canal • Behind the notch, articulation with – Lacrymal Labrynth of ethmoid Orbital process of palatine bone
- 10. THE MEDIAL /NASAL SURFACE Part of lateral wall of nose Posterosuperiorly – maxillary hiatus Above the hiatus – air sinuses Below the hiatus – anterior part of inferior meatus Behind the hiatus – articulates with perpendicular plate of palatine bone & encloses greater & lesser palatine canals
- 11. Infront of the hiatus – nasolacrymal groove articulates with descending process of lacrymal bone & lacrymal process of inferior nasal concha to forms nasolacrymal canal • More anteriorly – conchal creast for articulation with inferior nasal concha. • Above the conchal crest – atrium of middle meatus.
- 12. PROCESSES OF MAXILLA • 1. FRONTAL • 2. ZYGOMATIC • 3. ALVEOLAR • 4. PALATINE
- 13. FRONTAL PROCESS Projects upward & backwards to articulate above – nasal margin of frontal bone infront – nasal bone behind – lacrymal bone Lateral surface – divided by anterior lacrymal crest into anterior smooth & posterior grooved Anterior lacrymal crest gives attachment to lacrymal fascia & medial palpebral ligament
- 14. • Medial surface – forms lateral wall of nose • from above downwards – - Uppermost roughened area for articulation with ethmoid -2. Ethmoidal crest – a horizontal ridge, articulates with middle nasal concha -Below the ethmoidal crest- atrium of middle meatus
- 15. ZYGOMATIC PROCESS Pyramidal lateral projection Anterior, posterior & superior surfaces converge here Superiorly – rough, to articulate with zygomatic bone
- 16. ALVEOLAR PROCESS • Forms half of alveolar arch Bears socket for maxillary teeth In adults = 8 sockets
- 17. PALATINE PROCESS • Thick horizontal plate • Projecting medially • Forms largest part of roof & floor • Inferior surface – concave & forms anterior 3/4th of bony hard palate. • Posterolaterally –greater & lesser palatine foremen • Superior surface –concave from side to side & forms floor of nasal cavity.
- 18. ARTICULATIONS OF MAXILLA • Superiorly – 3 bones 1. Frontal 2. Nasal 3. Lacrymal • Laterally – 1 bone 1. Zygomatic bone
- 19. • Medially – 5 bones 1. Ethmoid 2. Inferior nasal concha 3. Vomer 4. Palatine 5. Opposite maxilla
- 20. • D Orbit, medial wall • E orbit, lateral wall • F Suture between sphenoid and zygomatic bones • Nasomaxillary suture • 1 Globe • 2 Ethmoid sinus • 3 Sphenoid sinus • 4 Nasal bone • 5 Maxilla, frontal process • 6 Orbit, lateral rim • 7 Sphenoid bone • 8 Optic foramen
- 21. • F Groove for infraorbital nerve • G Maxillary sinus, posterolateral wall • 5 Maxilla, frontal process • 9 Maxillary sinus • 10 Zygomatic arch • 11 Pterygoid bone • 12 Nasolacrimal duct • 13 Mandible, condyle Clear maxillary sinuses can almost rules out certain fractures such as LeFort, blowout fractures,zmc #
- 22. • H Maxillary sinus, anterior wall • I Maxillary sinus, medial wall • J Medial pterygoid plate • K Lateral pterygoid plate • 9 Maxillary sinus • 14 Mandible, ramus Fracture of the pterygoid plates may represent LeFort fracture
- 23. Buttresses of Maxillofacial • Force that are applied to the face are absorbed and transmitted by buttress system, mainly of two types • Vertical • Horizontal
- 24. Horizontal Buttresses • 1. Frontal Bar • 2. orbital rims • 3. Maxillary Alveolar • 4. Mandibular alveolar • 5. Inferior border of mandible
- 25. Vertical buttress • 1. Nasomaxillary, • 2. Zygomaticomaxillary • 3. Pterygomaxillary • 4. mandibular
- 26. Classification of Fracture of maxilla •Rene Le Fort classification (1901) Le Fort I Le Fort II Le Fort III
- 27. Marciani modification of Le Fort • Le Fort I - Low maxillary fracture Ia - Low maxillary fracture/multiple segments • Le Fort II - Pyramidal fracture IIa - Pyramidal and nasal fracture IIb - Pyramidal and NOE fracture • Le Fort III - Craniofacial disjunction IIIa - Craniofacial disjunction and nasal fracture • IIIb - Craniofacial disjunction and NOE fracture.
- 28. • Le Fort IV - LeFort II or III fracture &cranial base fracture IV a - + Supraorbital rim fracture IV b - + Anterior cranial fossa & supraorbital rim fracture IV c - + Anterior cranial fossa & orbital wall fracture
- 29. LE FORT FRACTURES • Among the most severe fractures seen in face and associated with high-energy trauma • Named after René LeFort, a French physician, who studied facial fractures in cadavers. Result was published in 1901 • Key facts - In each type, there is a partial or complete separation of maxilla from the remainder of the facial skeleton All LeFort fractures must extend through posterior face, transects the pterygoid processes Any combination of LeFort I, II, and III patterns can occur
- 30. ETIOLOGY &EPIDEMIOLOGY • Road traffic accidents (most common) -40% • Industrial accidents - 10 % • Assault -15% • Sports - 25 % • Fall - 10 % • Most maxillary fractures occur in young men aged between 16 to 40 years. • Peak age- 21 - 25 years • Male : Female - 4:1
- 31. Le Fort I : Guérin fractures OR Low Level • Result from a force of injury directed low on the maxillary alveolar rim in a downward direction • Escapes diagnosis
- 32. MOI--- Direct horizontal or angular blow at the level of upper teeth but below the anterior nasal spine = Le Fort I or horizontal maxillary fracture
- 33. LE FORT I • Fracture line passes fron nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction, and traverses the pterygomaxillary junction to interrupt the pterygoid plates • Alsp known as floating palate- seprates teeth from upper face
- 34. Sign and symptom • Swelling of upper lip and cheek •Ecchymosis–maxillary buccal sulcus •Nasal block –oral breathing •Eye or ocular sign are usually absent •Guerin sign –Echymosis in palate –greater palatine foramen bilaterally
- 35. Occlusion –Undisplaced incomplete fracture –no disturbance to occlussion –Displaced occlusion •Anterior open bite : backward and downward distraction of posterior maxilla –traction from medial pterygoid muscle •Posterior gagging of occlusion –threat to airway
- 36. Teeth fracture • Damage to the cusp of individual teeth due to impact from opposite teeth Palatal fracture •8–15% of Le Fort fractures •follow a sagittal or parasagittal direction, splitting the maxilla longitudinally close to the midline •exit anteriorly between the central incisors, or between the lateral incisor and the canine tooth
- 37. • Bilateral epistaxis or nasal bleeding may be observed •Pain while speaking and moving the jaw •Cracked pot sound •Floating maxilla •Palpation Step deformity along the piriform aperture, buccal sulcus and tuberosity region
- 38. Le Fort II/Pyramidal fracture • Starts from nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, • •Infero laterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; • •It then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates
- 39. Horizontal impacts along the Frankfort plane = Le Fort II fracture pyramidal fracture
- 41. Sign and symptom • gross edema of the middle third of the face known as ballooning or moon face • •bilateral circumorbital edema and ecchymosis(Black eye) • •Bilateral subconjunctival hemorrhage -medial half • •Bridge of the nose will be depressed (flat face) • •Anterior open bite -impaction of the fragment • •Gross downward and backward displacement of the fragment Posterior gagging of the occlusion with -anterior open bite (Dish shaped face)
- 42. • Pseudotelecanthus: swelling over the nasal bridge illusion of telecanthus, true telecanthus on the involvement of NOE complex •Bilateral epistaxis •Difficulty in mastication, and speech •Loss of occlusion may be seen •CSF leak may be present •Step deformity at the infraorbital margins •Anesthesia or paresthesia of the cheek is noted
- 43. LE FORT III • Craniofacial Dysjunctions • This fracture separates calvaria (skull) from the facial bones. • Most severe of all LeFort fractures •Anteriorly: nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones. •The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. •Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues supero-laterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. • From this point , fracture descends across the upper posterior aspect of maxillae in the region of sphenopalatine fossa and upper limit of pterygomaxillary fissures and fractures the roots of pterygoid laminae at its base. •Intranasally,a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoidplates to the base of the sphenoid.
- 45. Impact on the nasion at 30-60 degree above the horizontal = Le Fort III fracture (craniofacial disjunction)
- 47. FEATURES • high level fracture •Lateral direction with a severe impact •Clinically this fracture appears similar to the LeFortII fracture, but close examination will demonstrate a more serious condition. •After stabilizing the head and then gripping of the maxillary teeth with one hand and simple manipulation, will confirm complete movement of the middle third of the face. •Mobility of whole skeleton as a single block can be felt
- 48. Sign and symptom • Gross edema of the face, ballooning,“Panda facies” within 24 to 48 hours •Bilateral circumorbital/periorbital ecchymosis and gross edema ’ Racoon eye •Gross circumorbital edema will prevent eyes from opening •Bilateral subconjunctival hemorrhage •tenderness and separation at the frontozygomatic sutures.
- 49. • Characteristic ‘dish face’ deformity •enophthalmos •diplopia or •impairment of vision, temporary blindness, •Flattening and widening, deviation of the nasal bridge. •Epistaxis • CSF rhinorrhea
- 50. INVESTIGATION • CT-scan is best option for studying mid-facial fracture but plain radiograph may be help full too. •Radiographic examination –Water’s view: PA view with cephalad angulation –Caldwell view : PA view –Lateral view –Submentovertex view:
- 51. CT scan (coronal view) documenting a Le Fort I fracture
- 52. LE FORT II CT scan, axial view of a Le Fort II fracture, shows the fracture line through anterior and posterior maxillary sinus CT scan, axial view of a Le Fort II fracture, shows the fracture line through both infraorbital rims and zygomatic arch on the right
- 53. LE FORT III
- 54. MANAGEMENT Timings of surgery emergencies involving panfacial fractures require immediate surgery If no such medical emergencies surgery may be delayed Delayed repair (7-14 days) •manipulation of bones and soft tissue easier –suppression of edema. •risk of fibrosis and healing is there
- 55. • Principles of management REDUCTION FIXATION IMMOBILIZATION
- 56. DEFENITIVE MANAGEMENT –LE FORT I FRACTURE SURGICAL APPROACH- MAXILLARY VESTIBULAR REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
- 57. FIXATION- 4-point fixation with MINIPLATE. IMMOBILISATION- MAXILLOMANDIBULAR FIXATION(MMF)
- 58. LE FORT II SURGICAL APPROACH Coronal Approach A– Subciliary incision B – Sub tarsal incision C - Infraorbital incision D - Extension of Subciliary
- 59. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP FIXATION- 3-POINT fixation
- 60. LE FORT III CORONAL APPROACH PREAURICULAR APPROACH
- 61. A . LATERAL EYEBROW APPROACH B. UPPER-EYELID APPROACH GLABELLA APPROACH
- 62. • REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP • FIXATION- 3-point fixation • IMMOBILISATION- Maxillomandibular Fixation if required
- 63. THANK YOU
Editor's Notes
- #6: above incisior teeth shallow depression called incisve fossa depressor septi-- depressor alae nasi arise frfom incisive fossa and attaches to lateral to nasal septum