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MAXILLARY FRACTURES Is Mandatory and May Include Both Plain Films and a Computed Tomographic (CT) the Maxilla Forms the Largest Component of Scan

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MAXILLARY FRACTURES Is Mandatory and May Include Both Plain Films and a Computed Tomographic (CT) the Maxilla Forms the Largest Component of Scan Radiographic evaluation of the fracture MAXILLARY FRACTURES is mandatory and may include both plain films and a computed tomographic (CT) The maxilla forms the largest component of scan. The CT scan has now essentially the middle third of the facial skeleton. The maxil- replaced plain films as the Ògold standardÓ la is a key bone in the midface that is closely asso- in both evaluation and treatment planning. ciated with adjacent bones providing structural If physical findings and plain films are not support between the cranial base and the occlusal suggestive of a zygomatic fracture, the eval- plane. Fractures of the maxilla occur less fre- uation may end here. However, if they do quently than those of the mandible or nose due to suggest fracture, a coronal and axial CT the strong structural support of this bone. The scan should be obtained. The CT scan will midface consists of alternating thick and thin sec- accurately reveal the extent of orbital tions of bone that are capable of resisting signifi- involvement, as well as degree of displace- cant force. This structurally strong bone provides ment of the fractures. This study is vital for protection for the globes and brain, projection of planning the operative approach. the midface, and support for occlusion. Reestablishing continuity of these buttresses is the Historically, closed reduction was the foundation on which maxillary fracture treatment method of choice for nearly all zygomatic is based. fractures. Multiple methods were employed, but most involved simply exert- Renee LeFort (1901) provided the earliest clas- ing pressure underneath the malar emi- sification system of maxillary fractures. His nence and popping the fragments back into model described Ògreat lines of weakness in the alignment. Not only were these results fre- faceÓ using low-velocity impact forces directed quently unsatisfactory, but they were against cadaver skulls. A discussion of fractures of fraught with complications including per- the maxilla would not be complete without a sistent diplopia, orbital dystopia, malunion, description of LeFortÕs work. and significant residual deformity. In our The Lefort I fracture, or transverse fracture, own experience, closed reductions yield extends through the base of the maxillary sinuses unpredictable results with significant above the teeth apices essentially separating the chance of relapse. We feel that plate and alveolar processes, palate, and pterygoid process- screw fixation is now the standard of care. es from the facial structures above. This trans- The treatment of zygomatic fractures has verse fracture across the entire lower maxilla dramatically progressed over the past sev- separates the alveolus as a mobile unit from the eral decades from an entirely closed rest of the midface. Fracture dislocations of seg- approach to the more aggressive open ments of the alveolus may be associated with this reduction and rigid miniplate fixation of fracture. With high-energy injuries, the palate today. If a zygomatic fracture is displaced, may be split in the midline in addition to the we do an open reduction and rigid stabi- LeFort I fracture. lization with mini-and microplates. The A pyramidal fracture of the maxilla is synony- floor of the orbit is routinely explored and mous with a LeFort II fracture. This fracture pat- reconstructed, if needed, to restore orbital tern begins laterally, similar to a LeFort I, but volume. The complications of an inade- medially diverges in a superior direction to quately or unreduced zygomatic fracture include part of the medial orbit as well as the are very difficult to correct secondarily and nose. The fracture extending across the nose may usually avoidable. We feel that early diag- be variable, involving only the nasal cartilage or nosis combined with this aggressive surgi- as extensive as to separate the nasofrontal suture. cal treatment yields the best results. ©1997 Erlanger Health System Tennessee Craniofacial Center 1(800) 418-3223 The fracture extends diagonally Trauma Reconstruction from the pterygoid plates through the maxilla to the inferior orbital rim and up the medial wall of the orbit to the nose. This separates the maxillary alveolus, medial wall of the orbit and nose as a separate piece. A LeFort III fracture or craniofa- cial dysjunction denotes a complete separation of the midface or facial bones from the cranium. This frac- ture transverses the zygomati- cofrontal suture, continues through the floor of the orbit, and finally through the nasofrontal suture. The Twenty-four year old woman Postoperative photo after one bones of the orbit are separated involved in motor vehicle accident stage repair using craniofacial through the lateral wall, floor, and sustaining panfacial fractures. techniques. medial wall. It is unusual to have this fracture as a single segment of bone; more commonly, it commin- utes with varying combinations of LeFort classification of midfacial fractures. A. B. C. LeFort classification of midfacial fractures. (A) LeFort I or transverse fracture of the maxilla. (B) LeFort II or pyramidal fracture of the maxilla. (C) LeFort III or craniofacial dysjunction. ©1997 Erlanger Health System Tennessee Craniofacial Center 1(800) 418-3223 zygomatic, nasoethmoid, and orbital frac- fractures are to reestablish preinjury occlusion tures. The fractures may not be symmetric with normal height and projection of the face. To on both sides and minimal mobility may be accomplish this, the structural buttress of the present. maxilla must be aligned and stabilized to provide the necessary support and contour to the midface. Maxillary fractures today are often the The proper occlusal relationship between the den- result of motor vehicle accidents. These tal arches is established with intermaxillary fixa- high-velocity injuries many times produce tion (IMF), or more appropriately termed fracture patterns not classified by the stan- maxillomandibular fixation. Early placement of dard LeFort system, but are described sim- the patient in IMF can eliminate some of the sec- ply by the anatomic structure fractured and ondary deformities caused by LeFort fractures. the degree of comminution present. IMF is established by securing arch bars to the Computerized tomographic (CT) scans and upper and lower dental arches with individual the more recent development of three- wire ligatures around the teeth. The appropriate dimensional reconstructions have aided occlusion is then determined by wear facets, and greatly in the diagnosis, classification, and the maxillary and mandibular arch bar are preoperative planning of these complex secured together. This is one of the simplest and maxillary fractures. most effective forms of treatment. However, IMF Maxillary fractures are treated by reduc- is more commonly used in conjunction with other tion and immobilization. Establishment of immobilization and stabilization techniques. preinjury occlusion and midface buttress Recent advances in the treatment of maxillary alignment provides the foundation for this fractures have been the use of extended open- treatment. The goals of treatment of LeFort Maxillary Fractures Twenty-eight year old patient with (Top photo) Three Dimensional CT Postoperative result with restoration panfacial fractures. Scan shows comminuted maxillary of preinjury appearance. fractures. (Lower photo) Postoperative radiograph shows rigid fixation of all four buttresses. ©1997 Erlanger Health System Tennessee Craniofacial Center 1(800) 418-3223 reduction techniques with rigid plate and Maxillary Fractures screw fixation of the facial buttresses. Bone grafts have been used to replace missing or comminuted bone with early treatment of these injuries. This more aggressive surgical approach has dramat- ically improved the aesthetic results now obtainable with fewer secondary defor- mities. NASOETHMOID ORBITAL FRACTURES Trauma to the central midface fre- quently results in fractures of the nasoethmoid orbital (NOE) skeleton. This Twenty year old female with complex area consists of a union of bones Lefort I maxillary fracture and from the nose, orbits, maxilla, and crani- malocclusion. um. These fractures may be the most dif- ficult and challenging of all facial fractures to diagnose and treat. To the inexperienced examiner, NOE fractures may be misdiagnosed as simple nasal fractures, and a high degree of suspicion is necessary to make the diagnosis. These fractures may occur as isolated injuries or as part of more complex (LeFort) facial fractures. Swelling of the nose and medi- al canthal areas may mask the fractures CT scan shows fractures of all maxillary buttresses. and make the physical findings obscure. Failure to diagnose these injuries or inad- equate treatment will result in both func- tional and cosmetic deformities that are very difficult to correct secondarily. The successful surgical treatment of these complex injuries consist of early open repair with precise reduction and stabilization of bone fragments. Bone grafts are used to restore contour and support to areas of extremely comminut- ed or missing bone. Soft tissue manage- ment of the naso-orbital area is crucial to restoration of preinjury appearance. The application of craniofacial techniques in recent years has greatly enhanced the results now obtainable. Postoperative result after open reduction and rigid fixation. ©1997 Erlanger Health System Tennessee Craniofacial Center 1(800) 418-3223 .
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