Therapy of Fractures of the Middle Facial Third

By Dr. Vishaal Bhat on Thursday 22 November 2007 with 0 comments



Conservative ways.

Non-dislocated fractures or parts of bone complexes that break off incompletely do not require any fixation, just protection from further impacts, lying head at unhurt side, eating mushy food and anti-inflammatory treatments. The following fractures can be fixed by mono-fixation (a splint at injured jawbone) or by inter-maxillar immobilization: fractures of the alveolar ridge, one-sided fractures Le Fort I., sagittal fractures of maxilla s. The above described dental splints (Sauer’s splint) or wire fixtures reinforced by resin or composite materials, are used for those purposes. At some cases, fixation is preceded by a simple repositioning that puts fragments firmly together.


Surgical ways of therapy.

Osteosutures:

Surgical ways of repositioning and fixation are used more often at injuries of the middle facial third than those of the lower jawbone. Most often, a direct bone suture is applied. Osteosuture is performed either from the outside (skin) approach, often through soft tissue wounds, or from intra-oral side, to the front surface of maxilla, zygomatic-alveolar crista, hard palate or alveolar ridge. Surgical ways of therapy offer an advantage of repositioning of fragments under direct visual control, achieving their perfect toilet and correction, repositioning into proper positions and fixating them with sufficient firmness. An adaptive osteosuture serves the purpose of getting fragments close to each other and hold them at proper positions, not connecting them rigidly. Rigid connection is achieved with aid of bone splints and screws.


Maxillary Slings:

Loose parts of the middle facial third or whole level descend downwards by their weight and get dislocated backwards by an impact. The aim of therapy is to connect them back to the firm upper third (neurocranium) by a wire sling that ensures a good contact of broken surfaces and long-term rest which is not disturbed by chewing movements of the lower jaw. A hinge has to be selected and positioned in such a way so that it does not cause inconvenience to a patient, i.e. not on the outside, but rather underneath the skin or tissues. These requirements are met by the Adams’ hinges (1942). A high sling is placed at the zygomatic process of the frontal bone above zygomatic-frontal suture. Low slings are fit at undamaged zygomatic arches or the lower edge of nasal base (apertura piriformis nasi). With the aid of Kostečka’s needle or other inserting tools, wires are drawn into the oral cavity and fixated to the upper or lower dental splints. By fastening the wires, required fixation is achieved. The fixture stays at place for 7 weeks and is removed after that.


A rigid fixation:

At the middle facial third, only bone mini- or microsplints and corresponding screws of various lengths should be used. Gracile splints are rigid enough and inert for an organism (made of pure titanium). Besides high requirements on technical parameters of splints utilized, it is mandatory that a splint is positioned at the right place and fitted beforehand.

The traditional Le Fort’s classification of fractures determines also the most common placement of bone splints. They are positioned above particular breakages at fractures of nose, as well as the palate fractures.

Fractures of the zygomatic-maxillar complex are fixed by splints positioned at lateral edges of orbits at the zygomatic-frontal suture area and inside the oral cavity to the zygomatic-alveolar crista. If a lower orbit’s edge gets significantly dislocated, a well fitted splint has to be placed at this area as well. Suprazygomatic fractures (Le Fort III.) have to be fixed on both sides at lateral edges of orbits and at the nose root.

Repositioning and fixation of zygomatic-maxillar complex fractures:

These most frequent fractures of the middle facial third are successfully treated shortly after a dislocated injury (1 week after an injury) by one-time transcutaneous repositioning using a sharp hook, introduced beneath the zygomatic bone body through a cheek. Pulling out and entanglement of fragments can be checked by straightening of a step-like deformation on the orbit’s lower edge. Fragments fit into each other and no further fixation is required. Highly dislocated fractures, comminuted fractures and those fractures found long time after an injury cannot be repositioned by a bone hook alone. If the orbit’s lateral edge got damaged at the place of zygomatic-frontal suture followed by shifting of fragments, an osteosuture or fixation by a bone splint are applied. Repositioning of the zygomatic bone body is performed through the oral cavity -trans-antrally- by an elevator and fixation at a proper position is achieved by an acrylic column pushed against the firm wall of the antrum medial wall. If an acrylic column is fitted in the middle with an orthodontic screw, its length can be adjusted by turning it thus improving support and fixation. The screw can be later (after 7 weeks) removed easily after shortening it by turning and replacement the support from beneath the zygomatic bone body.


Category: Oro-Maxillo Facial Surgery Notes

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