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336
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Progression of pain: It may be persistent and progressive;
or initially mild gradually increases, later gradually subsides;
fluctuation in intensity whether increases and decreases in
intensity at regular intervals; quickly reaches maximum and
remains like that.
Duration of Pain
Periodicity of pain: Pain appears, persists for few weeks and
then disappears for few weeks; again reappear. Such periodicity is often observed in chronic peptic ulcer; trigeminal
neuralgia.
Precipitating/aggravating factors: Abdominal pain may get
worsened by taking food like in gastric ulcer. Pain due to
SRB’s Manual of Surgery
appendicitis, ureteric stone aggravates by change of position,
walking, jolting. Pain of urinary bladder stone aggravates
in standing position. In reflux oesophagitis pain increases
while scooping. Pain in pancreatitis increases while lying
down. Pain in intervertebral disc prolapse aggravates by
lifting the weight.
Relieving factors of pain: Pain reduce by certain methods
and patient uses that method to relieve the pain. Hunger pain
of early morning in duodenal ulcer is relieved by taking food.
Pain of pancreatitis is relieved in sitting and bending forward.
Propped up position relieves pain of reflux oesophagitis. In
acute peritonitis, pain reduces temporarily by lying still.
Associated symptoms: Acute pain may be associated with
pallor, sweating and vomiting. Migraine pain with vomiting
and visual disturbances; intestinal/ureteric colic with
sweating, vomiting and cold periphery; acute pyelonephritis
and urinary infections with chills/rigors and fever; ureteric
colic with haematuria; biliary colic with jaundice and pale
stool are other examples of such association.
Time of occurrence of pain is often important in diagnosing
the condition. In duodenal ulcer, hunger pain occurring in
early morning or later evening is typical. Migraine occurs in
early morning; frontal sinusitis induced headache occurs a
few hours after getting up.
Pain may move from one place to other: Radiation of pain
It is extension of pain from original site to another site with
layer is involved by inflammation/pathology pain is felt at
the anatomical site. Example is pain of acute appendicitis
where original visceral pain is at the umbilicus (T9 and T10
segments supply both umbilicus and appendix) shifts later
to right iliac fossa when once the parietal peritoneum of that
area is inflamed.
Types of pain:
Superficial pain: It is sharp usually localised pain, due to
irritation of peripheral nerve endings in superficial tissue by
chemical/mechanical/thermal/electrical injury. Segmental
pain: It occurs due to irritation of particular nerve trunk/root;
located in particular dermatome of the body supplied by the
sensory nerve trunk or root.
Deep pain: It is due to irritation of deeper structures like
muscles/tendons/bones/joints/viscera. It is vague and diffuse
when compared to superficial pain. It is often referred to
common segmental areas of representation. Often spasm
of skeletal muscle of same spinal cord segment can occur.
Psychogenic pain: It may be functional/emotional/hysterical.
Other pain: like due to thalamic/spinothalamic diseases/
causalgia (intense burning pain along the distribution of the
partially.
Grading of pain: It is done using pain scale. It is compared to a
10 cm line numbered 0 to 10. This is called as visual analogue
scale (VAS). Minimum is 0 means no pain. 10 is the worst
excruciating pain. 2 is mild; 4 is discomforting; 6 is distressing;
8 is intense.
REASONS TO CONTROL POSTOPERATIVE PAIN/ACUTE
B
PAIN
x Uncontrolled pain causes tachycardia, hypertension and vaso-
constriction
x Abdominal (upper abdominal mainly) and thoracic wound pain
restricts the respiration causing tachypnoea, altered respiration,
coughing, chest infection, pneumonia
x Persisting pain causes restricted movements, deep venous
thrombosis and its problems, bed sores
x Pain delays the recovery and also causes psychological trauma
to the patient
persisting of pain at original site. This radiating pain is of
same character of original site. Penetration of duodenal ulcer
Management of Pain
posteriorly causes pain both in epigastrium and back—is an
example. Pain of pancreatitis radiates to back. Referred pain:
Pain is not felt at the site of the disease but felt at distant
site. Diaphragmatic irritation causes referred pain at the tip
of shoulder through same segmental supply of diaphragm
(phrenic nerve C4, C5) and shoulder (cutaneous supply C4,
C5). Hip joint pathology may cause referred pain in knee
joint—through articular branches of femoral, obturator and
sciatic nerves. Other examples—referred ear pain from carcinoma tongue through lingual and auriculotemporal nerve;
referred pain in the epigastrium from the heart; referred pain
in the abdomen from pleura; referred pain over the testis
from the ureter. Shifting/migration of pain: Origin of pain is
one site; later pain shifts to another site and pain at original
site disappears. Pain when begins in viscera, it is felt at the
same somatic segmental area in the body; but once parietal
Correct the cause like removal of renal stone, cholecystec-
tomy for gallstones.
Analgesics.
Surgical removal of tumour.
Injection of phenol or alcohol.
Electric stimulation, massaging, infrared therapy, wax bath.
Proper physiotherapy.
Hormone therapy.
Injection to ganglion like in trigeminal neuralgia.
Chemotherapy for malignancies.
Radiotherapy.
Sympathectomy for vascular diseases, causalgia.
Cordotomy for severe pain in case of advanced tumours.
Mental relaxation.
Attending pain clinic.
Acute pain Drugs/opioids/epidural anaesthesia/drug infusion
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Chronic pain due to malignancy First level—simple analgesics (aspirin, paracetamol, NSAIDs, tricyclic antidepressants)
Second level—intermediate opioids codeine, tramadol, dextropropoxyphene
Third level—strong opioids like oral morphine, intravenous morphine, subcutaneous diamorphine,
epidural diamorphine. Analgesic infusion is also useful. Neurolytics are used whenever there is limited
life-expectancy. Other methods are—Subcostal phenol injection for rib secondaries/celiac plexus
block using alcohol/intrathecal hyperbaric phenol/percutaneous anterolateral cordotomy/pituitary
ablation/hormone ablation/palliative radiotherapy/steroids/flecainide therapy
Chronic pain in benign disease Local anaesthetics/steroid injections/nerve stimulation like acupuncture/nerve decompression/
pain due to sympathetic overactivity is corrected by—IV pentolamine (alpha adrenergic block),
stellate ganglion block, block using guanethidine, percutaneous chemical lumbar sympathectomy
using phenol. Other methods for chronic pain are—paracetamol/NSAIDs/antidepressants/opioids/
carbamazepine/ neuroablative surgeries
337
CHAPTER 1W General Surgery: Pain
Continuous epidural anaesthesia/analgesia using opioids.
Patient controlled analgesia (PCA) is injecting opioids through
epidural route or intravenous route by patient himself after
training him.
Intravenous infusions of the analgesia.
Pain may be:
x Acute pain.
x Chronic pain due to malignancy.
x Chronic pain due to benign disease.
Drugs for Pain
Drugs can be given orally, intramuscularly, few intravenously,
intrathecally, per rectally as suppositories, sublingually.
Narcotic Analgesics
Morphine 10–15 mg. Very useful in intractable pain. It can
cause nausea, constipation, and respiratory depression. Its
action is neutralised by naloxone.
Pethidine 50–100 mg IM.
Diamorphine 5–10 mg. It is used only in intractable pain.
Pentazocine 30–60 mg.
Dihydrocodeine.
Codeine phosphate is commonly used after intracranial
surgery. It should not be given intravenously as it may precip-
itate severe hypotension. Codeine also causes constipation.
Bupremorphine.
Non-narcotic Drugs
Aspirin.
Ibuprofen.
Naproxen.
All these NSAIDs cause gastric irritation and may risk the
gastric bleeding. NSAIDs are nonspecific cyclo-oxygenase
inhibitors. So gastric protection and platelet function are lost.
Rectal diclofenac as suppository is good analgesic.
Paracetamol is effective analgesic and antipyretic agent. It is
relatively less common to cause gastric bleeding.
Note:
Specific COX2 inhibitors are contraindicated in ischaemic heart disease.
Other Drugs
Anticonvulsants.
Antidepressants, anxiolytics.
Carbamazepine for neuralgia.
We seldom think of what we have, but always of what we lack.
Chapter
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2
Faciomaxillary Diseases
C hapter Outline
·
Diseases of the Palate
·
Orthopantomogram
·
Cleft Lip and Cleft Palate
·
Maxillofacial Injuries
·
Primary Care (Early
Care) in Maxillofacial
Injuries
·
Fracture Middle Third
Area
·
Zygomatic Complex
Fracture
·
Fracture of the Mandible
DISEASES OF THE PALATE
Cleft palate.
Torus palatinus—a bony hard swelling in the centre of the
hard palate.
Nasopalatine cysts.
Epstein‘s pearls—at the junction of soft and hard palates, in
the midline, in infants due to retained developmental cell rests.
Apical cyst or abscess.
Minor salivary gland tumour—commonest site is palate.
·
Dislocation of the
Mandible
·
Jaw Tumours
·
Epulis
·
Ameloblastoma
·
Dentigerous Cyst
·
Dental Cyst
·
Osteomyelitis of Jaw
·
Alveolar Abscess
·
Fibrous Dysplasia of
Bone/Jaw
·
Cherubism
Maxillary tumour extending into the palate.
Squamous cell carcinoma of the palate.
Gummatous perforation in the middle of the palate seen in
congenital syphilis.
Perforation of the palate anywhere in carcinoma palate.
ORTHOPANTOMOGRAM (OPG)
It is a plain X-ray of the mandible which shows the entire
mandible in a single plane. It is better than X-ray mandible
lateral view as it highlights proper dentition, inner and outer
plates of mandible and joints. It is like a rotational tomogram.
Indications
¾
Jaw tumours—Adamantinoma, dental cyst, denti gerous
cyst, osteoclastoma.
¾
Osteomyelitis of the mandible; Fracture mandible.
¾
Carcinoma oral cavity to check infiltration into the mandible.
CLEFT LIP AND CLEFT PALATE
Development of Face
Face develops from median nasal process, lateral nasal process,
maxillary process, mandibular arch, globular arch, olfactory
pit and eye. Any change in the development or fusion of these
arches leads to formation of different types of cleft lip or cleft
palate.
A
B
Figs. 2.1A and B: Orthopantomogram is being taken and also picture showing OPG X-ray.
LAHS CLASSIFICATION OF CLEFT DISORDERS
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B
x ‘L’ for lip, ‘A’ for alveolus, ‘H’ for hard palate, ‘S’ for soft palate
x Capital ‘LAHS’ for ‘complete type’
x Small letters ‘lahs’ for ‘incomplete type’
x Asterisks ‘lahs’ for microclefts
x ‘LAHSHAL’ for bilateral clefts
Incidence
339
CHAPTER 2 Faciomaxillary Diseases
Fig. 2.2: OPG showing jaw tumour probably adamantinoma.
Aetiology
Familial—more common in cleft lip or combined cleft lip and
palate (Risk is 1:25 live births).
Protein and vitamin deficiency.
Rubella infection.
Radiation.
Chromosomal abnormalities.
Maternal epilepsy and drug intake during pregnancy (steroids/
eptoin/diazepam).
Classication
I. Cleft lip alone: Unilateral; Bilateral; Median.
II. Cleft of primary palate (in front of incisive foramen) only:
a. Complete—means absence of pre-maxilla.
b. Incomplete—means rudimentary pre-maxilla.
i. Unilateral; (ii) Bilateral; (iii) Median.
III. Cleft of secondary palate (behind the incisive foramen) only:
a. Complete—nasal septum and vomer are separated
from palatine process.
b. Incomplete.
c. Submucous.
It can be:
–
Cleft with soft palate involvement.
–
Cleft without soft palate involvement.
IV. Cleft of both primary and secondary palates.
V. Cleft lip and cleft palate together.
Defect is often associated with other congenital anomalies of
cardiac, gastrointestinal, neurological system, Pierre-Robin
syndrome (most commonly associated syndrome with features
of isolated cleft palate, retrognathia, posteriorly displaced
tongue), Klippel-Feil syndrome, Stickler’s syndrome (eye,
skeletal, muscular, cleft disorder), Shprintzen’s syndrome
(cardiac and cleft disorder), Down’s syndrome, Treacher-Collin’s
syndrome, Apert’s syndrome and trisomy.
CLEFT LIP
B
x Central—rare. In upper lip. Between two median nasal processes.
(Hare lip)
x Lateral—maxillary and median nasal process, commonest; can
be unilateral or bilateral
x Incomplete cleft lip does not extend into nose
x Complete cleft lip extends into nasal floor
x Simple cleft lip is only cleft in the lip
x Compound cleft lip is cleft lip with cleft of alveolus
Common in Caucasians.
In 75% of cases it is unilateral. Commonly occurs on the left
side (60%).
In 50% of cases, it is combined cleft lip and palate. Incidence
is 1:600 live births. Common in boys.
In 15–25% of cases, it is cleft lip alone.
In 25–40% of cases it is cleft palate alone. Incidence is 1:1000
live births. More common in girls.
Problems in Cleft Disorders
Difficulty in sucking and swallowing. This is more commonly
observed in cleft palate than in cleft lip.
Speech is defective especially in cleft palate, mainly to
phonate B, D, K, P, T and G.
Altered dentition or supernumerary teeth.
Recurrent upper respiratory tract infection.
Respiratory obstruction (in Pierre-Robin syndrome)
Chronic otitis media, middle ear problems.
Cosmetic problems; Hypoplasia of the maxilla.
Problems due to other associated disorders.
Fig. 2.3: Central cleft lip (Hare lip, Type I cleft lip—It is rare).
Treatment for Cleft Lip
Millard criteria are used to undertake surgery for cleft lip.
MILLARD CRITERIA (RULE OF ‘10’)
B
10 pound in weight; 10 weeks old; 10 g% haemoglobin
Surgery is a science as well as an art.
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Millard cleft lip repair by rotating the local nasolabial flaps.
Management of associated primary or secondary cleft palate
deformity.
Proper postoperative management like control of infection,
training for sucking, swallowing and speech.
Tenninson’s ‘Z’ plasty (Teneninson-Randall triangular flap).
Note:
Delaire timing of the cleft surgery – Unilateral/bilateral cleft lip alone,
in one stage operation done in 4–6 months. For cleft palate alone
involving only soft palate, in one stage, surgery is done in 6 months.
For cleft palate alone but involving both soft and hard palates—soft
palate in 6 months; hard palate in 18 months. In combined cleft lip and
palate, unilateral or bilateral, in two stages—cleft lip and soft palate in
SRB's Manual of Surgery
6 months; hard palate in 18 months.
A B
Figs. 2.4A and B: (A) Lateral type of cleft lip (Type II variety—it is
commonest). It is due to imperfect fusion of maxillary process and
median nasal process. It can be unilateral or bilateral; (B) unilateral
cleft lip (commonest). It is due to imperfect fusion of maxillary process
and median nasal process.
PRINCIPLES OF CLEFT LIP REPAIR
B
A
B
Figs. 2.5A and B: (A) Bilateral cleft lip. (B) Cleft lip with cleft lip.
A
B
Figs. 2.6A and B: Cleft lip and cleft palate in an adult.
A
B
Figs. 2.7A and B: Cleft palate only. Lip is normal.
Pre-maxilla is not involved.
x “Rule of 10’ should be fulfilled
x Before 6 months, it should be operated
x Infection should not be present
x Millard advancement flap is commonly used for unilateral cleft
lip repair
x Bilateral cleft lip repair can be done either in a single or two stages
(with 6 months gap between each stage)
x One stage bilateral cleft lip repair is done using Veau III method/
Millard’s single stage/Black method
x Proper markings are made prior to surgery and incision should
be over full thickness lip
x Often 1:2,00,000 adrenaline injection is used to achieve haemostasis
x Three-layer lip repair should be done (mucosa, muscle and skin)
x Cupid’s bow should be horizontal
x Continuity of white line should be maintained
x Vermilion notching should not be there
Cleft Palate
It is due to failure of fusion of the two palatine processes.
Defect in fusion of lines between premaxilla (developed from
median nasal process) and palatine processes of maxilla one
on each side.
When premaxilla and both palatine processes do not fuse, it
leads into complete cleft palate (Type I cleft palate).
Fig. 2.8: Steps of cleft lip repair.
A
B
Figs. 2.9A and B: (A) Cleft palate with cleft lip in a child. Child also is
suffering from congenital cardiac defects; (B) Complete cleft palate Type I.
Incomplete fusion of these three components can cause
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incomplete cleft palate beginning from uvula towards posteriorly at various lengths. So it could be Type II a–bifid uvula,
Type II b–bifid soft palate (entire length) or Type II c –bifid
soft palate and posterior part of hard palate (but anterior part
of hard palate is normal).
Small maxilla with crowded teeth, absent/poorly developed
upper lateral incisors.
Bacterial contamination of upper respiratory tract with recur-
rent infection is common.
A
Figs. 2.10A and B: (A) Cleft palate Type II a—bifid uvula; (B) Cleft
palate Type II b—bifid soft palate (entire soft palate).
A B
Figs. 2.11A and B: (A) Cleft palate Type II c—bifid soft palate entire
length with cleft of posterior hard palate (anterior palate is normal). (B)
Adult complete cleft palate without cleft lip.
Chronic otitis media with deafness may occur.
Swallowing difficulties to certain extent and speech problems
B
can occur.
Cosmetic problems can occur.
Treatment for Cleft Palate
CRITERIA FOR SURGERY
B
x 10 kg weight
x 10 months of age (10–18 months)
x 10 g % haemoglobin
Fig. 2.12: Bilateral congenital craniofacial cleft
(Courtesy: Dr Sathish Bhat, Plastic
Cleft palate is usually repaired in 12–18 months. Early repair
Surgeon, Mangaluru).
causes retarded maxillary growth (probably due to trauma to
growth center and periosteum of the maxilla during surgery
if done early). Late repair causes speech defect.
Both soft and hard palates are repaired.
Abnormal insertion of tensor palati is released. Mucoperi-
osteal flaps are raised in the palate which is sewed together.
If maxillary hypoplasia is present, then osteotomy of the
maxilla is done. With orthodontic help teeth extraction and
alignment of dentition is needed.
Regular examination of ear, nose and throat during follow
up period.
Postoperative speech therapy.
Whenever complicated problems are present, staged surgical
procedure is done.
Wardill- Kilner push back operation—by raising mucoperi-
osteum flaps based on greater palatine vessels.
Secondary management:
¾
Hearing support is given using hearing aids if defect is
present; control of otitis media.
¾
Speech problems occur due to velopharyngeal incompetence; articulation problems also can occur—speech
therapy is given. It is corrected by pharyngoplasty, veloplasty, speech devices.
¾
Dental problems like uneruption, unalignments are
common. They should be corrected by proper dentist
opinion, and reconstructive surgery.
¾
Orthodontic management with alveolar bone graft, maxillary osteotomy—done in 8–11 years of age.
¾
Veloplasty, dental implants, rhinoplasty, orthognathic
surgeries, etc.
PRINCIPLES OF PALATOPLASTY
B
x Timing is between 10–18 months
x Mucoperiosteum flap is raised
x Palatal defect is closed using 3 layers—nasal, muscle and oral
layers
x Hook of pterygoid hamulus is fractured to relax tensor palate
muscle to relieve tension on suture line
341
CHAPTER 2 Faciomaxillary Diseases
Bleeding gums in uraemia are not so spongy as in scurvy: in fact, they may look nearly normal.—Frederic J Wright
342
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SRB's Manual of Surgery
Fig. 2.13: V-Y palatoplasty.
MAXILLOFACIAL INJURIES
It may be due to road traffic accidents, assaults, bullet injuries
or sport injuries.
Classication
Fracture in maxillofacial region can be grouped as:
Fracture lower third that comprises mandible.
Fracture middle third that comprises maxilla, zygoma and
nose.
Fracture upper third of the face involving part of the orbit,
frontal bones.
Maxillofacial fracture also can be grouped as:
Fractures of the face which do not involve the dental occlu-
sion—fractures of zygoma and nose.
Fracture which involves the dental occlusion—fracture
mandible and maxilla.
Fig. 2.14: Relation between middle third and
cranium in 45° plane.
Fig. 2.15: Posterior gagging of occlusion due to backward
displacement of fracture segment in middle third fracture.
Soft Tissue Injuries
Lacerations, contusions, cut wounds, etc.
Eyelid injuries with black eyes.
Facial nerve injury: Primary repair is required.
Parotid duct injury: Here primary anastomosis of the injured
duct is done, with a fine polythene cannula is kept as a stent
inside the duct which will be removed in 14 days.
Lacrimal apparatus injury: Here the duct is sutured with a fine
nylon thread in the canaliculus which is kept for 3 months.
Injuries to the Facial Bones
Fracture nose: Nasal bones are most commonly injured
bones in face. Patient presents with pain and swelling in
the nose with deviation and displace ment. Here reduction of
the fractured nasal bones and nasal septum under general
anaesthesia is done. Later position is maintained by nasal
packs from inside (which is removed in 7 days) and by a
nasal plaster from outside (which will be kept for 14 days).
Procedure is done using Walsham’s and Asch’s forceps.
Injuries to the maxilla.
Zygomatic bone injuries.
Mandibular bone fracture and mandibular dislocation.
Orbital bone fracture: Presents with diplopia, enophthalmous,
sensory loss in the area of infraorbital nerve.
Infraorbital ecchymosis of the orbit is called Panda sign.
Features
¾
Localised swelling due to haematoma.
¾
Facial oedema; Bleeding with open wounds.
¾
Asymmetry which is clinically confirmed by observing
supraorbital ridges, nasal bridge.
¾
Localised tenderness; Step deformity; Trismus; Diplopia.
¾
Features of associated injuries like intracranial, abdominal
or thoracic injuries.
Investigations: X-ray face; CT scan of head and jaw.
GENERAL TREATMENT FOR FACIOMAXILLARY INJURIES
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B
x Suturing of soft tissues
x Airway maintenance
x Control of bleeding
x Pain relief
x Control of infection
x Treating the individual
fractures
PRIMARY CARE (EARLY CARE) IN
MAXILLOFACIAL INJURIES
Injury can be isolated as single bone fracture or multiple bone
fractures. Real primary care is usually not required except when
there is mechanical respiratory block causing airway obstruction.
Respiratory Obstruction
abdomen or other areas, or they may interfere with pupillary reaction and neurological signs in the presence of intracranial injuries.
Antibiotics are needed. Tetanus toxoid and often antitetanus
globulin (ATG 3000 units IM) are required.
Haemorrhage in Maxillofacial Injuries
Haemorrhage in maxillofacial injuries is usually not life-threatening. But it should be identified and controlled properly. In
association with other internal injury, such haemorrhage may
be important to cause the circulatory failure.
Haemorrhage may be due to:
Soft tissue bleeding.
Bleeding from inferior alveolar artery, palatine vessels.
Nasal bleeding.
343
CHAPTER 2 Faciomaxillary Diseases
Causes
Oronasal airway block can occur by blood clot, vomitus,
foreign body, dentures, teeth, saliva, bone pieces, etc.
Backward falling of tongue can cause obstruction of the
nasopharynx and oropharynx. It is common in bilateral
mandibular fracture.
Occlusion of the nasopharynx and oropharynx can occur in
fracture maxilla with posterior and inferior displacement.
Haematoma in floor of the mouth or posterior oral cavity can
cause airway block.
Oedema of larynx/tongue/posterior third of oral cavity/
pharynx.
Surgical emphysema.
Treatment
Cleaning of the oral and nasal cavities to remove obstructing
agents like clot, dentures, teeth or bone. Gauze swabbing
and suction.
Fallen tongue should be placed forward using finger and
often temporary alignment of the occlusion may be needed.
Maxillary disimpaction is done when needed in fracture
maxilla.
Positioning of the patient is important. Prone/semiprone
position with head towards one side is the safest position.
If this is not possible, then patient may be placed in sitting
position which also improves the breathing. Placing the
patient flat on his back in supine position should be avoided
as much as possible.
Tracheostomy should be done when needed without delay
as it will be life-saving by facilitating the easy airway and
breathing.
Control of Pain and Infection
Analgesics like NSAIDs are used to control pain. Morphine and
analogues are not used as they may suppress the respiration.
They may mask the pain of alarming severe injury in chest,
Control of Bleeding
Blood transfusion, IV fluids, resuscitation.
Nasal packs; Fracture correction; Ligation of the bleeder.
Cauterisation; Packing the area.
Under running the bleeding field; Embolisation.
External carotid artery ligation above the level of the origin
of the superior thyroid artery.
Fractures not involving
occlusion
Central Dentoalveolar
• Fracture nasal bones and/or
nasal septum Subzygomatic
• Fracture of frontal process of
maxilla
• Fractures of above two
extending into ethmoidnasoethmoid
• Fractures above three
which extend into frontal
bone—fronto-orbito-nasal
dislocation
Lateral
• Fractures involving zygomatic bone, arch and maxilla
excluding the dentoalveolar
component
Le Fort classification
(Rene Le Fort—French surgeon classified these fractures by
dropping rocks on the face of the cadavers and later dissected the
area for study and research and published paper in 1911)
Types Features
Le Fort I (Guerin’s fracture-
low level) (floating fracture,
horizontal fracture of maxilla)
Fractures involving occlusion
• Le Fort-I-low level either
unilateral or bilateral
• Le Fort II-pyramidal either
unilateral or bilateral
Suprazygomatic
• Le Fort III—high level
• Craniofacial disjunction—
unilateral or bilateral
• Bleeding from nose
• Posterior gagging of
occlusion
• Upper lip swelling
• Palatal ecchymosis
• Occlusion derangement
• Floating maxilla
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• It runs horizontally above
the floor of the nasal cavity
involving lower third septum,
palate, alveolar process of
maxilla and lower third of
pterygoid plates of maxilla
Le Fort II (pyramidal fracture) • Oedema of middle third face
• Both sides circumorbital and
subconjunctival ecchymoses
• From the nasal bones
at top-most, fracture
runs laterally towards
lacrimal bones, medial
SRB's Manual of Surgery
wall of orbit, infraorbital
margin, through medial
to infraorbital foramen
and backwards below the
zygomaticomaxillary area
through lateral wall of
maxillary sinus and pterygoid plates. Zygoma is intact
with skull base
Le Fort III (craniofacial disjunction, high level)
• Here fracture runs parallel to
skull base. It passes through
the nasal bone, lacrimal
bone, ethmoid bone, optic
foramen, inferior orbital
fissure, pterygomaxillary
fissure and lateral orbital wall
with frontozygomatic suture
with zygomatic arch
• Nasal bleeding/obstruction/
deformity
• Deformity of face (dish face),
diplopia
• Retroposition of maxilla with
posterior gagging
• Limitation of ocular
movements, CSF rhinorrhoea
• Tenderness and separation
of infraorbital margin
• Lengthening of face
• Enophthalmos, ocular level
depression
• Hooding of eyes, occlusal
plane tilting
• Entire facial skeleton moves
as a single block
• Tenderness and separation
of suture line
• Diplopia
• Trismus, teeth mal-alignment
Guerin sign: Haematoma at
greater palatine foramen
Associated Injuries
All associated injuries should be assessed properly and individually. On priority basis it should be treated.
Soft tissue injuries.
Cranial injuries.
Orbital injuries.
Intra-abdominal/thoracic/pelvic injuries.
FRACTURE MIDDLE THIRD AREA
It includes:
Maxillae, zygomatic bones, palatine bones, nasal bones,
lacrimal bones, inferior conchae (one on each side).
The vomer, ethmoid and its attached conchae, pterygoid
plates of sphenoid.
Note:
Fracture middle third includes fracture maxilla, zygoma and nasal bones.
Features
Oedema face, subconjunctival haemorrhage, ocular ecchy-
mosis.
Bleeding from the nose.
Diplopia due to trapping of the extra-ocular muscles in the
fracture segments.
Anaesthesia of the cheek.
Trismus and malalignment of teeth.
Guerin‘s sign: Haematoma at greater palatine foramen.
Always patient should be examined and observed for CSF
leak and intracranial injuries.
Investigations: CT scan head; X-ray skull.
A
C
Figs. 2.16A to D: Le Fort classification—different types and also
dentoalveolar fracture (Refer table for details).
B
Fig. 2.17: Fixation of the splint to skull. It is often used with gunning
splints to fix it to skull.
D
Treatment
¾
It should be managed in a center for maxillofacial injuries.
¾
Antibiotics.
¾
https://t.me/medicina_free
Tracheostomy.
¾
Associated zygoma and nasal fractures are reduced first.
¾
Direct wire suturing of the zygomaticofrontal region.
¾
Fixation of teeth in occlusion using eyelet wires, bars or
cap splints.
¾
Once reduced, fracture bones are immobilised using
extra-oral rods called as Mount Vernon box frame.
¾
Initially intravenous fluids and blood transfusions are
required. Later Ryle’s tube feeding is done.
¾
Proper ophthalmic consultation is necessary when there
are orbital injuries.
Features
Swelling and bruising in the cheek with subconjunctival
haemorrhage.
Flattening of the cheek prominence.
Step in the margin of the bony orbit at the infraorbital
foramen.
Sensory loss over the supply of the branches of the superior
orbital nerve— teeth on the affected area are anaesthetic on
percussion.
Sensory loss over the supply of the infraorbital nerve usually
over infraorbital region, upper lip and alar region of the
nose—common.
Enophthalmos is due to herniation of the orbital fat across
the fracture floor of the orbit into the antrum.
Diplopia is due to entrapment of the inferior rectus muscle
preventing upward rotation of the eyeball while looking up.
Trismus with marked restriction of the lateral movements.
Epistaxis, lowering of pupil level.
Infraorbital ecchymosis of the orbit is called as Panda sign.
Investigations
¾
30° occipitomental X-ray is used commonly but often
obliquity of X-ray may be increased to 60°. In X-ray,
findings observed are:
–
Fracture line near infraorbital foramen, zygomatic arch
and lateral wall of the antrum.
345
CHAPTER 2 Faciomaxillary Diseases
Fig. 2.18: Photograph showing bilateral maxillary fracture.
ZYGOMATIC COMPLEX FRACTURE
Classication
Simple fracture which is stable and undisplaced— here frac-
ture line passes across the infraorbital foramen downwards
over anterior wall of the antrum.
Simple fracture which is displaced medially. It may be associ-
ated with rotation/tilt in vertical axis, either medial tilt or lateral
tilt. Infraorbital nerve may get compressed or branches of
superior dental nerve may get torn.
Unstable fracture with rotation around horizontal axis with
medial tilt or lateral tilt.
Comminuted fracture extending into the floor of the orbit.
Fracture of the zygomatic arch causes a localised depression
of the arch which displaces medially and tends to impinge on
the coronoid process of the mandible.
‘Blow-out’ fracture of the orbit is due to direct blunt trauma
on the eyeball causing depressed comminuted fracture of the
orbital floor with herniation of the orbital fat into the antrum.
Enbloc dislocation of zygomatic bone medially/inferiorly/
posterolaterally.
A B
C
Figs. 2.19A to C: (A and B) Diagrams showing different types of
zygomatic fractures, (C) Blow-out fracture.
Ankylosis of mandible joint causes receding of chin giving a characteristic shrew mouse prole. —Leon Dufourmentel
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