Prof. Tahrir N. Aldelaimi
B.D.S. (College of Dentistry , Baghdad University)
M.Sc. in Oral & Maxillofacial Surgery (College of Dentistry , Baghdad University)
F.I.B.M.S. in maxillofacial surgery ( Iraqi Board for Medical Specializations)
D.L.M.F.S. (Institute of Laser for Postgraduate Studies, Baghdad University )
Professor of Maxillofacial Surgery and Laser Surgery,
Department of Oral & Maxillofacial Surgery, College of Dentistry, Anbar University,
Cell phone: 00964-7814050913 Ramadi city, Anbar Province, Iraq.
Afrah A. Khalil
B.D.S. (College of Dentistry , Baghdad University)
M.Sc. in Oral & Maxillofacial Pathology (College of Dentistry , Baghdad University)
Specialist Dentist, Director of Dental Health Department,
Anbar Health Directorate, Ministry of Health,
Ramadi city, Anbar Province, Iraq.
Cell phone: 00964-7814050912 e-mail: firstname.lastname@example.org
Midfacial ( Le Fort) fractures are types of facial fractures involving the maxillary bone and surrounding structures in a usually bilateral and pyramidal. Incorrect and inappropriate treatment of trauma will end with secondary deformity that is very difficult to correct. Twenty five patients with maxillofacial trauma were seen at Maxillofacial Surgery Department at Ramadi Teaching Hospital, Anbar Province, Iraq; including 19(76%) males and 6(24%) females. Road traffic accident and war injuries were the most common cause for facial trauma. Disimpaction of the midface segments was performed manually with Rowe disimpaction forceps and circumzygomatic wire suspension technique was used as method of treatment. In all patients adequate results were achieved with adequate functional and aesthetic outcome.
Keywords: Le fort fractures; maxilla; facial trauma; maxillofacial, Circumzygomatic suspension , craniofacial.
Craniofacial trauma is as old as the human race. What has changed over the last years is the speed in which many of these traumas occurred, the way in which they are explored, and the way they are treated 1. Maxillofacial region comprises a complex anatomical arrangement of bone and soft tissues. Contained within the face are systems that control specific functions including hearing, smelling, seeing, eating , breathing, as well as talking. This complex anatomy makes injuries affecting this region one of the most complex and challenging problems facing surgeons 2. Fractures and traumas over the facial skeleton since recent times has been always produced, more or less, at low speed. It means that most of the fractures, despite its importance and consecuences, results in more or less big fragments. These big fragments are much easily brought together and stabilized, even which wire, than the very small fragments that are produced in high speed traumas. The result of a high speed trauma are great comminuted fractures involving single or various facial bones, soft tissues injuries in the form of open wounds and/or loss of tissues, and associated injuries in other regions. So when facing a craniofacial trauma, bone fractures of facial skeleton nor the open the wounds, are the first problem we must take care for. Time and systematic repair of these fractures provides the best chance to correct deformity and prevent unfavorable sequelae, Maxillary fractures often result from high-energy blunt force injury to the facial skeleton 3. Much of the understanding of patterns of fracture propagation in midface trauma originates from the work of René Le Fort. In 1901, he reported his work on cadaver skulls that were subjected to blunt forces of various magnitudes and directions. He concluded that predictable patterns of fractures follow certain types of injuries 4 . The middle third of the face is the area bounded superiorly by a line drawn from the zygomaticofrontal suture across the frontonasal and frontomaxillary suture to the zygomaticofrontal suture at the opposite side. Inferiorly by the occlusal plane or the alveolar ridge, and posteriorly as far as the frontal bone above and body of sphenoid below. It is composed of the following bones; two maxillae, two zygomatic bones, two palatine bones, two zygomatic process of temporal bone, two nasal bones, two lacrimal bones, vomer, ethmoid and its attached conchae, two inferior conchae, and pterygoid plates of sphenoid. It has relations with the brain, orbits, paranasal sinuses, mouth, nasopharynx and many nerves and vessels. Le Fort II fracture may result from a blow to the lower or mid maxilla and usually involve the inferior orbital rim. Such a fracture has a pyramidal shape and extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally 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. The fracture extends laterally through the lacrimal bones, floors of the Orbits, and inferiorly through the zygomaticomaxillary sutures, then passes posteriorly along the lateral wall of the maxilla, across the ptery-gomaxillary fossa and through the pterygoid plates 5,6 . The presented paper evaluate the midfacial (lefort II) fractures in Iraq and focus on the use of circumzygomatic wire suspension as a method of surgical treatment.
Material & Methods
Twenty five patients with maxillofacial trauma were seen at Maxillofacial Surgery Department at Ramadi Teaching Hospital, Anbar Province, Iraq; including 19(76%) males and 6(24%) females. Evaluation of the maxilla and facial bones was done only after the patient has been fully stabilized and life-threatening injuries have been addressed. In particular, airway considerations, C-spine injuries and intracranial injuries must take immediate priority. In emergency room, for all patients included in the study, a standardized case sheet form was made that includes: history, primary survey, life saving procedures, secondary survey, definitive treatment, intermediate phase, and rehabilitation. Patients in this study received immediate care According to ATLS approach to maintain or establish adequate airway, to monitor vital signs and to initiate an intravenous line. The facial structures of each patient were appropriately examined by radiograph and/or CT scan. Surgical priorities were then decided. Timing of primary surgery was decided according to many factors including: the need of a life saving procedure, patients general condition, past-medical history of the patient as well as the presence of associated injuries. On examination the maxillary segment is displaced posteriorly and inferiorly. This may cause premature contact of the molar teeth, resulting in an anterior open bite deformity. In severe cases, the upper airway may be compromised. The face and cranium should be palpated to detect for bony irregularities, step-offs, crepitus, and sensory disturbances. Mobility of the mid face may be tested by grasping the anterior alveolar arch and pulling forward while stabilizing the patient with the other hand. The size and location of the mobile segment may confirm the diagnosis of Le Fort II fracture. A thorough nasal and intraoral examinations were performed along with the rest of the pyramidal free-floating segment. Intranasal examination may reveal fresh or old blood, septal hematoma, or cerebrospinal fluid rhinorrhea. The intraoral examination should assess occlusion, overall dentition, stability of the alveolar ridge and palate, and soft tissue as well as midpalatal seperation. Finger palpation of the maxillary contour intraorally may provide additional information about the integrity of the nasomaxillary buttress, anterior maxillary sinus wall, and zygomaticomaxillary buttress. During examination of the eyes and orbit, search for integrity of the orbital rims, orbital floor, vision, extraocular motion, position of the globe, and intercanthal distance. Although most maxillofacial can wait, late repair after healing is extremely difficult, early treatment within 1-7 days gives the best results, but immediate surgery can be carried out for life threatening injuries or if the patient is going for the theatre for other reasons. Disimpaction of the midface segments was performed manually with Rowe disimpaction forceps carefully because injury to the nasolacrimal duct, inferior orbital nerve, and extraocular muscles may be involved. 0.5 mm stainless steel wire (SST) was stretched 10%. The awl was introduce extraorally near the junction of frontal and temporal processes of zygomatic bone, the temporal fascia was pierce, keeping the point close to the deep surface of the bone, the awl will pass just in contact with posterior surface of zygomatic bone, to enter the upper buccal sulcus in first molar area, then 0.5 mm SST wire was attached to the awl, after that the wire pick up and the awl withdrawn with bone contact, without emerging from the skin and pass to the point over the lateral aspect of zygomatic arch then the awl directed to oral cavity passing lateral to malar bone and to be emerge through the original point of access in upper buccal sulcus, finally the suspension wire was fixed to Erich arch bar or join the circumandibular wire via second tie wire, so that the midface will sandiwich between the cranium and the mandible. Additional 0.5mm SST ligature wire was placed in upper and lower incisors for tightening purposes and to present any unnecessary lateral movement, the cut ends should be bent into the interdental spaces to ovoid soft tissue trauma. To minimize postoperative edema, a light pressure dressing consisting of gauze and a head wrap may be placed and it may be removed after 2-3 days. prophylactic antibiotics covering gram-positive and anaerobic organisms were prescribed including (cefotaxime vial 1000mg, metronidazole vial 500mg and diclofenac sodium ampoule 75mg) and ampiclox vial 500mg ( ampicillin 250mg + cloxacillin 250mg) was added on neurosurgeon request for CSF Rhinorrhea cases as prophylactic triple antibiotic. After surgery, observe patients overnight for bleeding, airway problems, and vomiting, wire cutters was placed near the patient in the early postoperative period to help patient to expel vomited material. Prior to discharge, each patient was instructed about their soft and liquid diet and oral hygiene maintenance instructions. Follow-up visits were schuled at 1, 2, 4 weeks and at end of 6 week, suspension wires were removed. (Figs. 1-3).
Patient sample in this study composed of twenty five patients including 19(76%) male and 6(24%) female, with age range from 15 to 56 years old; mean was 32 years old who were treated at Maxillofacial Surgery Department at Ramadi Teaching Hospital, Anbar province, Iraq. Most cases 10(42%) were in the age group (25-34) years (Table 1). Regarding cause of trauma; road traffic accident 10(40%) was the most predominant cause followed by war injuries 6(24%) including patients were injured with missile fragments of explosive cars, explosive belts, mortars, and IED. According to site of injuries, isolated midfacial injuries were found in 20(80%) while combine facial skeletal injuries including that mandibular fractures were found in 4(20%) patients. Only 3(12%) patients were presented with active bleeding which would not stop without intervention. Regarding complications; anaesthesia and paraesthesia, eye globe rupture, lachrymal damage, facial scars and dental trauma were the most common complications and were present in 3(12%), 1(4%%), 1(4%%), 2(8%) and 2(8%) respectively. 14(56%) patient had facial soft tissue laceration that closed by primary suturing and 1(4%) local flap was used to close the wound.
Definitive surgery should not be undertaken until the patient has been stabilized regarding other life-threatening injuries and patients with airway compromise should not be induced for general anesthesia and routine orotracheal intubation. While tracheotomy to awake patient should be considered before surgery. Stabilization of patient with facial trauma and treatment of serious insults to the airway, neurologic system, cervical spine, chest, and abdomen prior to definitive treatment of the maxillofacial bones and emergencies were address related to facial trauma prior to definitive treatment 1,6,7 . These include airway compromise and excessive bleeding. If the airway is compromised and orotracheal intubation cannot be established, the midface complex may be impacted posteroinferiorly, causing obstruction. Disimpaction may be attempted manually and if the segments do not move readily and the airway is obstructed, an emergent tracheotomy become necessary. Severe bleeding may occur from soft tissue lacerations and/or intraoral or intranasal structures. A combination of pressure, packing, cauterization, and suturing will be useful. As for any procedure, the risks of general anesthesia and the stresses of surgery must be weighed against medical contraindications 7,8. Although treatment of maxillary fractures is not considered vital for survival, unrepaired fractures can potentially lead to significant functional and cosmetic complications. The epidemiologies of midface fractures are similar all over the world; young males are the typical patients, with road traffic accident, motor vehicle accidents and war injuries which refect the nature of conflict of Iraq were being the most common overall causes of facial and midfacial trauma. Typically, these fractures affect younger males 6,7,9,10. The incidence of midface fractures is far lower in children than in adults, owing to anatomic differences and the overall elasticity of children’s tissues 11,12 . Patients with facial fractures have obscuration of their bony architecture with soft tissue swelling, ecchymoses, gross blood, and hematoma. Focal areas of swelling or hematoma may overlie an isolated fracture. Periorbital swelling may indicate Le Fort fractures. A global posterior retrusion of the mid face creates a flattened appearance of the face. Diagnosis is made based on physical exam findings with confirmation by plan radiograph and/or axial CT 8,9,13,14. Low forces may create a fracture in the midface. This is partly the result of the presence of the large, air-filled sinus cavities. Therefore, the midface acts as a shock absorber. The midface is relatively resistant to vertically oriented forces. Facial fractures are of significant functional and aesthetic importance 12,14. Functional problems may lead to disorders of occlusion, nasal obstruction, and trigeminal-nerve sensation. Aesthetic losses include decreased midface height, facial width, facial projection, and malar eminence leading to a dish-face deformity. Antibiotics have been shown to decrease the incidence of infection after midface fractures and the earlier the repair of a midface fracture, the better the surgical result. Furthermore early repair prevents soft tissue scarring and memory from insetting, as well as fibrous malunion between the bony fragments. Fixation of unstable fracture segments to stable structures is the objective of definitive surgical treatment of maxillary fractures, thus the stable cranium above and occlusal plate below provide sources of stable fixation 15,16 . One goal of treatment is to restore proper anatomic relationships. In particular, attempt to normalize the integrity of the support bolsters of the facial skeleton, the midfacial height and projection, and dental occlusion and masticatory function. Longer-term follow-up care may be needed to monitor postoperative complications or deformity. The most important goal during the early postoperative period is maintaining a state of immobilization. Depending on the age and general health of the patient, the extensiveness and displacement of the fractures during the period of 6weeks 16,17,18. During this period, emphasize to the patient to maintain good oral hygiene and oral rinses with listerine antiseptic mouth wash. Throughout the postoperative course, the stability of the facial skeleton may be tested by palpating the patient’s maxillary teeth during clenching and relaxing of the muscles of mastication, any mobility will indicate poor healing and it is early to remove suspension wires 19,20,21
Figure 1. Preoperative (a and b) axial CT scans showed midface fracture with rupture Lt. eye globe. (c) Preoperative view of the patient with massive oedema at ER.
Figure 2. ( a, b ,and c) Introduction of awl to perform Circumzygomatic and Circumandibular suspension wires.
Figure 3. (a and b) Postoperative axial CT scans, (c ) Postoperative view.
|5(20%)||15(60%)||Isolated midfacial injury||Site of injury|
|1(4%)||4(12%)||Combine facial injury|
|1(4%)||2(8%)||Aesthesia & Paraesthesthia|
RTA= road traffic accident, MCA=motor cycle accident, FFH= fall from height
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