Fracture of the upper facial mass

Fracture of the upper facial mass

• Jaw fractures rarely involve the jaw bones alone. The surrounding facial bones are most often affected, in which case we are talking about fractures of the upper facial mass, also called the “middle level” of the face, located between the eyebrows and the dental occlusal plane.
• They most often spread to high-energy trauma or the surrounding facial bones are most often also affected.
• The usual classification of these fractures uses the LeFort classification. In addition to this simple classification, there are many other fractures, the diversity of which makes their classification impossible. Knowing that these fractures can cause functional and morphological disorders that are difficult to resolve
• The clinical examination, which is essential, is now well supported by medical imaging. It constitutes the first step in diagnostic and therapeutic management. The latter is often multidisciplinary and the maxillofacial phase is often deferred.
• Current radiological methods (scanner, etc.) effectively help with their exploration.
• Although osteosynthesis using miniaturized screw plates and immediate bone grafts prove to be of interest, the classic therapeutic arsenal remains relevant, as it is dependent on variable exercise conditions and anatomopathological disturbances.

1. Anatomical reminders:

• MFS (mid-face): Made up of 13 bones, one odd-numbered median bone (Vomer) and 6 even-numbered symmetrical bones, it is fixed and attached to the anterior part of the base of the skull,
• It is hollowed out by numerous cavities, some of which contain organs (orbits, nasal cavities and oral cavity), while others are aerial: the sinuses.
• Its architecture is organized around resistant structures making beams and pillars of the facial massif

upper and areas of weakness represented by the LEFORT lines

1- Facial biomechanics

• The architecture of the facial mass is organized around resistant bone structures
• “A system of boxes reinforced by bone frames (pillars and beams), thus contributing to its strengthening. This system of more compact bones determines:
• vertically the pillars and beams of the facial massif described by Sicher horizontally
• the spacers
• Sagittally a system of vertical blades (according to the work of Ombrédanne,) Fractures of the facial mass are organized around this bone architecture which is capable of absorbing vertical and horizontal forces, and of opposing all mechanical stresses by creating a system of damping and stabilization. But these

Resistance zones highlight areas of fragility that are often involved in fracture points.

2. Anatomical structures of resistance :

• The vertical system: it is made up of the Pillars of Sicher, consisting of 2 anterior canine or naso-ethmoido-frontal pillars, 2 lateral malar and zygomatic pillars and 2 posterior pterygoid pillars.
• The horizontal system : it is made up of the resistance beams described
• by (Ombredanne): 01 upper frontal beam, 01 middle infra-orbital and malar beam and 01 lower maxillary beam

3. Areas of weakness : described by Lefort, these are:

• The upper line: corresponds to the union of the skull and the facial mass.
• The middle line: starts from the nasal bones, runs around the lower edges of the malars and ends at the middle part of the pterygoid processes.
• The lower line: runs from the nasal notch to the lower part of the pterygoid processes.
• The resistant structures mentioned above are associated with fragile structures.
• Papyraceous represented by: the deep walls of the orbit and the walls and partitions of the sinuses.

4. etiologies

Fractures caused by:

• traffic accident, public highway.
• Work accident, domestic accident, violent sports
• Brawls, Ballistic Trauma,
• Iatrogenic fractures: fracture of the tuberosity during extraction of a DDS.
• Spontaneous fractures:
• during Lobstein’s disease, Paget’s disease, osteoporosis, osteoradionecrosis

5. Epidemiology

• Fractures of the upper facial mass represent one third of facial fractures and
• are frequently associated with mandibular fractures.
• These fractures are rarer in children than in adults. They mainly concern
• the adult male whose age is between 20 and 35 years old
• The seat of the trauma first affects the nasal bones, followed by damage to the
• upper facial mass

II- Examination of a facial trauma patient

* Emergencies

-Evaluation of vital functions: pulse, blood pressure, respiratory rate, assessment of various lesions

-Seek emergencies

1. Asphyxiation disorders

• Local causes: foreign body, floor hematoma, tongue falling backward, etc.
• Central causes: alteration of neurovegetative function
• Peripheral causes: suffocating hemopneumothorax

CAT: Upper airway freedom:

• PLS, “Mayo Cannula” to prevent the tongue from falling backward
• Oro or nasotracheal intubation, tracheotomy.
• Heimlich maneuver for foreign body in the upper back

2. Bleeding disorders : isolated facial disorders are not very common.

CAT: Emergency measure = hemostasis:

• Digital or instrumental compression
• Epistaxis: anterior nasal packing with hemostatic wick, or by “Packing”.
• Exceptionally, ligation of one or more external carotids

Shock: rare in isolated facial trauma

2-The clinical examination

-Examination

• Difficult, even impossible given the general condition of the patient.
• Specify: age, sex, location and circumstances of the accident, point of impact, violence, notion of loss of consciousness,
• associated functional signs (pain, functional impotence, difficulty opening the mouth, sensory or motor deficit).
• General and local history, current TRT, tetanus vaccination status

-Exo-oral examination:

*Inspection

• Flow of fluid (cerebrospinal fluid or blood) from the nose, ear, etc.
• Condition of the skin: bruise, hematoma, wounds.
• Look for involvement of noble organs: facial nerve (Check if the patient can frown and raise their eyebrows, close their eyes, blow, whistle, etc.)

*Palpation

• Presence of abnormal bony reliefs protected by depressible edema, shifting or sinking, abnormal mobility, painful points
• Hypoesthesia or anesthesia of the trigeminal nerve
• Study of mouth opening and closing

Endo-oral examination:

*Inspection

• Mucosal lesions (bruise, wound)
• Dental condition: fracture, dislocation, avulsion.
• Study of dental articulation in the 3 spatial directions.

*Palpation : Bilateral looking for pain or abnormal mobility.

• Anterior rhinoscopy: May show nasal obstruction, deviated septum, hematoma
• Otoscopy: otorrhagia (fracture of the mandibular condyle or rock)

3-Radiological examination

Systematic X-rays: Upper face, Waters and Blondeau, Profile view, Hirtz, Panoramic. Non-systematic X-rays:

Gosserez-Tréheux incidence, “malar contact” incidence CT: bone displacement and complex shapes

MRI: complements CT for the study of soft tissues

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V. Classification

At the end of this injury assessment, fractures of the middle level of the face can be simple, partial or often complex, occurring in cases of significant trauma, and can be divided schematically into three groups according to the location of the initial trauma.

Fractures without repercussions on the dental articulation

• :• Laterofacial fractures affecting the zygomatico-maxillary complex and the floor of the orbit,
• :• Centrofacial fractures which affect the nasal bones and the naso-ethmoido-maxillo-fronto-orbital complex (CNEMFO) severe cases

Fractures with repercussions on the dental articulation

• :• Occlusofacial fractures and intermaxillary disjunction with impact on the medial maxillary.

VI-Anatomoclinical forms

1. laterofacial fractures

-Orbitozygomatic (or orbitomalar ) fracture:

Clinical

Spontaneous pain, exacerbated by palpation of the fracture lines

Very rapid swelling and bruising, associated with subconjunctival hemorrhage

Flattening of the cheekbone (quickly masked by edema) with paradoxical widening of the middle floor Frequent epistaxis

Decreased mouth opening Absence of dental articulation disorder

Systematic search for changes in visual acuity and vertical diplopia

Anesthesia or hypoesthesia in the territory of the infraorbital nerve (wing of the nose, cheek, upper lip, dental arch) Palpation finds a “stair step” at the level of the inferior orbital rim

Radiological signs

Simple incidences (LOUISETTE, wATERS) are most often sufficient and highlight:

fracture lines which are located on the lateral orbital pillar, the inferior orbital margin and the zygomatic arch a hemo-sinus is usually observed (Blondeau)

…coronal CT scans may be necessary to clarify orbital involvement if there is any doubt about a significant breach of the orbital floor

Clinical forms:

– isolated fracture of the zygomatic bone

Note that isolated fractures of the malar are rare; they are most often disjunction fractures, the body of the malar being more solid than its attachments.

• Orbital floor fracture:

More common in children, it affects the very thin wall that separates the orbit from the maxillary sinus. Following a

violent shock to the eyeball which causes a sudden increase in intraorbital pressure with rupture of the most fragile wall (generally the floor of the orbit), more rarely the internal wall or both associated. At the time of the trauma, the examination is hampered by local edema; the clinical signs are poor: diplopia is frequent (due to incarceration in the fracture of the orbital contents) and constitutes a therapeutic emergency and enophthalmos may be observed.

Radiological exploration mainly shows a hemosinus on the Blondeau view. The CT scan clearly shows the displacements.

Fig 1: laterofacial fracture

1. Centrofacial fractures

Depending on the severity of the trauma, it produces either a simple and benign clinical picture of a fracture of the nasal region, or a serious and complex clinical picture involving the entire naso-ethmoido-frontal region.

• :• Fractured nose

The clinical diagnosis is simple (pain, mobility, edema). A profile X-ray of the nasal bones confirms the fracture line. A hematoma of the septum will be systematically sought.

Primary orthopedic reduction treatment is often disappointing and leaves a deformation of the nasal awning and/or septum requiring secondary rhinoseptoplasty.

$:9 Fracture of the naso-etmoi do-maxillo-fronto-orbital complex (CNEMFO)

The clinical picture is quite characteristic: after a violent centro-facial trauma, the trauma victim presents a recoil of the nasal region which appears impacted in the face.

At the orbital level there is a telecanthus (increase in the intercanthal distance normally less than 35 mm).

Epistaxis is common. A wound in the region is often associated. These serious fractures of the centrofacial region can be the cause of an osteo-meningeal breach by fracture of the cribriform plate of the ethmoid bone, which will cause anosmia (difficult primary diagnosis) and a flow of cerebrospinal fluid or cerebrospinal rhinorrhea.

The diagnosis of a breach is not always very obvious clinically because it can be transient, quickly hidden by edema and hematomas, but exposing the patient to serious secondary complications such as meningitis.

The radiological assessment will systematically include a CT scan in axial and coronal incidence. The treatment of these fractures is complex, usually requiring a neurosurgical approach.

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FRACTURE WITH JOINT DISORDER:

Often after a violent direct anteroposterior shock

Fracture of the incisor block: especially in children

Exo-oral examination: swelling, sometimes wound of the upper lip, bloody salivary discharge. Endo-oral examination: hematoma, pain on palpation of the external table, mobility of the incisor block, disturbance of the dental articulation

Radiological examination: Retroalveolar and occlusal bite.

Fracture of the palatal vault: Common in children, Fall with an object in the mouth. In exo-buccal: RAS

Intraoral: palatal mucosal tear, hematoma, sometimes speech disorders and CBS in the Val

Tuberosity fracture: Following extraction of an upper DDS, may be complicated by CBS.

1) LEFORT horizontal disjunction fracture

• Lefort I or Guérin fracture: low transverse fracture:

Mechanism : Violent shock to the upper dental arch, from front to back or from bottom to top

Features : passes horizontally through the nasal notch, canine fossa, antero-external then postero-external wall of the maxillary sinus. In the nasal fossae: It cuts the internal wall of the maxilla, the vertical blade of the palatine and the

Lower 1/3 of the pterygoid process

Clinical examination:

• Inspection:
  • Exo-oral: upper lip ecchymosis, skin tear, epistaxis.
  • Endo-oral: upper vestibular ecchymosis, oral hemorrhage due to section of the labial frenulum, horseshoe palatal hematoma. Disturbed dental articulation due to recession of the upper dentoalveolar plate (upper retromaxilla)
• Palpation: Pain in the anterior nasal spine, on pressure of the pterygoids “pathognomonic Guérin signs”, and mobilizable dento-alveolar plateau.

X-rays: Front, profile and Waters views, fracture lines clearly visible at the level of the pterygoid-max clefts. Panoramic X-ray if necessary.

Fig 2: Lefort I fracture

• Lefort II or pyramidal fracture:

Mechanism: Violent anteroposterior shock, often on the premaxilla.

Features : Cuts the middle part of the nasal bones below the frontonasal suture, cuts the ascending branch of the superior max, maxillary sinus.

In the nasal cavities: internal wall of the superior max, vertical blade of the palatine and the pterygoid process at mid-height.

NB: The zygomatomalar complex is respected.

Displacement : the incisal block tilts up and back, and the molar block down and back, creating an incisal gap due to premature molar contact.

Clinic :

Exo-buccal:

Significant facial edema and periorbital bruising when wearing glasses. Fading of the midface.

Stair steps to globular bone palpation

Endo-oral:

Incisor gap due to premature molar contact. Class III due to retromaxillary

Upper dental arch can be moved but the malars remain attached to the frontal.

X-ray:

Standard frontal and profile incidences, and especially Waters incidence (fracture lines) Frontal and sagittal tomography, CT and dental panoramic

Fig 3: Lefort II fracture

• Lefort III fracture: true craniofacial disjunction

Mechanism : Violent trauma to the nasal bumper or cheekbones.

The features:

The first passes through the nasal bones, the ascending ramus of the maxilla, the inguis, the ethmoid and the sphenoid. The second cuts the external wall of the orbit.

The 3rd cuts the zygomatic arch then the palatine and the pterygoid roots

The 4th, median, it cuts the nasal spine of the frontal, the perpendicular blade of the ethmoid and the vomer. Displacement: same as Lefort II except that the malars follow the maxillae

Clinic:

Exo-buccal : significant periorbital edema, subconjunctival ecchymosis and slight enophthalmia, with receding of the facial mass in profile.

Palpation: pain at the nasal root, orbital rim and zygomatic arch Hypo or suborbital anesthesia

Endo-buccal : Open bite due to premature molar contact, with Cl III giving the appearance of mandibular prognathism.

X-ray :

Upward facing and Waters: visualizes the disjunction.

Front and side tomography, CT scan or scanner: look for a tear in the dura mater.

Fig 4: Lefort III fracture

Depending on the terrain

Child :

Fractures are rare, due to the elasticity of bone tissue. These subjects are less exposed. The presence of dental germs and growth zones constitute weak points.

Toothless (old subject):

Less common, especially due to a fall during a fainting spell.

Comminuted fracture even after moderate shock due to bone fragility. Clinical diagnosis difficult (absence of teeth), hence the importance of X-rays.

CONCLUSION

A very detailed diagnostic approach to facial trauma has now become possible thanks to the development of medical imaging. However, this should not overshadow the clinical examination, based mainly on the condition of the dental arches and changes in bone contact.

Fracture of the upper facial mass

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Untreated cavities can cause painful abscesses.
Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.
 

Fracture of the upper facial mass