Oral Pathology and Surgery.
Fractures of the facial mass
I- Introduction:
They correspond to fractures of the skeleton of the middle level of the face resulting in a complete or partial solution of bone continuity between the maxilla and the underlying skeleton.
To explain the propagation of fracture lines, we describe:
a) force zones:
- the beams of Ombredanne:
Represented by:
-the palatine plateau
-the body of the malar
-the anterior edge of the maxilla
*the pillars of Sicher and Couly:
-the canine pillar
-the malar pillar - the pterygoid pillar
b) areas of weakness:
or Lefort zones which number 03
Role of the bumpers:
*Either they directly absorb the total energy by breaking on the spot (nasal pyramid).
*Or they support the shock and transmit it to their attachments which break: (malar).
II-anatomical reminders:
*The facial mass is made up of 13 bones:
01 single odd bone: vomer
06 even bones: maxillae, malar, unguis, palatines, nostrils, inferior turbinates.
*this set is contained in a space delimited:
-at the top, by the base of the skull;
-behind, by the plane of the pterygoid processes;
-at the bottom, by the occlusion plane.
*it is very richly vascularized, which explains the speed of consolidation. it is hollowed out by numerous cavities (orbit, FN, maxillary sinus).
With a complex biomechanical structure, the facial mass is made up of:
– rare trabecular bone (bony palate)
– compact bone of variable thickness (ethmoidal complex)
– very solid bones, real reinforcements at the level of the pillars
III-ETIOLOGIES
Age: 20-35 years
Sex: predominantly male.
Etiology: AVP, fights, work accidents, sports accidents, falls, ballistic trauma.
A- Examination of a trauma patient:
cf mandibular fractures
B/ CLINICAL FORMS
B.1fractures totales a) horizontal fractures
a.1 Le Fort I or Guérin fracture
The fracture lines detach the dental arch by passing above the apices, above the sinusonasal floor; they cut the lower 1/3 of the pterygoid processes and rather dislocate the lower edge of the nasal septum.
Clinical:
the intraoral examination finds:
– palatal ecchymosis in a “horseshoe” shape
– upper vestibular ecchymosis
– articulation disorder with premature molar contact, anterior open bite and laterodeviation are possible.
Palpation:
Shows painful points at the level of:
– the anterior nasal spine
– to pressure of the pterygoids (Guérin sign).
the dental arch is easily mobilized compared to the fixed malars.
* Mobility called “in denture”.
* Palatal ecchymosis in a “horseshoe” shape.
Radiographic exploration:
Coronal CT scans, perpendicular to the fracture plane, best show the lesions.
a.2 Le Fort II fracture
This is the low craniofacial disjunction
The line passes through:
– the nasal bones (OPN)
- the ascending process of the upper maxilla
-above the malar
-to reach the pterygoid process at mid-height
-It then runs along the internal wall of the sinus (between the middle and inferior turbinates) and returns to its starting point on the ascending process of the MS.
– at the level of the nasal septum the line is median cutting the bony septum from the nasal bones to the Vomer.
Clinic
The extraoral examination finds:
– peri-orbital ecchymoses “in glasses”
– facial edema - midface depression
– epistaxis.
Palpation reveals painful points and a “staircase” on the root of the nose,
the zygomatic process, and the infraorbital rim.
Hypo- or anesthesia of the infraorbital nerves is common.
Intraoral examination shows:
– posterior vestibular and palatal ecchymoses;
– an articulation disorder such as an incisor gap and premature molar contact.
Palpation finds a pathognomonic sign:
palatonasal mobility in relation to the skull and fixed zygomatics.
a.3 Le Fort III fracture:
This is the high craniofacial disjunction
. The fracture line runs through:
- OPNs
- the ascending process of the maxilla to reach the internal wall of the orbit.
-from the sphenomaxillary fissure it travels to the region of the frontomalar suture.
-it extends backwards where it cuts the zygomatic arch
-inside it cuts the pterygoid processes and the maxillary tuberosity at their upper 1/3.
-at the level of the nasal septum it cuts the nasal spine of the frontal bone, the perpendicular blade of the ethmoid and the vomer at its upper part
Clinical:
Inspection from the front shows
-significant periorbital edema which quickly becomes panfacial (football face) - very characteristic periorbital edema and ecchymosis when viewed through glasses (lorgnettes)
- epistaxis
chemosis.
false prognathism by recoil and impaction of the facial mass
– a collapsed nasal root.
Palpation finds painful frontozygomatic, zygomatotemporal and glabellar points.
It highlights the abnormal mobility of the face in relation to the skull.
– Sensitivity, in the territory of V2, is modified.
– Intraoral examination finds an occlusion disorder with incisor gaping and premature molar contact.
b- Vertical line fracturesb.1 Disjonction intermaxillaire:
Sagittal fractures mainly visible on CT scan, characterized by a line that is classically median or paramedian.
This fracture is always associated with another fracture.
Anteroposterior palatal wound
Interincisive diastema
Anteroposterior palatal bruiseb.2 -Fractures combinées:
– Richet fracture:
associates a Le Fort III fracture with a DIM;
– Walther fracture:
associates Le Fort III, Le Fort I fractures and a DIM;
– Bassereau fracture:
has two vertical lines, paramedian, separating the entire nasal bone and the ascending branches of the maxilla, and releasing the incisor block below;
– Huet fracture:
has two vertical lines more external than the previous one, passing through the canine premolar area, and opening the maxillary sinuses
B.2 Partial fractures:a-Fracture du malaire :
This is in fact a zygomato-malo-maxillary disjunction
Following an impact on the cheekbone
The line: is located approximately at the level of the malo-maxillary, malo-zygomatic, malo-frontal joints.
The movement occurs along two axes:
– vertical: there will be a depression of the zygoma and protrusion of the cheekbone or protrusion of the cheekbone and depression of the zygoma
– horizontal: there will be a depression of the lower part of the malar in the sinus or depression of the orbital process and protrusion of the cheekbone.
Clinically:
Edema of the cheekbone region;
Suborbital ecchymosis;
– epistaxis reflecting hemosinus
Facial asymmetry due to depression of the fractured malar
Painful palpation at the articular points and upper vestibule.
Suborbital hypoesthesia.
X-ray: Blondeau or Hirtz incidence
b- Fracture of the zygomatic arch
Frequent, it often goes unnoticed, can lead to permanent constriction of the max.
By impact directly on the arch
The fracture is more often W-shaped, but frequently V-shaped
Clinically:
A large edema masks the depression behind
Clear trismus.
X-ray: Lateralized Hirtz on the fractured side.
V/ Treatment
– Goals: these are * functional restoration of the pre-existing occlusion and
* morphological restoration by good projection of the facial mass.
– Means: they are orthopedic and/or surgical.
If circumstances allow, treatment must be complete and total from the outset.Le traitement fait appel a la chirurgie maxillofaciale
VI/ complications and sequelae:
*LOSS OF SUBSTANCES
Vicious callus
*Insufficient correction
*DELAYS IN CONSOLIDATION:
Beyond 6 weeks, they must look for an underlying infection (sinusitis, osteitis) and remove the osteosynthesis material.
True pseudarthrosis is exceptional, as is maxillary necrosis .
Their treatment is long, difficult and delicate.
OCCLUSAL SEQUELAE
They reflect consolidation in a vicious position associating functional masticatory disorders and morphological disorders,
at worst resulting in a global facial deformation with anterior vertical excess and retrusion of the middle level of the face.
*SINUS SEQUELAE
Like post-traumatic sinusitis, they are frequently associated with osteitis of the thin walls of the sinus. Bucco-sinus or bucco-sinuso-nasal communications generally remain sequelae of DIM.
NASAL SEQUELAE
At the origin of morphofunctional disorders, they can associate:
widening of the root of the nose, telecanthus, nasal saddle,
deviation of the dorsum and the septum.
VII/Conclusion:
Frequent in polytrauma, fractures of the facial mass engage:
Firstly, the vital prognosis due to all the injuries;
And, secondly, the functional and especially aesthetic prognosis due to their sequelae.
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.