Classification & management of zygomatic complex fractures including lateral wall of the orbit /certified fixed orthodontic courses by Indian dental academy
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Classification & management of zygomatic complex fractures including lateral wall of the orbit /certified fixed orthodontic courses by Indian dental academy
1. Classification and
management of zygomatic
complex fractures including
lateral wall of the orbit.
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4. Surgical anatomy
Quadrilateral in shape
Four process:
Temporal, Orbital, Maxillary, Frontal
Lateral wall and floor of the orbit.
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8. Mechanism of zygomatic injury
Direct
blow – malar eminence
Violent
face -
blows – contra lateral mid-
causes a fracture
dislocation of the zygoma by
reciprocal transfer of forces from
the opposite side of the facial
skeleton.
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9. Classification
Larsen
and Thomsen:
– A: Stable #, no/minimal displacement
,no intervention
– B: Stable #, with displacement,
reduction, no fixation
– C: unstable #, displacement, reduction
and fixation
Fracture
of zygomatic arch:
– Minimum/no displacement
– V-type #
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– Communiated #
10. Rowe and Killey’s Classification
Type
Type
Type
I – no significant displacement
II - # of zygomatic arch
III – rotation around vertical axis
– Inward displacement of orbital rim
– Outward displacement of orbital rim
Type IV – rotation around longitudinal axis
– Medial displacement of frontal process
– Lateral displacement of frontal process
Type V – displacement of complex enblock
Type VI – displacement of orbital floor
Type VII – displacement of orbital rim
Type VIII – complex communited #
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11. Mechanism of zygomatic injury
•Direction of dislocation:
several planes.
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13. Signs and symptoms of zygomatic
fractures
Orbital signs and
symptoms:
Proptosis
Enopthalmous
Double vision
Scleral show
Subconjuctival
hemorrhage
Periorbital oedema.
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14. Signs and symptoms of zygomatic fractures
Neurological
signs &
symptoms:
contusion or compression
of infra orbital nerve:
•Others:
•Flatness of the face
•Limitation of the jaw
movement
•Epistaxis
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15. Clinical examination:
Face examination.
Tenderness.
Greenstick fracture.
Step deformity.
Intra oral palpation.
Drooping of the upper lip.
Facial nerve examination.
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17. Treatment
Should
one surgically intervene ?
When is the optimal time ?
What is the most effective
method ?
- closed reduction without fixation ?
- open reduction and fixation ?
Demann
& Dortzbach
recommended early intervention
for muscle entrapment injuries.
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24. Treatment
Temporal fossa approach :
u
Reduction
u
Audible click
u
Elevator is withdrawn
u
Closure by layers
u
Post operative care.
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25. Treatment
Upper buccal sulcus approach :
• Intra oral approach
Advantages:
• less force is recquired for reduction
• Sparing a skin incision
• Less dissection
Technique :
• Incision – 1 cm
• Elevators:
Taylor monks
Rows.
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29. Treatment
Percutaneous
approach :
Insertion of hook
Rotation : 90
degrees
0.5 cm
Note :
The point of
instrument
must be kept in close
contact with the bone
all the times.
Complication: blindness
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31. Treatment
Intranasal transantral
approach :
Not commonly used
Rotation around vertical axis
Technique:
opening – inferior meatus
curved urethral sound
firm upward and downward
pressure
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32. Treatment
Temporary support :
Unstable following reduction
Gross contamination
Communition
- Antral pack,
- Wire – splint
- Inflatable balloon
- Plaster head cap
- Silicon elastomer
wedge
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33. Treatment
Fixation
Approaches to the infra orbital rim:
Existing skin lacertions
Infra orbital rim incision
Subtarsal incision
Blepharoplasty incison
Transconjuctival incision
A. Pre septal
B. Post septal.
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35. Treatment
Approaches to the lateral orbital rim :
Eye brow
incison
Upper lid
incision
Approaches to the zygomatic arch:
Pretragal incision
Coronal flap incision
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36. Treatment
Most
common methods of
fixation:
plates
Wire osteosynthesis
Rigid fixation-mini-
Less common methods are :
support.
External pin fixation
Maxillary antral
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37. Treatment
1.
Trans osseous wiring or
osteosynthesis :
Technique :
No.2 round bur,
5mm apart from the fracture ends
0.35 mm diameter soft stainless steel
wire
Figure of eight fashion
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38. Treatment
2. Bone plates :
2 mm plates – Zygomatic arch
1.5 mm – Zygomatico-Maxillary
buttress.
1.3 mm – Infra orbital rim
Order of fixation :
Zygomatic arch
Zygomatico frontal suture
Infraorbital rim
Zygomatic buttress.
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39. Treatment
4. Fixation with a pack in the
maxillary sinus :
To support zygomatic complex fractures
To support reconstructed comminuted
orbital floor.
Technique :
Incision
Window into the sinus
Bone pack – ribbon gauge
Concertina pattern
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40. Treatment
White head varnish :
Iodoform -10 g
Benzoin -10 g
Storax - 7.5 g
Balsam of tolu - 5 g
Solvent ether to 100 ml.
Aromatic resins – benzoic acid – potent
anticeptic and water proofing pack.
3 weeks
Easy to remove
Balloon or a foley’s catheter.
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42. Complications
Malposition of the soft tissue on the
bone :
Closure of periosteal incisions
Refixation of the tissue on the facial
skeleton.
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43. Complications
Complications of bone
Malpositions :
Maxillary sinusitis
Inaccurate alignment :
orbital rim
zygomatic arch
Reconstructed flat rather than as a
curve to achieve a satisfactory
reduction.
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44. Complications
:
Ocular complications
Traumatic diplopia
Enopthalmos
Retrobulbar hemorrhage &
blindness
Superior orbital fissure syndrome
Neurologic complications :
Damage to the infrawww.indiandentalacademy.com
orbital nerve.
45. MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
Shape: Pyramidal Apex
Optic foramen
Roof, Lateral wall,
floor & medial wall
Direct injury to globe
intraoccular pressure
Fracture floor/medial wall
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46. MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
• Applied anatomy
• Clinical features
• Radiographic features
• Management
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47. MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
Applied anatomy
Floor : Zygoma & Maxilla
Entrapment
“Trap door effect”
Diplopia , Enophthalmos
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48. MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
Clinical features
Pain
Edema
Ecchymosis
Proptosis
Paraesthesia
Emphysema
Diplopia
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49. MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
Radiographic features
Occipito-mental view
( PNS, Water’s View)
“Hanging Drop”
CT Scan:
Coronal cuts: Floor
Axial cuts: Medial wall
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50. MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
Management
Diplopia & Enophthalmos
Surgical & surgical only
Create a new floor
Bone
Cartilage
Metal: titanium
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51. MAXILLOFACIAL INJURIES
Orbital floor Fractures
(blow out #s)
Management
Incidence – 2 / 62
Reconstruct floor to prevent
enophthalmos & diplopia
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Hinweis der Redaktion
Immediate intervention nessasary
Prevent
Enopthalmos
diplopia
Approach through blepharoplasty incision for floor medial and lateral wall
Sub conjunctival approach with lateral canthplexy alternative
Aim to reconstruct the floor / medial wall
Choice of graft : calvarium