Fracture of the middle layer of the face

2021-02-02 12:00 AM

If a normal fracture should be treated on the third or fourth day after the injury, when the face has less oedema, it is easy to restore shape.

The middle bone mass of the face is composed of 13 symmetrical bones one after another (6 pairs of even bones and an odd bone is the cane leaf bone or the nasal septum). In which the upper jaw and cheekbones are large and basic bones.

Upper jaw bone characteristics

The maxilla is a fixed, thin bone due to the jaw sinusoidal, sheltered by:

Above is the skull floor.

Below is the lower jaw bone.

The two sides are the cheekbones, the bow continues.

In the event of an injury, often the protective bones are damaged, only strong force and the direct impact can fracture the upper jaw.

The maxilla is constructed to withstand the forces of impact from the bottom up, only the horizontal forces can easily break the jaw.

The maxilla is a spongy bone with many nourishing blood vessels, so when the upper jaw fractures a lot of bleeding, it also heals very quickly.

The upper jaw bone is attached to the base of the skull, so in cases of high facial separation or fracture of the high nasal septum, causing damage to the sieve, the hard meningeal tear causes cerebrospinal fluid to flow through the sieve holes. down the nose and from there may be a risk of infection of the brain or meningitis upstream.

Classification of upper jaw fractures

Whole upper jaw bone broken

Broken Lefort I (Broken Guerin)

Due to a strong traumatic force on the upper lip area.

Broken line:

Start with the chalk below the nasal cavity, to both sides, across the tips of the teeth, going below and # 1.5cm from the jaw-cheeks. Cut across the convex of the upper jaw bone and the lower 1/3 of the mandibular bone. The inside is also broken in the lower third of the cane leaf bone or the nasal septum.

Clinical:

Chew is difficult, entangled; bruising and edema of the upper lip-socket.

A horseshoe-shaped bruise in a frog's jaw appears several days after the injury.

Pain from the anterior nasal spine to the protrusion of the maxilla

Painful pain when pressing after protruding mandibular base: GUÉRIN sign.

Shake horizontally and anteriorly to see the arch of entire mobility: denture sign.

These two signs are used to distinguish Guérin fracture from alveolar fracture and other types of fracture.

Lefort II fracture (Low-face split fracture)

Due to the trauma force from front to back or from bottom to top, the point touches in the tooth area or the upper molar bone.

Broken line:

Passing between the main bone of the nose, injuring the inner wall of the eye socket, passing through the tear bone, cutting the margin under the eye socket or through the hole under the eye socket, then going under the cheekbones and going back through the old protrusion of the maxilla, Cut through the middle 1/3 of the jawbone. Inside the cut, the line passes between the septum of the nose. In this fracture, the cheeks are continued intact.

Clinical:

The middle part of the face is flat, edgy, hematoma of lower eyelid synaptic membrane, tearing due to edema and narrowing of the nasal tear duct. Bruising and pain along the fracture line in the base of the nose and the lower margin of the orbit. The face is numb if the nerve under the orbital is blocked.

Wrong bite. Touch the upper gum and the back of the wisdom tooth are painful. The place adjacent to the cheekbones tower in the upper gums can be seen to move the ladder.

Lefort III fracture (split skull fracture high face on cheekbone)

Due to strong impact from front to back or from high to low on the face block. The face block SHOULD come down and press against the sieve block. The patient is very dizzy.

Broken line:

There are 3 lines

The first line: passing through the main bone of the nose but high, close to the line connecting the forehead, nose, running along the inner wall of the eye socket through the nodule to the upper jaw bone through the torn bone, the paper bone to the butterfly slit and then cutting through 1/3 of the butterfly's foot bone. out.

The second line: runs from the outer corner of the cleft through the outer wall of the eye to the outer eye where the junction between the forehead and the cheekbones is connected.

The third sugar: inside, through 1/3 on the cane leaf bone, close to the skull base May affect the sieve leaf, the hard meningeal wall and the cerebrospinal fluid through which the sieve can flow.

Clinical examination:

The top part of the face deformed, heavily edematous, bruising around the eye sockets, eyelids, bilateral synaptic membranes called signs of wearing sunglasses or "Binoculars"

You can get concave eyes, a double vision if there is a fracture orbit floor.

Pain along the way connecting forehead, forehead, cheekbones, cheeks.

In the mouth: wrong bite, incisors, bruising.

Vertical fracture

Clinically, there is rarely a simple longitudinal fracture, but often a fracture in conjunction with transverse fracture, due to the trauma force from under the chin up.

Middle longitudinal fracture: fracture between the jawbone, separating the upper middle incisors. Torn palate mucosa, tight bite disturbance.

Lateral fracture: break between the incisor and canine.

The two types of fracture above sometimes coordinate, for example in the case of fracture type BASSEREAU (Broken guerin type in three pieces, middle piece with incisors)

A broken part of the upper jaw bone

Broken muzzle on the upper jaw bone.

Canine subsidence.

Fracture of under-orbital wall and orbit floor.

Tooth drive fracture.

Broken muzzle and dome of the palate.

X-ray

Film skull straight, tilted. Blondeau, Waters.

Treatment

If the injury to the facial jaw is related to the skull and brain:

Fainting time, no signs of the cranial brain: treatment for jaw fracture on day four.

There is brain damage: wait until day 14 or 17.

If the brain injury is closed in a coma.

Severe coma, immediate appearance: waiting 14 to 20 days, except abdominal surgery.

Severe coma, prolonged unconsciousness: waiting for weeks.

Secondary coma: treatment of traumatic brain injury, while for facial jaw injuries wait two or three weeks.

If a normal fracture: should be treated on the third and fourth day after the injury when the edema is relieved, easy to shape and restore the shape of the face mass and its function. Should not be late for more than 7 days.

In the principle of treatment, deep and bone lesions must be well resolved before the soft stitching. Especially the maxillary bone with sinus, if damaged, need surgery to drain through the nose or gums in the upper jaw to avoid sinusitis later.

Treatment of the upper jaw bone consists of steps.

Correction

Manual correction:

In case the wound is new, easy to manipulate, you can use your hand or tie steel thread to a group of strong teeth such as canines and molars to pull.

Manipulation by pulling force:

In case of fracture with longitudinal deviation:

The maxilla can be tilted outward or inward. If you want to rectify it, you must first take a row sample and then make a jaw base or a tray to cover the teeth. Jaw base is cut in half following a fracture line in the jaw. Then connect the two halves of the jaw base with one screw. Every day you can screw the screw to pull the jaw in or out until the bite is right.

In case of longitudinal fracture displaced outward, for simplicity, it is possible to force improved IVY or tie often with a second molar hook for the rubber to be pulled.

In case of fracture with horizontal deviation:

You need to tie the brace with a hook at both jaws to hook the rubber ring in the required direction and fix the jaws. It is important to note here that the upper jaw is fixed with the mandible against the lower jaw deliberately to ensure the bite, but since the lower jaw is moving, the jaw must be immobilized with a simple elastic bandage, the chin plaster bandage or surgery. according to ADAMS method

In case the upper jaw bone is fractured and subsided:

If surgical manipulation is indicated under endotracheal anaesthesia, ROWE and KILLEY clamps can be used to clamp the upper jaw bone, pull forward to bring the subsidence bone back to the old position, check with the bite joint.

Or use a rubber tube such as a big NÉLATON catheter. There is a strong wire in the tube, threaded through the nostrils to the throat and pulled out of the mouth. Thus, we have strong support to pull and straighten the face.

Orthopaedic manipulation is also possible:

This method uses traction between the cranial face, slowly and gradually manipulated.

The scissors include:

One leaning against the skull or skull.

A fulcrum in the mouth is the arches, troughs, and braces.

Intermediate components for the continuous or batch pull.

Orthopaedics by surgery:

When the patient arrives late, the fracture line has begun to heal, if the orthopaedic manipulation does not work, it should be corrected by surgery, using a chisel to reconstruct the old fracture for correction (for Lefort I and II fractures. ).

For Lefort III fractures: Can not use chisels for fracture. Often have to use surgery to cut bones in the buttock for orthopaedic surgery or use implant surgery to partially recover the deformation of the face.

Permanent

For upper jaw fractures, whether one or both jaws are motionless, they must rest against the skull, which is the most stable place.

Fixed with orthopaedic

A stationary kit consisting of three parts is used:

A trough in the mouth.

A skull rest.

A system that connects the two aforementioned components.

The system to connect the two upper parts is placed parallel to the bite plane, and a straight spindle is placed between the headrest and the trough. When the adjustment is good, tighten the screws to fix.

Fixed with surgery

If broken according to Lefort I or Gúerin, you can cut the skin # 1cm in the lower margin of the eye socket, drill holes to hang the upper jaw bone that was tied to the steel brace or hang the upper jaw bone into the cheeks supply.

If fracture according to Lefort II or III, to hang higher on the outer eye of the brow bone.

Evolution

If there are no complications, the broken bone is adjusted to the correct position and well fixed, will heal after 3 weeks

If the treatment is late, the bone has already deformed face, wrong joints, bad cal must be broken down to correct or rectify early; otherwise, it will result in very harmful function and aesthetics.

It is necessary to actively fight systemic and topical anti-inflammatory to avoid complications such as meningitis, tetanus, sinusitis, osteitis.

If there is a traumatic brain injury, the patient's destiny first and foremost, must respect the time allotted for management.

Symptoms

Complications immediately

Asphyxiation: Due to collapsed jaw sieve, swelling of the upper respiratory tract.

Bleeding: A fracture of the upper jaw is heavy bleeding. For first aid, first need to insert gauze tightly. The associated artery or the external carotid artery may later tie and stop bleeding in place.

Shock: Common when there is a total wound or skull.

Late complications

Meningitis caused by a broken sieve leaf fragment, cerebrospinal fluid flows out, through which bacteria invade; inflammation of the sinuses, osteitis, tetanus.

Slow bone healing: Due to inadequate manipulation and fixation, inadequate and general weakness.

Bad bone: deforming face, affecting function and aesthetics.

Neurological disorders: Numbness, metastasis under the eye socket and temporal cheekbones. Pain, loss of taste, loss of smell ...

Short eyelashes, upturned eyelashes: Due to loss of organization or shrinkage. Damage to eyeballs, tear bags, orbit floor damage cause disturbances of eyeball movement.