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Oral Surgery

Authors: Dr. Kalpana Sinsinbar, Dr. Yusuf Bharmal, Dr. Hardik Rupareliya

Abstract

The most complex area of skeleton in a human body is formed by the bones of the skull and face. The middle third of face- It is the area bounded superiorly by a line drawn from zygomaticofrontal suture across the frontonasal and frontomaxillary suture to the zygomaticofrontal suture at the opposite side. Inferiorly by alveolar ridge or occlusal plane and posteriorly as far as the frontal bone above and body of sphenoid below. It has relations with the brain,orbits,sinuses,oral cavity, nasopharynx and many more nerves and vessels. Hence functionally and esthetically it is an Important area of face.

INTRODUCTION Bony archietecture-

Our facial bony complex has 2 jaws –maxilla and mandible.

Maxilla is composed of-orbits,NOE complex and pair of zygomas, structures are secured by developmental sutures and they are the areas of weakness. Named as-FZ,ZM,ZS,NF,MF,NM Sutures.

Mandible – It is a U-shaped bone and it is the only mobile bone of the facial skeleton; since it houses the lower dentition,its motion is essential for mastication. Structural portions of mandible are-condylar process,coronoid process,ramus of mandible, angle of mandible and body of mandible bearing the teeth.

Fractures of these areas are potentially disfiguring as well as life-threatening. Hence a systematic and timely repair of fractures to correct the deformity and its consequences is mandatory.

Etiology of fractures-
  • 40%- Road traffic accients
  • 10%-industrial accidents
  • 15%-assault
  • 10%-fall
  • 25%-sports injury.
Epidemology-
  • Most maxillary fractures occurs in young men (age 16-40 yrs)
  • Peak age of incidence-21-25 yrs
  • Male:Female ratio- 4:1
MANAGEMENT OF MID-FACE FRACTURES-
  1. Emergency treatment and stabilization of patient
  2. Definitive treatment with reduction and fixation.

Team approach for the treatment involves opinions and treatment from

 

METHODS OF FIXATION

c.WIRING

d. INTERMAXILLARY FIXATION (IMF)

e. PLATES AND SCREWS

f. INTERNAL SUSPENSION-E.g.-circumzygomatic , infraorbital

g. CRANIOFACIAL SUSPENSION-e.g.-Halo frame, Box frame.

Although, Maxillofacial trauma cases can wait,late repair after healing is extremely difficult ,early treatment within 1-10 days gives the best results; but immediate surgery can be performed for life-threatening injuries or if the patient is going for the theatre for other reasons.

MAXILLARY FRACTURES

Lefort’s Classification`

  1. Lefort I-Transverse maxillary
  2. Lefort II-Pyramidal
  3. Lefort III-Craniofacial Dysjunction
DIAGNOSIS OF LEFORT III FRACTURE
  • Clinical evaluation provides only a rough idea of the condition and as soon as swelling hides, the underlying bony structures a better view is seen.
  • Plain film radiographs (OPG) and axial and coronal CT images are the basis for precise diagnosis and treatment plan.
CASE REPORT

A young male patient aged 22 years of accidental injury came to the emergency department of our BURHANI HOSPITAL, SURAT with severe facial injury and shoulder dislocation along with multiple abrasions all over the body.

Preliminary and emergency treatment was delivered by the Orthopaedic Surgeon Dr. Yusuf Bharmal which was done under anaesthesia includes –

  1. Management of facial injury by cleaning and stitches around the infraorbital area on the right eye and near the mandibular region were taken with 4-0 ethilon sutures. (3 stitches)
  2. Right shoulder was dislocated and was managed by closed reduction and immobilised with strapping.
  3. Bilateral knee abrasions where deep almost reached to the dermis level, were managed by asepsis and repetitive dressings.
  4. Right thumb nail was broken therefore removal was done followed by repetitive dressing alongwith few abrasions over abdomen with frequent dressings.

Later case was referred to Dr. Kalpana Sinsinbar (B.D.S., Burhani Hospital, Surat) for dental management and facial deformity management. On extraoral examination-

  • Facial edema
  • Disc-shape face on right side
  • Step deformity at right infraorbital margin was evident
  • Sub-conjunctival haemorrhage-right eye
  • Tenderness

On intraoral examination-

  • Loss of occlusion
  • Anterior open bite
  • Grade II Mobile tooth 43
  • Difficulty in mastication
  • Reduced mouth opening
  • Pain while moving the jaws along with Clicking sound.

Above stated observations and examinations led us to a faint view of fracture along maxilla on right side and condylar fracture on right side.

So for a confirmatory diagnosis patient was advised for OPG and CBCT.

RADIOGRAPHIC IMPRESSION
  • Condylar fracture on right side
  • Subcondylar fracture right side
  • Ellis class IV Fracture irt 43
  • Zygoma fracture on right side.
CBCT IMPRESSION
  • Condylar fracture on right side
  • Subcondylar fracture on left side
  • Zygomatic arch fracture on right side
  • Maxillary sinus wall fracture on right side
  • Ellis class IV Fracture irt 43
  • Alveolar fracture in between teeth 34-35.

Above radiographic reports called for the managed of the case by An Oral Maxillofacial Surgeon Dr. Hardik Rupareliya.

 
 
 

An OPD check-up was carried out and conclusion by Dr. Hardik Rupareliya was to do the reduction and IMF of fractured site. After 12 days of accident patient turn up on 13th day for surgical management. Pre-Op blood and urine examination, Physician fitness check-up was obtained and patient was instructed to get hospitalised and NBM by 6hours before surgery. Pre-Op antibiotics administration was also done for better results.

Patient was taken to OT under the presence of Anaesthetic doctor and GA was administered.

Aseptic conditions were achieved and arch bar fixation was done and condylar reduction was done.

For the management of zygomatic fracture an intraoral vestibular incision was taken and with the help of cautery access was achieved to the right zygoma, on the 13th day post trauma we could see callus formation at the site so proper reduction was achieved after removal of callus part followed by reduction of the site after proper irrigation for 5 minutes with betadienesaline solution and incision was closed by 4-0 vicryl suture. Sooner after the surgery, Patient was conscious and shifted to ward uneventfully.

Post operative antibiotics and analgesics along with liquid diet were initiated. For maintenance of oral hygiene, 2% CHLORHEXIDINE MOUTHWASH was advised to the patient.

Next day before discharge , elastics were placed for immobilization of the jaw and slight bite correction was also done. Post discharge antibiotics and analgesics were given for 3 days and patient was advised for regular follow ups.

After 45 days elastics and IMF were removed and patient was advised for remaining dental treatment.

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