The line is a fracture at the junction of the frontal sprouts upper jaw with the nasal part of frontal bone in her lattice notch. The front edge of the latter is connected to the nasal bones, and the rear - with the front edge of the plate perforated ethmoid bone, which is involved in the formation of the skull base in front of his pit. Rear bow sections of the frontal bone contains cells in contact with the ethmoid bone and forming the roof of its cells. Then the fracture line passes through the inner wall of the eye socket to the junction of the upper-and infraorbital slits, passes to the outer wall of the orbit, extending to her up and anterior to verhnenaruzhnogo its corner. Here the fracture line runs in the fronto-zygomatic suture or close to it, then goes backwards and down on a large sphenoid wing to the lower surface of the body and the upper division of pterygium spike. At the same time break the zygomatic process of temporal bone and nasal septum in the horizontal plane (Fig. 3.1).
At the turn of Le Fort I maxilla and other facial bones are separated from the cranial bones. In the anatomical boundaries of the upper jaw fracture takes place only in the frontal process and, apparently, its posterior orbital surface. Most of it goes to the neighboring bones or along the seams between them: the orbital surface of frontal bone, the lateral surface of the body of sphenoid bone, paper plate ethmoid bone, lacrimal bone (medial wall of the orbit), orbital surface of the zygomatic bone, orbital surface of the wing of a large sphenoid bone, zygomatic appendage of the frontal bone (lateral wall of the orbit), wing-spikes sphenoid bone. Considering that the orbital surface of frontal bone, ethmoid, sphenoid body formed anterior cranial fossa, and the body and great wing of sphenoid bone are involved in the formation of the middle cranial fossa, it becomes apparent that the fracture of the upper jaw of Le Fort I almost invariably accompanied by fractured skull. Therefore we can not but take into account the anatomical relationship of the frontal bone, referred to in the beginning of this section (Fig. 3.2 - 3.4).
This type of fracture can be attributed to a change only of the upper jaw, apparently arbitrarily, and the terms «craniofacial separation», «subbazalny change» more accurately reflect its essence as a fracture of the midface. Thus, fracture of Le Fort I may be regarded as the most typical for a fracture of the upper jaw of Le Fort I, when they are not masked by symptoms of brain damage.
When you save a mind and a satisfactory orientation of the patient complained of bleeding from the nose, double vision in the vertical position of the body, reduced visual acuity, a painful and difficulty swallowing, poor mouth opening, poor interdigitation, foreign body sensation in the throat, retch, choke and nausea. It is not always associated with brain injury, and may be due to irritation of the mucous membrane of the posterior wall of the pharynx or tongue a little latch to replace a backward and downward, along with hard and soft air.
On examination, there pronounced edema admaxillary soft tissues, resulting in the patient's face becomes lunoobraznuyu form. Edema is expressed predominantly in the century, the root of the nose, in the infraorbital and temporal regions. In the area of the zygomatic arch can be determined zapadenie tissues. This is found symptom points, characterized by bleeding in the upper and lower eyelids, conjunctiva (Fig.3.5). Sometimes swelling of the conjunctiva is so high that it vybuhaet between serried centuries in the form of yellowish translucent body oval. Reason exophthalmos - hemorrhage, retrobulbarno fiber. However, it is rare, often observed enophthalmos (zapadenie eyeball). In the horizontal position of a patient face flattened, possible small enophthalmos. After moving the patient in the vertical position of the upper jaw drops, her face grows longer and enophthalmos due to an increase in the orbit. Subjectively, it is accompanied by increased diplopia, and objectively - the displacement of the eyeballs and extending down the optic fissure. The patient, trying to eliminate diplopia, closes one eye, hand or finger under sums eyeball, lifting him. When interdigitation eyeballs move upwards, Ophthalmic slit narrows, and diplopia decreased. Return of the patient in a horizontal position is accompanied by a flattening of the face and changes in occlusion, a decrease in diplopia.
Palpation can determine bone protrusion or failure of the tissue between the nasal part of frontal bone and frontal offshoot of the upper jaw and nasal bones, as well as in the zone skulolobnogo seam (verhnenaruzhnogo angle of the orbit). There is a step in the field of bone zygomatic arch. Occasionally in the root of the nose can be determined by a crackling caused by air emphysema. In case of damage to the orbital nerve (n. ophthalmicus) is reduced or disappears pain sensitivity of skin in the forehead, upper eyelid, inner and outer corners of the optic fissure.
An examination of the mouth draw attention to the relation of dentitions. This is found open bite due to contact only the molars. However, other variants are possible relationships of dentition, that depends on the degree of displacement of the fragment broke off to the side, back and down and from the source patient's bite (orthognathic, straight progenichesky, cross, etc.). At maximum mouth opening distance between the upper and lower incisors is less than, the norm, due to displacement of the upper jaw down. Opening the mouth may be accompanied by pain in the upper jaw because of its sinking down. Soft palate is displaced backward and downward, his tongue regard tongue and posterior wall of the pharynx.
Pressing on the hook for pterygium sprouts sphenoid bone, hard palate or the last molars there is pain along the presumed crack fracture (positive symptom load). And slightly prolonged (1 min) pressure on the hard palate up causing a shortening of the midface, narrow eye slits and wrinkling of the skin at the root of the nose. When the alveolar process of capture fingers of his right hand and cautiously shaking a bone fragment in the anteroposterior direction can II finger of his left hand placed on the location of identified bone of steps to define a synchronous mobility in the fronto-nasal and fronto-zygomatic areas and stretches of the zygomatic arch. If these steps have not been established, with the shaking of the upper jaw should be examined II intercilium finger of his left hand, all the orbital margin and zygomatic arch. Detection of abnormal mobility of the upper jaw is a direct proof of its fracture.
Sometimes additional radical change in the sagittal plane, ie, the separation of the upper jaw in two halves. Line fracture never passes along the middle seam, and is parallel to it. Such patients can be detected or hemorrhage on a solid sky along the midline and bony step, or laceration of the mucous membrane of the hard palate and a small gap between the fragments lateral midline, leading to the nose, a wide wound that is reminiscent of congenital cleft palate, through which visible to the nasal cavity. For percussion upper jaw heard a dull sound.
At the turn of the upper jaw of the upper type is often damaged the optic nerve, which passes into the optic canal, located between the body and small wings of sphenoid bone. They displayed this decrease in visual acuity, sometimes falling out of the visual fields with lesions of the optic nerve fibers. In the upper orbital fissure are the oculomotor (III), block (IV), abducens (VI), orbital (a branch of the trigeminal nerve). In this regard, the patient can open his eyes or in part, or not open it; possible exotropia (defeat stem III pairs), limitation of movement of the eyeball downward and outward, double vision when looking at his feet (defeat IV pairs), convergent squint and double vision in the horizontal plane (the pair defeated VI), violation of pain sensitivity of skin in the upper eyelid, outer and inner corner of the eye slit the skin of the forehead (the orbital nerve lesion). The examination of patients with fracture of the upper jaw of Le Fort I need to participate neurologist and neurosurgeon.
In clinical practice, there are observations, when the upper jaw be affected as a single block with the frontal bone (Billet, Vigneul, M. B. Shvyrkov). In this case, the fracture line is not at the junction of the frontal sprouts upper jaw with a new part of the frontal bone, and in connection with the frontal parietal, ie in the area of the fronto-parietal suture. Then it comes down to scales of the temporal bone, or on a large wing of sphenoid bone, and passing behind the pterygoid processes of the bones and torn a hole in the ends of the connection sphenoid bone with the occipital. Must broken zygomatic arch. This change is usually bilateral, and the fracture line is almost symmetrical. An examination of the patient also noted marked swelling of the face. When shaking of the upper jaw of the alveolar bone to detect pathological mobility in all the typical places you can not. It is found in the fronto-parietal suture and the zygomatic arch. Ibid detect bone step. Greater displacement of the upper jaw down does not occur, malocclusion insignificant.
On the x-ray of facial bones can establish a violation of the integrity of bone tissue in the root of the nose, the zygomatic arch, a large wing of the sphenoid bone and fronto-malar junction, as well as decrease the transparency of the maxillary and sphenoid sinuses. On the lateral radiograph may be signs of a fracture of the body sphenoid bone (ris.3.6). Some patients there pnevmotsefaliya - accumulation of air in the anterior cranial fossa.
