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Fracture of the upper jaw of Le Fort II (medium type)
03-09-2009
Fracture line passes through the place of the frontal sprouts upper jaw with the nasal part of frontal bone on the inner wall of the orbit to the infraorbital fissure. Further extends anteriorly on the lower wall of the orbit to the infraorbital region, crossing his or skuloverhnechelyust Board the seam, or close to it. Then comes down and backwards on the front surface of the upper jaw, extending to the pterygoid bone sphenoid bone (sometimes on the border of the upper and middle third) (ris.3.7).
Breaking the nasal septum in the horizontal plane. Fracture line may pass directly to the infraorbital canal and through the infraorbital foramen with substantial damage to infraorbital nerve. If the fracture line crosses the zygomatic bone, zygomatic nerve may be damaged.
In the case of a fracture in Le Fort II upper jaw with bone nose broken off from the zygomatic bone. This more or less radical change of the frontal, Lattice, body sphenoid, lacrimal, and palatine bones of the orbital surface of the zygomatic bone. Therefore, in this case we can talk not only about the turn of the upper jaw, but the other had a fracture near her arrangement of the bones, including those involved in the formation of the skull base (see Fig.3.2, 3.3, 3.8).
Existing literature terms «Maxillofacial separation» and «sub-orbital fracture» to some extent reflect the essence of a fracture of the upper jaw of the type.
It should be remembered that, in addition to the typical location of fracture lines on the Le Fort II, possible fracture in the sagittal plane, ie crack fracture through the hard palate. It is known that the upper jaw fused to the embryonic period and only the palatal processes. Such a change not only dangerous for the patient, how substantially complicates the consolidation of fragments of the jaw. Clinical manifestation of his described above. At the turn of Le Fort II is always a chance of a skull fracture and associated brain damage that largely depends on the direction of the fracture line and its location in the area of the bones forming the base of the skull. Frequency of damage caused by ethmoid not only because it participates in the formation of the medial wall of the orbit, but also because the grid cutting the frontal bone, which runs the zone of fracture, its rear edge is connected to the perforated plate of bone.
Patients may complain of pain in the upper jaw, with the increasing interdigitation and chewing of food, foreign body sensation in the throat, retch, difficulty breathing through your nose and sometimes double vision, numbness of the skin in the infraorbital region and upper lip, lower eyelid , wing, and the skin of the nasal septum, numbness of incisors, canines, premolars, and the mucous membrane of the alveolar process to the vestibular side within these teeth and sometimes a reduction or loss of smell in case of cancellation or denial of the olfactory filaments (fild olfactoria), passing through a hole perforated plate lattice bone.
If the damage (flattening) nasolacrimal duct may occur complaints lacrimation, as confirmed by an objective study. Configuration of the face is altered due to pronounced swelling, and sometimes subcutaneous emphysema and hemorrhages in the soft tissue infraorbital and zygomatic areas. Characteristic localization of bleeding in the area of the orbit. Impregnation of soft tissues with blood more pronounced in the root of the nose, upper and lower eyelids, conjunctiva and sclera of the eyeball. Hemorrhage in the tissue age and swelling sometimes so pronounced that it was hard not to view the eyeball. Hematoma may extend to the supraorbital and infraorbital area. Hemorrhage less intensively or can not be determined in the area of the upper-outer quadrant of the orbit, if the hematoma is caused only by bone injuries.
However, soft tissue contusion okoloorbitalnoy zone at the time of injury may lead to the uniformity of the location of the zone of hemorrhage around the orbit. Often permeation conjunctival blood so much that pronounced chemosis, and she vybuhaet between serried centuries.
When haemorrhage retrobulbarno fiber can be determined exophthalmos. In the horizontal position of the patient's face flattened by moving fragments backwards and pronounced contouring cheekbones. In the vertical position of a patient face a slightly longer due to the shift of the upper jaw down. On palpation of soft tissues infraorbital area and the root of the nose, there is sometimes a crackling - a sign of subcutaneous emphysema, which, in our opinion, is caused by peeling of the mucous membrane of the maxillary sinus with displacement of fragments of the upper jaw, which is accompanied by the creation of a space with negative pressure. When you break the mucous membrane of the air rushes into a zone of low pressure and penetrates into the subcutaneous fatty tissue. Pain sensitivity is reduced or absent in the zone of innervation of a small crow's feet. Along the lower edge of the orbit clearly palpable bony protrusion (step). At the root of the nose to determine its much more difficult because of pronounced tissue swelling and severe pain. Most here revealed the absence of a finger bone bases in case of displacement of bone fragments, sometimes by a crackling air emphysema.
If you place the index finger of his left hand on the bottom edge of the orbit in the projection of the bone spur, large - at the root of the nose and right hand slightly shook his upper jaw in the anteroposterior direction, shifting it by no more than 2-3 mm can be determined synchronous «stirring» bone fragment at the same time in either place. In this case the skin over the root of the nose will tuck or change in color due to its uneven tension in the displacement of fragments. Palpation of the same three fingers of his left hand (I, II and III), the root of the nose, infraorbital region to the left and the right to verify the synchronous displacement of fragments in three points. In the case of damage to the nasolacrimal canal, except for watering, you may receive blood from the lacrimal points.
It is known that at the turn of the upper jaw, regardless of the type of fracture gap may be of different length and arranged at different levels depending on the form, injuring object, force of its impact and the bone structure of the individual. Clinical experience shows that when the turn of Le Fort II fracture line in the lower wall of the orbit can pass outwards from the infraorbital canal infraorbital directed not to the edge, and walk towards the lower-outside corner of the orbit, ie through the zygoma and along the rising ground of the upper jaw to the wing-shoot. In this situation, as a rule, injured skulolitsevaya skulovisochnaya and zygomatic branches of the nerve, which is located on the outer wall of the orbit and enters the thickness of the zygoma through skuloglaznichnoe hole (foramen zygomatico-orbitale), divided into two branches. On the temporal surface of zygomatic bone is located skulovisochnoe hole (foramen zygomatico-temporale), which goes through the zygomatic nerve branch of the same name, pierced temporal muscle and fascia, innervates the skin of the anterior portion of the temporal and posterior parts of the frontal region. Through skulolitsevoe hole (f. zygomatico-facialis), located on the outer surface of the zygomatic bone, the same name comes a nerve innervating a small part of the face. It is in these areas, patients subjectively noted numbness of the skin, which finds confirmation in the objective determination of pain sensitivity with a sharp sterile needle. This numbness of the skin in the area of innervation of a small crow's feet does not happen. If the infraorbital nerve trauma in the infraorbital groove, it is possible disorder of pain sensitivity in the classic variant and in the zone of innervation of the branches of the zygomatic nerve. With this arrangement, the slit bottom of the fracture of the orbit descends together with the eyeball, which is accompanied by diplopia and enophthalmos as at the turn of the type of Le Fort I. This may make it difficult topic diagnostic breakthrough, but the paresthesia skin zygomatic and temporal regions would allow the temporary difficulties.
On examination, the threshold is determined by malocclusion of the mouth - most often in contact only molars. However, the bite may be direct, progenicheskim, cross, depending on the initial ratio of jaws, the magnitude and direction of displacement otlomlennogo fragment. In anticipation of the mouth, as a rule, there is a hemorrhage in the upper part of large and small molars, extending not only to transition the crease, but also on the buccal region. Palpable bone protrusion on skuloalveolyarnomu ridge and behind him. Pain sensitivity of the mucous membrane of the gums is reduced or absent within the incisors, canines and premolars. Soft palate is displaced posteriorly, and a little tongue touching the back wall of the throat or tongue.
In the upper division Pterygopalatine mandibular fold, the anterior palatal arch and soft palate may be due to hemorrhage soaking it with blood coming down the hill from the place of fracture of the upper jaw and pterygium sprouts sphenoid bone. Sometimes vybuhaet side wall of the pharynx, indicating the presence of hematoma in peripharyngeal space. Pain symptom burden positive: when pressing on the hook pterygium sprouts sphenoid bone or upper molars having pain at the fracture line. In determining the pain symptom load in the vertical position of a patient simultaneously shifted up bone fragments, respectively, frontal appendage of the upper jaw, lower edge of the orbit and skuloalveolyarnogo ridge that define palpation. In addition, there skinfold in the root of the nose. When teeth percussion sound is low.
On the x-ray of facial bones in nosopodborodochnoy and lateral projections can be noted a discontinuity of bone in the root of the nose, the lower edge and bottom of the orbit, skuloalveolyarnogo crest, reducing the transparency of the maxillary sinuses.
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Articles for theme "fracture of the jaw":
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03-09-2009
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.
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