Lecture 3 maxillofacial trauma part 3

Anatomic consideration
• The craniofacial skeleton is made up of 22 bones. These bones surround
different cavities that form the skull such as orbital cavity, nasal cavity, oral
cavity, maxillary sinuses, etc. In the craniofacial skeleton, thin bony walls are
connected by thicker bony portions.
• These thick bony portions are referred to as ‘buttresses’ and are a key factor
in the reconstruction of panfacial fractures. They were described by Sicher
and Tandler (1928), Merville (1974) and later expanded by Gruss and
Mackinnon (1986). These buttresses maintain the various dimensions of the
face such as height, width, anteroposterior projection, etc. They are also the
lines along which the masticatory forces and other dynamic forces are
distributed. The reduction and fixation of panfacial fractures is done at the
various buttresses to maintain the architecture of the facial skeleton.
2

Principles in managing panfacial fractures
• There are two main theories in the management of panfacial
fractures:
1. Bottom up and inside out
• This sequence involves reduction of all the fractures keeping
the mandible as base. Mandibular fracture is first reduced and
the rest of the fractures are reduced sequentially from down
upwards and at each level the fixation is done from the
innermost bone proceeding outward, e.g. a nasal bone
fracture is reduced first and a zygomatic fracture is reduced
next.
3

2. Top down and outside in
• In this sequence the calvarium is used as a base. The
fixation of other bones is done from the topmost
proceeding downward, e.g. a frontal bone fracture is first
addressed before a maxillary fracture.
• The mandibular fracture is reduced last and at each level
the fixation is done from the most lateral bone inwards,
e.g. a mandibular angle fracture reduction precedes the
reduction of a body or symphysis fracture.
4

Bottom up and inside out Top down and outside in
1. Tracheostomy 1. Tracheostomy
2. Repair of palatal fracture 2. Repair of frontal sinus fracture
3. Maxillomandibular fixation 3. Repair of zygomaticomaxillary complex
4. Repair of condylar fractures (including
arches)
4. Repair of naso-orbito-ethmoidal fractures
5. Repair of mandibular fractures (angle,
symphysis, ramus)
5. Repair of Le Fort fractures (including
midpalatal split)
6. Repair of zygomaticomaxillary complex
fractures (including arches)
6. Maxillomandibular fixation
7. Repair of frontal sinus fracture 7. Repair of condylar fractures
8. Repair of naso-orbito-ethmoidal bone
fracture
8. Repair of mandibular fractures
(symphysis, body, ramus)
9. Repair of maxilla
5

Principles of fracture repair
• This includes:
1) Reduction
2) Fixation
3) Immobilisation
4) Early return of function
6

Reduction: Restoration of the fractured fragments to their
original anatomical position.
The restoration of the fragments to their correct position
may be brought about by:
a. Closed reduction
b. Open reduction
7

Closed reduction
• Closed reduction refers to reduction of the fracture
segments to their previous anatomic and functional
position by manipulation without direct visualisation of the
fracture.
• Closed reduction is often followed by closed fixation.
Healing of the bone occurs by secondary intention with
callus formation.
8

Closed manipulation
• The dentulous fracture segments especially of mandible
can be reduced by closed manipulation unless extremely
displaced from muscular forces. These segments guided
by the occlusion of teeth can be reduced and fixed by
closed method.
9

External reduction devices
• When the fractured segments do not override much,
manipulation using instruments can be employed to bring
the segments to occlusion. For example:
Rowe’s disimpaction forceps can be used to disimpact the
fractured maxilla and bring it to occlusion.
Midpalatal split maxillae are reduced by Hayton William
forceps.
Walsham forceps can be used to manipulate certain nasal
fractures.
Asch forceps for septal fracture reduction.
10

(A)Fracture
reduction
using Rowe’s
maxillary
disimpaction
forceps.
(B) Septal
fracture
reduction with
Asch forceps.
(C)Walsham
forceps for nasal
bone fracture
reduction.
11

(1) Reduction of
maxillary fracture
using disimpaction
forceps,
(2) Walsham’s
disimpaction
forceps
12

Intraoral or extraoral traction
• They are employed in cases where reduction has been delayed or
in cases where muscular forces prevent effective manipulation.
Intraoral traction involves fixation of prefabricated arch bars to
the maxillary and mandibular arches and traction of the segments
to normal occlusion using elastics.
• Extraoral traction, on the other hand, involves anchorage from
the intact skull for traction. The process of traction is extremely
slow and the patient is encouraged to open and close the mouth
to facilitate the elastic traction. When satisfactory occlusion is
achieved, elastics are removed and intermaxillary fixation is done
using wires.
13

(1)Intraoral traction,
(2)Intraoral
fixation/ligation with
wires-IML or IMF
14

Advantages of closed reduction
 Inexpensive
 Only stainless steel wires needed (usually arch bars also)
 Easy availability, convenient
 Short procedure, stable
 Gives occlusion some “leeway” to adjust itself
 Generally easy, no great operator skill needed
 Conservative, no need for surgical tissue damage
 No foreign object or material left in the body
 No operating room needed in most cases, outpatient treatment
 Callus formation (secondary bone healing) allows bridging of small
bony gaps
15

Disadvantages of closed
reduction
 Cannot obtain absolute stability (contributing to nonunion and infection)
 Noncompliance from patient due to long period of IMF
 Difficult (liquid) nutrition
 Complete oral hygiene impossible
 Possible temporomandibular joint sequelae (MPDS)
 Muscular atrophy and stiffness
 Denervation of muscles; alteration in fibre types
 Myofibrosis
 Changes in temporomandibular joint cartilage
 Weight loss
 Irreversible loss of bite force
 Decrease range of motion of mandible
 Impaired pulmonary function, may be problematic for patient with premorbid pulmonary condition
 Risks of wounds to operators manipulating wires
16

Open reduction
• Open reduction is the surgical intervention for reduction of the
fractured segments. After introduction of antibiotics, possibility
of surgical opening of facial bone fractures increased
significantly.
• This is especially important with respect to the facial skeleton,
where an exact reduction results in an optimal functional and
aesthetic result.
• Healing takes place by primary intention where no callus
formation occurs during healing. Usually it is followed by
direct fixation of the fracture fragments with internal fixators.
17

Advantages of open reduction with rigid internal
fixation
 Early return to normal jaw function
 Normal nutrition
 Normal oral hygiene after a few days
 Avoidance of airway problem
 Can get absolute stability, promotes primary bone healing
 Bone fragments re-approximated exactly by visualization
 Avoids detrimental effects to muscles of mastication
 Does not require patient’s compliance or supervision
 Permits the physical therapy early postsurgically
 Avoids IMF for patient with occupational benefits in avoiding mandible fixation, e.g. lawyers,
teachers, sales people, seizure disorders
18

 Helpful in special nutritional requirements (diabetics, alcoholics, psychiatric
disorders, pregnancy)
 Easy oral access (for example in intensive care unit patients)
 Decreased patient discomfort, greater patient satisfaction
 Less myoatrophy
 Decreased hospital time
 Substantial savings in overall cost of treatment
 Lower risk of major complications
 Lower infection rates, improved overall results
 Lower rate of malunion/nonunion
19

Disadvantages of open reduction with rigid internal fixation
 Most obvious; need for an open surgical procedure
 Significant operating room time
 Prolonged anaesthesia
 Expensive hardware
 Some risk to neuromuscular structures and teeth
 Need for secondary procedure to remove hardware
 “Unforgiving procedure”, the rigidity of the plate means no manipulation
is permissible
20

 Needs much operator skill, meticulous technique needed
 Directly compared to maxillomandibular fixation
 Higher frequency of malocclusion
 Higher frequency of facial nerve palsy
 Scarring (extraoral and intraoral)
 Needs sophisticated material
 No bridging of small bone defect (absence of callus)
21

• In this phase the fractured fragments (after reduction) are
fixed, in their normal anatomical relationship to prevent
displacement and achieve proper approximation. Fixation
devices can be placed internally or externally.
22

a. Direct skeletal fixation Consists of:
(i) Direct external skeletal fixation, where the device is
outside the tissues, but inserted into the bone percutaneously
(ii) Direct internal skeletal fixation—by devices which are
totally enclosed within the tissues and uniting the bone ends by
direct approximation.
In direct external fixation, bone clamps or pin fixation can be
used, while direct internal skeletal fixation is carried out with
transosseous or intraosseous wiring or using bone plating
system.
23

b. Indirect skeletal fixation Here, the control of bone
fragments is done via the denture bearing area. By means of
arch bars and IML or Gunning splint, if the patient is edentulous.
It can be extraoral or intraoral method.
24

Indirect fixation (Closed Reduction)
A. Intermaxillary fixation or maxillomandibular fixation (IMF or MMF).
B. Craniomaxillary or craniomandibular suspension
C. External fixation.
D. Bone Clamps
E. Kirshner wires
F. Haloframes
G. Plaster of Paris head cap
H. Box frame
25

Immobilization
• During this phase, the fixation device is retained to stabilize the
reduced fragments into their normal anatomical position, until
clinical bony union takes place. The fixation device is utilized for a
particular period to immobilize the fractured fragments.
• Immobilization period will depend on the type of fracture and the
bone involved. For maxillary fractures 3 to 4 weeks of
immobilization period is sufficient, while for mandibular fracture it
can vary from 4 to 6 weeks. In condylar fracture the recommended
immobilization period is 2-3 weeks only, for prevention of ankylosis
of TMJ.
26

Next steps
• Prevention of infection and gradual
rehabilitation of function
27

• In order to stabilize the reduced facial fractures, some
type of anchoring device is applied to maxillary dental
arch and mandibular dental arch and intermaxillary
fixation is carried out by applying wires or elastic bands
between the upper and lower dental arch anchoring
devices. The main methods for such fixation are dental
wiring, arch bars and splints.
28

• There are various methods available for anchoring the dental
arches. The type of device to be chosen will depend on the
type of fracture, site of fracture, number of teeth present and
their periodontal status and availability of the anchoring
device.
29

• The anchoring devices can be fitted on the dental arches under
local anaesthesia with or without sedation, prior to surgical
procedure (if at all it is planned) to cut down the total
operating time. In case of multiple fractures or extremely
uncooperative patient, it can be done under general
anaesthesia at the time of surgery.
30

Different Types of Dental Wiring Techniques
i. Essig’s wiring
ii. Gilmer’s wiring
iii. Risdon’s wiring
iv. Ivy eyelet wiring
v. Col. Stout’s multiloop wiring
31

1. Direct dental wiring
a. Direct interdental wiring (Gilmer wiring)
b. Risdon’s wiring
c. Button wiring
32

2. Interdental eyelet wiring (Ivy loop method)
3. Continuous or multiple loop wiring
4. Arch bars
i. Prefabricated .
ii. Custom made—prepared individually for a specific
patient.
5. Cap splints
6. Gunning splint
7. Bonded modified orthodontic brackets
8. Intermaxillary fixation screws
33

Direct interdental wiring.
Direct interdental wiring (Gilmer wiring)
34

Interdental eyelet wiring (Ivy loop method)
38

Maxillomandibular fixation using Ivy
eyelets for angle fracture
40

Continuous or multiple loop wiring
41

Col. Stout’s
multiloop wiring
43

• Many types of prefabricated arch bars are
available.
• But the most popular one and commonly used is
the Erich‘s arch bar.
• It is a prefabricated arch bar with hooks
incorporated on the outer surface with flat
malleable stainless steel metal strip.
44

Indications for use
1. When the remaining teeth are insufficient to allow efficient eyelet wiring.
2. When the distribution of the teeth in the arch is such that efficient
intermaxillary fixation is not possible.
3. In cases of simple dentoalveolar fractures or where multiple toothbearing
fragments in either jaw requires reduction into an arch form before
intermaxillary fixation is applied.
4. As an integral part of internal skeletal suspension in the treatment of fractures
involving the middle third of the facial skeleton.
5. In cases where external skeletal fixation is planned, an anterior projection bar
is attached to an individually made arch bar.
6. Where laboratory and technical facilities are inadequate or nonexistent.
45

Operative technique
 The fracture is first reduced and the teeth in the main fragments of the
fracture are tied to a metal bar which is adapted to the dental arch. Various
types of arch bar available are Erich type, German silver and Jelenko type.
 It is wise to place the wires for securing the arch bar around the teeth away
from the fracture in order to prevent subluxation of the teeth involved in the
fracture line. To be retentive, the wires holding the bar must lie below the
contact points and, if possible, around the necks of the teeth.
 The arch bars have hooks or other provisions for maintenance of
intermaxillary fixation. Small notches created on the bar with the help of a file
prevent the wires from slipping. The hooks in the upper jaw face in an
upward direction whereas the hooks in the lower jaw face downward
direction.
46

The arch bars have hooks or other provisions for
maintenance of intermaxillary fixation. Small notches created
on the bar with the help of a file prevent the wires from
slipping. The hooks in the upper jaw face in an upward
direction whereas the hooks in the lower jaw face downward
direction.
The arch bar is adapted to the buccal surface of the lower
and upper jaws by bending first at the buccal surface of the
last teeth on one side and passing across the midline to the
opposite side.
Now the arch bar is secured to each tooth using a 0.35 mm
soft stainless steel wire. Each wire passes over the bar
mesially, around the tooth and under the bar distally. The
ends of the wire are twisted on the buccal side.
47

Once the fragments have been tightly secured to the arch bar,
it is difficult to correct any errors in a vertical displacement of
the occlusion. It is advisable, therefore, not to tighten any
ligatures until all have been inserted and any vertical
displacement has been corrected by articulating the jaws.
Intermaxillary fixation is achieved by passing tie wires around
the lower arch bar and inserting them either through hook,
around the upper arch bar. A more rigid fixation can be
achieved by threading the tie wire through the wire loop,
which will secure the arch bar to the teeth. The tie wires are
first pulled, tightened and then cut so that the end can be bent
over the bar into an interdental space where it will not cause
soft tissue damage.
48

• On the upper jaw, the hooks are arranged in an upward
direction. The bar is attached to the lower jaw with the
hooks in a downward direction.
• The arch bar should be adapted to the buccal surface of
each arch by giving a shape of the arch by bending it.
Bending of the arch bar should start at the buccal side of
the last tooth progressing past the midline and finishing at
the other end.
• The arch bar is fixed to each tooth, with 26 gauge
stainless steel wire, which is passed from the mesial
surface of a tooth to the lingual side and back on the
buccal side from the distal surface of the tooth.
49

• It provides an effective, quick and inexpensive
method of fixation. The bar is available in spool
form. The bar should be cut accurately to the
length of the dental arch.
• Accuracy in this regard will prevent injury to the
adjacent soft tissues by protruding ends. Each arch
bar is to be fixed to the upper and lower dental
arches.
50

• One end of the wire is above the bar and the other below. By
twisting the two ends of wire together, the bar is attached
securely and firmly to the necks of the teeth on the buccal
surface of the arch.
• The twisting of the wires should be always done in a
clockwise manner, so that later on removal of wires can be
done in anticlockwise manner. Improper adaptation of the bar,
ligation of an insufficient number of teeth and inefficient
tightening will result in inadequate stability of the arch bar.
• Advantages of the arch bar include less trauma because of
the thin wire and greater stability in an arch, even if some
teeth are missing, because the edentulous gaps can be
spanned by this rigid appliance.
52

Maxillomandibular fixation using arch
bars to preserve dental occlusion 54

Cap splints
• For many years, cap splints were used as a
significant means of immobilisation.
• The possible indications for their use in the
present days are confined to the following:
55

 For prolonged fixation on the mandibular teeth in a patient
with fracture of the tooth-bearing segment of the mandible
and bilateral displaced fractures of the condylar neck.
 In a case, where a portion of the mandible is missing with
considerable soft tissue loss. Here the cap splint helps in
maintaining the correct relationship of remaining tooth-bearing
segments till the reconstruction is completed.
 In patients with severe periodontal disease in which case
temporary retention is essential for proper fracture healing.
Here the cap splint helps to splint the loose teeth together
and facilitates the application of the intermaxillary fixation.
 Cap splints are also used for extraoral fixation in case of
complicated midfacial fractures which particularly involves
mandible.
56

Bonded modified orthodontic brackets
• Orthodontic brackets can be bonded onto teeth and
intermaxillary fixation applied with the help of
elastic bands.
• This type of intermaxillary fixation can be used for
fractures with minimum displacement.
• The orthodontic brackets have to be modified by
attaching small hooks on them for application of the
elastic bands.
58

Intermaxillary fixation screws
• Arch bars and wires have a chance of accidental
skin puncture causing risk of HIV/hepatitis
transmission.
• Karlis first described the use of cortical bone screw
fixation for treating mandible.
59

• Advantages
1) Ease of application.
2) Decreased operating time—decreased overall cost.
3) Decrease risk of disease transmission.
• Armamentarium
 Local anaesthesia
 24 g wire
 IMF screws
 Screwdriver
• Disadvantages
1) Lacks tension band effect.
2) May interfere with internal fixation plates, so recommended for only
minimally displaced fracture.
61

Technique
1) Local anaesthesia medial to canine (upper and lower).
2) Self-tapping IMF screw 8–14 mm length is inserted in
transmucosal fashion/mucosa incised with No. 15 blade.
3) Care taken to avoid iatrogenic injury to mental nerve
branches.
4) 24 g wires used for MMF.
62

(A)IMF screws. Note the
head is double
headed with a hole for
gaining entry of wire.
(B) Wire passed through
the hole in the IMF
screw head.
(C) MMF done using IMF
screws.
63

• Length of Fixation Traditionally the length of IMF used for adult
mandibular fractures has been 6 to 8 weeks.
• It appears that each individual case must be judged on its merits
but that most uncomplicated fractures in children are united in 2 to
3 weeks, in adults 3 to4 weeks, and in older patients in 6 to 8
weeks.
• Several other factors should be taken into account when deciding
on the appropriate regime for a particular patient.
• The following situations generally require longer periods of IMF:
comminuted fractures; fractures in alcoholics, particularly those
with nutritional problems; fractures in patients with psychosocial
handicaps; fractures treated late; and fractures with teeth
removed in the line of the fracture.
64

• In condylar fracture IMF is used for a maximum of 2
to 3 weeks in adults and 10 to 14 days in children,
after which there is a period of aggressive
functional rehabilitation.
• Longer periods of IMF can lead to bony ankylosis
or fibrosis and severe limited mouth opening.
65

Custom made Splints
• Custom made appliances are fabricated for individual patient. The
splints can be constructed using acrylic material or cast metal.
• Indications
1. When the wiring of the teeth will not provide adequate fixation.
2. When horizontal splinting across the fracture zone is required without
closing the patient’s mouth.
3. When both the jaws are edentulous.
4. In case of growing children, where mixed dentition is present and
number of firm teeth for anchorage are not adequate.
5. In case of pregnant women and mentally challenged patients, where
IML is not desirable.
66

Acrylic Splints
• i. Lateral compression splint.
• ii. Gunning splint
67

• Lateral compression splint: It is made for the
stabilization of mandibular arch. Mainly used in case of
children, where there is mixed dentition and presence of
developing teeth buds (open reduction and direct fixation
is contraindicated).
• It can be also used in adult mandibular body fracture,
where the stability cannot be obtained by means of other
type of horizontal wiring methods.
68

• Gunning splint: In edentulous jaws, patient’s own
dentures, suitably modified can be used or specially
constructed Gunning splint can be used.
• Circumferential wiring is used to fix the splint to the
mandibular bone and upper denture or splint is fixed to
the maxilla by means of peralveolar wiring.
70

Obwegeser’s method of circummandibular wiring 72

Methods of Fixation
Treatment without Any Form of Fixation
This method is reserved for the following:
i. Fractures exhibiting minimal displacement and mobility;
without occlusal discrepancy or with very minimal occlusal
discrepancy.
ii. Green stick fractures.
iii. Elderly edentulous patients who are in the high/ poor risk
category and who have no gross displacement.
73

Treatment with Intraoral Fixation Alone
This method can be employed for the treatment of the
following:
Dentoalveolar fractures
Unilateral fracture—maxilla
Dentulous mandibular body fracture with minimal
displacement or no displacement
Edentulous mandibular body fractures
74

• This fixation can be achieved by the following:
1. The use of an arch bar or suitable type of wiring methods
described earlier.
2. Cap splints with locking plates and a connecting bar.
3. Acrylic splints – lateral compression or Gunning type
splint.
4. Intermaxillary ligation or fixation IML/IMF – whenever
required the jaws are rigidly fixed to each other in centric
occlusion. Both the jaws are united as a block, must be
fixed to the skull in case of maxillary fractures.
75

External Fixation
• The intact skull serves as a fixation point for the
fixation of facial fractures. Usually a plaster of Paris
head cap is applied for external skeletal fixation.
76

External skeletal fixation
with plaster of Paris skull
cap
77

• The metallic ‘Halo frame’ devised by Crewe in 1943
is directly secured to the skull by multiple screw
pins inserted into the external cortex of the skull.
• Vertical rods, bilateral check wires, side bars can
be added to the central Halo frame, which is a
versatile apparatus of great stability
78

The metallic ‘Halo frame’, devised
by Crewe 79

Extraoral fixation device consisting of metallic halo frame,
possible combination of rods and universal joints
80

Internal Fixation
• This type of fixation is achieved entirely or primarily
by passing wires within the tissues.
81

Direct suspension
• In this method the same principle, as extraoral fixation is
used except, the wires are passed subcutaneously from
stable skeletal points into the oral cavity and are fixed on
both sides to the arch bars under traction (craniofacial
suspension).
• Depending on the type of fracture, the point of fixation
may vary. The wires are always passed from a stable
point above the fracture line.
82

• The various areas for direct suspension of wires can be chosen.
a. Pyriform fossa
b. Zygomatic buttress
c. Zygomatic arch
d. Infraorbital rim
e. Zygomatic process of the frontal bone.
83

Direct suspension wires at different locations
84

(A) Pyriform aperture suspension wiring along with wiring at anterior nasal
spine.
(B) Suspension wiring from the infraorbital rims on either side to arch bar
85

Indirect support
• Craniomandibular suspension is brought about by
sandwiching the fractured areas between the mandible
and some part of the facial skeleton above the fracture
line through the medium of suspensory wires connected
to a mandibular arch bar.
• The appropriate sites can be chosen as indicated in direct
suspension procedure.
86

Transosseous or intraosseous wiring
• It can be used at various sites. Open reduction is needed.
• Here the fractured fragments are approximated in their
normal anatomical position after reduction and the holes
are drilled on either sides of the fracture line and 26 or 28
gauge stainless steel wire is passed to interconnect the
holes and both the ends of the wires are grasped on the
outer cortex and twisted, cut and finished.
• This type of direct internal fixation offers semirigid
stability.
87

Transosseous wiring
at various sites in the
facial area
88

Transosseous or intraosseous wiring can be done at the
following sites:
a. Zygomaticofrontal
b. Zygomaticomaxillary
c. Zygomatic bone (comminuted)
d. Palatal processes
e. Frontonasal
f. Mandibular angle at superior border or inferior border
g. Edentulous mandible at the site of fracture
h. Condylar fractures—subcondylar or high condylar
Wire osteosynthesis is the oldest, simplest and most
popular method for internal fixation.
89

Disadvantages:
Intermaxillary fixation is always needed
There is no three-dimensional stability to the fragments
Interfragmentary pressure cannot be controlled
Under-functional stress, the wire synthesis lacks
adequate rigidity, direction control and surface contact
Delayed healing as compared to bone plate system,
because of micromovement at the fracture side.
90

Direct support
• This may be employed in the case of a comminuted
orbital floor by utilizing an antral pack or balloon.
• It can be also used for stabilizing zygomatic
complex fractures.
91

Miniplate osteosynthesis
• The extraordinarily good results with compression
osteosynthesis with plates or lag screws in the mandible
have led to the development of similar procedure for the
midface.
• Champy and Michelet introduced miniplate
osteosynthesis suitable for facial fracture fixation.
93

Internal Fixation by Means of Bone Plate
Osteosynthesis
Indications
1) Cases where there is absolute contraindications to IMF, i.e.
in epileptics, mentally retarded uncooperative patients,
asthmatics, alcoholics, drug abusers, pregnant women, etc.
2) When the patient wants to return back to work early.
3) Edentulous patients with loss of bone segments, which need
the maintenance of the gap or grafting, if indicated.
4) In subcondylar and angle fractures of the mandible, early
mobilization of the joint is required.
5) Atrophic mandible requiring additional reinforcement.
96

Contraindications
1) In heavily contaminated fractures, where there is active
infection and discharge. However, some surgeons advocate
the use of compression osteosynthesis in such cases.
2) In badly comminuted fracture, where open reduction may
pose risk of compromising vascularity.
3) In children having mixed dentition, where there is a danger
of injuring the developing teeth buds.
4) Presence of gross pathological abnormalities in the bone.
97

Advantages
I. Simple technique.
II. Decreased intraoperative time.
III. Most of the time, intraoral approach is sufficient. However, in certain cases
extraoral approach may be required.
IV. Direct control of occlusion in intraoral technique.
V. Postoperative intermaxillary fixation is not needed or period of IMF is reduced.
VI. Early return of function.
VII. Reduced hospital stay.
VIII. Better aesthetics and function, better three dimensional stability.
IX. Minimization of immediate postoperative complications, as mouth is not
locked.
X. Better maintenance of oral hygiene
XI. Nutritional intake does not suffer.
XII. Psychological advantage.
XIII. No weight loss
XIV.No speech problem.
98

Treatment of Fractures of
the Zygomatic Bone
• In majority of cases early operation is advisable,
provided that there are no ophthalmic or cranial
complications.
• Whenever there is a gross periorbital oedema and
ecchymosis, postponement of the operation for 3 to
5 days can be done, but it should not be prolonged
more than two weeks.
104

Keen’s approach Intraoral Procedure
107

• Alternate methods like intranasal elevation via
intranasal antrostomy or oroantral elevations
were suggested.
108

Direct extraoral elevation can be done by inserting a sharp
curved hook directly through the skin below and above the
prominence of the zygomatic bone. 109

Lecture 3 maxillofacial trauma part 3

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