Fig. 16.1
Image of skull – frontal view
The Le Fort Classification
One of the main classifications utilised to describe maxillofacial trauma is the Le Fort Classification. This was devised by a French surgeon who struck cadavers with a cannon ball to observe any reproducible fracture patterns and eventually describing three fracture patterns (Fig. 16.2).
Fig. 16.2
Le Fort divisions I, II, and III
Le Fort I
This is a horizontal maxillary fracture resulting in the tooth-bearing maxilla being detached from the midfacial skeleton. The fracture line passes above the teeth, but below the zygomatic processes.
Le Fort II
This is a pyramid-shaped fracture with the nasofrontal sutures at the apex and maxilla forming the base. The fracture extends through the posterior tooth-bearing segment of the maxilla, nasal bones and orbital floors.
Le Fort III
Also known as craniofacial disjunction, the fracture results in separating the middle third of the face from the cranial vault. The fracture lines extend more laterally than Le Fort II through the nasal bones, zygomaticofrontal sutures (ZF), maxilla & orbital floors.
Core Operations
There are five main sub divisions in OMFS
- 1.
Dentoalveolar
- 2.
Trauma
- 3.
Deformity
- 4.
Oncology
- 5.
Salivary Gland
Dentoalveolar
Dentoalveolar surgery is taught and practised at dental school and often involves removal of teeth which are decayed, actively infected or impacted.
Investigations
Intraoral radiographs
Dental panoramic pantomogram (DPT)
Cone beam computed tomography (CBCT)
CT has allowed for improved 3D visualisation of teeth and associated structures
Dental Extractions
Indicated when a tooth is deemed unsalvageable/decayed
If these teeth are left, they can become susceptible to infection.
If the infection persists, it can potentially compromise the airway depending on the tissue spaces the infection is draining into (see Table 16.1 below). This usually depends on the teeth.
Table 16.1
Sites of swelling and the location of teeth that might be the underlying cause
Swelling
Tooth in question
Submandibular
Lower posterior
Submental
Lower anterior
Periorbital
Upper anterior
Intraoral
Adjacent tooth
In a fluctuant infection, incision and drainage (I + D) may be required to drain the pus.
However, patients with associated sepsis and trismus (limited mouth opening) will often require a GA for the extraction, I + D of the infected tissue space and several doses of IV antibiotics.
The attachment of the mylohyoid muscle is important, as it can dictate the course of the infection.
Submandibular infection normally originates from posterior teeth, as the roots of the teeth lie below the mylohyoid muscle.
Signs/Symptoms
Pain originating from region of the tooth in question
Sepsis
Trismus
Difficulty swallowing
Drooling
Sublingual firmness
Altered voice
Facial swelling
Step-by-Step Summary: Dental Extractions
- 1.
Inject local anaesthesia
- a.
Infiltration of gums around tooth
- b.
Regional block
- i.
Inferior dental (ID) nerve
- ii.
Infraorbital nerve
- i.
- a.
- 2.
Raising of gum flap, and bone removal
- 3.
Use of surgical instruments to loosen and deliver tooth
- 4.
Incision into swelling/abscess
- 5.
Placement of drain (usually corrugated)
- 6.
Ensure adequate haemostasis
Complications
See Table 16.2
Table 16.2
Potential complications of tooth extraction
Tooth | Complication | Result |
|---|---|---|
Upper molars | Oroantral communication | Communication between maxillary sinus and oral cavity |
Lower premolars | Mental nerve paraesthesia | Numbness of lower lip |
Lower wisdoms | ID nerve paraesthesia | Numbness of lower lip, tongue, gums |
General complications include:
Pain
Swelling
Bleeding
Infection
Retained roots
Damage to adjacent teeth
Further surgery
Weakness of lower lip
An extraoral submandibular incision can result in damage to the marginal mandibular branch of the facial nerve.
Scarring
This can be problematic if the incision is extraoral.
Trauma
Traumatic injury to the face can result in a variety of consequences depending on the severity of the injury.
Dental
Mandible
Zygomatic complex
Orbit
Dental Trauma
Patients can present in a variety of ways to Accident and Emergency, but in essence it is better managed in dental practice.
Investigations
DPT – to estimate damage to the teeth
Chest X ray – to ensure that any unaccounted teeth have not been inhaled into the lungs
Signs/Symptoms
Pain
Bleeding
Missing teeth
Deranged occlusion
Chipped teeth
Avulsion (complete loss of tooth)
Step-by-Step Summary: Dental Trauma
- 1.
Ensure any avulsed teeth are stored in milk/normal saline
- 2.
Obtain good local anaesthesia
- 3.
Attempt to manipulate the teeth/bone back to normality and check the occlusion
- 4.
Make sure the correct teeth are in the correct socket!
- 5.
Splint the teeth using orthodontic wire and dental composite (dental adhesive material)
- 6.
Ensure the patient attends their dentist for follow-up care
Mandibular Trauma
Mandibular trauma is common, and the complexity of its management can vary
Teeth are fundamental to the success of treatment: they are used as a guide to achieve adequate reduction of the fractured mandible
Treatment requires general anaesthetic
The following anatomical classification is useful to be able to communicate the type of fracture:
Condyle
Part of the mandible, anchoring the mandible to the skull within a fibromuscular sling
Angle
Distal to the last standing molar
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