25 YEARS MAN WITH FRAKTUR

RIMA ORBITA LATERAL ET INFERIOR,

FRAKTUR ZYGOMATICOMAXILLARY,
FRAKTUR MAXILLA AND FRAKTUR
PARASIMFISIS MANDIBULA
Compiled by :

Rully Prasetyo Sn G99161002

Supervisor :

Amru Sungkar, dr., Sp. B Sp. BP-RE

IDENTITY

 Name : Mr. M

 Age : 25 Years old

 Sex : Male

 Address : Boyolali

 No. MR : 01389xxx

 Hospitalized: 29th August 2017

 Examined : 31th August 2017

CHIEF COMPLAIN

 Decreased Awareness due to traffic accidents

 PRESENT ILLNES
jaw pain
Fainting (+)
(+) Boyolali
Trauma
Hospital
vomiting Dizziness
(-) (-)

 Pain in the face felt after the patient got due to traffic accident is
felt constantly when he tries to open his mouth.

 Tooth loss (+), mouth bleeding (-), nose bleeding (-)

 Fainting (+), vomiting (-), dizziness (-)

 After the incident the patient is brought to Boyolali Hospital

 Due to the limited facilities, the patients are referred to RSDM .

 PAST ILLNES

HT Denied

DM Denied

Allergy Denied

Operation Denied
History
 FAMILY HISTORY

HT Denied

DM Denied

Allergy Denied

Operation Denied
History
SOCIAL ECONOMIC HISTORY

 Patient lives with his parents. Patient is treated in RSDM

using BPJS facility.
PHYSICAL EXAMINATION
 PRIMARY SURVEY

1. Airway : clear

2. Breathing 20 times / min

I : expansion of chest wall : right = left

P : crepitus (-/-), pain (-/-)

P : Sonor / sonor

A : SDV (+/+), additional sounds (-/-)

3. Circulation : BP 120/80 mmHg, pulse 80x/min

4. Disability : GCS E3V4M6, light reflex (+/+), isokor pupil,

lateralization (-)

5. Exposure : Temperature 36.8 C, injury (+), view the status

local
 LOCAL STATUS
 Orbita

Inspection : oedem (+), deformity

(+)Palpation : pain (+), crepitation (+)

 maxilla

Inspection : oedem (+) symmetrical(+),

deformity(-)Palpation : pain (-),
crepitation (-), discontinued (-)

 zygomaticomaxillary

Inspection : oedem (-/+) symmetrical(+),

deformity(-)Palpation : pain (-),
crepitation (+), discontinued (-)
 LOCAL STATUS

 Mandibula

Inspection : oedem (+/-)

symmetrical(+), deformity(-)Palpation
: pain (-), crepitation (-), discontinued
(-)
ASSESMENT 1
 Susp Sinistra rima orbita inferior

 Susp dextra maxillary fracture

 Susp mandibula fracture

 Susp zygomaticomaxillary fracture

PLAN 1
 Hospitalized

 Check blood laboratory

 Education of relaxation technique

 LABORATORY
FINDINGS
Pemeriksaan Hasil Satuan Rujukan
HEMATOLOGI
Hemoglobin 9.5 g/dL 12.0 – 15.6
Hematokrit 27 % 33 - 45

Leukosit 7 ribu/uL 4.5 – 11.0

Trombosit 300 ribu/uL 150 – 450
Eritrosit 3.22 juta/uL 4.10 – 5.10
Golongan Darah 0

Kimia Klinik
Creatinine 0.6 Mg/Dl 0.9 – 1.3
Ureum 35 Mg/dl <50
SEROLOGI HEPATITIS
HbsAg Nonreactive Nonreactive
RADIOGRAPHY FINDING
Kesimpulan

 Fraktur rima orbita lateral

et inferior, fraktur
zygomaticomaxillary
sinistra, fraktur maxilla
sinistra dan fraktur
parasimfisis mandibula
 ASSESMENT 2
 Sinistra rima orbita lateral et inferior

 Sinistra maxillary fracture

 Paramsimfisis mandibula fracture

 Sinistra zygomaticomaxillary fracture

PLAN 2
 ORIF
LITERATURE
REVIEW
Anatomy of
Maxillary
Le Fort Classifications
Le Fort
 Le Fort I (Low Maxillary)
 Transverse maxillary fracture

 Involves anterolateral
maxillary wall, medial

maxillary wall, pterygoid

plates, septum at

floor of nose
 Le Fort II ( Pyramidal)
 Caused typically from a
superiorly directed force

against the maxilla.

 Involves nasofrontal
suture, orbital foramen,
rim,

and floor frontal process

of lacrimal bone,

zygomaxillary suture,
lamina papyracea of

ethmoid; pterygoid plate

and high septum
 Le Fort III (Craniofacial Dysjunction)
Separates facial skeleton
from base of skull, typically

caused by high velocity

impacts.

 Involves nasofrontal
suture, zygoma and
zygomatic arch;

pterygoid plates and

nasal septum
 Anatomy of
Mandibular
Processus Condylaris

Processus Coronoideus

Ramus Mandibulae

Angulus Mandibulae

Corpus Mandibulae
Foramen Mentale
Protuberantia Mentalis
 Biomechanical of Mandibular
Horizontal axis rotation:

 Open/Close mouth movement

(pure rotation) / hinge
movement.

Vertical axis rotation:

Horizontal axis Vertical axis  Condylus move to anterior.

Sagital axis rotation:

Rotation  Condylus move to inferior

Sagital axis
 Biomechanical of Mandibular
Translation:

 When ramus, condylus, and

teeth move upward
simultantly in a same direction
and speed.

 Occurred on superior cavity of

joint at discus articularis
superior and inferior surface of
fossa articularis (Between
discus condylus complex and Translation
fossa articularis).
 BACKGROUND OF
MANDIBLE FRACTURE
 Mandible fractures are a frequent injury because of the mandible's
prominence and relative lack of support. As with any facial fracture,
consideration must be given for the need of emergency treatment to
secure the airway or to obtain hemostasis if necessary before initiating
definitive treatment of the fracture.
Location of
mandibular fractures
 Classification of
mandibular fractures
Fracture that does not produce a wound open to the
SIMPLE OR external environment, whether it be through the skin,
CLOSED mucosa, or periodontal membrane

Fracture in which an external wound, involving skin,

COMPOUND mucosa, or periodontal membrane, communicates
OR OPEN with the break in the bone

COMMINUTED Fracture in which the bone is splintered or crushed

 Fracture in which one cortex of the bone is
GREENSTICK
broken and the other cortex is bent

Variety in which two or more lines of fracture on

MULTIPLE the same bone are not communicating with
one another

Fracture resulting from severe atrophy of the

ATROPHIC bone, as in edentulous mandibles

Fracture in which one fragment is driven

IMPACTED firmly into the other
 Mandibular Fracture
Biomechanical

Trauma  Mandibular 
Tension and Compression

Tension happened on alveolar

Trauma
region

Compression happened on
basal mandibular region
 Mandibular Fracture Biomechanical
Because of many muscles
stick on symphisis
mandibular

+ Tension and compression

Trauma trajectory effect  Torsion

Torsi
Torsion on symphisis 
Rotation
 Mandibular Fracture Biomechanical
Because of many muscles
stick on symphisis
mandibular

+ Tension and compression

Trauma trajectory effect  Torsion

Torsi
Torsion on symphisis 
Rotation
 Diagnosis

Mechanism Present
Anamnesis
of trauma illness

deformity tooths
inspection
wound malocclusion

Physical
examination
TMJ ginggiva
palpation
False
tooths
movement
 IMAGING STUDIES

The following types of radiographs are helpful

in diagnosis of mandibular/ maxillary fractures:

Reverse
Panoramic Eisler
Towne’ view
X-ray
Towne’s Temporomandibular
Skull PA/Lat
view Joint

Complex
CT Scan maxillofacial
fracture
Imaging finding
Imaging finding
TREATMENT

MEDICAL
THERAPY
TREATMENT

SURGICAL
THERAPY
 Medical Therapy
 Prophylactic antibiotics are controversial

 Literature review of 5 studies with the highest level of evidence

 Conclusion : not enough data to evaluate efficacy of

antibiotic use in non-mandibular fractures

 There is evidence that postoperative antibiotics are not

beneficial

 Limited data regarding choice duration, or timing of

antiobiotics
 Surgical Therapy
Close
reduction
Surgery
Therapy
Open
reduction
When to repair a maxillary fracture
surgically?

 Dependent on nature of injury ; extent of injury,

complexity of injury

 Dependent on patient ; comorbidities, goals and desires

(functions vs aesthetics)

 Dependent on surgeon ; judgment, comfort level

Close Reduction
Erich arch bars
Bridle wire
Ivy loops
Etc…
OPEN REDUCTION
Plate fixation
Wire osteosynthesis
 CONCLUSIONS

The treatment of mandibular fractures

depends on the biologic character,
adaptive capability of the
masticatory system, and type of the
fracture . These will differ widely
among patients, and it is the lack of
sound biology and adaptation that
can lead to an unfavorable outcome.
Choi KY et al.2012