Oral and Maxillofacial Surgery

Definition:

Mid-face

The area between

a superior plane
drawn through
the zygomaticofrontal sutures
tangential to the
base of the skull
and inferior
plane at the level
of the maxillary
dental occlussal
surface.

Structures connection
(structures in relation)

Orbit
Maxillary sinus
Nasal bone
Naso-orbital
ethmoid (NOE)
complex
Zygomatic
complex
Frontal bone and
sinus

Vertical and horizontal pillars

Area of strength
Vertical and horizontal pillars
Muscular attachment
Area of weakness
Sutures
Lining tissues and air-filled cavities

Pattern of fractures
of mid-face skeleton

Alveolar fracture and dental fracture

Le Fort s fracture ((french surgeon Rane Le Fort

1901)

Naso-orbital ethmoid fracture

Zygomatic complex and arch fracture

Frontal sinus and bone fracture

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Alveolar bone fracture

Involve block of
alveolar bone
with or without
Intrusion of
teeth
Extrusion of
teeth
Luxation of teeth
Fracture of teeth
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Le Forts fractures

Le Fort I (low
level or Guerian
fracture)
Unilateral/ bilateral
Horizontal fracture
through the maxilla
above the level of
the nasasl floor and
alveolar process
Piriform rims
Anterior maxilla
Zygomatic buttresses
Ptrygoid laminae

Signs and symptoms

Slight swelling of upper lip

Ecchymosis in upper lip sulcus

Hematoma intra-orally over zygoma and in palate

Disturbed occlusion

Mobility of teeth of the involved segment of maxilla

Combination of soft tissue laceration

Exposure of nares and the maxillary antra in case of

gross injury

Impacted type of fracture is oftenly not mobile and

teeth cusps may be damaged

Cracked-pot percussion of upper teeth

Le Forts fractures

Le Fort II
(pyramidal or subzygomatic)

Separation of NF suture,
medial orbital walls
(lacrimal bone), inferior
orbital floor and rim
(adjacent to infrorbital
canal and foramen),
anterior maxilla below
zygomatic buttress and
ptrygoid laminae about
halfway up.
Separation of the block from the base of skull is completed
via the nasal septum and may involve the floor of the
anterior cranial fossa

LeForts fractures

LeFort III
(cranifacial dysjunction, high
transverse, suprazygomatic)

Separation of NF suture,
medial orbital walls (involve
the depth of the ethmoid
bone and cribriform plate,
pass below optic foramen
and cross the inferior orbital
fissur), inferior orbital floor,
lateral orbital wall, ZF
suture, zygomatic arch,
suprazygomatic to the root
of ptrygoid plate.
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Signs and symptoms

although it is possible to distinguish between le fort II and III, the
signs and symptoms are almost similar

Gross edema of soft tissue

Bilateral circumorbital
ecchymosis
Bilateral subconjunctival
hemorrahge
Obvious deformity of the
nose
Nasal bleeding and
obstruction
CSF leak rhinorrhea
Dish-face deformity
Limitation of ocular
movement
Possible diplopia and
enophthalmous
Retropostioning of the
maxilla with anterior open
bite
Lengthening of the face

Difficulty in mouth opening

Mobility of the upper jaw
Occusional hematoma of
the palate
Cracked-pot sound on
percussion
Step deformity at infraorbiatal margin
Anasthesia of midface
Nasal bone moves with
mid-face as a whole
Tenderness and sepration
at FZ suture
Tenderness and deformity
of zygomatic arch
Depression of occular level
and pseudoptosis
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Bowerman classification of midface-fracture

(1994)

Fracture not involving the occlusion

Central region
Nasal bone/ septum (lateral, anterior injuries)
Frontal process of the maxilla
Nasoethmoid
Fronto-orbito-nasal dislocation
Lateral region (zygomatic complex EX dento alveolar
frcature

Fracture involving the occlusion

Dento alveolar

Subzygomatic:
Le Forts (I, II)
Supra zygomatic:
Le Fort III
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These fractures may occur unilaterally or bilaterally, with separation
of maxillary midline and or extension to frontal or temporal bone

Prevalence of mid-face fractures

Fracture Type

Prevalence

Zygomaticomaxillary complex (tripod fracture)

LeFort

40 %

15 %

II

10 %

III

10 %

Zygomatic arch

10 %

Alveolar process of maxilla

5%

Smash fractures

5%

Other

5%
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Diagnosis

Inspection
Extra-oral

(e.g. swelling, deformity, asymmetry

Leaks)

Intra-oral
(e.g. hematoma, occlusion)

Palpation

Step deformity, criptation, cracked pot sound, mobility

Radiographical investigations
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Radiographical examination
Plain radiograph

Occipitomental

(10 or 30 degree)

Waters view

Suitable for isolated orbital

fracture
Search line (Campbells line 1977)

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Radiographical examination

Lateral skull view

OPG
Occlusal view of the
maxilla
Perapical views of
damaged teeth

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Radiographical examination

CT scan
3-D CT imaging
Coronal sections
Axial sections

1. Whenever intracranial damage and

frontal sinus are suspected
2. Extensive fracture that involves
nasoethmoid complex or orbital
region
3. Orbital trauma to evaluate the
degree of orbital injury and
enophthalmos

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Indications for treatment

Physical signs of a fracture of the maxilla.

Evidence of a fractured maxilla on imaging.

Disruption of the occlusion of the teeth.

Displacement of the maxilla.

Post traumatic facial deformity.

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Indications for treatment

Fractured or displaced teeth.

Cerebrospinal fluid leak.

Abnormal eye movement or restriction of

eye movement.

Occlusion of the nasolacrimal duct.

Sensory or motor nerve deficit.

Other evidence of loss of function

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Aims of treatment

Relieve pain

Restore function.

Restore bone anatomy.

Prevent infection

Restore the dental occlusion

Restore jaw movement at the earliest

possible stage
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Restore normal nerve function

Factors affecting the risk

Association with multiple injuries.

Presence of uncontrolled haemorrhage

Impairment of the airway.

Presence of bone comminution

Association with a dural tear.

Association with a base of skull fracture.

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Factors affecting the risk

Presence of a pre-existing dentofacial

deformity.

Time elapsed since the injury.

Presence of a medical or surgical factor

which would delay general anesthesia

Presence of any factor which would delay

healing. (eg nutritional deficiency or
alcoholism)
Stage of dental development (deciduous,
mixed or permanent dentition)
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Factors affecting the risk

Presence of fractured teeth.

Total absence of teeth (edentulous)

Inability of the patient to co-operate with

treatment.
Association with fractures of the mandible
especially bilateral fractures of the
condyles.
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Principles of treatment
Closed reduction may be appropriate in
cases

Simple uncomplicated fractures

Complex or comminuted fractures

Medical or surgical contraindications to

open reduction
Maxillary fractures in children
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Open reduction may be appropriate

where

Immediate or early jaw function is

desirable

Difficulty is encountered in reducing the

fracture by a closed method

The fracture is unstable

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Definitive treatment

Reduction
Manual manipulation

Use of dis-impaction forceps

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Fixation and immobilization

Extraoral fixation
Craniomandibular fixation
Box-frame (pin fixation)
Halo-frame
Plaster of paries headcap

Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame
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Immobilization within the tissue

Direct fixation

Transosseous wiring at
fracture sites
Frontozygomatic sutures
Infrorbital margin
Midline of the palate

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Immobilization within the tissue

Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular
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Immobilization within the tissue

Support via the maxillary sinus by

filling materials

Ribbon gauze
Balloon
Folly catheter
Polyethylene material

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Length of the hospital stay will depend

on a number of factors including:
Presence of other injuries
Age and medical status of the patient
Severity of the injury
Technique employed in the reduction and
fixation of the fracture

Presence or absence of medical or

surgical complications
Social circumstances of the patient
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