it includes the basics of trauma of the middle third of the facial skeleton

1. (Department of Oral & Maxillofacial Surgery)
FRACTURE OF MIDDLE THIRD OF
FACIAL SKELETON
Presented By:
Dr. Samarth Johari

2. CONTENTS
 Introduction
 Articulation with skull base
 Physical characteristics of the midfacial
skeleton
 Areas of weakness
 Areas of strength
 Classification
 Le Fort I
 Le Fort II
 Le Fort III
 Diagnosing a maxillofacial injury
 Reduction of mid face fractures
 Treatment modalities
 Surgical approaches
 Plate systems & techniques for rigid
internal fixation
 First mandible, second maxilla in
combined fractures
 Sinus drainage
 Referrences

3. INTRODUCTION
• Defined as: an area bounded
superiorly by a line drawn across skull
from zygomaticofrontal suture across
frontonasal & frontomaxillary sutures
to the zygomaticofrontal suture on the
opposite side & inferiorly by the
occlusal plane of upper teeth (or by
alveolar ridge if patient is edentulous)

4. • Following bones constitute the middle third of the face:
i. Two maxillae
ii. Two zygomatic bones
iii. Two zygomatic processes of temporal bones
iv. Two palatine bones
v. Two nasal bones
vi. Two lacrimal bones
vii. Vomer
viii.Ethmoid & its attached conchae
ix. Two inferior conchae
x. Pterygoid plates of sphenoid
Frontal bone, body;
greater & lesser wings of
sphenoid bone are
protected by the
cushioning effect achieved
when fracturing forces
crush weaker bones of
middle third of face

5. ARTICULATION WITH SKULL BASE

7. PHYSICAL CHARACTERISTICS OF
THE MIDFACIAL SKELETON
• Made up of considerable number of bones – rarely fractured in isolation
• All the bones are comparatively fragile, articulate in a most complex fashion
• Greatest portion is maxilla:
i. Capable to absorb force and transmit to the adjacent articulating bones
ii. Acts as a cushion for the trauma directed to the cranium
• Middle third is anatomically complicated – Generally comminuted fractures

8. AREAS OF WEAKNESS
• Developmental Sutures
• Air filled spaces
• Neurovascular bundle

9. AREAS OF STRENGTH
• Described by Sicher & Tandler in 1928
• Thickened Bones that transmit chewing forces to supporting regions of
skull
• Analogus to architectural concepts of support

10.  Horizontal Buttresses:
i. Supra-Orbital Rims with Frontal bones
ii. Infra-Orbital Rims
iii. Zygomas
iv. Alveolar Process

11.  Vertical Buttresses:
i. Medial / Nasomaxillary
pillars
ii. Lateral / Zygomatico-
maxillary pillars
iii. Posterior/ Pterygomaxillary
pillars

12. EFFECTS OF MID FACE FRACTURES
• Involvement of brain &
cranial nerves:
i. Communition of
ethmoid
occurs with Le Forte II &
III fractures & severe
nasal fractures

13. ii. Damage to infraorbital & zygomatic nerves
Occur with zygomatic & Le Forte II fractures
iii. Damage to cranial nerves within orbit
Occur in Zygomatic, Le Forte II & III fractures

14. CLASSIFICATION
• Based on cadaveric studies conducted by Rene Le Fort in 1901
 Le Fort I (low-level fracture)
 Le Fort II (pyramidal or subzygomatic fracture)
 Le Fort III (high transverse or suprazygomatic fracture)

15. • According to Rowe & Williams, 1985:
A. Fractures not involving the occlusion
1. Central region-
a. Fractures of nasal bones &/or nasal septum
i. Lateral nasal injuries
ii. Anterior nasal injuries
b. Fractures of frontal process of maxilla
c. Fractures of type (a.) & (b.) which extend into the ethmoid bone (naso-
ethmoid)
d. Fractures of type (a.), (b.) and (c.) which extend into frontal bone (fronto-
orbito-nasal dislocation)

16. 2. Lateral region-
Fractures involving the zygomatic bone, arch & maxilla (zygomatic
complex)excluding the dentoalveolar component
A. Fractures involving the occlusion
1. Dentoalveolar
2. Subzygomatic
a. Le Fort I (low level or Guerin)
b. Le Fort II (pyramidal)
3. Suprazygomatic
a. Le Fort III (high level or craniofacial dysjunction)

17. • Along with Le Fort fractures nasal septum & palate may also be fractured
• Palatal fractures - classified by Hendrickson and colleagues based on
fracture pattern:
Type I: alveolar
Type II: sagittal
Type III: parasagittal
Type IV: para-alveolar
Type V: comminuted/complex
Type VI: transverse
• Type III fractures are the most encountered pattern as the parasagittal bone
of the palate is thinner than the mid sagittal buttress

18. • Modified lefort classifications by Marciani Rd 1993:
Lefort I – Low Maxillary Fractures
I a _ Low maxillary Fracture /Multiple Segments
Lefort II- Pyramidal Fracture
II a - Pyramidal and nasal Fractures
II b - Pyramidal and naso Orbito ethmoidal (NOE) Fracture

19. Lefort III - Craniofacial Dysjunction
III a- Craniofacial Dysjunction and Nasal Fracture
III b- Craniofacial Dysjunction and NOE
Lefort IV - Lefort II or III fracture and cranial base fracture
IV a- Supra orbital fracture
IV b – Anterior Cranial Fossa and Supra Orbital Rim Fracture
IV c - Anterior Cranial Fossa and Orbital wall fracture

20. Le Fort I
• Also known as low level fracture, Guerin
fracture, floating fracture, horizontal fracture,
pterygomaxillary dysjunction, subzygomatic
fracture
• Above nasal floor
• Lateral margin of anterior nasal aperture
• Zygomatic buttress
• Lower third of pterygoid laminae
• Lateral wall of nose
• Lower third of nasal septum
• Joins lateral frature behind tuberosity

21. CLINICAL FEATURES:
Swelling of the upper lip
Ecchymosis present in the buccal sulcus beneath
each zygomatic arch
Anterior open bite
Deranged occlusion
Midline split of the palate
Subluxation of teeth

22. The impacted Le Fort I fracture (Telescoping
fracture) –difficult to diagnose – ‘grating sound’
Percussion - ‘cracked pot’ sound
Haemorrhage in the maxillary sinuses

23. Le Fort II
• Also known as pyramidal or subzygomatic fracture

24. Clinical features
No alteration of pupillary level
Haematoma in the upper buccal sulcus
Step deformity : infra orbital margins
Classic raccoon sign : caused by bilateral periorbital edema &
ecchymosis

25. Limitation of orbital movement with
diplopia and enophthalmos
CSF rhinorrhea : due to dural tear
Anaesthesia or Paraesthesia of the
cheek
Gagging of occlusion and retro-
positioning of the maxilla
On manipulation: movement being
detected at the infra orbital margins
and nasal bridge

26. Le Fort III
• Also known as high transverse or suprazygomatic fracture

27. Clinical features
Lenghtening of the face
Classic dish shaped deformity
Alteration of the occular level
unilateral or bilateral hooding of the eye
# of the zygomatic arch :
flattening of the zygomatic complex
Tenderness and deformity over the zygomatic arch

28. Disruption of the cribriform
plate :CSF rhinnorhoea
Telecanthus
Epiphora
Tenderness and separation at
the F-Z suture
Mobility of the whole facial
skeleton as a single block
Gagging of occlusion in the
molar area

29. Battle’s sign
Subconjunctival haemorrhage
& chemosis
Orbital dystopia with
associated antemongloid
slant

30. DIAGNOSING A MAXILLOFACIAL
INJURY
• Inspection
• Palpation
• Diagnostic Imaging
 Conventional Radiographs
 CT -Axial section -Coronal section

31. Local clinical examination
Extra oral examination
On inspection check for:
 Lacerations or injury over head
 Check for edema, ecchymosis (periorbital,
conjunctival, scleral) and soft tissue lacerations
 Any obvious bony deformities, haemorrhage,
epistaxis or otorrhoea, rhinorrhea
 occular involvement

32. On Palpation:
It should begin at the back of the neck and cranium,
Upper face,the zygomatic arch, bone and orbit
Ares of tenderness, deformities are to be noted
Step deformity, subcutaneous, emphysema
Mobility of maxilla
Eyelids separated and vision tested, check for
diplopia, light reflex
Check for Paraesthesia

35. Intra oral examination
 Derangement of occlusion, gagging of
occlusion, lacerations, ecchymosis
 Palpation
 Areas of tenderness, bony irregularities, crepitus
mobility of teeth noted
 Examination of teeth
 Pharynx evaluated for laceration & bleeding

36. Radiographic Evaluation
Plain Radiographs :
PNS
Lateral skull
CT Scan
Axial & Coronal sections

37. PNS view

39. Most important step.
Universal rule of mechanics
Reduction:
Manual reduction / Hand manipulation
For fresh #, Non impacted
Special instruments
For old, Grossly displace or impacted
REDUCTION OF MIDFACE
FRACTURES

40. Special Instruments
For Le Fort I fracture disimpaction
Rowe’s Disimpaction Forceps
- Rowe (1966)

43. Hayton Williams Forceps

44. Le Fort II & III –
When inadequate alignment results,
individual segments are reduced
separately.
Direct reduction: Elevator, bone hook or
wire inserted through the fragment.
Traction using elastic bands applied to
maxillary and mandibular arch bar can be
used for reducing fracture.

45. TREATMENT
MODALITIES• Changes in treatment strategy:
Before introduction to O.R.I.F external fixators & plaster head caps were used
With introduction to corrosion resistant & saliva resistant cheap steel, intra-
oral tooth-borne wiring techniques were used
Tissue inert steel wires – internal wire suspension techniques
Disappointing results – specially in higher Le Fort levels
Reason: tooth borne appliances – no complete control over bone

46. Improvement in antibiotics & anaesthesia management
Open reduction techniques became popular
Introduction to micro-screws & plates – even small fragments were preserved for
exact anatomical reduction & fixation

47. • Timing of surgical intervention:
 Best results – immediately after trauma
 In presence of soft tissue lacerations – surgical treatment within 8 hrs after
trauma
 Late interventions – difficult (due to enormous swelling of soft tissues)
Go for intramaxillary fixation & wait for few days, but not more than 12 to 14
days – because bony consolidation occurs rapidly

48. • Closed reduction & internal fixation by Intermaxillary Fixation:
 I.M.F can be continued for 2-3 weeks until fractures are bridged with woven
 Bell et al in 1975 conducted a study on monkeys & demonstrated that after Le
Fort I osteotomy, without bony fixation, I.M.F for 3-4 weeks resulted in a healed
maxilla in correct position
 Disadvantages-
• Tooth borne ligatures control fracture only on occlusal level
• No satisfactory result in case of severe displacements in region of facial
buttresses
• Breathing difficulty – due to nasal pack or feeding tube

49. • Closed reduction & internal fixation by External Appliances:

50. • Wire suspension in combination with closed or open reduction:
 Mobile maxillary part is suspended to fixed
point on non fractured skull
 Common techniques:
i. Frontomalar suspension
ii. Suspension on glabella
iii. Piriform aperture wiring
iv. Infraorbital wiring
v. Circumzygomatic wiring
 Removed after 6 weeks

51. • Open reduction & internal fixation by interosseous wiring:
 Introduced for midfacial fractures by
Adams in 1942 & refined by Manson et al
 Gruss & Mackinnon in 1986 emphasized
on importance of immediate bone
grafting to stabilize buttresses
 Requires additional 2-3 weeks of I.M.F

52. • Open reduction & internal fixation by miniplates, microplates & screws:
 Champy et al – method of monocortical plate fixation in mandible.
 Miniaturized plates were applied to midfacial fractures by Harle & Duker in 1975
by Luhr in 1979

53. SURGICAL APPROACHES
• Intra-oral approach by gingivobuccal sulcus (sublabial) incision or by
marginal gingival (sulcular) incision:

54. • Lower eyelid approach:

55. • Transconjunctival lateral canthotomy approach:

56. • Upper lid blepharoplasty approach:

57. • Brow incision:

58. • Coronal approach:

59. PLATE SYSTEM & TECHNIQUES FOR
RIGID INTERNAL FIXATION

62. FIRST MANDIBLE, SECOND
MAXILLA IN COMBINED FRACTURES

63. MAXILLARY SINUS DRAINAGE
• Usually unnecessary
• Drainage usually occurs spontaneously by the fractured lateral wall and
lacerated mucosal lining
• Infection is rarely seen
• When occurs, is most likely to be because of loose screws, plates or
necrotic bone fragments
• Infection subsides when the loose structures are removed

64. REFERRENCES
• Maxillofacial surgery by Peter Ward Booth
• Killey’s fractures of middle third of facial skeleton
• Maxillofacial injuries by Rowe & Williams, volume 1
• Fonseca Oral and Maxillofacial Surgery, fourth edition
• Surgical approaches to the facial skeleton by Edward Ellis III