midface fracture oral surgery b.d.s

1. 1
 BY CHIDAMBRA MAKKER
 B.D.S FINAL YEAR
 ROLL NO. 22

2. 2
DIRECT VIOLENCE
a. Fights
b. Metal rods,bricks
fist fight etc
c. Fall
d. Road traffic
accident
e. Occupational
hazards( atletic
injury)
f. Iatrogenic (during
dental treatment
INDIRECT VIOLENCE
a. Fall from a height
b. Excessive muscle contraction

3. Fractures of the middle third may be subdivided into:
 Dento-alveolar fractures.
 Fractures of the maxilla.
 Fractures of the zygomatic bone & arch.
 Blow out fractures.
 Nasal-orbital-ethmoidal fractures.
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4. It consists of fracture, subluxation, or avulsion of the
teeth with or without an associated fracture of the
alveolus, and they may occur as a clinical entity or in
conjunction with any other type of fracture.
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6. RENNE LE FORT CLASSIFIED MID-FACE FRACTURE
INTO:
Le Fort type I
Le Fort type II
Le Fort type III
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7. MODIFIED LE FORT
CLASSIFICATION ( by marchiani 1993)
Le fortI - low maxillary fracture
Ia- low maxillary fracture/multiple segments
Le fort II- pyramidal fracture
IIa- pyramidal and nasal fracture
IIb- pyramidal fracture with nasoethmoidal fracture
Le fort III- craniofacial dysfunction
IIIa- craniofacial disjunction with nasal fracture
IIIb – craniofacial disjunction with nasoethmoidal fracture
Le fort IV - le fort II and le fort III and cranial base fracture
IVa- le fort II and le fort III and cranial base fracture with supraorbital rim fracture
IVb - le fort II and III and cranial base fracture with anterior cranial fossa and
supraorbital rim fracture
IVc- le fort II and III and cranial base fracture with anterior cranial fossa and orbital
wall fracture

8. 8
Low level fracture

9. It results from a force delivered
above the level of the teeth.
Le fort 1
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10. The fracture courses from the lateral border of the
pyriform aperture above the canine eminence
behind the maxillary tuberosity  across the lower
third of the pterygoid plate.
* It may be unilateral or
bilateral
* It may occur single or in
combination with Le Fort
type II or III fractures.
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11. 11
low level or Guerin type

12. Extra-orally
 Swelling of the upper lip.
 Soft tissue laceration.
 Open mouth to accommodate the displaced dento-
alveolar portion.
 Epistaxis.
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Intra-orally
 Malocclusion.
 Mobility of tooth bearing portion
 Ecchymosis in buccal sulcus beneath zygomatic
arch
 Percussion of upper teeth results in a distinctive
cracked-pot sound

13. 13
Sub-zygomatic fracture
Pyramidal fracture

14. It results from a force
delivered at a level of the
nasal bones.
The fracture line occurs along
the nasofrontal suture 
lacrimal bone  across the
infra- orbital rim in the
region of the zygomatico-
maxillary suture 
above the canine eminence
 inferiorly and distally
along the lateral antral
wall, but at a higher level
than Le Fort type I 
across the pterygoid plate
at its middle.
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16. Extraorally
- Ballooning of the face.
- Lenghtenening of the face
- Circumorbital ecchymosis
- Subconjunctival
Hemorrhage adjacent to
those parts of orbit where
fracture has occurred
- Diplopia and
enophthalmous due to orbit
damaged
-anesthesia or
paranesthesia of cheeks
-diplopia
-Chemosis
- CSF rhinorrhoea(not
clinically detected)
- Step deformity in the
lower border of the
orbit
-Intact zygomatic bone &
arch
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17. Intraorally
-Malocclusion
-Gagging of the posterior teeth and anterior
open bite
-Mobility of the maxilla
-Ecchymosis of the sulcus
- ‘cracked pot’ sound on tapping teeth
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18. 18
Supra-zygomatic fracture
High level

19. The fracture is caused by a force at the orbital level
, the resultant fracture is craniofacial
disjunction.
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20. The fracture line courses through the zygomaticotemporal
and zygomaticofrontal sutures lateral orbital wall
inferior orbital fissure medially to the naso-frontal suture
 fractures the pterygoid plate at its base.
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22. Extraorally
- Severe edema of the face
“ballooning”
- Lengthening of the face
- Flattening of the cheek
- Circumorbital ecchymosis
- Subconjunctival
Hemorrhage
-Enophthalmos
-CSF rhinorrhoea
-Hooding of eyes
-mobility of whole
facial skeleton as a
single block
Intraorally
-Gagging of the posterior
teeth and anterior open
bite
-Ecchymosis and
Hemorrhage of the buccal
sulcus
-Mobility of the maxilla
-Mandibular interference
-displacement of midline of
upper jaw
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23.  Occipto-mental view
 CT scan
TYPES
* Axial scan
* Coronal scan
* 3D CT
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 1. CABD
 2. REDUCTION AND FIXATION
AND IMMOBILIZATION

26. REDUCTION
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CLOSED REDUCTION
OPEN REDUCTION
Is reduction of fracture segment to
previous anatomical and functional
position without direct visualisation
Is surgical reduction of fracture segments
• Rowe’s disimpaction forceps can
be used to disimpact the fractured
maxilla and t bring it to occlusion
•Hayton william forceps used to
reduce midpalatal split maxilla

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28. Methods
 Maxillo-mandibular fixation
 Internal fixation
 Skeletal suspension
 Support
 External fixation
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29. A) Closed reduction & fixation
* Digital pressure.
* Arch bar tightened in the unfractured side and loose in
the fractured side.
* Adjust occlusion, tighten the fractured side then secure
MMF.
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B) Open reduction & fixation
* Cases of unstable fractures.
* Arch bars are prepared
* Sulcus incision to expose the fracture site in canine
& buttress regions
* Transosseous wiring or miniplates are used for
fixation.

30. i) Essig’s wiring– Is used to stabilize dentoalveolar
fractures in individual dental arches ,anchoring
device for IMF and for stabilizing luxate teeth. 26
gauze wire is used.
The wire is passed around the necks of teeth, one end
going from buccal to lingual and other end from
lingual to buccal . Wire is twisted buccaly cut and
placed interdentally. Atleast 3 teeth away fracture
line taken
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31. ii)Gilmer’s wiring – intermaxillary fixation done. At least 1
anterior and 1 posterior teeth should be available for
stabilization. 26 gauze wire. Both ends are brought
together buccally n twisted.
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32. iii) risdon’s wiring– is method of horizontal wire
fixation. 2nd molar on either side chosen for
anchorage.
Wire passed around neck and brought bucally and
twisted. Additional wire used to secure tooth.
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iv) Ivy eyelits wiring-- two teeth selected together
and wire passed from lingual to buccal

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v) col. Stout’s multiloop wiring– 4 posterior
quadrants used for wiring. 26 gauze wire used

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vi) Arch bars– are flat stainless steel metal strips.
Arch bars are fixed to the teeth bucally and 26 gauze
wire is passed mesial surface to lingual side and
back to buccal side from distal aspect of the tooth.

36.  Is direct wiring across the
fracture line.
 Effective method of
fixation and
immobilization
 It is done at- frontonasal
suture, zygomatico-
frontal suture,orbital
rim,zygomatico-
maxillary suture,
zygomatic bone, alveolar
bone
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37.  Occurs due to direct trauma to the orbit with an object
larger than globe size
 Increase in hydraulic pressure within orbit so
enophthalmous
 Fracture gives way to maxillary sinus.
 Sometimes muscle prolapse into sinus(hernia).
 Diplopia
 Diagnosis- fored duction test, hanging drop method in
PA view, ct scan, water’s position radiograph
 Treatment- sialstic bone sheet or bone graft
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38.  Inadequate reduced fractures  causes facial
deformities
 Obstruction of nasolacrimal duct due to le fort II
fracture  causes epiphora, dacryocystitis
 Enophthalmous
 Failure of recovery ofoculomotor nerve and abducent
nerve  causes strabismus, ptosis, diplopia
 Fracture involving cribriform plate may cause
anosmia
 Malocclusion
 Palatal fistula
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