FRACTURE OF MIDDLE THIRD
OF
FACIAL SKELETON

www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
Maxillofacial Injuries
• Treatment divided into following
phases
Emergency or initial care
Early care
Definitive care
...
Emergency Care
•
•
•
•
•

Preserve the airway
Control of hemorrhage
Prevent or control shock
C-Spine stabilization
Control...
Emergency Care
• Evaluate the airway
Existence & identification of obstruction
Manually clear of fractured teeth, blood
...
Emergency Care
• Airway Management
Maintain an intact airway
Protect airway in jeopardy
Provide an airway

• C-Spine in...
Airway Management
• Chin lift to open intact
airway
• Intubation
Oral: C-spine injury
absent on X ray
Nasotracheal intub...
Emergency Care
• Extensive vascularity of head & neck
may lead to massive blood loss
Monitor vital signs closely
Intrave...
Treatment of Blood Loss & Shock
• Hemorrhage most common cause of
shock after injury
• Multiple injury patients
have hypov...
Treatment of Blood Loss & Shock
• External bleeding controlled by
direct pressure over bleeding site
• Gain prompt access ...
Stabilization of associated injuries
• C-spine injury is primary concern
with all maxillofacial trauma victims
Any patien...
Head/Neck/C-Spine Stabilization

www.indiandentalacademy.com
Early Care
Emergency care has stabilized patient
Initial stabilization of fractures
Debridement & dressing of soft tiss...
Diagnosis of Maxillofacial Injuries
• Inspection
• Palpation
• Diagnostic Imaging
Plain films
CT
Stereolithography (whe...
Diagnosis of Maxillofacial Injuries
• INSPECTION
Hemorrhage
Otorrhea
Rhinorrhea
Contour deformity
Ecchymosis
Edema
...
Inspection

Sublingual ecchymosis

Step defects, ridge
discontinuity, malocclusion

www.indiandentalacademy.com
Diagnosis of Maxillofacial Injuries
• PALPATION
“Step” Defect
Crepitus
Bony segments
Subcutaneous
emphysema
Mobility
...
Midface Fractures
•
•
•
•
•
•
•

LeFort I Transverse Maxillary
Lefort II Pyramidal
Lefort III Craniofacial Dysjunction
Zyg...
Midface Fractures
• Three buttresses
allow face to absorb
force
 Nasomaxillary
(medial) buttress
 Zymaticomaxillary
(lat...
Lefort Classification
• Weakest areas of midfacial complex
when assaulted from a frontal
direction at different levels (Re...
Lefort I Fracture
Transverse Maxillary

www.indiandentalacademy.com
Lefort II Fracture
Pyramidal

www.indiandentalacademy.com
Lefort III Fracture
Craniofacial Dysjunction

www.indiandentalacademy.com
Facial Examination
• Evaluate for laceration
• Obvious depression in
skull
• Asymmetry
• Discharge from nose or
ear
 Assu...
Facial Examination
• Evaluate mandibular
opening
• Palpation of buccal
vestibule
Crepitus of lateral antral wall

• Occlus...
Facial Examination
• Orbits evaluated
 Periorbital edema and
ecchymosis
 Gross visual acuity
determined
 Diplopia
 Pup...
Facial Examination
• Orbits evaluated
 Lid lacerations
 Attachment of medial
canthal tendon
Rounding of lacrimal
lake
...
Facial Examination
Orbits Evaluated

www.indiandentalacademy.com
Facial Examination
Palpation of Midface/bridge of nose

www.indiandentalacademy.com
Radiographic Evaluation
• Plain Films
Lateral Skull
Waters View
Posteroanterior view of skull
Submental vertex

• CT S...
Radiographic Evaluation

Lateral skull

Water’s View

www.indiandentalacademy.com
Radiographic Evaluation

CT Scan

3D CT

www.indiandentalacademy.com
Radiographic Evaluation

Stereolithography
allows actual model
of defect. A nice
reconstruction tool
to use if available
w...
Treatment of Midface Fractures
• Once patient’s condition
stabilized, no need to
rush to surgery
 Address rapidly
develop...
Diagnosis of Lefort I Fractures
• Direction of force
• Maxilla displaced
posteriorly and inferiorly
 Open bite deformity
...
Treatment of Lefort I Fractures
 Direct exposure of all
involved fractures
 Reduction and anatomic
realignment of the
ma...
Treatment of Lefort I Fractures

www.indiandentalacademy.com
Diagnosis of Lefort II and III
• Clinical evaluation provides only a
rough impression since swelling
hides the underlying ...
Diagnosis Lefort II and III
• Bilateral periorbital
edema & ecchymosis
• Step deformity
palpated infraorbital &
nasofronta...
Treatment of Lefort II and III
• Fractures should be treated as early
as the general condition of the
patient allows
• Tea...
Treatment of Lefort II and III
• Intubation must not interfere with ability
to use IMF
• Exposure & visualization of all f...
Fractures
Teeth and occlusion
are the key to
reconstruction and
provide the
foundation upon
which other facial
structures ...
Treatment of Lefort II and III
Severely comminuted fractures
preliminary approximation may be
performed with wire
Establ...
Treatment of Lefort II and III
Reestablishment of the correct
intercanthal distance
Infraorbital rim fixated
Orbit is r...
Lefort II & III Reconstruction

www.indiandentalacademy.com
Lefort II & III
Reconstruction

www.indiandentalacademy.com
Thank you
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Lefort fractures /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078


The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.


Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
00919248678078

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Lefort fractures /certified fixed orthodontic courses by Indian dental academy

  1. 1. FRACTURE OF MIDDLE THIRD OF FACIAL SKELETON www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. Maxillofacial Injuries • Treatment divided into following phases Emergency or initial care Early care Definitive care Secondary care or revision www.indiandentalacademy.com
  4. 4. Emergency Care • • • • • Preserve the airway Control of hemorrhage Prevent or control shock C-Spine stabilization Control of life-threatening injuries head injuries, chest injuries, compound limb fractures, intra-abdominal bleeding www.indiandentalacademy.com
  5. 5. Emergency Care • Evaluate the airway Existence & identification of obstruction Manually clear of fractured teeth, blood clots, dentures Endotracheal intubation & packing of oronasal airway www.indiandentalacademy.com
  6. 6. Emergency Care • Airway Management Maintain an intact airway Protect airway in jeopardy Provide an airway • C-Spine injury may be present • Altered level of consciousness is the most common cause of upper airway obstruction www.indiandentalacademy.com
  7. 7. Airway Management • Chin lift to open intact airway • Intubation Oral: C-spine injury absent on X ray Nasotracheal intubation: C-spine injury suspected or certain • Surgical Airway Cricothyroidotomy Tracheosotomy www.indiandentalacademy.com
  8. 8. Emergency Care • Extensive vascularity of head & neck may lead to massive blood loss Monitor vital signs closely Intravenous infusion • Penetrating injuries need to be explored Arteriogram Esophagram www.indiandentalacademy.com
  9. 9. Treatment of Blood Loss & Shock • Hemorrhage most common cause of shock after injury • Multiple injury patients have hypovolemia • Goal is to restore organ perfusion www.indiandentalacademy.com
  10. 10. Treatment of Blood Loss & Shock • External bleeding controlled by direct pressure over bleeding site • Gain prompt access to vascular system with IV catheters • Fluid replacement Ringer’s Lactate Normal saline Transfusion www.indiandentalacademy.com
  11. 11. Stabilization of associated injuries • C-spine injury is primary concern with all maxillofacial trauma victims Any patient with injury above clavicle or head injury resulting in unconscious state Any injury produced by high speed Signs/symptoms of C-Spine injury Neurologic deficit Neck pain www.indiandentalacademy.com
  12. 12. Head/Neck/C-Spine Stabilization www.indiandentalacademy.com
  13. 13. Early Care Emergency care has stabilized patient Initial stabilization of fractures Debridement & dressing of soft tissues Elective tracheostomy Physical exam & history Laboratory tests Complete head & neck examination Diagnosis of maxillofacial injuries www.indiandentalacademy.com
  14. 14. Diagnosis of Maxillofacial Injuries • Inspection • Palpation • Diagnostic Imaging Plain films CT Stereolithography (where available) www.indiandentalacademy.com
  15. 15. Diagnosis of Maxillofacial Injuries • INSPECTION Hemorrhage Otorrhea Rhinorrhea Contour deformity Ecchymosis Edema Continuity defects Malocclusion www.indiandentalacademy.com
  16. 16. Inspection Sublingual ecchymosis Step defects, ridge discontinuity, malocclusion www.indiandentalacademy.com
  17. 17. Diagnosis of Maxillofacial Injuries • PALPATION “Step” Defect Crepitus Bony segments Subcutaneous emphysema Mobility www.indiandentalacademy.com
  18. 18. Midface Fractures • • • • • • • LeFort I Transverse Maxillary Lefort II Pyramidal Lefort III Craniofacial Dysjunction Zygomatic Complex Orbital Floor Nasal Fractures Naso-orbital/Ethmoid www.indiandentalacademy.com
  19. 19. Midface Fractures • Three buttresses allow face to absorb force  Nasomaxillary (medial) buttress  Zymaticomaxillary (lateral) buttress  Pyterigomaxillary (posterior) buttress www.indiandentalacademy.com
  20. 20. Lefort Classification • Weakest areas of midfacial complex when assaulted from a frontal direction at different levels (Rene’ Lefort, 1901) Lefort I: above the level of teeth Lefort II: at level of nasal bones Lefort III: at orbital level www.indiandentalacademy.com
  21. 21. Lefort I Fracture Transverse Maxillary www.indiandentalacademy.com
  22. 22. Lefort II Fracture Pyramidal www.indiandentalacademy.com
  23. 23. Lefort III Fracture Craniofacial Dysjunction www.indiandentalacademy.com
  24. 24. Facial Examination • Evaluate for laceration • Obvious depression in skull • Asymmetry • Discharge from nose or ear  Assume CSF leak • Palpation to note bone discontinuity  Bimanually in systematic manner www.indiandentalacademy.com
  25. 25. Facial Examination • Evaluate mandibular opening • Palpation of buccal vestibule Crepitus of lateral antral wall • Occlusion evaluated Absence and quality of dentition noted • Ecchymosis common finding • Pharynx evaluated for laceration & bleeding www.indiandentalacademy.com
  26. 26. Facial Examination • Orbits evaluated  Periorbital edema and ecchymosis  Gross visual acuity determined  Diplopia  Pupillary size & shape  Subconjunctival hemorrhage  Funduscopic evaluation www.indiandentalacademy.com
  27. 27. Facial Examination • Orbits evaluated  Lid lacerations  Attachment of medial canthal tendon Rounding of lacrimal lake Increased intercanthal distance Epiphora  Prompt Ophthamology consult www.indiandentalacademy.com
  28. 28. Facial Examination Orbits Evaluated www.indiandentalacademy.com
  29. 29. Facial Examination Palpation of Midface/bridge of nose www.indiandentalacademy.com
  30. 30. Radiographic Evaluation • Plain Films Lateral Skull Waters View Posteroanterior view of skull Submental vertex • CT Scan 1.5 mm cuts axial and coronal views www.indiandentalacademy.com
  31. 31. Radiographic Evaluation Lateral skull Water’s View www.indiandentalacademy.com
  32. 32. Radiographic Evaluation CT Scan 3D CT www.indiandentalacademy.com
  33. 33. Radiographic Evaluation Stereolithography allows actual model of defect. A nice reconstruction tool to use if available www.indiandentalacademy.com
  34. 34. Treatment of Midface Fractures • Once patient’s condition stabilized, no need to rush to surgery  Address rapidly developing edema  Formulate treatment plan  Observe sequelae in the case of orbital injuries www.indiandentalacademy.com
  35. 35. Diagnosis of Lefort I Fractures • Direction of force • Maxilla displaced posteriorly and inferiorly  Open bite deformity • Hypoesthesia of infraorbital nerve • Malocclusion • Mobility of maxilla  Noted by grasping maxillary incisors www.indiandentalacademy.com
  36. 36. Treatment of Lefort I Fractures  Direct exposure of all involved fractures  Reduction and anatomic realignment of the maxillary buttresses to reestablish Anterior projection Transverse width Occlusion  Restoration of occlusion using IMF  Internal fixation using miniplate fixation www.indiandentalacademy.com
  37. 37. Treatment of Lefort I Fractures www.indiandentalacademy.com
  38. 38. Diagnosis of Lefort II and III • Clinical evaluation provides only a rough impression since swelling hides the underlying bony structures • Plain film radiographs and axial and coronal CT images are the basis for precise diagnosis & treatment plan www.indiandentalacademy.com
  39. 39. Diagnosis Lefort II and III • Bilateral periorbital edema & ecchymosis • Step deformity palpated infraorbital & nasofrontal area • CSF rhinorrhea • Epistaxis www.indiandentalacademy.com
  40. 40. Treatment of Lefort II and III • Fractures should be treated as early as the general condition of the patient allows • Team approach to treatment Neurosurgery Ophthamology Oral/Maxillofacial surgery www.indiandentalacademy.com
  41. 41. Treatment of Lefort II and III • Intubation must not interfere with ability to use IMF • Exposure & visualization of all fractures Approaches to inferior rim Infraorbital Subciliary Transconjunctival Mid lower lid Coronal approach Gingivobuccal incision www.indiandentalacademy.com
  42. 42. Fractures Teeth and occlusion are the key to reconstruction and provide the foundation upon which other facial structures are built www.indiandentalacademy.com
  43. 43. Treatment of Lefort II and III Severely comminuted fractures preliminary approximation may be performed with wire Establishment of the correct occlusion Correct reconstruction of the outer facial frame for proper facial dimensions Correct position for nasoethmoidal complex www.indiandentalacademy.com
  44. 44. Treatment of Lefort II and III Reestablishment of the correct intercanthal distance Infraorbital rim fixated Orbit is reconstructed Occlusion unit with IMF is fixated www.indiandentalacademy.com
  45. 45. Lefort II & III Reconstruction www.indiandentalacademy.com
  46. 46. Lefort II & III Reconstruction www.indiandentalacademy.com
  47. 47. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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