Mid face fractures /certified fixed orthodontic courses by Indian dental academy

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


Introduction
Upper 1/3rd

Middle 1/3rd

Lower 1/3rd

Maxillae
MidFace
Palatine bones
Zygomatic bones
Zygomatic processes of
temporal bones
nasal bones
lacrimal bones
Vomer
Ethmoid bones & it’s
concha
inf. Turbinates
Pterygoid plates of
sphenoid

Surgical Anatomy
Central midface :
Crumple Zone
Complex Articulation
Protects brain and
skull


Articulation with
Skull Base


Areas of Weakness
Developmental
Sutures
Air filled spaces
Neurovascular
bundle


Areas of Strength
Thickened Bones
Higher ratio of cortical:cancellous
Analogus to architectural concepts of support
Sicher & Tandler in 1928


Vertical Buttresses

Anterior / Nasomaxillary pillars
Middle / Zygomatico-maxillary pillars
Posterior/ Pterygomaxillary pillars

Horizontal Buttresses

Supra-Orbital Rims with Frontal
bones
Infra-Orbital Rims
Alveolar Process

Muscular Attachment

Static structure
Muscles of
mastication
Extra-ocular
muscles
Buccinator
Facial mimetic
muscles


Classification


FRACTURES NOT INVOVING OCCLUSION

A. CENTRAL REGION
Fractures of the nasal bones and / or nasal
septum
- lateral nasal injuries
- anterior nasal injuries
Fractures of the frontal process of the maxilla
Fractures of (1) and (2) which extend into the
ethmoid bone ( nasoethmoid)
Fractures of types (1), (2) and (3) which
extend into the frontal bone (fronto- orbitonasal dislocation)

B. LATERAL REGION
Fractures involving the zygomatic bone,
Zygomatic arch and
maxilla
(zygomatic complex) excluding the dento-

alveolar component

FRACTURES INVOLVING
OCCLUSION
Dento alveolar
Subzygomatic :
-- Le Fort I ( low level)
-- Le Fort II (pyramidal)
Suprazygomatic
--Le Fort III (High-level)

Rowe & William’s (1985)
FRACTURES NOT INVOVING THE
DENTOALVEOLAR COMPONENT

FRACTURES INVOLVING THE
DENTOALVEOLAR COMPONENT


Classification
Alphonse Guerin ( 1888)
Rene LeFort (1901)
 Experimental cadaveric
studies
 # along the lines of weakness
 Assault from frontal / lateral
impact
 Avoided areas of strength
 LeFort I
 LeFort II
 LeFort III

Le Fort I
Guerin #,Floating #
Fracture extends
transversely above
level of teeth
Traumatic force
directed
to the lower maxillary
region
B/L or U/L
U/L: auxillary # :
midline of the palate

MAXILLOFACIAL INJURIES
MIDFACE FRACTURES
Le-Fort I Fracture
(Guerin # / Low level # / Floating #)
Nasal floor
Pyriform rim
Zygomatic buttress
Pterygoid lamella
Lateral wall nose
Nasal septum tuberosity


Le Fort II:
Pyramidal #
Begins above level
of teeth
a violent force to the
central region of the
mid
Central portion
mobilized
independently
Pa Skull- Pyramidal
shaped.

MIDFACE FRACTURES
Le-Fort II Fracture
( Pyramidal # / Subzygomatic # )
Nasal bone
Frontal bone
Orbit
Lacrimal bone
Infraorbital foramen
Maxillary antrum
ZM suture

Le Fort III:
Craniofacial Dysjunction

Fracture extends through
zygomatic arch
Entire midface separated &
suspended solely by soft
tissues

MIDFACE FRACTURES
Le-Fort III Fracture
( High transverse/Suprazygomatic/Craniofacial disarticulation)

Fronto-nasal suture
Ethmoid cribriform plate
Frontal process maxilla
Medial wall orbit
Optic foramen
Inferior orbital fissure
Pterygoid lamella
Lateral wall of orbit Z-F
suture

GK / MAXFAC
SDM DHARWAD

These fractures may occur unilaterally or
may be associated independently with a

fracture of the zygomatic complex

There may be midline separation of the
maxilla and / or extension of the fracture
pattern into the frontal or temporal bones

Factors influencing displacement
Degree of force
Direction of force
Resistance to the force offered by the facial
bones
Point of application of force
Cross sectional area of object
Attached muscles

Diagnosis of Maxillofacial Injuries
Inspection
Palpation
Diagnostic Imaging



Plain Radiographs
CT -Axial section -Coronal section


Local clinical examination
gently clean up the face
Inspection
Palpation
Diagnostic Imaging
Extra oral examination
Lacerations or injury over head
Check for edema, ecchymosis (periorbital,
conjunctival, scleral) and soft tissue
lacerations
Any obvious bony deformities, haemorrhage,
epistaxis or otorrhoea, rhinorrhoea
occular involvement

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

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

Clinical Features
LeFort - I
Swelling of the upper lip
Ecchymosis present in the buccal sulcus
beneath each zygomatic arch
Patient keeping the
mouth slightly open
Occlusion derranged
Midline split of the palate

Subluxation of teeth

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


LeFort - II / III
Swelling : gross; (moon face) eyelids
conjunctiva
Ecchymosis : bilateral circum-orbital
(panda face/raccoon face)
: subconjunctival
Chemosis
Infra orbital step
(Le Fort II)
Nasal deformity


Retropositioning of maxilla : Deranged

occlusion : post gagging : V. D
Mobility of midface

Hematoma on palate
Dish face
Loss of function:
Diplopia? Anosmia
Nares filled with clotted blood

Emphysema, Epiphora,
CSF Rhinorrhea,Hooding of eye

LeFort - II
No alteration of pupillary level
Haematoma in the upper buccal sulcus
Step deformity : infra orbital margins
Limitation of orbital movement with diplopia
and enopthalmos
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


LeFort - III
Lenghtening of the face
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
Tenderness and separation at the F-Zsuture
Mobility of the whole facial skeleton as a single
block
Gagging of occlusion in the molar area
Disruption of the cribriform plate :CSF rhinnorhoea

Radiographic Evaluation

Plain Radiographs :
P - A skull
PNS
Lateral skull
CT Scan
Axial & Coronal sections


PNS view


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Mid face fractures /certified fixed orthodontic courses by Indian dental academy

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