fractures in the middle third of the face

1. JOYAL JOICE
FINAL YEAR PART II

2.  INTRODUCTION
 FRACTURE LINES
 CLINICAL FEATURES
 MANAGEMENT
 REFERENCE

3. Le fort II fractures are also known as pyramidal or sub-zygomatic fractures. Violent
forces usually from an anterior direction, sustained by the central region of the
facial skeleton over an area extending from the glabella to the alveolar margins
results in a fracture of a pyramidal shape. The force may be delivered at the level of
the nasal bones.

4.  Assault
 Falls
 Vehicle accidents
 Sports injury

5.  The fracture runs from the thin middle area of the nasal bones down either side,
crossing the frontal process of the maxillae into the medial wall of each orbit .Within
each orbit the fracture line crosses the lacrimal bone behind the lacrimal sac, before
turning forward to cross infraorbital margin slightly medial to or through infraorbital
foramen . The fracture now extends downwards and backwards across the lateral wall of
the antrum below the zygomatico-maxillary suture and divides the pterygoid laminae
about halfway up. Separation of the block from the base of the skull is completed via the
nasal septum and may involve the floor of anterior cranial fossa

7. EXTRAORAL:
 Moon face
 Increased vertical dimension
 Dish face deformity
 Bilateral circumorbital ecchymosis
 Bilateral subconjuctival hemorrhage on medial half of eye
 Chemosis
 Increased intercanthal distance
 Epistaxis
 CSF rhinorrhea
 Tenderness
 Step defect infraorbital region
 Infraorbital nerve paresthesia/anesthesia

8.  Loss of occlusion
 Shortening of face in case of impaction of fracture fragment into the
cranial base
 Flat face and nasal disfigurement
 Airway obstruction
INTRAORAL :
 Anterior open bite
 Molar gagging
 Midpalatal split

9. GENERAL PRINCIPLES OF TREATMENT :
1.The complexity of the facial skeleton
2.Associated facial bone fractures
3.Relation to the airway
4.Problems of fixation

10.  REDUCTION OF THE MAXILLA:
1.Manual method of reduction : Fractured maxilla maybe manipulated by hand if its
within 3-4 days of fracture. Manipulation should be done in such a way so as to
disimpact the mandible and move it forwards.
2.Reduction by means of wires : If the maxilla is not very mobile or if it is impacted
against the superior segment, it may be difficult to mobilize it manually. In this case ,
wires maybe twisted around the periodontally sound maxillary molars bilaterally.
3.Reduction by using maxillary disimpaction forceps : Rowe’s maxillary disimpaction
forceps .In case of a split in the palate, Hayton Williams forceps to first approximate the
palate
4.Reduction by means of traction : Tractional force maybe used if the fracture is not fresh
one. In this case partial callus formation begins to take place between the fractured
fragments and it is thus difficult to achieve manual mobilization of the maxilla

12.  Surgical approaches to the maxilla
1.Intraoral buccal vestibular approach
2.Infraorbital incisions : transconjuctival, subciliary, infraorbital
3.Lateral eyebrow incision
4.Bicoronal incision
5.Transverse nasal incision
6.Vertical nasal incision

13. Buttress of the midface :
1.Vertical buttress :
Nasomaxillary buttress
Zygomaticomaxillary buttress
Pterygoidmaxillary buttress
2.Horizontal buttress:
Supraorbital rims
Infraorbital rims
Alveolar process

14. 1. Internal fixation (immobilization within the tissues)
2. External fixation (extra-oral immobilization)

15. 1.Internal fixation
a. Direct osteosynthesis
i. miniplates and screws
ii. transosseous wires
b. Suspension wires
i.frontal
ii.cirumzygomatic
iii.zygomatic
iv.infraorbital
v.circumpalatal
vi.piriform aperture suspension
vii.peralveolar suspension CIRCUMZYGOMATIC
SUSPENSION WIRES
ORBITAL RIM WIRES
MINIPLATE
S
PIRIFORM APERTURE WIRING

16. 2.External fixation
a. Craniomandibular
i.box frame system
ii.halo frame
iii.Plaster of paris head cap
b. Craniomaxillary
i.Supraorbital pins
ii.Zygomatic pins
iii.Halo frame
BOX
FRAME
HALO
FRAME
POP HEAD CAP WITH METAL
FRAME

17.  Direct osteosynthesis of the maxillary fractures :
1.Wire osteosynthesis – transosseous wiring may be done .Fracture lines maybe be
eposed by incisons. The fracture is reduced and brought into proper aligment. Holes
are drilled with a bur on either side of the fracture line. A 26 gauge wire is passed
through these holes to connect them and then twisted together. The cut ends are cut
tucked into the nearest hole in the bone.
2.Suspension wires for fixation of maxilla –
Principle of internal suspension :
1.Direct suspension : This technique was basically designed to suspend a mobile bone
to a firm and stable bone above the fracture by means of a subcutaneous wire.
2.Indirect suspension : If required it was sandwiched between the stable mandible
below it. This helped in keeping it immobilized the fractured unit.

18. DIRECT OSTEOSYNTHESIS THREE POINT FIXATION

19.  EXTERNAL FIXATION :
The stable skull bones serves as a point of fixation for the fractures of facial skeleton.
A metallic frame attached to the outer cortical bone may be used or a plaster of paris
head cap is used .
 Craniomaxillary fixation : this is a method of fixation of the mobile maxillary
segment to the stable cranium . There are connectors placed on the maxillary arch
bars which connect the maxillary arch to the external head gear. This can also be
used for traction and then fixation.
Eg : haloframes / levant frames
 Craniomandibular fixation : this helps to fix the fractured maxilla to a stable
cranium . The fractured maxilla may be sandiwiched in between the mandible and
the stable cranium.
Eg : use of box frames

20. Disadvantages :
 Cumbersome method
 Conspicous and inhibits social activity
 Lengthens the period of hospitalisation
Contraindications :
 Presence of mental confusion
 Cerebral irritation
 Epilepsy
 Alcoholics

21.  Fractures of middle third of face – Rowe and killey
 Textbook of oral and maxillofacial surgery- Neelima Anil Malik
 Textbook of oral and maxillofacial surgery-Chitra Chakravarthy
 Textbook of oral and maxillofacial surgery-Gustav O Kruger