A seminar prepared during my omfs posting hours. Short points are added for easiness to study and bihart. Reference taken from Balaji and Neelima Anil Malik

1. Submitted By:
Dr.MOHAMMED SHALIK
Al-Azhar Dental College

2.  BONES CONSTITUTING THE MIDDLE THIRD OT THE FACE.
 CLASSIFICATION.
 LEFORT FRACTURES.
 ZYGOMATICO COMPLEX FRACTURES.
 NASAL ORBITAL ETHMOIDAL FRACTURE.
 COMPLICATIONS OF MID FACE FRACTURE.

3.  Maxilla(2)
 Palatine bones(2)
 Zygoma (2)
 Zygomatic process of temporal bone(2)
 Nasal bone (2)
 Lacrimal bone(2)
 Ethmoid and its attached conchae(1)
 Inferior conchae(2)
 Pterygoid plates of sphenoid(2)
 Vomer(1)

6. 1.RENE LEFORT – 1901-PARIS
- Le fort I
- Le fort II
- Le fort III

7. 2.CLASSIFICATIONS GIVEN BY ROWE AND WILLIAMS –
1985.
FRACTURES NOT INVOLVING OCCLUSION
A)CENTRAL REGION
a) Fractures of the nasal bone and nasal septum.
b) Fractures of the frontal process of maxilla.
c) Fractures of the type a and b which exending into
ethmoid bone.
d) Fractures of the type a &b & c which extending into
the frontal bone.

8. B)LATERAL REGION
a) Fractures involving zygomatic bone, arch and maxilla
excluding dento-alveolar segment.
FRACTURES INVOLVING OCCLUSION
1.Sub-zygomatic.
2.Supra-zygomatic.
3.Dentoalveolar.

9. 3.ERICH’S DIRECTION OF FRACTURE LINE
- Horizontal fracture
- Pyramidal fracture
- Transverse fracture

10. 4.DEPENDING ON THE RELATIONSHIP OF THE FRACTURE LINE
TO THE ZYGOMATIC BONE
- Sub zygomatic
- Supra zygomatic
5.DEPENDING ON THE LEVEL OF FRACTURE LINE
-Low level fracture
-Mid level fracture
-High level fracture

11. LE FORT I FRACTURE
- Low level fracture
- Subzygomatic fracture
- Gurin’s fracture
- Floating maxilla
- Horizontal fracture of the maxilla

12.  commences at the anterior nasal aperture
 passes above the nasal floor
 passes laterally above the canine fossa and traverses
the lateral antral wall
 passes below the zygomatic buttress to the
pterygomaxillary fissure and fractures the pterygoid
plate at the junction of their lower third and upper two
third
• Line of fracture is the same at the opposite side.
Fracture line

13. EXTRA ORAL
• Swelling of upper lip and laceration
• Increased vertical dimension of face
• Epistaxis
• Pain

14. INTRA ORAL
• Buccal sulcus eccymosis
• Guerin’s sign
• Labial mucosa laceration
• Anterior open bite
• Posterior gagging of occlusion
• Tenderness at nasal aperture &zygomatic buttress

15.  Bone plate
 Circumzygomatic wiring (IMF +Zygomatic arch
suspension)
• Floating of maxilla at level of nasal floor
• Midpalatal split with/without laceration
• Dull cracked pot sound on percussion of teeth

16. Le Fort II
- Mid level fracture
- Pyramidal fracture
- Sub-zygomatic fracture

17. ETIOLOGY
 Violent force applied from anterior direction on the
face.
 The force delivered at the level of the nasal bone.

18. 1
• STARTS BELOW THE NASOFRONTAL SUTURE
2
• CROSSES THE FRONTAL PROCESS OF MAXILLA ON EITHER SIDE
3
• PASSES ANTERIORLY ACROSS THE LACRIMAL BONE
IMMEDIATELY ANTERIOR TO THE NASOLACRIMAL CANAL
4
• PASSES DOWNWARD , FORWARD AND LATERALLY CROSSING
THE INFERIOR ORBITAL MARGIN IN THE REGION OF
ZYGOMATICO-MAXILLARY SUTURE
5
• CROSSES THE LATERAL WALL OF ANTRUM > REST AS LEFORT I

19. EXTRA ORAL
• Moon face
• Increased vertical dimension
• Dish face deformity
• Bilateral circumorbital eccymosis
• Subcounjunctival hemorrhage
• Chemosis
• Incresed intercanthal distance
• Epistaxis
• CSF rhinorrhea
• Step deformity + tenderness infraorbital region
• Infraorbital nerve paresthesia

20. INTRA ORAL
• Anterior openbite
• Molar gagging
• Midpalatal split
• Buccal ecchymosis
• Dull sound on percussion
• Mobility of maxilla at infraorbital level

21.  Zygomatic arch suspension or frontal bone suspension
 Intraosseous wiring may be done at infraorbital
margins

22.  Transverse fracture
 Supra-zygomatic fracture
 High level fracture
 Craniofacial dysjunction

23. TRANVERSES THE LATERAL ORBITAL WALL
CONTINUES POSTERIOLY AND CROSSES THE
THIN ORBITAL PLATES
UPPER LIMIT OF THE LACRIMAL BONE
CROSSES NASAL BONE AND THE FRONTAL
PROCESS OF THE MAXILLA
STARTS AT NASO-FRONTAL SUTURE

24. EXTRAORAL
• Moon face
• Bilateral circumorbital
ecchymosis
• Subconjunctival hemorrhage
• Diplopia, resticted eye
movement, enophthalmos
• Incresed intercanthal distance
• Depressed nasal bridge

25. INTRAORAL
• Anterior open bite
• Molar gagging
• Mid palatal split
• Mobility of maxilla at FZ and
nasal bone level.
• Epistaxis
• Anosmia
• Elongation of face
• Tenderness +step deformity
at FZ suture
• Altered papillary level
• Hooding of the eye

26.  Intra-osseous wiring at zygomatico-frontal sutures +
fronto-malar suspension wiring.
 Intra-osseous wiring at the infra-orbital margin, if step
deformity exists.

27.  Plain radiographes
- Paranasal sinus view
- OPG
 CT scans

29.  Reduction of maxilla
• Manual method of reduction
• Reduction by means of wires
• Reduction by using maxillary disimpaction forceps
• Reduction by means of traction
 Wire osteosynthesis
 Plate osteosynthesis
 Internal suspension
- Frontal suspension
- Circum zygomatic suspension

30. zygomatic buttress suspension
- infraorbital suspension
-piriform aperture
External skeletal fracture
- craniomaxillary fixation
- craniomandibular fixation

31. ETIOLOGY
- Falls
- Assaults
- Vehicle accidents
- Sports injury

32. MANSON AND COLLEAGUES
- Based on CT scan findings
• High energy fracture
• Moderate energy fractures
• Low energy fractures

33.  Based on the extent of involvement of structures of the
orbit and the degree and direcetion of displacement
A)fractures of the body of the zygomatic complex involving
orbit
-Minimal or no displacement
-Inward and downward displacement
-Outward displacement
-Comminution of the complex as whole
B) Fractures of the zygomatic arch alone not involving the orbit
-Minimal or no displacement
-V- type in fracture
-Comminuted

34.  ZINGG SEPARATES THE INJURIES INTO TYPES A,B,C
Type A injuries are isolated to one component of the tetrapode
structures;
- Zygomatic arch
- Lateral orbital walls
- Inferior orbital rim
• Type B fractures involve all four buttress
• Type C injuries are complex fractures with comminution of the
zygomatic bone itself.
 BASED ON THE DIRECTION OF DISPLACEMENT OF
THE FRACTURED ZYGOMATIC BONE
- Displacement of zygoma around a horizontal axis
- Displacement of zygoma around a vertical axis

35. EXTRAORAL
• Periorbital edema and
echymosis
• Subcounjunctival
haemorrhage
• Flattening of malar
prominence
• Flattening of zygomatic
arch

36. • Air empysema
• Unequal pupillary levels
• Diplopia
• Enopththalmos
• Resticted eye movements
• Tenderness
• Step deformity
• Hyposthesia in infraorbital region
• Epistaxis

37. INTRAORAL
• Trismus
• Eccymosis of upper buccal sulcus
• Pain and step deformity of buttress
• No change in occlusion

38.  Plain radiographs; pranasal sinus view
 CT scan
 Other tests to be done
- forced duction test

39. 1) CLASSIFICATION ACCORDING TO THE DIRECTION OF
DISPLACEMENT OF THE ORBITAL WALLS
- blow out fracture
- blow in fracture
2) DEPENDING ON THE FRACTURE OF ORBITAL WALLS OR RIM
OF THE ORBIT
- Pure blow out fracture
- Impure blow out fracture

41.  The orbital fat tend to herniate into antralcavity through
the displaced fracture
 enophthalmos
 Restricts the normal movements of the eye
 Diplopia
 the pressure within the orbit due to the traumatic force
may also causes a rupture of the medial or lateral walls of
the orbit
 Circumorbital edema and echymosis
 Paresthesia of infraorbital nerve
 Subcounjunctival hemorrhage
 Surgical empysema

42.  Stable fracture :reduction without fracture
 Unstable fracture : reduction + fixation.
 fixation in the form of trans-osseous wiring or bone
plates
 Surgical approaches
• Intraoral maxillary vestibular approach
• Lateral eyebrow approach
• Upper eyelid approach
• Lower eyelid approach
• Coronal approach

43.  GILLE’S TEMPORAL APPROACH
incision made in the temporal region , it is possible
to pass the instrument down between the temporalis
muscle and fascia. This instrument reaches on medial
surface of the zygomatic arch. If it is moved medially,
this instrument passes below the zygomatic bone and
it can be elevated.
-it is used for depressed zygomatic fractures and elevate
a displaced zygoma

45.  BUCCAL SULCUS APPROCH
-used for reduce both the zygomatic arch and the body
of the zygomatic fractures

46. • Type I
-Simplest form of fracture. it involves only one portion of the medial
orbital rim with its attached medial canthal ligament.
• Type II
-Occur bilaterally or unilaterally
-may be fractured in large central segment or be comminuted
- the canthus remain attached to the large central segment
• Type III
-it involves comminution of the fragment containing the medial
canthal ligament.
Classification

48.  Epistaxis with / without CSF rhinorrhoea.
 Subconjunctival haemorrhage on the medial half of eye
 Swelling – nose
 Tenderness – nasal bone &medial orbital margin
 Mobility – nasal complex
 Detachment of the medial canthal ligament
 Fracture of septal cartilage
 Traumatic telecanthus
 Epiphora
 Difficulty in breathing

49.  Closed reduction
 Open reduction

50.  General complications
non union
malunion
delayed union
infection
 Meningitis
 Bone deformity
 Diplopia
 Superior orbital fissure syndrome
 Anosmia
 Anaesthesia of the maxillary branch of trigeminal nerve
 Facial asymmetry

51.  Textbook of oral& maxillofacial surgery
- SM Balaji
 Textbook of oral &maxillofacial surgery
-Neelima Anil Malik

52. THANK YOU!!!!!