This document discusses fractures of the middle third of the face and mandible. It begins by outlining the boundaries and structures that make up the middle third of the face. It then describes the three types of Lefort fractures - Lefort I, II, and III - providing details on their characteristics, signs and symptoms, and treatment approaches. The document also discusses fractures of the zygomatic complex, mandible classifications and treatments. It concludes by covering potential complications from maxillofacial injuries.

1. Fractures of
middle third
of face
Instructor – Dr. Jesus George1

2. Boundaries of middle 1/3 of face
2
 Superiorly- a line drawn from zygomaticofrontal suture
,across frontonasal suture,frontomaxillary suture.
 Inferiorly-occlusal plane of upper teeth.
 Posteriorly-sphenoethmoidal junction.

3. Nerve supply & blood supply
3
 Maxillary branch of trigeminal nerve
 Maxillary artery & its branches

4. Bones constituting middle1/3 of face
4
 2 maxillae
 2 palatine bones
 2 zygomatic bones
 2 zygomatic processes of temporal bone
 2 nasal bones
 2 lacrimal bones
 Ethmoid bone
 2 inferior conchae
 2 pterigoid plates of sphenoid
 Vomer

5. Classification
5
 Lefort I
 Lefort II
 Lefort III

6. Lefort I #
6
 Also called horizontal # of maxilla or Guerin's # or
floating # (separation of dentoalveolar part of maxilla
 Fractured fragments are freely mobile
 Horizontal # line above the apices of teeth
 Line starts at the point on lateral margin of anterior nasal
aperture above the nasal floor, passes laterally above the
canine fossa traverses lateral antral wall, dipping down
below the zygomatic buttress across pterigomaxillary
fissure & fractures pterigoid lamina at the junction of
lower 1/3 & upper 2/3
 Usually bilateral

7. Cont.
7
 Signs & symptoms
 Slight swelling & edema of lower part of face with upper
lip swelling
 Ecchymosis in labial & buccal vestibule
 Contusion of upper lip
 Laceration of upper lip & oral mucosa
 Bilateral epistaxis
 Mobility of dentoalveolar fragment of upper jaw
 Disturbed occlusion
 Inability to masticate food

8. Cont.
8
 Pain while speaking & moving jaw
 In impacted # upward displacement of entire fragment &
Anterior open bite
 Percussion of upper teeth – dull cracked up sound

9. 9

10. Lefort II #
10
 Pyramidal or subzygomatic #
 # line runs below the frontonasal suture crossing the
frontal process of maxilla, passes anteriorly across the
lacrimal bones anterior to lacrimal canal, then passes
downward, forward & laterally crossing inferior orbital
margin in zygomatico maxillay suture, then it extends
downward, forward & laterally to lateral wall of antrum
medial to zygomatico maxillary suture line, then it passess
beneath the zygomatic buttress fracturing pterigoid
lamina at the midway

11. 11

12. Cont.
12
 Signs & symptoms
 Gross edema of middle 1/3 of face giving a moon’s face
appearance
 Bilateral circumorbital edema & ecchymosis ( black eye)
 Bilateral subconjunctival hemorrhage
 Bridge of nose is depressed
 If impaction of fragments is there anterior open bite
 If there is downward & backward displacement of
fragments, elongation & lengthening of face & posterior
gagging of occlusion with anterior open bite

13. Cont.
13
 Bilateral epistaxis
 Difficulty in mastication & speech
 Loss of occlusion
 Airway obstruction due to posterior displacement of
fragments
 CSF leak may be seen
 Step deformity in infraorbital margin
 Anesthesia or paresthesia of cheek

14. 14

15. Lefort III #
15
 Also known as high level #
 Force is in lateral direction
 Line starts near frontonasal suture, causing dislocation of
nasal bones & disruption of cribriform plate of ethmoid
bone tearing dura mater & causing CSF rhinorrhea, then
crosses through both nasal bones & frontal process of
maxilla, then traverses upper limit of lacrimal bones, then
it crosses thin orbital plate of ethmoid bone, it passes
through medial orbital wall, then it reaches upper
posterior aspect of maxilla & fractures pterigoid lamina at
the base
 Entire middle 1/3 is separated from cranial base

16. 16

17. Cont.
17
 Signs & symptoms
 Gross edema of face
 Bilateral circumorbital or periorbital ecchymosis
 Tenderness & separation at frontozyomatic suture
 Dish face deformity
 Enophthalmos
 Diplopia
 Temporary blindness or impairment of vision
 Nasal septal deviation
 Epistaxis

18. Cont.
18
 CSF rhinorrhea

19. # of zygomatic complex
19
 Zygomatic bone is closely associated with maxilla, frontal
& temporal bones – so they are known as zygomatic
complex #
 Signs & symptoms
 Flattening of cheek because of inward displacement of
fragments
 Unilateral epistaxis
 Circumorbital ecchymosis
 Subconjunctival hemorrhage
 Limitation of ocular movement

20. Cont.
20
 Anesthesia of cheek, nose, lip
 Edema of cheek & eyelids
 Step deformity in infraorbital margin
 Limitation of mandibular movement
 Ecchymosis & tenderness in upper buccal sulcus
 Change in sensation of teeth & gum
 Enophthalmos

21. Treatment of midface #
21
 Manual reduction
 Arch bars are applied on teeth, lower jaw acts as
template
 In fresh # maxilla is held b/w index finger & thumb &
brought into normal occlusion
 Row’s disimpaction forceps (used in pairs) one end in
nasal floor & other in hard palate
 In split palate, Hayton william’s forceps is applied to
buccal aspect of alveolar process & medial compression
until 2 jaws are approximated

22. Cont.
22
 Reduction by traction
 Used in delayed cases where the fragments are not
sufficiently mobile
 Intra oral elastic traction is given to restore normal
occlusion
 After getting correct occlusion IMF for 3-4 weeks
 If only slight mobility, & occlusion is not disturbed
progress of healing is supervised, patient is advised to
avoid chewing for 2-3 weeks ( soft diet)

23. Cont.
23
 Open reduction
 Circumvestibular incision from 1st
molar of one side to
the other side
 Mucoperiosteal flap is reflected
 Fragments are mobilized
 Disimpaction forceps is used & fragments are brought
into normal occlusion
 IMF is done & fragments are fixed under direct vision by
miniplates or intraosseous wiring

24. Treatment zygomatic #
24
 Keen’s approach
 Buccal vestibular incision is given in 1st
& 2nd
molar region
behind the zygomatic buttress
 Curved elevator is passed supraperiosteally up beneath
the zygomatic bone
 Depressed bone is elevated with upward, forward &
outward movement

25. Cont.
25
 If gross separation of zygomaticofrontal suture
 Incision is made 1 cm above the outer canthus of eye
 Holes are drilled 0.5cm from the fractured ends
 Intraosseous wiring or miniplates are given
 Wound is closed in layers
 Associated coronoid #
 If coronoid is completely detached & causing limitaion of
mouth opening, it can be excised through intraoral
approach

26. Fractures
of mandible
26

27. Introduction
27
 Largest, heaviest & strongest bone of face
 Blood supply
 Inferior alveolar artery
 Nerve supply
 Inferior alveolar nerve

28. Classification
28
 Body #
 Condyle #
 Angle #
 Dentoalveolar #
 Symphysis #
 Ramus #
 Coronoid #
 Parasymphysis #

29. Management
29
 Closed reduction
 Presence of teeth provides guidance for reduction
 Dental wiring or arch bar is used to get the occlusion
 IMF for 6 weeks
 In edentulous patients gunning splint is used
 Indications
 Nondisplaced #
 Grossly displaced #
 Atrophic edentulous mandible
 Lack of soft tissue over the # site

30. Cont.
30
 # in children with developing tooth buds
 Coronoid process #
 Open reduction
 Indications
 Displaced #
 Multiple #
 Associated midface #
 Associated condylar #

31. Cont.
31
 Contraindications
 If GA is not advisable
 Severe comminution or loss of soft tissue
 Severe infection

32. Symphysis & parasymphysis #
32
 Lip is everted & vestibular incision is made
 Periosteum is reflected & mental nerves are identified
 Reduction & plate fixation is done
 Closure is done in layers
 Pressure dressing is given to prevent hematoma

33. Body, angle & ramus #
33
 Mucosal incision is made 3-5 mm below mucogingival
junction
 Incision should not extend beyond mandibularocclusal
plane to prevent herniation of buccal pad of fat
 Periosteum is reflected & mandible is exposed
 Reduction & fixation is done
 Wound is closed in layers

34. Fractures of mandibular condyle
34
 Classification
 No displacement:-a crack is seen.
 Deviation :-simple angulation exists b/w condylar neck &
ramus.
 Displacement :-overlap exists b/w condylar process &
ramus.
 Dislocation :-condylar fragment is pulled anteriorly &
medially.

35. Cont.
35
 Clinical features
 Evidence of trauma in symphysis region.
 Pain & swelling in the region of tmj.
 Limitation of oral opening
 Deviation toawards the involved side on opening
mouth.
 Posterior open bite on contralateral side.
 Posterior cross bite on ipsilateral side
 Blood in external auditory canal.
 Pain on palpation on # site.
 Lack of condylar movement on palpation

36. Cont.
36
 Difficulty in lateral excursion & protrusion.
 Anterior openbite &posterior gagging of occlusion in
bilateral subcondylar #.
 Otorrhoea if there is #of middle cranial fossa.
 Treatment
 Nonsurgical management
 Condylar # without displacement or with min.
displacement, without much occlusal disturbance&
functional range of motion-patient is asked to restrict
movements & semisolid soft diet for 10 to 15 days

37. Cont.
37
 In case of deviation on oral opening without much
occlusal discrepancy,simple muscle training
 In case wherethe condylar fragment overriding is seen
with altration in ramus height,producing
malocclusion,initial elastic traction followed by imf is
given for 2to3 weeks.
 Early mobilization is advocated in young children to
avoid ankylosis of tmj.

38. Cont.
38
 Surgical management
 Indications
 # dislocation in auditory canal or intracranial fossa.
 Anterior dislocation with restricted mandibular
movement.
 Bilateral condylar # with craniofacial dysjunction
 Method of fixation
 Temporal region is shaved.
 The skin over the preauricular region is prepared.
 Preauricular incision is made.
 Zygomatic arch is located.

39. Cont.
39
 Inverted L-shaped incision is made from lower boder of
zygomatic arch to outer surface of ramus.
 If condyle is displaced laterally, periostuem over the
condyle is retracted & condylar retractor is inserted from
posterior border medially to protect the vital structures.
 A hole is drilled through the cortex, &a26 guage wire is
passed through the hole.another hole is drilled on the
ramus.
 Miniplates can also be used.
 # is reduced & IMF is done.
 Wound is closed in layers.
 Immobilization for 15 to 20 days

40. Management of teeth retained in # line
40
 Antibiotic therapy
 Splinting of the tooth if mobile
 Endontic therapy if needed
 Immediate extraction # is infected
 Indication for removal of tooth in # line
 Longitudinal # involving crown & root
 Complete subluxation of tooth from the socket
 Pre –existing periapical pathology
 Grossly infected # line

41. Cont.
41
 Bad periodontal status
 Advanced caries
 Root stumps

42. Complications of maxillofacial injuries
42
 Anaesthesia
 Anaesthesia of lower lip because of the injury to
mandibular nerve.
 It may occur in # of body of mandible.
 It usually recovers in a few weeks.
 If infraorbital nerve is involved anaesthesia occurs in
lower eyelid,lateral part of nostril,upper lip in the
affected side & anterior teeth

43. Cont.
43
 Malunion & deformities
 Deformities occur if reduction is not satisfactory.
 In middle 1/3 injuries,improper reduction result in
flattening of face,anterior openbite with posterior gagging
of occlusion.
 Infection
 it occurs if root stumps are kept in # line or if the
general resistance of the patient is poor or if there is
mobility at the # site.

44. Cont.
44
 Non -union & delayed union
 Occurs if tooth has retained in # line.
- If the # is infected.
- Inadequate immobilization.
- Patients with systemic disease or nutritional
deficiencies.
 It can be treated by
- Removing the cause(infection,teeth in # line).
- Freshening the ends & rewiring
- If there is bone loss, grafing is done.

45. Cont.
45
 Derangement of occlusion
 Minor occlusal derangements are corrected as the
patient starts using the teeth.
 If there is persistance of traumatic occlusion it can be
corrected by selective grinding.
 If severe occlusal derangement, it is corrected by
refracturing the fragment & correction is done.

46. Cont.
46
 Ankylosis of TMJ
 It is more in young adults.
 It occurs in intra capsular #.
 Prolonged immobilization may cause ankylosis.
 Other complications
 Diplopia
 Enophthalmos
 Strabismus
 Deviated nasal septum
 Epiphora
 Anosmia