The maxilla is the middle third of the facial skeleton, formed by two pyramidal halves. It has four processes and a hollow body forming the maxillary sinuses. It assists in forming several structures and is attached to the skull base by strong buttresses that distribute forces. The maxilla has transverse and vertical buttresses. Children have smaller sinuses and tooth buds, while adults have larger sinuses penetrating the midface. The alveolar process provides tooth support but weakens with tooth loss. Maxillary fractures can occur from direct impacts and vary in severity and pattern. The Le Fort classification identifies fracture patterns based on lines of weakness. Treatment involves reduction, immobilization with intermaxillary fixation, and stabilization with plates or wires

1. Juhi Agrawal
Moderator- Dr. V. K. Tiwari

2.  Middle third of the facial skeleton
 Formed by union of two symmetrical irregular
pyramidal halves
 A body and four processes
 Frontal
 Zygomatic
 Palatine
 Alveolar

3.  Body is hollowed on its anterior aspect forming
the maxillary sinuses
 Assists in formation of
 Orbit (orbital floor)
 Nasal fossa
 Oral cavity
 Palate
 Pyriform aperture
 Support for the nasal bones and nasal cartilages

6.  Attached to the base of the skull by a series of
buttresses
 Vertical system strong and capable of
 Horizontal system resisting force
 The buttress system distributes the load over
the entire craniofacial skeleton

7.  Vertical buttresses
 Anteriorly, the nasofrontal buttress
 Laterally, the zygomaticomaxillary buttress
 Posteriorly, the pterygomaxillary buttress

10.  Transverse maxillary buttresses include
 The superior orbital rims
 The inferior orbital rims
 The palate

12.  The forces are distributed through
 The articulation of the maxilla against the
frontomaxillary, zygomaticomaxillary, and ethmoidal
maxillary sutures
 The palatine bone and pterygoid plates of the
sphenoid give additional stability posteriorly to the
maxilla which extend to the strong buttresses of the
sphenoid bone in the skull base
 The vomer, the perpendicular plate of the ethmoid,
and the zygoma distribute the load to the temporal
and frontal bones and to the anterior cranial fossa

14.  Children
 Maxillary sinuses are small
 Tooth buds are present
 Adults
 Large
 Penetrate most of the central structure of the midface,
nose, and periorbital area
 Thus a thin orbital floor and thin anterior and posterior
medial wall of the maxilla
 Tooth buds are absent in adult and causes weakening
of the bone of the midface

16. Alveolar process of the maxilla
 Strong and thick
 Provides excellent support to the teeth
 Also support the horizontal processes of the
maxilla through the palate
 Alveolar process thins, weakens, and resorbs
with loss of teeth and entire maxilla may thus
become weaker, and recession may occur
 Resorption of the anterior surfaces of the
maxilla may occur simultaneously

17.  Muscles attaching to the maxilla
 Muscles of facial expression anteriorly
 Pterygoid muscles posteriorly
 Although muscle contraction has less role but it
explains the displacement of the fractured
segments

20. The nerves pass through
 Anterior wall of the maxilla (anterior superior dental
alveolar nerve and other branches of infraorbital
nerve)
 Palatine canal between the maxilla and the palatine
bones in the posterior portion of the palate (palatine
branches of the second division of the trigeminal
nerve)
 Lateral walls of the maxilla (branches of the
posterior superior dental alveolar nerves)

22.  Direct impact
 Vary from simple incomplete fractures of a
portion of the alveolar process of the maxilla to
comminuted fractures of the entire midface
area
 Pattern and distribution depend on the
magnitude and the direction of force
 Frontal
 Lateral
 Inferior impact

23.  Segmental fractures get displaced posteriorly by the
pterygoid muscles
 Sagittal fracture gets pulled laterally by facial muscle
attachments
 Higher maxillary fractures get displaced in downward
and backward direction by the pull of the pterygoid
muscles
 Maxillary fractures in association with fractures of the
zygoma cause posterior and medial displacement of
fragment due to pull of masseter muscles

25.  Le Fort classification identifies the patterns of
midfacial fractures
 The thinner areas- weakened sections through
which fracture lines occur, designated as "lines of
weakness"
 Fracture lines travel adjacent to the thicker portions
of the bones, designated as "areas of strength”
 Straightforward pure bilateral Le Fort I, Le Fort II, or
Le Fort III fractures are less common than
combination patterns
 Fracture is usually more comminuted on the side of
the injury

26. The highest level and components of the fracture
on each side
 Le Fort I: Maxillary alveolus
 Split palate
 Alveolar tuberosity fracture
 Le Fort II: Pyramidal fracture
 Le Fort III: Craniofacial disjunction
 Le Fort IV: Frontal bone

27.  Guérin fracture or transverse fracture
 Traverse the maxilla horizontally above the level of
the apices of the maxillary teeth
 Section the entire alveolar process of the maxilla,
vault of the palate, and inferior ends of the
pterygoid processes in a single block
 Extends transversely across the base of the
maxillary sinuses and is almost always bilateral

29.  Pyramidal fractures
 Blows to the central maxilla with a frontal
impact
 The fracture begins above the level of the
apices of the maxillary teeth laterally and
posteriorly in the zygomaticomaxillary fissure
 Extends through the pterygoid plates

30.  Travels medially and superiorly to pass through
anterior wall of the maxillary sinus near
zygomatico-maxillary suture
 Then passes through the orbital plate of maxilla
and medial portion of the inferior orbital rim
 Crosses through the lacrimal bone and frontal
process of maxilla

31.  Extends across the nasal bone, usually at the
junction of thin and thick parts of the bones
 Damage to the ethmoidal areas is routine
 Centrally, it may traverse the nose high (at the
junction of the nasal bones and frontal bone) or
low (through the nasal cartilages)
 Frontal sinus may be fractured in high-energy
central midface impacts

33.  Craniofacial disjunction
 Fracture extends through the zygomaticofrontal
suture and the nasal frontal suture
 Across the floor of the orbits
 Separate all midfacial structures from the cranium
 Maxilla is usually separated from the zygoma
 Traverses through upper one third of pterygoid
plates

37.  Antero-posterior fracture
 Less common fractures
 Splits the maxillary alveolus longitudinally near
the junction of the maxilla with the vomer
 Exits anteriorly to traverse between the cuspid
teeth
 Extends through the maxillary portion of hard
palate back through the horizontal portion of the
palatine bone

38.  Usually involve the palate alone and Le Fort I
level, occasionally extend to the Le Fort II level
 They increase the comminution of the Le Fort
fracture and make the treatment more difficult
 Displacement depends on the direction and
degree of fracture and muscle forces

41. HISTORY
 Frontal or lateral impact
 Thrown forward, striking the middle third of the
face against an object such as steering wheel
of an automobile
 Force sustained on the lower maxilla
 An alveolar or transverse fracture of the maxilla is
likely

42.  Force is more violent and sustained at a higher
level
 Frontal impact- Le Fort II fracture
 Higher energy impact injuries- combination of the Le
Fort I and Le Fort II fractures
 Lateral impact- Le Fort III level fracture on one side
and a Le Fort II level fracture on the other side
 Upward forces by impaction of the mandible
against the maxilla can cause maxillary
fractures

43.  Elongated, retruded appearance in the middle
third of the facial skeleton, so-called donkey-
like facies
 Maxillary dentition is frequently rotated
 Le Fort fractures of all types- malocclusion and
bilateral maxillary sinus fluid on radiographs
 Le Fort (II and III) fractures- bilateral periorbital
ecchymosis

44.  Symmetrical facial swelling
 Subconjunctival haemorrhage and swollen
eyelids
 Epistaxis
 CSF rhinorrhoea
 Intra-oral examination
 Ecchymosis in upper buccal sulcus
 Irregularity of central portion of hard palate
 Hematoma of the soft palate

45.  Teeth examination
 Complete transverse fractures-
 vertical and downward displacement, may have normal
occlusion
 Backward and downward displacement or lateral twist
of maxilla, and premature occlusion in the posterior
dentition with an anterior open bite occurs
 Fractured segment is usually mobile or may be
impacted (manifest as an open bite)

46.  On palpation
 With the tips of the fingers both externally through
the skin and internally intraorally
 Bimanual examination- grasp the teeth and
alveolar process between thumb and index finger of
one hand and movement is felt by palpating the face
with the fingers of the other hand
 Mobility of the maxilla, may be absent in greenstick
fractures or impacted fractures
 Infraorbital margin integrity (LeFort II)

47.  If the maxilla medially is higher than the
zygoma
 Zygomatic fracture
 If the maxilla medially is lower than the zygoma
 Pyramidal fracture
 Nasal bones palpation
 Nasal fracture is a routine component of Le Fort II
and III fractures

48.  Plain films
 Difficult to demonstrate on routine plain radiographs
 Waters view
 Caldwell view
 Submental vertex views
 Lateral view
 Bilateral maxillary sinus opacity should always
suggest the possibility of a maxillary fracture

49.  CT scan
 Preferred for maxillary fractures
 Especially those within the orbit, pterygoid plate and
palate
 Axial and coronal CT scans taken from the palate
through the anterior cranial fossa
 Both bone and soft tissue windows for evaluation of
the orbital portion of the fracture and for the brain
 Bilateral maxillary sinus fluid usually represents a
maxillary fracture until proven otherwise

50. Emergency measures
 Establishment of an airway
 Control of hemorrhage
 Closure of soft tissue lacerations
 Placement of the patient in intermaxillary
fixation

51.  Severly displaced fractures may block the airway
 Hemorrhage, swelling, and secretions
 Structures forced into the pharyngeal region, eg.,
Loose teeth, pieces of broken bone, broken
dentures, blood clot
 Measures taken
 Cleansing of the mouth
 Removal of loose dentures or teeth
 Prone positioning
 Nasopharyngeal airway insertion
 If transportation needed, tracheostomy may be required

52.  Two components of treatment
 Reduction of displaced fragments and their
replacement thus re-establishment of normal
occlusion
 Immobilization of reduced segments against the
cranium until consolidation occurs

53.  Arch bars ligated to the upper and lower
dentition and arch bars are linked with either
elastic or wire
 As soon after a maxillary injury as possible
 Eliminates much of the deformity of a midfacial
fracture
 Reduces the distraction of the fragments

55.  Frequently facilitates cessation of hemorrhage
 Places the maxilla at rest, which is an
important treatment when dural fistulas exist
 When mandible is intact, it limits the downward
and posterior displacement of the lower portion
of the midface and keys a major portion of the
lower midface into proper anterior-posterior
reduction

57. Importance of post-operative IMF
 The midface should be considered a dependent
structure because of its thin bone which are not
conducive to stability
 Most of its injuries are comminuted
 Malleable plates and small screws viewed as a relative
positioning device rather than rigid fixation
 Maxilla has weak sagittal buttresses

58. Alveolar fractures
 Two guiding principles
1. Teeth of the non-fractured side of the maxilla are
utilized for reduction and fixation of the fractured
fragments
2. Teeth of the mandible are maintained in occlusion
with those of maxilla

59.  Simple fractures can be digitally repositioned
 Teeth selected for anchorage according to their
ability to withstand stress and strain
 Methods
 Horizontal and lateral interdental wiring
 Intraoral retention appliances
 Open reduction by plates and screws to unite
the alveolar fragment to the remainder of the
maxilla

61.  Maintainance of reduction
 IMF
 Barton bandage- figure of eight bandage
 Fixation maintained for at least 4 to 12 weeks
or until clinical immobility has been achieved

63.  Complete separation of lower maxilla from its
attachment to remaining maxilla
 Or separation of maxilla from the cranium
 Floating maxilla
 Treatment dictated by direction and degree of
displacement
 Simple downward displacement- occlusion
maintained
 Lateral or backward displacement- malocclusion is
present

65.  Immobilisation of maxilla against the cranium
maintaining the normal occlusion
 Normal occlusion- IMF
 Immobilisation
 External splints- older method
 Barton bandage
 Adhesive tape made splint
 Plaster headgear
 Plate and screw fixation

67.  Suspension wires
 Passed from the arch bars to a point above the most
superior level of the Le Fort fracture on each side
 Thought to contribute to stability by compression of
the midfacial skeleton
 But they reduced the vertical height of the midface
and retrude the midface

68. Suspension wires
 LeFort I-
 Zygomatic
 Infraorbital
 Piriform aperture
 Circumzygomatic
 LeFort II
 Circumzygomatic
 Frontal- central and lateral
 LeFort III
 Frontal- central and lateral

72.  Wire interfragment fixation
 Was used for bone alignment and reduction
 Provides only a one-dimensional force of apposition
so rigid bone stabilization not produced
 Three-dimensional stabilization
 Multiple wire points of fixation per fragment
 Plate and screw technique which provides stability
by the placement of two screws (two points of
fixation) per bone fragment

73.  The goals in midface fracture treatment
 Achieving the original dimensions of the facial bones
to re-establish midfacial height and projection
 Provide proper occlusion
 Restore the integrity of the nose and orbit
 Stabilize these dimensions with bone grafts and
plate and screw fixation

74. Anatomic reconstruction of the buttresses of the maxilla
 Anteriorly, the nasomaxillary and
zygomaticomaxillary buttresses are reconstructed -
bone grafts and rigid fixation
 Posterior height- IMF
 Posterior (ramus) height of the mandible must be
correct for a proper reconstruction
 Important to have the mandible anatomically
reconstructed as a buttress
 Ramus and subcondylar fractures are stabilized by open
reduction and rigid fixation

75.  Three incisions required for exposure
 Molar to molar sublabial incision- access to maxillae,
up to the orbital rims
 Blepharoplasty incision of the lower eyelid or
subconjunctival approach- access to inferior and
lateral walls of orbit
 Bicoronal scalp incision extended down to the ears-
access to frontal, nasoethmoid, zygomatic process
and orbital bones and zygomatic arches

77.  Less frequent
 Usually associated with fractures of the middle
third of the face
 Absence of teeth provide a measure of
protection for the edentulous elderly patient
 Older patients are not usually exposed to the
traumatic hazards of the lifestyle of the younger
age groups
 Dentures provide some protection by absorbing
traumatic forces

78. Minimal displacement causing little facial
deformity
 Soft diet for 3 to 8 weeks after which usually
healing has occurred
 New denture is constructed after this to correct
malocclusion discrepancy

79. If mobility or
significant
displacement
 In the past, wires
were passed
through the
fragment and
attached to a
cranial fixation
appliance

80.  Today, reduction and immobilization of the
midface fracture segments by open reduction
and plate and screw fixation is usually
performed

81.  If Le Fort I level segments are so comminuted
that accurate reduction is difficult, denture or a
splint designed to key the position of the lower
midface segments to the mandible is
recommended
 Bone grafts may be required
 Splints may be screwed temporarily to the
alveolus of the maxilla, palate, or mandible,
which provides a straightforward and rapid
initial fixation of the denture

82. Early
 Haemorrhage
 Airway obstruction
 Infection
 Lacrimal obstruction
 CSF rhinorrhoea
 Blindness
Late
 Nonunion or malunion
 Plate exposure
 Lacrimal system obstruction
 Infraorbital and lip hypoesthesia or anesthesia
 Devitalization of teeth

83.  Nasal cavity or nasopharynx
 Tamponade in closed midface injuries
 Anterior-posterior nasopharyngeal packing
 Manual reduction of the displaced maxilla
 Reduction in intermaxillary fixation
 Angiographic embolization
 External carotid and superficial temporal artery
ligation as a last resort

84.  Airway is compromised by
 Posterior displacement of the fracture fragments
 Edema and swelling of the soft tissues in the nose,
mouth, and throat
 Treatment
 Nasopharyngeal airway
 Intubation
 Tracheostomy

85.  Less common
 Causes
 Faulty immobilization of fragments
 Foreign bodies in the wound
 Teeth in the line of fracture
 Associated soft tissue wounds
 Pre-existing sinusitis may get flared up

86.  Treatment
 Removal of any devitalized bone fragments or soft
tissue
 Sinus drainage by nasal-antral window or
endoscopic drainage of the maxillary sinus by
enlarging its orifice
 Extraction of loose or devitalized teeth or foreign
material
 Administration of antibiotics

87.  High le fort (II and III) level fractures associated
with fractures of the cribriform area
 Antibiotic prophylaxis
 Recumbent nursing
 Blowing of the nose and placement of obstructing
nasal packing should be avoided

88.  Rare complication
 May complicate le fort II and III
 Cause
 Swelling of the nerve within the tight portion of the
optic canal
 Interference with the capillary blood supply of the
optic nerve by swelling and edema
 Rarely optic nerve gets severed by bone fragments

89.  True nonunion is rare
 Delayed union is frequent
 Thin bone of the maxillary sinuses
 Comminuted fractures
 Delayed union results in malocclusion
 If the arch bars or intermaxillary fixation is
removed too soon, the maxilla may slowly drift
into malocclusion especially if comminuted
fracture at the le fort I level

90.  Impacted fractures or partially healed fractures
 Osteotomy and full open reduction
 Occlusion maintained by intermaxillary fixation
 Rigid fixation
 Bone grafts
 Lack of good bone or bone gaps in the buttress
areas
 Taken from the calvarial, iliac, or rib donor sites
 Attached with plate and screw fixation
 Supplement (but do not replace) plates for rigid
fixation

91.  Le Fort I and Le Fort III
 Due to
 Fracture displacement in the bones composing the
nasal lacrimal duct
 Bone proliferation after fracture near the nasal
lacrimal canal that obstructs the duct in its bony path
 Duct transection in the canal

92. Treatment
 Canalicular lacrimal system is intact and duct is
obstructed- dacryocystorhinostomy
 Nasal lacrimal sac and canaliculi injury
 Protection against obstruction - anatomic
repositioning of the fracture fragments of the medial
portion of the maxilla and nasoethmoidal-orbital area
 If obstruction has occurred, external drainage and
secondary dacryocystorhinostomy is required

95.  Central third of the upper midfacial skeleton
 Medial orbital walls
 The nasal process of the frontal bone,the frontal
process of the maxilla, and the thick upper portions
of the nasal bones
 Posteriorly- the frontal process of the maxilla, the
thinner lacrimal bone, and the delicate lamina
papyracea

96.  The anterior ethmoidal foramen is situated
along the upper border of the lamina
papyracea and transmits the nasociliary nerve
and the anterior ethmoidal vessels
 The posterior ethmoidal foramen gives
passage to the posterior ethmoidal nerves and
vessels which rupture in significant
nasoethmoidal-orbital fractures and is one of
the causes of significant orbital hematoma

97.  Medial posterior portion of the medial orbital
wall
 Body of the sphenoid, immediately in front of the
optic foramen
 In severe skeletal disruption, the fracture lines
involve the optic foramen and superior orbital fissure
producing shearing of nerve fibers or a disturbance
of circulation to the optic nerve or a pressure injury to
the nerve, which might result in blindness

98.  Area between the orbits and below the floor of
the anterior cranial fossa
 Contains
 Two ethmoidal labyrinths
 Superior and middle turbinates
 Median thicker plate of septal bone
 Perpendicular plate of the ethmoid
 Roughly pear shaped in transverse section,
being wider in the middle than in the posterior
portion

99. Relations
 Above by the cribriform plate in the midline and by
the roof of each ethmoidal mass on the sides
 Below at the level of the horizontal line through the
lower border of the ethmoidal labyrinths
 Laterally, medial wall of the orbit
 Anteriorly, the frontal process of the maxilla and the
nasal process and spine of the frontal bone
 Divided into two approximately equal halves by the
nasal septum

100.  A pyramid with a median partition
 Inferior wall, or floor of the frontal sinus
 Roof of the orbit
 Thinnest portion of the frontal sinus
 Anterior wall
 Thickest
 Compact and some cancellous bone
 Posterior wall
 Is thinner than the anterior wall
 Almost entirely of compact bone, which separates
the sinus from the frontal lobe

101.  The nasofrontal ducts descend from the posterior
inferior portion of the sinus to middle turbinate of
the nose
 Size, shape, and septation vary greatly
 May occupy most of the frontal bone or only a small
portion of the lower central portion
 The two sides are usually strikingly asymmetric
 May be the size of an ethmoid cell or may be
pneumatizing the entire frontal bone and roof of the orbits
 Always larger on one side than on the other
 Occasionally, one or both frontal sinuses may be absent
 Contains highly variable partial and complete septa.

102.  Pyramidal or cuboidal in shape
 3.5 to 5 cm long and 1.5 to 2.5 cm wide
 Cellular in structure
 8 to 10 cells with thin lamellar walls
 Divided into anterior and posterior sections
 Drain into the middle meatus of the nose

104.  A typical cause is a blunt impact over the upper
portion of the bridge of the nose by a blunt object,
striking the nasofrontal area and crushing injury
with comminuted fractures is produced
 Orbital roof, the interorbital space, and the
perpendicular plate of the ethmoid are frequently
involved
 The anterior cranial fossa may be fractured or
penetrated
 May also involve the roofs of the ethmoid sinuses
and the lateral walls of the ethmoid sinuses

105.  Neurologic complications
 Laceration of the dura covering the frontal lobes
 Laceration of the tubular sheaths enveloping the
olfactory nerves
 Contusion or severance of the nerves as they
perforate the cribriform plate
 Penetration of the brain by sharp-edged ethmoidal or
frontal cell walls
 Blunt contusion of brain tissue

106.  Splintering of the lamina papyracea facilitates
an enlarged blowout fracture
 Lacerations may sever the levator palpebrae
superioris or penetrate through the medial
canthal ligament and lacrimal system
 Less commonly, the medial canthal tendon
may be avulsed from bone with its contained
lacrimal system

107.  Unilateral (36%) or bilateral (64%)
 The unilateral type-
 Upper le fort II or III injuries or in fractures involving
the frontal area progressing into the nasoethmoidal
region
 Also involves the zygoma and the medial inferior
orbit.

108.  Produced by two types of backward and lateral
displacement
 First type
 The frontal process of the maxilla and the nasal
bones penetrate the interorbital space, comminuting
the ethmoidal cells and outfracturing the medial walls
of the orbit
 Medial canthal tendon attachments are displaced
with the bone, and the medial canthi are displaced
laterally

109.  In the second
 More common type
 Nasal bones and the frontal process of the maxilla
are splayed outward and projected backward into the
medial portion of the orbital cavity along the lateral
surface of the medial orbital wall
 The medial canthal tendon usually is not severed
from bone, nor is the lacrimal or canalicular system
transected in the absence of cutaneous lacerations
 Traumatic telecanthus contributed to an increase in
the thickness of the medial orbital wall from the
overlapping bone fragments

110. TYPE DESCRIPTION
I Incomplete fracture, mostly unilateral, displaced only inferiorly at the
infraorbital rim and piriform margin
II Section the entire nasoethmoidal area as a unit, telecanthus
doesnot occur, rotated and posteriorly displaced, and considerable
canthal distortion occurs
III Comminuted nasoethmoidal fractures with the fractures remaining
outside the canthal ligament insertion
IV Either have avulsion of the canthal ligament (uncommon) or extend
underneath the canthal ligament insertion

112.  Nose flattened and appear to have been
pushed between the eyes
 Loss of dorsal nasal prominence
 Obtuse angle is noted between the lip and
columella
 The medial canthal areas are swollen and
distorted with palpebral and subconjunctival
hematomas
 Ecchymosis and subconjunctival hemorrhage

113.  Crepitus present directly over the medial canthal
ligaments
 Bimanual examination of the medial orbital rim
 Performed by placement of a palpating finger deeply over
the canthal ligament and a clamp inside the nose with its
tip directly under the finger. The frontal process of the
maxilla may then, if it is fractured, be moved between the
index finger and the clamp, indicating instability
 Confirms both the diagnosis and the need for an open
reduction
 If the clamp is placed under the nasal bones, it
erroneously identifies a nasal fracture as canthal
instability.

114.  Intranasal examination
 Swollen, bulging mucosa with fractures of the septum
suggested by its displacement, swollen mucous
membranes, and septal hematoma
 Septal hematomas should be specifically searched for
 Often accompanied by the signs of bilateral
orbital blowout fractures or fractures of the
frontal bone, maxilla, and zygoma

115.  If the patient is irritable, restless, or
unconscious or had a loss of consciousness, a
frontal brain injury should be suspected
 CSF rhinorrhea, often masked by bloody
drainage, distinguished by the "double ring"
sign
 When the degree of comminution of the
fracture is sufficient, the medial canthal
ligament and its attached frontal process of the
maxilla move laterally producing Telecanthus

116.  Plain radiographs
 often mask the fractures
 critical details obscured and always incomplete
 CT scan shows fractures of
 frontal process of the maxilla
 nose
 medial and inferior orbital rims
 medial orbital wall and orbital floor

117.  Fractures of the anterior cranial fossa difficult to
detect in the ordinary axial CT section, especially if
displacement is minimal
 Air in the subdural or extradural space or rarely in a
ventricle is a sign of communication of the intracranial
area with the nasal cavity or sinuses
 Fractures of the frontal sinus
 Depression of the anterior or posterior walls of the frontal
sinus
 Air-fluid level implying nasofrontal duct obstruction
 Displacement of either the anterior wall alone or the
anterior and posterior walls of the sinus may be observed.

118.  Fragmentation and a "buckled" appearance of
the cribriform plate- penetration of bone
fragments toward the base of the brain
 Brain tissue in the nose may also be seen,
which is an indication for neurosurgical
intervention

119.  Brain trauma should always be suspected
 Neurosurgical intervention is required in
patients who have depressed or open frontal
skull or cranial base fractures
 neurologic examination must assess the level
of consciousness, motor response, eye
movements, and response to questions

120.  CSF leak must be assumed in any patient with
a nasoethmoidal-orbital fracture