A Comprehensive educational presentation on the fractures of the middle third of the facial skeleton. By: Dr. Abdul Karim Sharif, MD, PGD Ghalib University Lecturer Kabul, Afghanistan 2015

1. FRACTURES OF THE MIDDLE
THIRD OF THE FACIAL
SKELETON
ABDUL KARIM SHARIF, MD, PGD
School of Dentistry, Ghalib University
Kabul, Afghanistan
October 2015

2. Bones constituting the Middle Third of the
Face
• Maxilla (2)
• Palatine bones (2)
• Zygoma (2)
• Zygomatic Processes of Temporal bone (2)
• Nasal bone (2)
• Lacrimal bones (2)
• Ethmoid and its attached conchae (1)
• Inferior conchae (2)
• Pterygoid plates of sphenoid (2)
• Vomer (1)

3. Physical Characteristics of the Midfacial
Skeleton
• Made up of considerable number of bones – rarely
fractured in isolation
• All the bones are comparatively fragile, articulate in a
most complex fashion
• Greatest portion is maxilla
• Capable to absorb force and transmit to the adjacent articulating
bones
• Acts as a cushion for the trauma directed to the cranium
• Middle third is anatomically complicated – Generally
comminuted fractures

4. Classification of Fractures of the Middle
Third of the Facial Skeleton
• Rene LeFort – 1901 – Paris
• LeFort I
• LeFort II
• LeFort III

5. Classification of Fractures of the Middle
Third of the Facial Skeleton …
• Erich’s – 1942 – Direction of fracture line
• Horizontal Fracture
• Pyramidal Fracture
• Transverse Fracture

6. • Depending on the relationship of the fracture line to the
zygomatic bone;
• Subzygomatic Fracture
• Suprazygomatic Fracture
Classification of Fractures of the Middle
Third of the Facial Skeleton …

7. • Depending of the level of a fracture line:
• Low level fracture
• Mid level fracture
• High level fracture
Classification of Fractures of the Middle
Third of the Facial Skeleton …

8. LeFort I Fracture
• Low Level Fracture
• Subzygomatic Fracture
• Guerin’s Fracture
• Floating Maxilla
• Horizontal Fracture of the Maxilla

9. LeFort I Fracture
• Separation of complete
dentoalveolar part of the maxilla
(pterygomaxillary dysjunction)
• Fractured fragment held by the
means soft tissues
• Fractured fragment is freely
moblie
• A violent force applied over a
more extensive are, above the
level of the teeth

10. • 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 lamina at the junction
of their lower third and upper
two-thirds.
• Line of fracture is the same at the
opposite side
LeFort I Fracture (Fracture Line)

11. • Slight swelling and edema of the lower part of the face
along with the upper lip swelling (gross edema not
present)
• Ecchymosis in the labial and buccal vestibule
• Contusion of the skin of the upper lip may be seen
• Bilateral epistaxis
LeFort I Fracture (Signs and Symptoms)

12. LeFort I Fracture (Signs and Symptoms) …
• Mobility of the upper dentoalveolar portion of the jaw to
digital pressure
• Disturbed occlusion
• Pain while speaking and moving the jaw
• Sometimes upward displacement of the entire fragment –
anterior open bite
• Percussion to maxillary teeth – dull cracked up sound

13. LeFort I Treatment
• Bone Plate
• Circumzygomatic Wiring (IMF + Zygomatic arch
suspension)

14. Zygomatic Arch Suspension
(Circumzygomatic Wiring) + IMF

15. Zygomatic Arch Suspension
(Circumzygomatic Wiring) + IMF

16. LeFort II Fracture
• Mid level fracture
• Pyramidal Fracture
• Subzygomatic fracture

17. LeFort II Fracture
• Violent force applied from anterior direction on the central
region of middle third of the facial skeleton.
• Force delivered at the level of the nasal bone

18. LeFort II Fracture (Fracture Line)
• Starts below the
nasofrontal suture 
crosses the frontal
processes of maxilla on
either side  passes
anteriorly across the
lacrimal bones
immediately anterior to
the nasolacrimal canal
 passes downward,
forward and laterally
crossing the inferior
orbital margin in the
region of
zygomaticomaxillary
suture  crosses the
lateral wall of antrum 
rest as LeFort I

19. LeFort II Fracture (Signs and Symptoms)
• Ballooning or Moon Face
• Circumorbital edema and ecchymosis (Black Eye)
• Bilateral subconjunctival hemorrhage (Middle half of the eye)
• Flat face (Nasal depression or disfigurement)
• Bilateral epistaxis
• Difficulty in mastication and speech

20. LeFort II Fracture (Signs and Symptoms)
• Shortening of the face, anterior open bite
• Elongation of the face (Dish-shaped face)
• Loss of occlusion
• Airway obstruction
• CSF leakage
• Step deformity at the infraorbital margins may be seen
• Anesthesia/paresthesia of the cheek

21. LeFort II Fracture (Treatment)
• Zygomatic Arch Suspension or Frontal Bone Suspension
• Intraosseous wiring may be done at infraorbital margins

22. LeFort III Fracture
• Transverse fracture
• Suprazygomatic fracture
• High level fracture
• Craniofacial dysjunction

23. LeFort III Fracture
• The line of fracture extends above the zygomatic bones
on both sides as a result of trauma being inflicted over a
wider area, at the orbital level

24. LeFort III Fracture (Fracture Line)
• Starts at naso frontal
suture  crosses nasal
bone and the frontal
process of the maxilla
 upper limit of the
lacrimal bones 
continues posteriorly
and crosses the thin
orbital plates 
traverses the lateral
orbital wall.

25. LeFort III Fracture (Signs and Symptoms)
• Clinically similar to the LeFort II, but close examination demonstrates LeFort III
• Gross edema of the face, balooning. “Panda Facies”, 24 –
48 hrs
• Bilateral Circumorbital ecchymosis and gross edema
(Racoon Eye)
• Bilateral subconjunctival hemorrhage (Posterior limit will not be seen)

26. LeFort III Fracture (Signs and Symptoms)
• Tenderness and separation at the frontozygomatic sutures
• Lengthening of the face
• Lowering the ocular level
• Characteristic “dish face” deformity
• May be enophthalmous, diplopia or impairment of vision,
temporary blindness …
• Flattening and widening
and deviation of the nasal bridge
• Epistaxis, CSF rhinorrhea

27. Treatment
• Intraosseous wiring at zygomaticofrontal sutures +
Frontomalar suspension wiring
• Intraosseous wiring at the infraorbital margin, if step
deformity exists