FRACTURES

1. MAXILLARY FRACTURE
DR DAVIS NADAKKAVUKARAN
READER
MALABAR DENTAL COLLEGE

2. CONTENTS
• INTRODUCTION
• CLASSIFICATION
• CLINICAL FEATURES
• INVESTIGATION
• MANAGEMENT

3. INTRODUCTION
They are also called midface fractures.
These fractures will produceDISH FACE DEFORMITY.

4. CLASSIFICATION
Rene Le fort (1904)
Le Fort 1 /guerin fracture
Le Fort 2/pyramidal fracture
Le Fort 3/craniofacial dysjunction

5. MODIFIED Le Fort fracture classification
Le Fort level Description
Le Fort 1 Low maxillary fracture
Le Fort 1 a Low maxillary fracture with
Multiple segments
Le Fort 2 Pyramidal fracture
Le Fort 2 a Pyramidal and nasal fracture
Le Fort 2 b Pyramidal and naso orbital ethmoidal fracture
Le Fort 3 Craniofacial dysjunction
Le Fort 3 a Craniofacial dysjunction and nasal fracture
Le Fort 3 b Craniofacial dysjunction and NOE fracture

6. Le Fort I fracture
 It is the fracture of the pterygoid plates.it is also called horizontal
fractures.
Other names
Subzygomatic fracture
Guerin’s fracture
Floating maxilla

7. Lateral margin of lateral nasal aperture
Running horizontally above nasal floor
Laterally above canine fossa
Goes below the zygomatic buttress
Crossing the anterior wall of maxillary sinus
Posteriorly across pterygomaxillary fissure
and fracture the pterygoid plates
FRACTURE PATTERN

8. ETIOLOGY
A strong blow with a sharp object to the level above the tooth bearing region
-------------- fracture of the entire segment----------complete detatchment of tooth
bearing part of maxilla from the cranial base.(FLOATING MAXILLA)

9. SIGNS AND SYMPTOMS
EXTRAORALLY
 Minimal external signs of injury
 Swelling of the upper lip
 Increase in vertical dimension of the face
 Bilateral bleeding from the nose
 Pain during speech and mastication

10. INTRAORALLY
• ECCHYMOSIS: In buccal sulcus in zygomatic region
in greater palatine foramen region(Guerin ‘s
sign)
• Laceration in labial mucosa
• The fractured maxilla shifts downwards and backwards
creating an anterior openbite
• Premature contact in posterior molar region
• Tenderness in the region of maxillary buttress
• If a midpalatal split is present, bruising in
the palate
• Air emphysema of facial soft tissues.
• Dull hollow sound on percussion of teeth.

11. Le Fort II fracture
 A violent force from the anterior direction acts on the middle third of the facial skeleton
 extending from the glabella to the alveolar margin results in the fracture of pyramidal shape.

12. From middle third of nasal bone
Cross the frontal process of maxilla on either side
From middle third of nasal bone
Crosses lacrimal bone anterior to nasolacrimal duct
Downwards,forwards&laterally -cross infraorbital rim
Lateral wall of maxillary antrum,beneath zygo.buttress
Pterygomaxillary fissure &fracture pterygoid plates
FRACTURE PATTERN

13. ETIOLOGY
Strong force applied in the central region at the level of nasal bones.

14. SIGNS AND SYMPTOMS
EXTRAORALLY
 Moon face
 Increased vertical dimension
 Dish face deformity
 Bilateral circumorbital ecchymosis
 Subconjunctival heamorrhage
 Chemosis
 Increased intercanthal distance
 Epistaxis
 CSF rhinorrhea
 Tenderness
 Infraorbital nerve paresthesia

15. INTRA ORALLY
 Anterior openbite
 Molar gagging
 Midpalatal split
 Buccal ecchymosis
 Dull sound on percussion of teeth
 Mobility of maxilla at infraorbital level

16. Le Fort III Fracture
 High level/Suprazygomatic fracture
 The line of fracture lies above the zygomatic bones on both the sides.
 The force is applied from the lateral direction with the severe impact
 This fracture detaches the entire middle third of the face from the cranial base
 and thus called as craniofacial dysjunction.

17. FRACTURE PATTERN
Starts from the frontonasal suture
Nasal bones,lacrimal bones,thin orbital plate of
ethmoid bone
Fracture line redirect at the optic foramen
At posterior part of inferior orbital fissure
One part-fractures the root of the pterygoid plates
One part-seperates zygomatic bone from frontal
bone

18. SIGNS AND SYMPTOMS
Extra oral
 Moon face
 Panda face appearance
 Subconjunctival heamorrhage
 Diplopla,restricted eye movement
 Increased intercanthal distance
 Depressed nasal bridge
 Epistaxis
 Anosmia
 Elongation of the face
 Altered pappillary level
 Hooding of the eye

19. INTRAORALLY
Anterior openbite
Molar gagging
Midpalatal split
Mobility of maxilla at F-Z suture

20. RADIOGRAPHIC EXAMINATION OF MAXILLARY FRACTURE
 Paranasal sinus view
 Lateral skull view
 OPG
 CT
 MRI
 Occlusal radiograph
 IOPAR

21. MANAGEMENT OF MAXILLARY FRACTURE
It is mainly based on 3 principles
 REDUCTION
 FIXATION
 IMMOBILIZATION

22. REDUCTION OF MAXILLA
1.Manual method of reduction
2.Reduction by means of wires
3.Reduction by using maxillary disimpaction forceps
4.Reduction by means of traction
MANUAL METHOD OF REDUCTION
 Here fractured maxilla is manipulated by hand within 3-4 days of fracture.
 During fracture maxilla moves downward and backward direction
 Manipulation in such a way that it will disimpact the mandible and move
it forward.
 After this wiring can be done.

23. REDUCTION BY MEANS OF WIRES
 If mailla is impacted,it is difficult to mobilise the segment manually.
 In this case wire is fix two double wires encircling the first and second
Ma*illary molars and twisting them individually on either side.
REDUCTION BY USING MAXILLARY DISIMPACTION FORCEPS
 Row’s maxillary disimpaction forceps are used.
 Smaller unpadded blade-is placed in nasal floor
 Larger curved padded end –intraorally into palate.

24. REDUCTION BY MEANS OF TRACTION
If the fracture is not a fresh fracture,there is partial callus formation in between
the fractured segment ,so manual mobilization is difficult to achieve
o Elastics can be used for traction.
o Arch bars are placed in upper and lower arches and elastics are engaged on
these
o Arch bars to pull the maxilla forward.
o Once satisfactiry occlusion is achieved, IMF is done

25. CLASSIFICATION OF METHOD OF MAXILLARY FIXATION
1)Internal fixation
a)Direct osteosynthesis
miniplates and screws
transosseous wiring
b)Suspension wires
frontal central lateral suspension
circum zygomatic
zygomatic
circumpalatal
infraorbital
piriform aperture suspension
peralveolar suspension
2)External fixation
a)craniomandibular
box frame systems
halo frames
plaster of paris head cap
b)Craniomaxillary
supraorbital pins
zygomatic pins
halo frame

27. CRANIOMAXILLARY FIXATION
• Mobile maxillary segment is fixed to the stable cranium
• Connectors from the arch bar of maxilla to external head gear
eg:haloframe
CRANIOMANDIBULAR FIXATION
• The fractured maxilla is sandwiched between the mandible and the stable
cranium
EXTERNAL SKELETAL FIXATION

28. REFERENCES
Textbook Of Oral and Maxillofacial surgery ---Neelima Anil Malik