SORRY FOR SHORT COMINGS

1. DIAGNOSIS&TREATMENT
OFMIDFACIAL
FRACTURES
Dr. Danyal Khalid
MDS,RESIDENT OMFS
danyalkhalid4@gmail.com/0512313667

2. Table of content
• Introduction
• Causes
• Midfacial bones
• Facial Buttresses
• Nerve supply of Midfacial region
• Important blood vessels
• History and examination
• Types of Midfacial fractures
• LeFort I,II,III and management
• CSF rhinorrhea
• Recent advances
• Coclusion 2

3. 3
Introduction

4. 4
Introduction
• Middle third of the facial skeleton is an area bounded
– Superiorly by a line drawn across the skull from the
zygomaticofrontal suture of one side, across the
frontonasal and frontomaxillary sutures to the
zygomaticofrontal suture on the opposite side
– Inferiorly by the occlusal plane of the upper teeth,
or, if the patient is edentulous, by the upper
alveolar ridge.

5. • Posteriorly, the region is demarcated by the
sphenoethmoidal junction, but includes the
free margin of the pterygoid laminae of the
sphenoid bone inferiorly.
5

6. Causes of facial fractures
• Motor vehicle accidents
• Assault/Domestic violence
• Falls
• Sports- related incidents
• Pathological
• Work- related incidents
• Warfare
6

7. Midfacial bones
Sphenoid (1)
Ethmoid (1)
7

8. 8
• The frontal bone, the sphenoid body and greater and
lesser wings are not usually fractured.
• In fact, they are protected to a considerable extent by
the cushioning effect achieved as the fracturing force
will crush the relatively weaker bones comprising the
middle third of the facial skeleton.
WHICH LEADS US TO TALK OF BUTTRESSES

9. Facial buttresses
• The central midface has many fragile bones that could
easily be crushed when subjected to strong forces.
• They are surrounded by thicker bones of facial
buttress system lending it some strength and
stability.
9

10. Midface buttresses are composed of:
• Frontal bone
• Maxillary bones
• Zygomatic bones
• Sphenoid bone
AND THEIR ATTACHMENTS TO ONE ANOTHER
10

11. • 2 Components of Buttress system:
– Verticalbuttresses
– Horizontalbuttresses
11

12. • Vertical buttresses:
1. Nasomaxillary
2. Zygomaticomaxillary
3. Pterygomaxillary
4. Vertical mandible
• Resist occlusal load.
12

13. • Horizontal buttresses:
1. Frontal bar
2. Infraorbital rim & nasal
bones
3. Hard palate &
maxillary alveolus
• Interconnect and provide
support for the vertical
buttresses.
13

14. Nerve Supply
• The middle third of the face supplied by 2nd division
of the Trigeminal nerve.
14

15. Maxillary nerve branches
Maxillary nerve
Infraorbital
Posterior superior alveolar
Palatine
Nasopalatine
Zygomatic nerve
15

16. 3/12/2016 16
Blood supply
• The facial region is supplied by branches of
external carotid artery.

17. 17
Important blood vessels
• The third part of the maxillary artery and its
terminal branches are closely associated with
the fractures of the middle third of the face.
• Occasionally the artery or its greater palatine
branch is torn in the region of the
pterygomaxillary fissure or pterygopalatine
canal resulting in severe life threatening
hemorrhage into the nasopharynx.

18. 18
History taking

19. 19
Take AMPLE history
• A - Allergies
• M - Medications (Anticoagulants, insulin and
cardiovascular medications especially)
• P – Previous medical/surgical history
• L – Last meal (time)
• E – Events/Environment surrounding the
injury (Exactly what happened)

20. 20
History taking
• How did the accident occur?
• When did the accident occur? Time since
injury.
• What are the specifics of the injury, including
the type of object contacted, the direction
from which contact was made?

21. 21
• Did loss of consciousness, vomiting, bleeding
occur?
• What symptoms are now being experienced
by the patient, including pain, altered
changes, and change insensation, visual
bite?

22. 22
Physical examination

23. 23
Physical examination
• Evaluate soft tissues for wounds.
• Palpate bony landmarks beginning with the:
– Supraorbital and lateral orbitalrims
– Infraorbitalrims
– Malareminences
– Zygomaticarches
– Nasalbones.

24. 24
Physical examination
• Any steps or irregularities along the bony
margin are suggestive of a fracture.
• Numbness over the area of distribution of the
trigeminal nerve is usually noted with
fractures of the facial skeleton.
• Inspect oral cavity for lost teeth, lacerations,
occlusal alterations, step deformities.

25. 25

26. Types of Midfacial
fractures
26

27. Types of Midfacial fractures
• LeFort I, II, III Rene LeFort 1901
• Zygomatic complex fractures
• Zygomatic arch fractures
• Orbital blow out
• Nasal fractures
• NOE (Naso Orbital Ethmoid) fractures
MAY BE ISOLATED OR OCCUR IN COMBINATION
27

28. 28
Classifications
• Helps for communication purpose and to plan
treatment.
• Rene LeFort:
– LeFort I, LeFort II and LeFortIII.
• However there were other classifications also..

30. • Erich’s (1942)- direction of the fracture line.
30

31. 31
• Another classification based on relationship of
the fracture line to the zygomatic bone -
–Below the zygomatic bone - Subzygomatic
fractures
–Above or including the zygomatic bone -
Suprazygomatic fracture

32. 32
• Another classification depending on the level
of a fracture line
– Low levelfracture
– Mid levelfracture
– High levelfracture
• The most universally used classification is
LeFort’s classification.

33. PALATAL FRACTURE CLASSIFICATION
Type I:Alveolar fracture
Type Ia:Anterior alveolus
Type Ib: Posteriolateral
Type II :Sagittal fracture
Type III :Parasagittal fracture
Type IV: Para-alveolar fracture
Type V:Complex comunited fracture
Type VI: Transverse fracture

34. PALATAL FRACTURE CLASSIFICATION

35. LeFort I fracture
• Results from a horizontal force delivered above the
level of the teeth (to the maxilla).
• The fracture courses from the lateral border of the
pyriform aperture above the canine
lateral antral wall  behind the
eminence
maxillary
tuberosity  across the lower third of the pterygoid
plate.
35

36. • Almost always involves the pterygoid process of
the sphenoid bone.
• The fracture separates the maxilla from the
pterygoid plates and nasal and zygomatic
structures.
36

37. • This type of trauma may separate the maxilla
in one piece from other structures, split the
palate, or fragment the maxilla.
• May involve the maxillary sinuses.
• The resultant “floating” component is the
lower part of the maxilla and its teeth.
37

38. • The nasal septum may be fractured also.
• Le Fort I fracture may be unilateral or bilateral.
• It may occur on its own or in combination with
other midfacial fractures.
38

39. 39
Clinical findings of LeFort I:
–Extra-orally
• Swelling of the upperlip.
• Soft tissue laceration.
• Open mouth to accommodate the
displaced dentoalveolar portion.
• Epistaxis.

40. Intra-orally
• Malocclusion.
• Mobility of tooth bearing portion.
• Dull sound on percussion.
• Ecchymosis of the maxillary buccal sulcus.
40

41. LeFort II fracture
• Results from a force delivered at a level of the
nasal bones in superior direction.
• The fracture line occurs along the nasofrontal
suture
orbital
 lacrimal bone  across the infra-
rim in the region of the zygomatico-
maxillary suture  above the canine eminence
 inferiorly and distally along the lateral antral
wall, but at a higher level than Le Fort type I 
across the pterygoid plate at its middle.
41

42. • Separation of the maxilla and the attached
nasal complex from the orbital and zygomatic
structures.
42

43. Clinical Findings of LeFort II
–Extraorally
• Ballooning of the face
• Lengthenening of the face
• Circumorbital ecchymosis
• Subconjunctival Haemorrhage
• Epistaxis
• Diplopia
43

44. 44
• Enophthalmos
• CSF rhinorrhoea
• Step deformity in the lower border of the
orbit
• Intact zygomatic bone and arch
–Intraorally
• Malocclusion
• Gagging of the posterior teeth and anterior
open bite
• Mobility of the maxilla
• Ecchymosis of the sulcus

45. LeFort III
• Results when horizontal forces are applied at a
level superior enough (at orbital level) to
separate the NOE) complex, the zygomas, and
the maxilla from the cranial base (Craniofacial
separation/dysjunction).
45

46. • The fracture line courses through the
zygomaticotemporal and zygomaticofrontal
sutures lateral orbital wall inferior orbital
fissure medially to the naso-frontal suture
 fractures the pterygoid plate at its base.
46

47. • Most severe of the LeFort fractures.
• Often associated with extensive soft tissue
injury.
• Large force needed to cause this type of
fracture.
• The resultant “floating” component is almost
the entire face.
47

48. Clinical Findings of LeFort III
– Extraorally
• Severe edema of the face “ballooning”
• Lengthening of the face
• Flattening of the cheek
• Circumorbital ecchymosis
• Subconjunctival Haemorrhage
• Epistaxis
• Enophthalmos
• CSF rhinorrhoea
48

49. Cerebrospinal fluid
CSF surround the brain and spinal cord ,and may function
as shock absorber for CNS.it may also serve as immunological
function analogus to the lymphatic system
Suspect in post-traumatic otorrhea/rhinorrhea or recurrent
meningitis
Salty taste
 β2-transferrin it is absent in tears,nasal discharge,saliva
and serum
Anosmia

50. Management strategy
1). Confirm the fluid is CSF.
2). Identify the site of origin of the leak.
3). Determine etiology/mechanism
Most bedside test are unreliable and include:
”reservoir sign,”target/halo sign,qualitative
glucose
Most accurate confirmatory test β2-
transferrin
CT cisternography is the test of choice for
localizing site of fistula

51. Indication for surgical intervention
1. Traumatic CSF leak that persist more than > 2 weeks inspite of non
surgical measures
2. Spontaneous leaks that those of delayed onset trauma or
surgery:usualluy require surgery because of high incidence of
recurrence
3. Leaks complicated by recurrent meningitis

52. 52
–Intraorally
• Gagging of the posterior teeth and
anterior open bite
• Ecchymosis and Haemorrhage ofthe
buccal sulcus
• Mobility of the maxilla
• Mandibular interference

53. • Obstructed airway – soft palate rest on
posterior dorsum of tongue
53

54. • Bilateral circumorbital ecchymoses
facies, or racoon eyes
• Bilateral subconjunctival haemorrhage
– panda
54

55. • Diplopia due to:
– Edema andhematoma
– Restrictive motility disorder(mechanical)
– Cranial nerve injury(neurogenic)
55

56. 56
Radiographs needed
• Occipito-mental view (Water’s View)
• CT scan
– Axialscan
– Coronalscan
–Sagittal
– 3dimensional

60. 60
Treatment for LeFort fractures
• First aid and Preliminary treatment
• Definitive treatment
–Reduction
–Immobilization

61. 61
• The principles of definitive
LeFort fractures consist of
treatment of
reduction and
fixation of the fractured bones to one another
and to the skull
–achieved by either conservative or
operative methods.

62. 62
• The sooner the treatment is carried out, the
better the prognosis.
• Restoration of the occlusion is a must.
• The bony framework and buttresses of the
midface must also be repositioned or restored
and fixed.

63. Surgical approaches
• Choice of approach
depends
• Fracture pattern
• Amount of displacement
• Other accompanying
fractures
• Surgeon’spreference

64. Various skeletal incisions for exposure
of midface skeleton are follows:
1. Supraorbital eyebrow incison
2. Subciliary incision
3. Median lower eyelid incision
4. Infraorbital incision
5. Transconjunctival incision
6. Transverse nasal incision
7. Vertical nasal incision
8. Medial orbital incision.
64

65. 65
Methods of reduction for LeFort
fractures
• Manual reduction
– Simple manipulation by hand
– Gauze or rubber catheters
– Special instruments
• Reduction by traction
– Conservative treatment
– Supervised spontaneous healing
– Open reduction

66. 66
Manual reduction
– Carried out in all fresh fractures where the
fragments are not impacted.
– As a rule, arch bars are first applied to the
teeth.
– The lower jaw serves as a template, so that
the occlusion can be checked.

67. 67
• Simple manipulation by hand is possible in
fresh fractures, maxilla is held between the
index finger and thumb and brought into
normal occlusion.
• Another method is to fix two double wires
encircling the first and second maxillary
molars and twisting them individually on
either sides.

68. 68
• Both the twisted wire ends are held by means
of wire holders or hemostats and
simultaneously downward movement of the
maxilla will help to achieve the normal
occlusion.

69. • Popescu in 1966, have described reduction by
rubber dam sheets or by means of long
ribbon/strip gauze or rubber catheters.
• Whenever the maxilla is impacted and simple
manual mobilization is not possible, then this
method can be tried, if sophisticated instruments
are not available.
69

70. • The rubber catheter’s end is passed from the
nostril into the oropharynx and it is grasped
with the help of hemostat and brought out of
the oral cavity.
70

71. 71
• So, you have one end coming out from nostril
and other end through the oral cavity, same
procedure is repeated on the other side
through the nostril.
• After grasping all four ends of the catheter and
stabilizing the head, maxilla can be rocked
into the normal occlusion.

72. 72
• Reduction by using special instruments—
Specially constructed disimpaction forceps can
be used to take firm grasp of the maxilla and
reduce it into the position.

73. • Rowe’s maxillary disimpaction forceps:
– Available as right and leftforceps.
– Always used inpairs.
– These are two pronged (divided) forceps,
where one prong fits into the nasal floor
and another one on the hard palate.
73

74. • Anterior traction in the case of a split palate, may be
facilitated by the use of the special forceps devised by
Hayton Williams.
74

75. • Applied to the buccal aspect of the alveolar
process and medial compression exerted until
the two halves of the upper jaw are
approximated.
75

76. 76
Reduction by traction
– Repositioning the fractures that are already
in a state of partial fusion OR when
attempted manual reduction is met with
failure, then reduction by elastic traction is
tried to interdigitate the fractured
fragments.

77. 77
• Mainly used in delayed cases, where the
fracture is 10 to 14 days old and no longer
sufficiently mobile.
– Intraoral elastictraction.
– Extraoral elastic traction with appropriate
extension bars and side bars.
• Intraoral intermaxillary elastic traction may be
used in an appropriate direction to restore
normal occlusion then replaced by IMF.

78. 78
• Conservative Treatment
– Reduction and fixation of the fractured
midface is indicated in cases, where surgery
is not possible due to poor general
condition of the patient or where there is
extensive comminution with tissue loss,
making internal skeletal fixation impossible.
– Also used as a supplementary measure with
the surgical treatment of midfacial fracture.

79. 79
• Supervised SpontaneousHealing
– Where mobility at the fractured maxilla is
only slight, and occlusion is not disturbed.
– Progress of healing is merelysupervised.
– The patient should avoid chewing during
the first 2 to 3 weeks and should take a
liquid/semisolid diet.

80. 80
Intermaxillary fixation (IMF):
Maintained for 3 to 4 weeks and at the end
of this period IMF wires and the lower arch
bars are removed.

81. 81
Internal skeletal wire suspension:
Many times in addition to IMF, additional
support is required for immobilization of
the jaws.
Craniomaxillary or craniomandibular
suspension can be carried out using the
stable point above the fracture line.
The selection of the site for suspension
wire will be dependent on the level of
fracture line.

82. • LeFort I fracture: Intermaxillary fixation by
zygomatic arch suspension, if necessary
additional suspension at the piriform aperture.
82

83. • LeFort II: Zygomatic arch suspension or frontal
bone suspension. Intraosseous wiring may be
done at infraorbital margins.
83

84. • LeFort III: Intraosseous wiring at
zygomaticofrontal sutures
frontomalar suspension is
and bilateral
used after the
application of arch bars. Intraosseous wiring
may be done at the infraorbital margin, if step
deformity exists
84

85. Maxillary suspension
85

86. 86
• Open Reduction
– Carried out under endotracheal anesthesia with
nasal intubation.
– Intraoral vestibular incision is taken from first
molar to first molar region on either side.
– Mucoperiosteal flap is reflected to expose the
fracture line.
– After identifying the fracture line, in old fractures,
an osteotome is inserted to mobilize the fragment.

87. 87
– Disimpaction forceps can be used and the
fragment is brought into normal occlusion by
manipulation.
carried out and fracture– Temporary IMF is
fragments are fixed under direct vision by
intraosseous wiring or minibone plates with
screws.

88. Microplatefixation
• Low profileplates
• Made of titanium
• Come in variety of shapes
• Use advocated mostly in midface fractures and have been use
successfully for fixation of the bones of the of the cranium, orbital
rim, zygomatic process, anterior maxilla, and nasal orbital
ethmoidal complex

89. ADVANTAGES
• Thinner and more malleable than conventional miniplates
• Low profile useful in areas with minimum overlying soft tissues
such asinfra- orbital rim, frontozygomatic sutures, and zygomatic
arch – less palpability
• Canbe applied through smaller incisions- aesthetics
• Easyadaptation to the bone surface
DISADVANTAGES
• Low mechanicalstrength
• Cannot be used in load bearing areas

90. Advancesinfixationsystemsfor
maxillofacialfractures
• Bioresorbable plates
• Three dimensionalplates
• Locking technique

91. Bioresorbableplates
• Most resorbable plate and screw fixations use isomer configurations of
alpha-hydroxy polylactic and polyglycolic acids.
ADVANTAGES
• Degradation of the material by citric acid cycle into CO2 and H2O
• No interference with imaging (CT,MRI, standard radiographs)
• No effect on postoperative radiation treatment

92. Possible disadvantages of resorbable fixation include the
following:
• Less mechanical strength when compared with titanium alloys of
similar sizes
• “Memory” of the material, which may distort reduction of fracture
• Increased reactivity & inflammatory response during the
degradation phase
• Increased operative working time
• Screw breakage
• High cost

95. CONCLUSION:
 Lefort fractures are common in trauma patient.
 They require accurate radiologic diagnosis and surgical
management to prevent severe functional debilities and
cosmetic deformity
 A thorough understainding of anatomy craniofacial
butresses and treatment options will give the maxillofacial
surgeon the optimal tools for achieving successful result.

96. 3/12/2016 96
References
• Contemporary Oral and Maxillofacial Surgery 6th
Edition – Hupp, James (Chapter 25 Management of
facial fractures)
• Maxillofacial injuries – A synopsis of Basic Principles,
Diagnosis and Management - George Dimitroulis,
Brian Avery (Chapter 6 ).
• https://sites.google.com/site/drtbalusotolaryngology
/rhinology/buttress-system-of-midface ‘Buttress
system of midface’. Accessed on 14.2.2016.
• Textbook of Oral and Maxillofacial Surgery 3rd Edition
– Neelima Anil Malik (Chapter 29 + 30).

97. 3/12/2016 97
Thankyoufor
listening
