“MID FACEFRACTURES”

Dr. Safia
FCPS
Associate Professor
Oral & Maxillofacial Surgery
SIOHS-JSMU, Karachi.
WHAT ISMID FACE??
Area between a superior plane drawn
through the zygomaticofrontal sutures
tangential to the base of the skull and
an inferior plane at the level of the
maxillary dental occlusal surfaces.
 BONESOFMIDFACE :
(17 BONES)
Paired Bones Unpaired Bones

Maxilla Vomer

Zygomatic bone Ethmoid

Zygomatic process of Sphenoid (Pterygoid

temporal bone plates)

Palatine bone

Nasal bone

Lacrimal bone

Inferior conchae
Anatomical specimen showing the disarticulated bones of the skull
exploded and mounted to demonstrate their complex interrelationship.
 MECHANISM OFMIDFACE FRACTURE :
Th ese facial bones in isolation are comparatively fragile but gain
strength and support a s they articulate with ea c h other.
It is this strength gained from ea c h other that ha s been
described a s the facial buttress byManson.

• Area of strength
• Vertical and horizontal pillars
• Muscular attachment
• Area of weakness
• Sutures
• Lining tissues and air-filledcavities
Vertical buttress:
■ nasomaxillary
■ zygomaticomaxillary
■ pterygomaxillary

Horizontal buttress:
■ frontal bar(supra
orbital rims)
■ infra orbital rims
■ maxillary palate
• Vertical buttresses:
1. Nasomaxillary
2. Zygomaticomaxillary
3. Pterygomaxillary
4. Vertical mandible

• Resist occlusal load.

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• Horizontal buttresses:
1. Frontal bar
2.Infraorbital rim & nasal bones
3.Hard palate & maxillary
alveolus

• Interconnect and provide

support for the vertical
buttresses.
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 ANATOMICAL CONSIDERATIONS:

∏ This structure is analogous to a matchbox sitting below and anterior to hard

shell containing brain

∏ Act as cushion for trauma directed towards cranium from anterior or antero-
lateral direction
 HISTORY:

In 1901 , Rene Le Fort published his landmark work, a three-part experiment

using

32 cadavers.

The heads of the cadavers were subjected to low velocity forces; the soft

tissuewere then removed and the bones were examined.

 HISTORY

Le Fort noted that generally face was fractured and the skull was not. He
then stated
that fractures occurred through three weak lines in the facial bony structure.
From
these three lines the Le Fort classification system was developed.
ETIOLOGY:

∏ Assault
∏ RTA
∏ Alcohol and Drug abuse
∏ Gunshot wounds
∏ Sports
∏ Falls
∏ Industrial accidents
Classificatio
n
1. ALPHONSO GUERIN(1886)

2. RENELEFORTFRACTURECLASSIFICATION (1901)

3. ROWEAND WILLIAM CLASSIFICATION (1985)

4. MODIFIED LEFORTCLASSIFICATION(MARCIANI,1993)
5. ERICH’S CLASSIFICATION(1942)
• Weakest areas of midfacial complex when assaulted from a frontal direction at different
levels (Rene’ Lefort, 1901)
• LeFort-I Transverse Maxillary
• Lefort-II Pyramidal
• Lefort-III Craniofacial Dysjunction
• Zygomatic Complex, Orbital Floor
Midface
• Nasal Fractures, Naso-orbital/Ethmoid
Fractures
Lefort I Fracture Lefort III Fracture
Lefort II Fracture Craniofacial
Transverse Maxillary Pyramidal Dysjunction
 1)Rene Le Fort classification(1901):

LeFort classification:
•LeFort I
•LeFort I
•LeFort II
 3.Rowe & william’s classification:

A –FRACTURESNOT INVOLVING DENTOALVEOLAR COMPONENTS

1.Central region
a- fracture of nasalbone &/or nasal septum
- lateral nasal injuries
- anterior nasal injuries
．
b fracturesof frontal process of maxilla
．
c fracturesof type a & b which extend into ethmoid
bone
d． fracturesof type a ,b ,c which
extendsinto frontal bone

2.Lateral region-
Fracturesinvolving zygomatic bone,arch& maxillaexcluding
dentoalveolar component
B–FRACTURESINVOLVING DENTOALVEOLARCOMPONENT

1.Central region
a-dentoalveolar fractures
b-lefort I (subzygomatic fractures)

2.Combined central & lateral region

a-high level
b-LeFort III with midline split
c-LeFort III with midline split + fracture
of roof of orbit or frontal bone
 Limitations of the lefort
classification

• The LeFort classification has proven to be less

satisfactory to describe more complex fracture
patterns, comminuted, incomplete, combination
maxillary fractures or to
describe fractures of the part bearing the occlusal
segment.
2)Marciani modification of LeFort:

LEFORT I:LOW MAXILLARYFRACTURE

Le Fort I (a)Le fort I-multiple segment
LEFORT II:PYRAMIDALFRACTURE
Le Fort I(a):lefort I+nasal
Le Fort I(b):le fort II(a)+ethmoid
LEFORT II:CRANIOFACIALDYSJUNSTION
Le Fort II(a):LeFort II+nasal fracture
Le Fort II(b):LeFort III(a)+ethmoid
LEFORT IV:LEFORT IOR LEFORT IIWITH CRANIAL
BASE
Le Fort IVwithsupraorbital rim
LeFort IV+anterior cranial base
LeFort IV(b)+lefort IV(a)
PREVALENCEOFMID-FACE
FRACTURES
Fracture Type Prevalence

Zygomaticomaxillary complex (tripod fracture) 40 %

I 15 %
LeFort II 10 %
III 10 %
Zygomatic arch 10 %
Alveolar process of maxilla 5%
Smash fractures 5%
Other 5%
Erich’s classification (1942)
Horizontal, pyramidal, transverse

Classification based on relationship of fracture line to zygomatic bone

Subzygomatic, suprazygomatic

Classification based on level of fracture line

Low, mid, high level fractures
• Erich’s (1942)- direction of the fracture line.

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PALATAL FRACTURE:
 Handrickson M, Clark n, TYPE1: Type 2: Type 3:
Manson P,Palatal fracture Anterior alveolus posterolateral sagittal

classification, patterns and

Treatment with rigid internal
fixation:. Plast recostr surg
101(2):319-332,1998
Type 4: Type 5: Type 6:
parasagittal ParaAlveolar Complex/comminuted

Type 7: transverse
LEFORTI
 A violent force applied over a more extensive are, above
the level of the teeth will result in a Le Fort I Fracture.
Which is not confined to smaller section of the alveolar
bone
Low-level fracture, a subzygomatic Fracture.
Guerin’s fracture
Horizontal fracture
Floating fracture
LEFORT 1:Fractureline:
Istline :startsfrom the lateral border of the pyriform aperture
passesabove thenasal floor,then itgoes posteriorly above the
canine fossa going backward below the zygomatic butress
coming on the posterior wall of themaxilla,where it risesabruptly
crossing the pterygo-maxillary fissure& breaksthe pterygoid
plates in lower1/3& upper 2/3parts.

2nd line :starts from samestarting point and also passesalong the
lateral wall of nose and subsequently joins the lateral line of #
behind thetuberosity.

3rd line :detaches the nasal septum fromanterior nasal

spine upto vomerbone.
 A typical Lefort-I fracture is always bilateral with the fracture of lower
thirdof
nasal septum.
It can also occur as unilateral
fracture.
Lefort-I may occur as a single entity or in association with Lefort-II &
III #.
• 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.

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LEFORTII
 LEFORTII
■ Pyramidal or
fracture subzygomatic
fracture
from
■ anterior direction,
Violent force, sustained by
usually a
the central region of the middle n
third of the facial skeleton over
an area extending from the
glabella to the alveolar margin
results in a fracture of a pyramid
shape.
■ The force may be delivered at
the level of the nasal bones.
 FRACTURE
LINE
it starts just below the
frontonasal suture bilaterally
Runs from the thin middle area
of the nasal bones down either
side.
Crossing the frontal processes
of the maxillae into the medial
wall of each orbit.
Within each orbit, the fracture
line crosses the lacrimal bone
behind the lacrimal sac.
Before turning forwards to cross the
infra- orbital margin slightly medial to
or through the infra-orbital foramen.
The fracture now extends downwards
and backwards across the lateral wall of
the antrum below the
zygomatic-maxillary suture.
Divides the pterygoid lamina about
halfway up.
LEFORT2: FractureLine
LEFORTIII
 LEFORTIII
Suprazygomatic or transverse
fracture or high level fracture.
 THEFRACTURE
LINE
Runs from near the frontonasal suture transversely backwards,
parallel with the base of the skull and involves the full depth of the
ethmoid bone, including the cribriform plate.
Within the orbit, the fracture passes below the optic foramen into
the posterior limit of the inferior orbital fissure.
From the base of the inferior orbital fissure the fracture line extends
in two directions:
Backwards across the pterygo-maxillary fissure to fracture the roots of
the pterygoid laminae.( layer, thin plate) ( makes body of sphenoid bone)
Laterally across the lateral wall of the orbit separating the zygomatic
bone from the frontal bone by fronto-zygomatic suture.
The entire mid-facial skeleton becomes detached from the cranial base.

FZSUTUTE #

Zygomatic arch#
 CLINICAL ASSESSMENT OF
MIDFACE FRACTURES
Extra-oral & Intra-oral
examination.

▶ Inspection.

▶ Palpation.
 Extra-oral examination

Swelling &Facial Asymmetry.

Bruising of upper lip a nd lower halfof mid-face.

Circum-orbital Ecchymosis ( bilateral =Racoon’s

eye).

Subconjunctival Hemorrhage.

Periorbital Oedema.
 Cerebrospinal fluid rhinorrhoea

Lengthening of Midface

Depressed midface (dish face)

Saddle shaped depression of

nose

Enophthalmos

Proptosis

Diplopia
 Cerebrospinal Fluid
Rhinorrhoea

-Watery nasal or postnasal salty

discharge.
Hand kerchief test

CSF content assessment- most reliable(Biochemical

analysis)
Glucose >30mg/dl---compared to nasal secretion
“HALO” sign
CSF)
ß2 Transferrin isoenzyme- most diagnostic (double ring
(pathognomonic of sign)
Palpation -

1. Subcutaneous Emphysema –
Crepitus

2. Tenderness

3. Step Deformity

4. Abnormal Mobility of bone

5. Impairment of sensation
Palpation of facialskeleton
 Intra-oral examination

Inspection

1. Disturbed occlusion (posterior occlusal gagging , open

bite)

2. Haematoma intraorally over root of zygoma

3. Haematoma in palate (Guiren’s sign)

4. Fractured cusps of teeth

5. Midline diastema
Clinical
features:
 Inspection :

Slightswelling and edema of thelower part ofthe face

along withtheupper lipswelling

Ecchymosisin the labial and buccal vestibule,as well as

contusion of theskinof theupper lip maybe seen

Bilateralnasalepistaxismaybe observed
 The patient may develop open bite if
the

fractured segment is mobile , due to

posterior gagging of occlusion.

Sometimes fracture of the palate can

also

be associated with

Le Fort I fracture.
 Occlusion may be disturbed,difficult
mastication

Pain while speaking and movingthe

jaw

• GUERINsign: ecchymosis of palate ,

bilateral greater palatine foramen.
PALPATION :

In Le Fort I, the teeth and maxilla are

mobile (floating maxilla), but the nose
and upper face is fixed.

Sometimes there will b e upward

displacement of the entire fragment,
locking it against the superiorintact
structures, suc h a fracture is called
a s impacted or telescopicfracture.
Percussion of the maxillary teeth results
in distinctive 'cracked-pot sound',

No tenderness and mobility of the

zygomatic arch and bones.
Clinical
features:
Clinical features
-
The resulting gross edema of
the
middle third gives an appearance
of "moon face" to the patient.

• Depressed nasal bridge,

• Dish shape deformity.
CSF rhinorrhoea is possible and should be

looked for.

Bilateral circumorbital ecchymosis giving

an appearance of 'raccoon eyes' is

invariably seen in the fractures of both Le

Fort II and Le Fort III.

Subconjunctival hemorrhage develops

rapidly in the area adjacent to the site of

injury.(mostly in medial half )

Diplopia may be seen in cases of
orbital floor injury.

Pupils are at level unless there is

gross unilateral enophthalmos.

Anaesthesia or paraesthesia of the

cheek as a result of injury to the
infraorbital nerve due to the
fracture of the inferior orbital rim.
 On intraoral examination, retropositioning of the whole
maxilla
and gagging of the occlusion are seen.

Hematoma formation is seen in the buccal sulcus opposite

to the maxillary first and second molar teeth as a result of
fracture of the zygomatic buttress.
 ExtraoralpalpationofLFII:

Step deformity at the infraorbital rims or

frontonasal junction is noticed.

Orbital wall fractures can cause

entrapment with limitation of ocular

movement.
When maxillary teeth are
grasped, the mid-facial
skeleton moves as a pyramid
and the movement can be
detected at the infraorbital
margin and the nasal bridge.
 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
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–Intraorally
• Gagging of the posterior teeth and
anterior open bite
• Ecchymosis and Haemorrhage of
the buccal sulcus
• Mobility of the maxilla
• Mandibular interference

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

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 –
• Bilateral circumorbital pand
ecchymoses facies, or a
racoon eyes
• Bilateral subconjunctival
ecchymosis

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• Diplopia due to:
–Edema and hematoma
–Restrictive motility disorder
(mechanical)
–Cranial nerve injury (neurogenic)

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 Radiographs
needed
• Occipito-mental view (Water’s
View)
• CT scan
–Axial scan
–Coronal scan
–Sagittal
–3 dimensional

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LEFORTI –Waters
view
32-year-old man, driver in a
motor vehicle accident.

.
• Management of Mid face
fractures
• instruments—
Specially constructed disimpaction forceps
can be used to take firm grasp of the
maxilla and reduce it into the position.

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

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• Rowe’s Disimpaction Forceps

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 STAGE III. DEFINITIVE TREATMENT
LEFORT I FRACTURE
SURGICAL APPROACH- MAXILLARY VESTIBULAR

1. 3.

4.
2.
REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
 Maintained for 3 to 4 weeks and at the
end of this period IMF wires and the
lower arch bars are removed.

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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.
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The procedure for internal skeletal wire
suspension is done through a minor
surgery.
• Application of arch bars
• Reduction of fracture by closed method
- occlusion is checked
• Fixation of the midface to the base of
the skull by means of suspension wires.
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Indicationsfor ClosedReduction:
Non displacedfracture,
Grosslycomminuted fractures,
Fractures exposed by significant lossof overlying soft tissues,
Edentulous maxillary fractures,
Inchildren withdeveloping dentition.

Indications for openreduction:

Displaced fractures,
Multiple fracturesof the facial bones,
Fracturesof the edentulous maxillawith severe displacement,
Delayof treatmentand interposition of soft tissuesbetween non-contacting displaced
fracturesegments,Specific systemic conditions contraindicating IMF.
Classification of methods of Maxillary Fracture
Fixation

A ) Internal Fixation-
1. Suspension Wires
2. Direct
Osteosynthesis

B) External Fixation-
1. Craniomandibular
2. Craniomaxillary
 Internal
Fixation
Suspension Wires – non-rigid
osteosynthesis -

i. Frontal-central or laterally placed

ii. Circumzygomatic
iii. Zygomatic
iv. Circumpalatal/palatal screw
v. Infraorbital
vi. Piriform Aperture
vii. Peralveolar
 Internal
Fixation

Suspension Wires- Circum

 Internal
Fixation
Suspension Wires-
Circum
 Internal
Fixation

Suspension Wires- Orbital rim

wiring
Suspension
Wires-
Piriform aperture
wiring
 Internal Fixation

Direct Osteosynthesis -

1. Interosseous
Wires.

2. Plates and
Screws.
 Direct
osteosynthesis
Intraosseous
Wires-
1. Maxillary (Lefort –I )
2. Zygomaticomaxillary (Lefort –
3. II) Frontonasal (LeFort –II &III)
4. Zygomaticofrontal (Lefort III)
5. Zygomatic bone (comminuted)
Micro plates
Harle & duker(1975;Luhr(1979) 0.3 – 0.6 mm
Used for : FN region ,Frontal bone,Frontal process
of maxilla
Sites of application:Linear/T/Y plate at FN region,
Long curve plate for frontal process of maxilla or
frontal bone

Mesh fixation Used for retention and alignment

of
small fragments or bone grafts.
Sites of application: Anterior and lateral wall of
maxilla and Anterior table of frontal bone
FIXATION- 4-point fixation with MINIPLATE.
IMMOBILISATION- MAXILLOMANDIBULAR FIXATION(MMF)
Existing Laceration

Maxillary vestibular
approach can also be
taken for LeFort II
fracture
 GLABELLA
CORONAL APPROACH APPROACH
▶ FIXATION- 3-POINT fixation
IMMOBILISATION- MAXILLOMANDIBULAR FIXATION
 STAGE III. DEFINITIVE TREATMENT
LEFORT III FRACTURE-
▶ SURGICAL APPROACH-

Existing Laceration
A . Lateral eyebrow approach GLABELLA
APPROACH
B. Upper-eyelid approach
Coronal approach -
PREAURICULAR APPROACH
Zygoma hook
▶ FIXATION- 3-point
fixation
IMMOBILISATION- MAXILLOMANDIBULAR FIXATION if
required
Zygomatic
fractures

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 Anatomy of Zygomatic
bone
• 4 processes which articulate
with:
– Maxillary bone
– Frontal bone
– Temporal bone
– Sphenoid bone

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 Zygomatic
fracture
• It is unusual for the zygomatic bone itself to
be fractured, but in extreme violence, the
bone may be comminuted or split across.
• The isolated zygomatic arch fracture may
occur without displacement of the
zygomatic bone.

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 Types of zygomatic
fracture
• – separate
of zygoma from its 4
articulations
• – fracture
of zygomatic arch in isolation

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 Classification of zygomatic fractures
(Henderson, 1973)

• Type 1 – Undisplaced fracture

• Type 2 – Arch fracture only
• Type 3 – Tripod malar fracture
(Fronto-Zygomatic suture intact)
• Type 4 – Tripod malar fracture
(Fronto-Zygomatic suture distracted)
• Type 5 – Pure blowout fracture
• Type 6 – Orbital rim fracture
• Type 7 – Comminuted and other fractures
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 Early clinical features of Zygomatic fracture

– Swelling and bruising over cheek

– Depressed cheek prominence
– Trismus and restricted lateral mandibular
movements
– Ecchymosis at maxillary buttress region
– Step deformity along infraorbital margins and
possibly along lateral orbital margin and
zygomatic buttress
– Diplopia
– Enophthalmos
3/1–
2/2016 Epistaxis on side of 10
3
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Late clinical features of Zygomatic
fracture
– Flat cheek
– Enophthalmos
– Altered pupillary level
– Infraorbital
paraesthesia
– Diplopia

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• Anaesthesia or paraesthesia of infraorbital
and anterior superior alveolar nerve, may
take 5-9 months for full recovery.

• Proximal part of nerve recovers first ie.

Cheek before upper lip. After 1 year 10%
still complain of paraesthesia.

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 Radiographs
• Water's view:
• Submentovertex -
"jughandle"
• Caldwell view
• CT Scan

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 Treatment

• Whenever there is a gross periorbital

edema and ecchymosis, postponement of
the operation for 3 to 5 days can be done,
but it should not be prolonged more than
two weeks.

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• elevation will
sufficient, because of high degree of be
Simple stability
due to integrity of temporal fascia and the
interdigitation of the fracture lines. No
additional fixation is required after reduction.
• Type 1 : No treatment
• Type 2 : Unless vertically displaced
• Type 3 : and
• Type 4 : Open reduction may be required and
transosseous wiring is advisable.

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• Require open
reduction and transosseous wiring or
bone plating.
• Types 5, 6, and 7, 8

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• The approach of Gillies,
Kilner and Stone (1927) is popular for
reduction of fractures of zygoma

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 Methods of reduction:
• Closed reduction (Gillies temporal
approach) using:
- Bristow’s elevator
- Rowe’s zygomatic elevator

• Open reduction ( surgical )

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 Gillies Temporal
Approach

• At temporal region, temporalis muscle and

temporal fascia are main structure.
Between these two structures a natural
anatomical space exists into which an
instrument can be inserted and it can be
utilized to elevate the displaced zygoma or
its arch into position.
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• The hair is shaved from the
temporal region of the scalp.
• The external auditory meatus is plugged with
cotton to prevent any fluid or blood getting
inside.
• An incision about 2 to 2.5 cm in length is
made, inclined forward at an angle of 45
degrees to the zygomatic arch, well in the
temporal region.
• Care is taken to avoid injury to the superficial
temporal vessels. 3/12/2016
• The temporal fascia is exposed
which can be identified as white
glistening structure.
• The incisionis taken into the fasciaand the
fibers of temporalis muscles will be seen.
• Long Bristow’s periosteal elevator is
passed below the fascia and above
the muscle.

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• Once this correct plane is identified and
instrument is inserted through it, downward
and forward, the tip of the instrument is
adjusted medially to the displaced
fragment.
• A thick gauze pad is kept on the lateral
aspect of the skull to protect it from the
pressure of elevator while reduction is
going on.
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• The operator has to grasp the handle of the
elevator with both hands and assistant has
to stabilize the head of the patient.
• (During elevation procedure care should be
taken that pressure is not exerted on the
lateral surface of the skull to end up with
depressed fracture of the skull).

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• The tip of the elevator is manipulated
upward, forward and outward.
• The snap sound will be heard as soon
as reduction procedure is complete.
• Wound is closed in layers after withdrawing
the elevator.

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• Care is taken that after surgery at least for 5
to 7 days, no pressure is exerted on the
area till the bone consolidates.
• Patient is instructed to sleep in supine
position or not to sleep on the operated
side.

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 Intraoral
procedure
• Keen’s approach (1909): Introral buccal
vestibular incision is taken in first and
second molar region behind the zygomatic
buttress.
• A pointed curved elevator (Monks’ pattern)
is passed supraperiosteally up beneath the
zygomatic bone.
• The depressed bone is then elevated with
an upward, forward and outward
movement. 3/12/2016
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 In (A)Intraoral
reduction of
zygomatic bone
fracture by
Keen’s
Approach
(B)Stabilization of
reduced
fracture by
using balloon
catheter

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12
7
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•
–Use of antral pack or balloon catheter
can be done which is previously
described.
•

–Direct figure of eight intraosseous wiring

can be done through extraoral infraorbital
incision or semilunar orbital bone plate
can be fixed 3/12/2016
 Other indirect
approaches
• Towel Clip : applied
directly

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Open reduction techniques:
• Lateral brow incision
• Subcilliary (blepheroplasty)
incision
• Infraorbital crease incision
• Bicoronal / Hemicoronal flap

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• Trans osseous wiring:
– Wiring - 24 - 30 gauge stainless steel
wire

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• Mini bone
plates

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 Zygomaticomaxilla
ry Complex
It will show following signs and
symptoms:
1. Cosmetic
2. Neurological
3. Antral
4. Masticatory
5. Ophthalmic

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•
–Loss of contour or prominence of cheek
will be seen.
–Correction may be done either by surgical
refracturing or camouflaging the
deformity by means of onlay bone
grafting or alloplastic material like
hydroxylapatite blocks.

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• Neurological:
–The paresthesia, dysesthesia or
anesthesia may be present.
–Observation for recovery of infra orbital
nerve should be done for 6 to 12 months,
otherwise surgical exploration of the
nerve can be done.

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•
– Persistent sinusitis may be due to the
presence of loose necrotic bone pieces
or a foreign body, which should be
removed via Caldwell Luc operation.

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•
–Depressed zygomatic arch fracture
impinges on the coronoid process bringing
about limitation of the mandibular
movements and opening.
–In extensive fracture, via coronal incision the
arch should be exposed, refractured and
stabilized by direct fixation method.
–Osteotomy and bone grafting can be done if
required.
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