By.
DR.TARIQ JAVED
Assistant Professor
ORAL & MAXILLOFACIAL 1
SURGERY,UMDC,FAISALABAD
Mid-face
Definition:
The area between a
superior plane drawn
through the
zygomatico-frontal
sutures tangential to
the base of the skull
and inferior plane at the
level of the maxillary
dental occlusal surface.
2
Anterior Aspect of Facial Bones
2 Maxillae
2 Zygomatic bones
2 Lacrimal bones
2 Nasal bones
2 Inferior nasal conchae
2 Palatine bones (not
visualized
1 vomer
1 mandible
MAXILLA
Contributes
a large
share in the
formation of
facial
skeleton
MAXILLA
ANTERIOR SURFACE :
Nasal notch(medially)
Anterior nasal spine
Infraorbital foramen
Incisive fossa
Canine fossa
4 PROCESSES OF MAXILLA :
Frontal process
Zygomatic process
Alveolar process
Palatine process
Branches of maxillary nerve
SENSORY INNERVATION OF UPPER
JAW
ANTERIOR SUPERIOR ALVEOLAR NERVE
Maxillary incisors and canine tooth
Buccal soft tissues of incisors and canine
MIDDLE SUPERIOR ALVEOLAR NERVE :
Maxillary premolars and portion of 1st
molar tooth
Buccal soft tissues of premolars
POSTERIOR SUPERIOR ALVEOLAR
NERVE :
Maxillary molars except for the portion of
1st molar tooth
Buccal soft tissues of molars
ANTERIOR PALATINE NERVE :
Lingual soft tissues of molars and
premolars
NASOPALATINE NERVE :
Lingual soft tissues of incisors and canine
Structures connection
(structures in relation)
Orbit
Maxillary sinus
Nasal bone
Naso-orbital
ethmoid (NOE)
complex
Zygomatic
complex
Frontal bone and
sinus 12
Vertical and horizontal pillars
•Area of strength
•Vertical and horizontal pillars
•Muscular attachment
•Area of weakness
•Sutures
•Lining tissues and air-filled cavities 13
Vertical
Buttresses
Resist
occlusal
load
Horizontal
Buttresses
Fracture Patterns
Pattern of fractures
of mid-face skeleton
Alveolar fracture and dental fracture
Le Fort ‘s fracture ((french surgeon
Rane Le Fort 1901)
Naso-orbital ethmoid fracture
Zygomatic complex and arch fracture
Frontal sinus and bone fracture
17
Alveolar bone fracture
Involve block of
alveolar bone
with or without
Intrusion of
teeth
Extrusion of
teeth
Luxation of teeth
Fracture of teeth
18
LeFort
Fractures
Experimentally
determined
weak points
Can be in
combinations
bilaterally
Useful descriptor
Results from
anterior forces
Le Fort’s fractures
Le Fort I (low
level or Guerian
fracture)
Unilateral/ bilateral
Horizontal fracture
through the maxilla
above the level of
the nasasl floor and
alveolar process
Piriform rims
Anterior maxilla
Zygomatic buttresses 20
Ptrygoid laminae
Le Fort 1
LeFort Fracture 1
Le Fort I (“floating palate”)
Characterized by a horizontal fracture through the
maxillary sinuses
With separation of the entire palate and maxillary
alveolar processes.
This fracture type includes the lower nasal septum
and inferior aspect of the pterygoid plates.
Le Fort I
Le fort I fracture
Le Fort Fracture 2
Le Fort II (“pyramidal”) is
characterized by an inverted
‘V’ type fracture through the
medial orbital and lateral
maxillary walls.
Through the nasal septum,
frontal process of the maxilla,
medial wall of the orbit,
inferior orbital rim, superior,
lateral, and posterior walls of
the maxillary antrum, and
midportion of the pterygoid
plates.
This type of fracture can be
associated with posterior
displacement of the facial
bones resulting in a “dish-
face” deformity
Le Fort II
Le Fort II
fracture
Le Fort 3
Le Fort III ("craniofascial disjunction”) is
Characterized by separation of the entire viscerocranium
from the base of the skull.
Horizontal fracture through the orbits beginning near the
nasofrontal suture and extending posterior to involve the
nasal septum, medial and lateral orbital walls, zygomatic
arches, and base (superior aspect) of the pterygoid plates.
This type of fracture also may result in a “dish-face”
deformity.
Le Fort III
Le Fort III fracture
LeFort Fractures
Midface fracture
Le Fort , Le Fort , Le Fort
FIG 3 - LeFort lines used for classifying fractures of the middle third of the
face.
Anatomy Identity
4. Water’ view
(Occipito-mental )
Maxillary fracture
Orbital fracture
Frontal bone / sinus
Blow out fracture
Signs and symptoms
Slight swelling of upper lip
Ecchymosis in upper lip sulcus
Hematoma intra-orally over zygoma and in palate
Disturbed occlusion
Mobility of teeth of the involved segment of maxilla
Combination of soft tissue laceration
Exposure of nares and the maxillary antra in case of
gross injury
Impacted type of fracture is oftenly not mobile and
teeth cusps may be damaged
Cracked-pot percussion of upper teeth 40
Le Fort’s fractures
Le Fort II
(pyramidal or subzygomatic)
Separation of NF suture,
medial orbital walls
(lacrimal bone), inferior
orbital floor and rim
(adjacent to infrorbital
canal and foramen),
anterior maxilla below
zygomatic buttress and
ptrygoid laminae about
halfway up.
Separation of the block from the base of skull is completed
via the nasal septum and may involve the floor of the
anterior cranial fossa 41
LeFort’s fractures
LeFort III
(cranifacial dysjunction, high
transverse, suprazygomatic)
Separation of NF suture,
medial orbital walls (involve
the depth of the ethmoid bone
and cribriform plate, pass
below optic foramen and
cross the inferior orbital
fissur), inferior orbital floor,
lateral orbital wall, ZF suture,
zygomatic arch,
suprazygomatic to the root of
ptrygoid plate.
42
Signs and symptoms
although it is possible to distinguish between le fort II and III, the
signs and symptoms are almost similar
Gross edema of soft tissue Difficulty in mouth opening
Bilateral circumorbital Mobility of the upper jaw
ecchymosis Occusional hematoma of
Bilateral subconjunctival the palate
hemorrahge Cracked-pot sound on
Obvious deformity of the percussion
nose Step deformity at infra-
Nasal bleeding and orbiatal margin
obstruction Anasthesia of midface
CSF leak rhinorrhea Nasal bone moves with
Dish-face deformity mid-face as a whole
Limitation of ocular Tenderness and sepration
movement at FZ suture
Possible diplopia and Tenderness and deformity
enophthalmous of zygomatic arch
Retropostioning of the Depression of occular level
maxilla with anterior open and pseudoptosis
bite
Lengthening of the face 43
Bowerman classification of midface-fracture
(1994)
Fracture not involving the occlusion
• Central region
Nasal bone/ septum (lateral, anterior injuries)
Frontal process of the maxilla
Nasoethmoid
Fronto-orbito-nasal dislocation
• Lateral region (zygomatic complex EX dento alveolar
frcature
Fracture involving the occlusion
• Dento alveolar
• Subzygomatic:
Le Fort’s (I, II)
• Supra zygomatic:
Le Fort III
44
These fractures may occur unilaterally or bilaterally, with separation
of maxillary midline and or extension to frontal or temporal bone
Prevalence of mid-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%
49
Emergency Management
Airway Control
Control airway:
• Chin lift.
• Jaw thrust.
• Oropharyngeal suctioning.
• Manually move the tongue forward.
• Maintain cervical immobilization
Emergency Management
Intubation Considerations
Avoid nasotracheal intubation:
• Nasocranial intubation
• Nasal hemorrhage
Avoid Rapid Sequence Intubation:
• Failure to intubate or ventilate.
Consider an awake intubation.
Sedate with benzodiazepines.
Emergency Management
Intubation Considerations
Consider fiberoptic intubation if
available.
Alternatives include percutaneous
transtracheal ventilation and
retrograde intubation.
Be prepared for cricothyroidotomy.
Emergency Management
Hemorrhage Control
Maxillofacial bleeding:
• Direct pressure.
• Avoid blind clamping in wounds.
Nasal bleeding:
• Direct pressure.
• Anterior and posterior packing.
Pharyngeal bleeding:
• Packing of the pharynx around ET tube.
History
Obtain a history from the patient,
witnesses and or EMS.
AMPLE history
Specific Questions:
• Was there LOC? If so, how long?
• How is your vision?
• Hearing problems?
History
Specific Questions:
• Is there pain with eye movement?
• Are there areas of numbness or tingling
on your face?
• Is the patient able to bite down without
any pain?
• Is there pain with moving the jaw?
Physical Examination
Inspection of the face for
asymmetry.
Inspect open wounds for foreign
bodies.
Palpate the entire face.
• Supraorbital and Infraorbital rim
• Zygomatic-frontal suture
• Zygomatic arches
Physical Examination
Inspect the nose for asymmetry,
telecanthus, widening of the nasal bridge.
Inspect nasal septum for septal
hematoma, CSF or blood.
Palpate nose for crepitus, deformity and
subcutaneous air.
Palpate the zygoma along its arch and its
articulations with the maxilla, frontal and
temporal bone.
Physical Examination
Check facial stability.
Inspect the teeth for malocclusions,
bleeding and step-off.
Intraoral examination:
• Manipulation of each tooth.
• Check for lacerations.
• Stress the mandible.
• Tongue blade test.
Palpate the mandible for tenderness,
swelling and step-off.
Physical Examination
Check visual acuity.
Check pupils for roundness and
reactivity.
Examine the eyelids for lacerations.
Test extra ocular muscles.
Palpate around the entire orbits..
Physical Examination
Examine the cornea for abrasions
and lacerations.
Examine the anterior chamber for
blood or hyphema.
Perform fundoscopic exam and
examine the posterior chamber and
the retina.
Physical Examination
Examine and palpate the exterior
ears.
Examine the ear canals.
Check nuero distributions of the
supraorbital, infraorbital, inferior
alveolar and mental nerves.
Maxillary Fractures
High energy injuries.
Impact 100 times the force of gravity
is required .
Patients often have significant
multisystem trauma.
Classified as LeFort fractures.
Maxillary Fractures
LeFort I
Definition:
• Horizontal fracture
of the maxilla at
the level of the
nasal fossa.
• Allows motion of
the maxilla while
the nasal bridge
remains stable.
Maxillary Fractures
LeFort I
Clinical findings:
• Facial edema
• Malocclusion of
the teeth
• Motion of the
maxilla while the
nasal bridge
remains stable
Maxillary Fractures
LeFort I
Radiographic
findings:
• Fracture line which
involves
Nasal aperture
Inferior maxilla
Lateral wall of
maxilla
CT of the face and
head
• coronal cuts
• 3-D reconstruction
Diagnosis
Inspection
Extra-oral
(e.g. swelling, deformity, asymmetry
Leaks)
Intra-oral
(e.g. hematoma, occlusion)
Palpation
Step deformity, criptation, cracked pot sound,
mobility
Radiographical
investigations
66
Radiographical examination
Plain radiograph
Occipitomental
(10 or 30 degree)
Water’s view
Suitable for isolated orbital
fracture
Search line (Campbell’s line 1977)
67
Radiographical examination
Lateral skull view
OPG
Occlusal view of the
maxilla
Perapical views of
damaged teeth
68
Radiographical examination
CT scan
3-D CT imaging
• Coronal sections
• Axial sections
1. Whenever intracranial damage and
frontal sinus are suspected
2. Extensive fracture that involves
nasoethmoid complex or orbital
region
3. Orbital trauma to evaluate the
degree of orbital injury and
69
enophthalmos
Indications for treatment
Physical signs of a fracture of the maxilla.
Evidence of a fractured maxilla on imaging.
Disruption of the occlusion of the teeth.
Displacement of the maxilla.
Post traumatic facial deformity.
70
Indications for treatment
Fractured or displaced teeth.
Cerebrospinal fluid leak.
Abnormal eye movement or restriction of
eye movement.
Occlusion of the nasolacrimal duct.
Sensory or motor nerve deficit.
Other evidence of loss of function
71
Aims of treatment
Relieve pain
Restore function.
Restore bone anatomy.
Prevent infection
Restore the dental occlusion
Restore jaw movement at the earliest possible
stage
72
Restore normal nerve function
Principles of treatment
Closed reduction may be appropriate
in cases
Simple uncomplicated fractures
Complex or comminuted fractures
Medical or surgical contraindications
to open reduction
Maxillary fractures in children
73
Open reduction may be
appropriate where
Immediate or early jaw
function is desirable
Difficulty is encountered in
reducing the fracture by a
closed method
The fracture is unstable
74
Definitive treatment
Reduction
Manual
manipulation
Use of dis-
impaction forceps
75
Fixation and immobilization
Extraoral fixation
Craniomandibular fixation
Box-frame (pin fixation)
Halo-frame
Plaster of paries headcap
Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame
76
Immobilization within the tissue
Direct fixation
Transosseous wiring at
fracture sites
Frontozygomatic sutures
Infrorbital margin
Midline of the palate
77
Immobilization within the tissue
Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular
78
Surgical Approaches
Coronal
Sublabial
Transconjunctival
Lateral Brow
Coronal Approach
Hemicoronal
Approach
Lateral Brow Incision
Avoid shaving brow hairs
Goal is the ZF suture
Sublabial
Approach
Leave
mucosa to
sew to later
Identify and
preserve V2
LeFort I
84
Arch bars
85
Reduction instruments
Rowe disimpaction forceps
86
Reduction
87
Placing the patient into MMF
88
Apply plates to the linear fracture side
89
Apply plates to the comminuted fracture
side
90
occlusion checked.
91
Maxillary Fractures
LeFort II
Definition:
• Pyramidal fracture
Maxilla
Nasal bones
Medial aspect of
the orbits
Maxillary Fractures
LeFort II
Clinical findings:
• Marked facial edema
• Nasal flattening
• Traumatic
telecanthus
• Epistaxis or CSF
rhinorrhea
• Movement of the
upper jaw and the
nose.
Maxillary Fractures
LeFort II
Radiographic
imaging:
• Fracture involves:
Nasal bones
Medial orbit
Maxillary sinus
Frontal process of
the maxilla
CT of the face and
head
Arch bars
95
Mobilization
96
Reduction instruments - Rowe
disimpaction forceps
97
Reduction
98
Fixation
99
First plate
100
Plating the contralateral zygomatic
buttress
101
Plates at Infraorbital rim
102
Additional screw and plate placement
103
Nasofrontal plate(s)
104
Check occlusion
105
Maxillary Fractures
LeFort III
Definition:
• Fractures through:
Maxilla
Zygoma
Nasal bones
Ethmoid bones
Base of the skull
Maxillary Fractures
LeFort III
Clinical findings:
• Dish faced
deformity
• Epistaxis and CSF
rhinorrhea
• Motion of the
maxilla, nasal
bones and zygoma
• Severe airway
obstruction
Maxillary Fractures
LeFort III
Radiographic
imaging:
• Fractures through:
Zygomaticfrontal
suture
Zygoma
Medial orbital wall
Nasal bone
CT Face and the
Head
Maxillary Fractures
Treatment
Secure an airway
Control Bleeding
Head elevation 40-60 degrees
Consult with maxillofacial surgeon
Consider antibiotics
Admission
Arch bars and mobilization
110
Reduction
111
Carroll-Girard technique
112
Stromeyer hook is inserted transcutaneously
113
First plate
114
Contralateral frontozygomatic buttress
115
Additional plates (if required)
116
Zygomatic arch plate
117
Check occlusion
118
119
Diagnosis
Inspection
Extra-oral
(e.g. swelling, deformity, asymmetry
Leaks)
Intra-oral
(e.g. hematoma, occlusion)
Palpation
Step deformity, criptation, cracked pot sound,
mobility
Radiographical
investigations
120
Radiographical examination
Plain radiograph
Occipitomental
(10 or 30 degree)
Water’s view
Suitable for isolated orbital
fracture
Search line (Campbell’s line 1977)
121
Radiographical examination
Lateral skull view
OPG
Occlusal view of the
maxilla
Perapical views of
damaged teeth
122
Radiographical examination
CT scan
3-D CT imaging
• Coronal sections
• Axial sections
1. Whenever intracranial damage and
frontal sinus are suspected
2. Extensive fracture that involves
nasoethmoid complex or orbital
region
3. Orbital trauma to evaluate the
degree of orbital injury and
123
enophthalmos
124
Indications for treatment
Physical signs of a fracture of the maxilla.
Evidence of a fractured maxilla on imaging.
Disruption of the occlusion of the teeth.
Displacement of the maxilla.
Post traumatic facial deformity.
125
Midface Disimpaction
May be necessary to restore
facial dimensions before fixation
Palate
Fracture
Wire can be
placed
posteriorly for
stabilization
before
triangular
reduction
Surgical Approaches
Coronal
Sublabial
Transconjunctival
Lateral Brow
Coronal Approach
Hemicoronal
Approach
Lateral Brow Incision
Avoid shaving brow hairs
Goal is the ZF suture
Sublabial
Approach
Leave
mucosa to
sew to later
Identify and
preserve V2
Indications for treatment
Fractured or displaced teeth.
Cerebrospinal fluid leak.
Abnormal eye movement or restriction of
eye movement.
Occlusion of the nasolacrimal duct.
Sensory or motor nerve deficit.
Other evidence of loss of function
133
Aims of treatment
Relieve pain
Restore function.
Restore bone anatomy.
Prevent infection
Restore the dental occlusion
Restore jaw movement at the earliest possible
stage
134
Restore normal nerve function
Principles of treatment
Closed reduction may be appropriate
in cases
Simple uncomplicated fractures
Complex or comminuted fractures
Medical or surgical contraindications
to open reduction
Maxillary fractures in children
135
Open reduction may be
appropriate where
Immediate or early jaw
function is desirable
Difficulty is encountered in
reducing the fracture by a
closed method
The fracture is unstable
136
Definitive treatment
Reduction
Manual
manipulation
Use of dis-
impaction forceps
137
Fixation and immobilization
Extraoral fixation
Craniomandibular fixation
Box-frame (pin fixation)
Halo-frame
Plaster of paries headcap
Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame
138
Immobilization within the tissue
Direct fixation
Transosseous wiring at
fracture sites
Frontozygomatic sutures
Infrorbital margin
Midline of the palate
139
Immobilization within the tissue
Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular
140
Immobilization within the tissue
Support via the maxillary sinus by
filling materials
• Ribbon gauze
• Balloon
• Folly catheter
• Polyethylene material
141
142
Length of the hospital stay will depend
on a number of factors including:
• Presence of other injuries
• Age and medical status of the patient
• Severity of the injury
• Technique employed in the reduction and
fixation of the fracture
• Presence or absence of medical or
surgical complications
• Social circumstances of the patient
143
144
145
146
147
