Mid Face Fractures / Orthodontic Courses by Indian Dental Academy

MIDFACE FRACTURES
INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

Introduction
Upper 1/3
rd

Middle 1/3
rd

Lower 1/3
rd
MidFace
Maxillae
Palatine bones
Zygomatic bones
Zygomatic processes of
temporal bones
nasal bones
lacrimal bones
Vomer
Ethmoid bones & its
concha
inf. Turbinates
Pterygoid plates of
sphenoid
Surgical Anatomy
Central midface :
Crumple Zone

Complex Articulation

Protects brain and
skull

Articulation with
Skull Base
Areas of Weakness
Developmental
Sutures

Air filled spaces

Neurovascular
bundle

Areas of Strength
Thickened Bones
Higher ratio of cortical:cancellous
Analogus to architectural concepts of support
Sicher & Tandler in 1928
Vertical Buttresses

Anterior / Nasomaxillary pillars
Middle / Zygomatico-maxillary pillars
Posterior/ Pterygomaxillary pillars
Horizontal Buttresses
Supra-Orbital Rims with Frontal
bones
Infra-Orbital Rims
Alveolar Process
Muscular Attachment
Static structure
Muscles of
mastication
Extra-ocular
muscles
Buccinator
Facial mimetic
muscles

Classification
FRACTURES NOT INVOVING OCCLUSION
A. CENTRAL REGION
Fractures of the nasal bones and / or nasal
septum - lateral nasal injuries
- anterior nasal injuries
Fractures of the frontal process of the maxilla
Fractures of (1) and (2) which extend into the
ethmoid bone ( nasoethmoid)
Fractures of types (1), (2) and (3) which
extend into the frontal bone (fronto- orbito-
nasal dislocation)
B. LATERAL REGION
Fractures involving the zygomatic bone,
Zygomatic arch and
maxilla
(zygomatic complex) excluding the dento-
alveolar component
FRACTURES INVOLVING
OCCLUSION
Dento alveolar
Subzygomatic :
-- Le Fort I ( low level)
-- Le Fort II (pyramidal)
Suprazygomatic
--Le Fort III (High-level)
Rowe & Williams (1985)
FRACTURES NOT INVOVING THE
DENTOALVEOLAR COMPONENT

FRACTURES INVOLVING THE
DENTOALVEOLAR COMPONENT

Classification
Alphonse Guerin ( 1888)
Rene LeFort (1901)
Experimental cadaveric
studies
# along the lines of weakness
Assault from frontal / lateral
impact
Avoided areas of strength
LeFort I
LeFort II
LeFort III
Le Fort I
Guerin #,Floating #
Fracture extends
transversely above
level of teeth
Traumatic force
directed
to the lower maxillary
region
B/L or U/L
U/L: auxillary # :
midline of the palate
MAXILLOFACIAL INJURIES
MIDFACE FRACTURES
Le-Fort I Fracture
(Guerin # / Low level # / Floating #)
Nasal floor
Pyriform rim
Zygomatic buttress
Pterygoid lamella
Lateral wall nose
Nasal septum tuberosity
Le Fort II:
Pyramidal #
Begins above level
of teeth
a violent force to the
central region of the
mid
Central portion
mobilized
independently
Pa Skull- Pyramidal
shaped.
MIDFACE FRACTURES
Le-Fort II Fracture
( Pyramidal # / Subzygomatic # )

Nasal bone
Frontal bone
Orbit
Lacrimal bone
Infraorbital foramen
Maxillary antrum
ZM suture
Le Fort III:
Craniofacial Dysjunction

Fracture extends through
zygomatic arch
Entire midface separated &
suspended solely by soft
tissues www.indiandentalacademy.com
GK / MAXFAC
SDM DHARWAD
MIDFACE FRACTURES
Le-Fort III Fracture
( High transverse/Suprazygomatic/Craniofacial disarticulation)

Fronto-nasal suture
Ethmoid cribriform plate
Frontal process maxilla
Medial wall orbit
Optic foramen
Inferior orbital fissure
Pterygoid lamella
Lateral wall of orbit Z-F
suture
These fractures may occur unilaterally or
may be associated independently with a
fracture of the zygomatic complex

There may be midline separation of the
maxilla and / or extension of the fracture
pattern into the frontal or temporal bones
Factors influencing displacement
Degree of force
Direction of force
Resistance to the force offered by the facial
bones
Point of application of force
Cross sectional area of object
Attached muscles
Diagnosis of Maxillofacial Injuries
Inspection
Palpation
Diagnostic Imaging
Plain Radiographs
CT -Axial section -Coronal section
Local clinical examination
gently clean up the face
Inspection
Palpation
Diagnostic Imaging
Extra oral examination
Lacerations or injury over head
Check for edema, ecchymosis (periorbital,
conjunctival, scleral) and soft tissue
lacerations
Any obvious bony deformities, haemorrhage,
epistaxis or otorrhoea, rhinorrhoea
occular involvement

Palpation

It should begin at the back of the neck and
cranium, Upper face,the zygomatic arch ,bone
and orbit

Ares of tenderness, deformities noted

Step deformity,subcutaneous emphysema

Mobility of maxilla

Eyelids separated and vision tested, check for
diplopia, light reflex

Check for Paraesthesia
Intra oral examination

Derangement of occlusion, gagging of
occlusion, lacerations, ecchymosis
Palpation
Areas of tenderness, bony irregularities,
crepitus mobility of teeth noted
Examination of teeth
Pharynx evaluated for laceration & bleeding
Clinical Features
LeFort - I
Swelling of the upper lip
Ecchymosis present in the buccal sulcus
beneath each zygomatic arch
Patient keeping the
mouth slightly open
Occlusion derranged
Midline split of the palate
Subluxation of teeth

The impacted Le Fort I fracture (Telescoping
fracture) difficult to diagnose grating
sound
Percussion cracked pot sound
Haemorrhage in the maxillary sinuses
LeFort - II / III
Swelling : gross; (moon face) eyelids
conjunctiva
Ecchymosis : bilateral circum-orbital
(panda face/raccoon face)
: subconjunctival
Chemosis
Infra orbital step
(Le Fort II)
Nasal deformity
Retropositioning of maxilla : Deranged
occlusion : post gagging : V. D
Mobility of midface
Hematoma on palate
Dish face
Loss of function:
Diplopia? Anosmia
Nares filled with clotted blood
Emphysema, Epiphora,
CSF Rhinorrhea,Hooding of eye
LeFort - II
No alteration of pupillary level
Haematoma in the upper buccal sulcus
Step deformity : infra orbital margins
Limitation of orbital movement with diplopia
and enopthalmos
Anaesthesia or Paraesthesia of the cheek
Gagging of occlusion and retro-positioning of
the maxilla
On manipulation: movement being detected at
the infra orbital margins and nasal bridge
LeFort - III
Lenghtening of the face
Alteration of the occular level
unilateral or bilateral hooding
of the eye
# of the zygomatic arch :
flattening of the zygomatic complex
Tenderness and deformity over the zygomatic arch
Tenderness and separation at the F-Zsuture
Mobility of the whole facial skeleton as a single
block
Gagging of occlusion in the molar area
Disruption of the cribriform plate :CSF rhinnorhoea
Radiographic Evaluation
Plain Radiographs :
P - A skull
PNS
Lateral skull
CT Scan
Axial & Coronal sections

PNS view



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