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INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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Oral and Maxillofacial Surgery
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Mid-faceMid-faceDefinition:Definition: The area between The area between
a superior plane a superior plane drawn through drawn through
the zygomatico-the zygomatico-frontal sutures frontal sutures
tangential to the tangential to the base of the skull base of the skull
and inferior and inferior plane at the level plane at the level of the maxillary of the maxillary dental occlussal dental occlussal
surface.surface.www.indiandentalacademy.comwww.indiandentalacademy.com
Structures connectionStructures connection(structures in relation)(structures in relation)
OrbitOrbit Maxillary sinusMaxillary sinus Nasal boneNasal bone Naso-orbital Naso-orbital
ethmoid (NOE) ethmoid (NOE) complexcomplex
Zygomatic Zygomatic complexcomplex
Frontal bone and Frontal bone and sinussinus
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Vertical and horizontal pillarsVertical and horizontal pillars
•Area of strength•Vertical and horizontal pillars •Muscular attachment
•Area of weakness •Sutures•Lining tissues and air-filled cavitieswww.indiandentalacademy.comwww.indiandentalacademy.com
Pattern of fracturesPattern of fracturesof mid-face skeletonof mid-face skeleton
Alveolar fracture and dental fractureAlveolar fracture and dental fracture
Le Fort ‘s fracture (Le Fort ‘s fracture ((french surgeon Rane Le (french surgeon Rane Le Fort 1901)Fort 1901)
Naso-orbital ethmoid fractureNaso-orbital ethmoid fracture
Zygomatic complex and arch fractureZygomatic complex and arch fracture
Frontal sinus and bone fractureFrontal sinus and bone fracture
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Alveolar bone fractureAlveolar bone fracture
Involve block of Involve block of alveolar bone alveolar bone with or withoutwith or without
Intrusion of Intrusion of teethteeth
Extrusion of Extrusion of teethteeth
Luxation of teethLuxation of teeth Fracture of teethFracture of teeth
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Le Fort’s fracturesLe Fort’s fractures Le Fort I (low Le Fort I (low
level or Guerian level or Guerian fracture)fracture)
Unilateral/ bilateralUnilateral/ bilateral Horizontal fracture Horizontal fracture
through the maxilla through the maxilla above the level of above the level of
the nasasl floor and the nasasl floor and alveolar processalveolar process
Piriform rimsPiriform rims Anterior maxillaAnterior maxilla Zygomatic buttressesZygomatic buttresses Ptrygoid laminaePtrygoid laminae
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Signs and symptomsSigns and symptoms Slight swelling of upper lipSlight swelling of upper lip
Ecchymosis in upper lip sulcusEcchymosis in upper lip sulcus
Hematoma intra-orally over zygoma and in palateHematoma intra-orally over zygoma and in palate
Disturbed occlusionDisturbed occlusion
Mobility of teeth of the involved segment of maxillaMobility of teeth of the involved segment of maxilla
Combination of soft tissue lacerationCombination of soft tissue laceration
Exposure of nares and the maxillary antra in case of Exposure of nares and the maxillary antra in case of gross injurygross injury
Impacted type of fracture is oftenly not mobile and Impacted type of fracture is oftenly not mobile and teeth cusps may be damagedteeth cusps may be damaged
Cracked-pot percussion of upper teethCracked-pot percussion of upper teeth www.indiandentalacademy.comwww.indiandentalacademy.com
Le Fort’s fracturesLe Fort’s fractures Le Fort IILe Fort II (pyramidal or subzygomatic)(pyramidal or subzygomatic) Separation of NF suture, Separation of NF suture,
medial orbital walls medial orbital walls (lacrimal bone), inferior (lacrimal bone), inferior orbital floor and rim orbital floor and rim (adjacent to infrorbital (adjacent to infrorbital canal and foramen), canal and foramen), anterior maxilla below anterior maxilla below zygomatic buttress and zygomatic buttress and ptrygoid laminae about ptrygoid laminae about halfway up.halfway up.
Separation of the block from the base of skull is completed Separation of the block from the base of skull is completed via the nasal septum and may involve the floor of the via the nasal septum and may involve the floor of the anterior cranial fossaanterior cranial fossawww.indiandentalacademy.comwww.indiandentalacademy.com
LeFort’s fracturesLeFort’s fractures
LeFort III LeFort III (cranifacial dysjunction, high (cranifacial dysjunction, high
transverse, suprazygomatic)transverse, suprazygomatic) Separation of NF suture, medial Separation of NF suture, medial
orbital walls (involve the depth orbital walls (involve the depth of the ethmoid bone and of the ethmoid bone and
cribriform plate, pass below cribriform plate, pass below optic foramen and cross the optic foramen and cross the
inferior orbital fissur), inferior inferior orbital fissur), inferior orbital floor, lateral orbital orbital floor, lateral orbital wall, ZF suture, zygomatic wall, ZF suture, zygomatic
arch, suprazygomatic to the arch, suprazygomatic to the root of ptrygoid plate.root of ptrygoid plate.
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Signs and symptomsSigns and symptomsalthough it is possible to distinguish between le fort II and III, the although it is possible to distinguish between le fort II and III, the signs and symptoms are almost similarsigns and symptoms are almost similar
Gross edema of soft tissueGross edema of soft tissue Bilateral circumorbital Bilateral circumorbital
ecchymosisecchymosis Bilateral subconjunctival Bilateral subconjunctival
hemorrahgehemorrahge Obvious deformity of the Obvious deformity of the
nosenose Nasal bleeding and Nasal bleeding and
obstructionobstruction CSF leak rhinorrheaCSF leak rhinorrhea Dish-face deformityDish-face deformity Limitation of ocular Limitation of ocular
movementmovement Possible diplopia and Possible diplopia and
enophthalmousenophthalmous Retropostioning of the Retropostioning of the
maxilla with anterior open maxilla with anterior open bitebite
Lengthening of the faceLengthening of the face
Difficulty in mouth openingDifficulty in mouth opening Mobility of the upper jawMobility of the upper jaw Occusional hematoma of Occusional hematoma of
the palatethe palate Cracked-pot sound on Cracked-pot sound on
percussionpercussion Step deformity at infra-Step deformity at infra-
orbiatal marginorbiatal margin Anasthesia of midfaceAnasthesia of midface Nasal bone moves with Nasal bone moves with
mid-face as a wholemid-face as a whole Tenderness and sepration Tenderness and sepration
at FZ sutureat FZ suture Tenderness and deformity Tenderness and deformity
of zygomatic archof zygomatic arch Depression of occular level Depression of occular level
and pseudoptosisand pseudoptosis
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Bowerman classification of midface-fracture Bowerman classification of midface-fracture (1994)(1994)
Fracture not involving the occlusionFracture not involving the occlusion• Central regionCentral region
Nasal bone/ septum (lateral, anterior injuries)Nasal bone/ septum (lateral, anterior injuries) Frontal process of the maxillaFrontal process of the maxilla NasoethmoidNasoethmoid Fronto-orbito-nasal dislocationFronto-orbito-nasal dislocation
• Lateral region (zygomatic complex EX dento alveolar Lateral region (zygomatic complex EX dento alveolar frcaturefrcature
Fracture involving the occlusionFracture involving the occlusion• Dento alveolarDento alveolar
• Subzygomatic:Subzygomatic: Le Fort’s (I, II)Le Fort’s (I, II)
• Supra zygomatic: Supra zygomatic: Le Fort IIILe Fort III
These fractures may occur unilaterally or bilaterally, with separation of maxillary midline and or extension to frontal or temporal bone
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Prevalence of mid-face fracturesPrevalence of mid-face fractures
Fracture TypeFracture Type PrevalencePrevalence
Zygomaticomaxillary complex (tripod fracture)Zygomaticomaxillary complex (tripod fracture) 40 %40 %
LeFortLeFortII 15 %15 %IIII 10 %10 %IIIIII 10 %10 %
Zygomatic archZygomatic arch 10 %10 %Alveolar process of maxillaAlveolar process of maxilla 5 %5 %Smash fracturesSmash fractures 5 %5 %OtherOther 5 %5 %
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Diagnosis Diagnosis InspectionInspection Extra-oral Extra-oral (e.g. swelling, deformity, asymmetry(e.g. swelling, deformity, asymmetryLeaks) Leaks) Intra-oralIntra-oral(e.g. hematoma, occlusion)(e.g. hematoma, occlusion)
PalpationPalpationStep deformity, criptation, cracked pot sound, mobilityStep deformity, criptation, cracked pot sound, mobility
Radiographical investigationsRadiographical investigationswww.indiandentalacademy.comwww.indiandentalacademy.com
Radiographical examinationRadiographical examinationPlain radiographPlain radiograph
OccipitomentalOccipitomental(10 or 30 degree)(10 or 30 degree) Water’s viewWater’s viewSuitable for isolated orbital Suitable for isolated orbital
fracturefractureSearch line (Campbell’s line 1977)
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Radiographical examinationRadiographical examination
Lateral skull viewLateral skull view OPGOPG Occlusal view of the Occlusal view of the
maxillamaxilla Perapical views of Perapical views of
damaged teethdamaged teeth
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Radiographical examinationRadiographical examination
CT scanCT scan 3-D CT imaging3-D CT imaging
• Coronal sectionsCoronal sections• Axial sectionsAxial 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 enophthalmos www.indiandentalacademy.comwww.indiandentalacademy.com
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Indications for treatmentIndications for treatment
Physical signs of a fracture of the maxilla.Physical signs of a fracture of the maxilla.
Evidence of a fractured maxilla on imaging.Evidence of a fractured maxilla on imaging.
Disruption of the occlusion of the teeth.Disruption of the occlusion of the teeth.
Displacement of the maxilla.Displacement of the maxilla.
Post traumatic facial deformity.Post traumatic facial deformity.
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Indications for treatmentIndications for treatment
Fractured or displaced teeth.Fractured or displaced teeth.
Cerebrospinal fluid leak.Cerebrospinal fluid leak.
Abnormal eye movement or restriction of Abnormal eye movement or restriction of eye movement.eye movement.
Occlusion of the nasolacrimal duct.Occlusion of the nasolacrimal duct.
Sensory or motor nerve deficit.Sensory or motor nerve deficit.
Other evidence of loss of functionOther evidence of loss of functionwww.indiandentalacademy.comwww.indiandentalacademy.com
Aims of treatmentAims of treatment Relieve painRelieve pain
Restore function.Restore function.
Restore bone anatomy.Restore bone anatomy.
Prevent infectionPrevent infection
Restore the dental occlusionRestore the dental occlusion
Restore jaw movement at the earliest possible Restore jaw movement at the earliest possible stagestage
Restore normal nerve functionRestore normal nerve function www.indiandentalacademy.comwww.indiandentalacademy.com
Factors affecting the riskFactors affecting the risk
Association with multiple injuries.Association with multiple injuries.
Presence of uncontrolled haemorrhagePresence of uncontrolled haemorrhage
Impairment of the airway.Impairment of the airway.
Presence of bone comminutionPresence of bone comminution
Association with a dural tear.Association with a dural tear.
Association with a base of skull fracture.Association with a base of skull fracture.www.indiandentalacademy.comwww.indiandentalacademy.com
Factors affecting the riskFactors affecting the risk
Presence of a pre-existing dentofacial Presence of a pre-existing dentofacial deformity.deformity.
Time elapsed since the injury.Time elapsed since the injury.
Presence of a medical or surgical factor Presence of a medical or surgical factor which would delay general anesthesiawhich would delay general anesthesia
Presence of any factor which would delay Presence of any factor which would delay healing. (eg nutritional deficiency or healing. (eg nutritional deficiency or alcoholism)alcoholism)
Stage of dental development (deciduous, Stage of dental development (deciduous, mixed or permanent dentition)mixed or permanent dentition)
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Factors affecting the riskFactors affecting the risk
Presence of fractured teeth.Presence of fractured teeth.
Total absence of teeth (edentulous)Total absence of teeth (edentulous)
Inability of the patient to co-operate with Inability of the patient to co-operate with treatment.treatment.
Association with fractures of the mandible Association with fractures of the mandible especially bilateral fractures of the especially bilateral fractures of the condyles.condyles.
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Principles of treatment Principles of treatment Closed reduction may be appropriate in Closed reduction may be appropriate in
casescases
Simple uncomplicated fracturesSimple uncomplicated fractures
Complex or comminuted fracturesComplex or comminuted fractures
Medical or surgical contraindications Medical or surgical contraindications to open reductionto open reduction
Maxillary fractures in childrenMaxillary fractures in childrenwww.indiandentalacademy.comwww.indiandentalacademy.com
Open reduction may be appropriate whereOpen reduction may be appropriate where
Immediate or early jaw function is Immediate or early jaw function is desirabledesirable
Difficulty is encountered in reducing the Difficulty is encountered in reducing the
fracture by a closed methodfracture by a closed method
The fracture is unstableThe fracture is unstable
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Definitive treatmentDefinitive treatment ReductionReduction
Manual manipulationManual manipulation
Use of dis-impaction forcepsUse of dis-impaction forceps
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Fixation and immobilizationFixation and immobilization
Extraoral fixationExtraoral fixation
Craniomandibular fixationCraniomandibular fixationBox-frame (pin fixation)Box-frame (pin fixation)Halo-frameHalo-framePlaster of paries headcapPlaster of paries headcap
Craniomaxillary fixationCraniomaxillary fixationSupra-orbital pinsSupra-orbital pinsZygomatic pinsZygomatic pinsHalo-frameHalo-frame
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Immobilization within the tissueImmobilization within the tissueDirect fixationDirect fixation
Transosseous wiring at Transosseous wiring at fracture sitesfracture sites Frontozygomatic suturesFrontozygomatic sutures Infrorbital marginInfrorbital margin Midline of the palateMidline of the palate
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Immobilization within the tissueImmobilization within the tissue
Internal-wire suspensionInternal-wire suspension
Circumzygomatico-mandibularCircumzygomatico-mandibular
Infraorbital border-mandibularInfraorbital border-mandibular
FrontomandibularFrontomandibular
Pyriform fossa-mandibularPyriform fossa-mandibular
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Immobilization within the tissueImmobilization within the tissue
Support via the maxillary sinus by Support via the maxillary sinus by filling materialsfilling materials
• Ribbon gauzeRibbon gauze• BalloonBalloon• Folly catheterFolly catheter• Polyethylene materialPolyethylene material
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Length of the hospital stay will depend Length of the hospital stay will depend on a number of factors including:on a number of factors including:
• Presence of other injuriesPresence of other injuries
• Age and medical status of the patientAge and medical status of the patient
• Severity of the injurySeverity of the injury
• Technique employed in the reduction and Technique employed in the reduction and fixation of the fracturefixation of the fracture
• Presence or absence of medical or Presence or absence of medical or surgical complicationssurgical complications
• Social circumstances of the patient Social circumstances of the patient www.indiandentalacademy.comwww.indiandentalacademy.com
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Conclusion Conclusion
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ReferencesReferences Maxillofacial Injuries - Rowe and Williams.Maxillofacial Injuries - Rowe and Williams. Oral and Maxillofacial Trauma - Raymond J.Fonseca.Oral and Maxillofacial Trauma - Raymond J.Fonseca. Maxillofacial Surgery - Peter Ward Booth.Maxillofacial Surgery - Peter Ward Booth. Killey's fracture of middle third of facial skeleton.Killey's fracture of middle third of facial skeleton. Maxillofacial trauma by Robert H.Mathog.Maxillofacial trauma by Robert H.Mathog. Pediatric Maxillofacial Surgery- KabanPediatric Maxillofacial Surgery- Kaban Management Of Midfacial Fractures – Joms (1993)51;960-968Management Of Midfacial Fractures – Joms (1993)51;960-968
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Thank you
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