MIDFACE FRACTURES

Midface fractures

Fractures of the middle third may be subdivided into:

Dento-alveolar fractures. Fractures of the maxilla. Fractures of the zygomatic bone & arch. Blow out fractures. Nasal-orbital-ethmoidal fractures.

Dento-alveolar fractures

It consists of fracture, subluxation, or avulsion of the teeth with or without an associated fracture of the alveolus, and they may occur as a clinical entity or in conjunction with any other type of fracture.

FRACTURES OF THE MAXILLA

Fractures of the maxillaClassification

The Le Fort classification defines the weakest areas of the midface complex when it is assaulted from a frontal directions at a different levels into :

Le Fort type I

Le Fort type II

Le Fort type III

LeFort Classification

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Le Forte type I fracture

Fracture lines

Le Fort type I

It results from a force delivered above the level of the teeth.

The fracture courses from the lateral border of the pyriform aperture

Le Fort type I

above the canine eminence lateral antral wall behind the maxillary tuberosity across the lower third of the ptergoid plate.

The nasal septum may be fractured

Le Fort type I fractures

* It may be unilateral or bilateral

* It may occur single or in conjunction of with Le Fort type II or III fractures.

*The clinical findings may be largely masked by more severe fractures.

* Caused by blow with a sharp object above the apices of the teeth.

Clinical findings in Le Forte I fractures

low level or Guerin type

Le Fort type I fractures

Clinical findings:

Extra-orally Swelling of the upper lip. Soft tissue laceration. Open mouth to accommodate the displaced

dento-alveolar portion. Epistaxis.

Le Fort type I fractures

Clinical findings:

Intra-orally Malocclusion.

Mobility of tooth bearing portion. Ecchymosis of the buccal sulcus. Dull sound on percussion.

Le Forte type II fractures

Fracture lines

Le Fort type II

It results from a force delivered at a level of the nasal bones.

The fracture line occurs along the nasofrontal suture lacrimal bone across the infra- orbital rim in the region of the zygomatico-maxillary suture

Le Fort type II

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.

Clinical findings in Le Forte II fractures

Sub-zygomatic fracture

Pyramidal fracture

Le Fort type II fractures

Clinical Findings:

Extraorally

- Ballooning of the face.

- Lenghtenening of the face

- Circumorbital ecchymosis

- Subconjunctival Hg.- Epistaxis- Dipobia (cont)

Le Fort type II fractures

Clinical Findings: (cont)

Extraorally

- Enophthalmos- CSF rhinorrhoea- Step deformity in the

lower border of the orbit- Intact zygomatic bone &

arch

Le Fort type II fractures

Clinical Findings:

Intraorally- Malocclusion- Gagging of the posterior

teeth and anterior open bite

- Mobility of the maxilla- Ecchymosis of the

sulucs

Le Forte type III fractures

Fracture lines

Le Fort type III

The fracture is caused by a force at the orbital level , the resultant fracture is craniofacial dysjunction.

It is called :high level fracture or supra-zygomatic fracture

Le Fort type III

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

Clinical findings in Le Forte III fractures

Supra-zygomatic fracture

High level

Le Fort type III fractures

Clinical Findings

Extraorally

- Severe edema of the face “ballooning”

- Lengthening of the face

- Flattening of the cheek

- Circumorbital ecchymosis

- Subconjunctival Hg

Le Fort type III fractures

Clinical Findings (cont)

Extraorally- Epistaxis- Enophthalmos- CSF rhinorrhoea

Le Fort type III fractures

Clinical Findings Intraorally- Gagging of the posterior

teeth and anterior open bite

- Ecchymosis and Hg of the buccal sulcus

- Mobility of the maxilla- Mandibular interference

Radiology for maxillary fractures

Occipto-mental view CT scan

Occipto-mental view

Occipto-mental view

Computerized tomography

TYPES

* Axial scan

* Coronal scan

* 3/D CT

imaging

Axial scan

Computerized tomography

Axial scan

Computerized tomographyAxial scan

Coronal scan

Axial scan

Coronal scan Axial scan

3/D Computerized tomography

Treatment of the maxillary fractures

First aid treatment

Preliminary treatment

Definitive treatment

Treatment of the maxillary fractures

REDUCTION

IMMOBILIZATION

Treatment of the maxillary fractures

REDUCTION

* Digital pressure

* The use of Rowe’s

forceps , Hayton-

Wiliams disimpac-

tion forceps.

* Surgical

Rowe’s Desimpaction Forceps

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Maxillary fracturesImmobilization

Methods MMF Internal fixation Skeletal suspension Support External fixation

Maxillary fracturesImmobilization

Circumzygomatic suspension Obwegeser technique

Maxillary suspension

1- Frontal susp.

2- Pyriform fossa susp.

3- Infraorbital rim susp.

4- Circumzygomatic susp.

Antral support

Treatment of unilateral Le Fort type I fractures

A) Closed reduction & fixation

* Digital pressure.

* Arch bar tightened in the unfractured side and loose in the fractured side.

* Adjust occlusion, tighten the fractured side then secure MMF.

Treatment of unilateral Le Fort type I fractures

B) Open reduction & fixation

* Cases of unstable fractures.

* Arch bars are prepared

* Sulcus incision to expose the fracture site in canine & buttress regions

* Transosseous wiring or miniplates are used for fixation.

Transosseous wiring

Sulcus incision Fracture exposure Reduction Drilling wholes 24-26 guage wire is

used

Treatment of bilateral Le Fort type I fractures

Reduction closed or open Immobilization suspension or internal fixation

Treatment of Le Fort type Il fractures

Reduction closed or open Immobilization suspension or internal fixation

Treatment of Le Fort type Ill fractures

Reduction Immobilization suspension or internal fixation

Zygomatic complex fractures

Zygomatic complex fractures

Second most common fracture of the facial bones behind nasal bone fractures

Zygoma forms prominence of cheek which subsequently contributes to frequency of fractures

Major contact areas are with the maxilla and frontal bones

Also forms portion of lateral wall and floor of the orbit

ARTICULATIONS

Frontozygomatic Zygomaticotemporal Zygomaticomaxillary

Foramina

Foramen allows for passage of zygomaticofacial and zygomaticotemporal nerves of V2 that supply sensation to cheek and anterior temple

Infraorbital N. Of V2 courses the floor of the orbit and exits the infraorbital foramen or notch

COMMON FRACTURE SITES

Frontozygomatic suture Infraorbital rim Junction of the

zygomatic arch and temporal bones

Orbital floor Maxillary buttress

Classification of Zygomatic Fractures

Clinical features of Zygomatic Fractures

Clinical features of Zygomatic Fractures

Common clinical features: Edema Circumorbital ecchymosis Subconjunctival

hemorrage Malar depression Step defect at infraorbital

rim Step defect at

frontozygomatic suture Epistaxis

Clinical features of Zygomatic Fractures

Step defect at zygomatic buttress of maxilla intraorally

Ecchymosis at maxillary buttress region

V2/infraorbital nerve paraesthesia or anesthesia

Clinical features of Zygomatic Fractures

LESS COMMON FINDINGS Enopthalmos or Proptosis Diplopia (monocular vs. binocular) Decreased mobility of extraocular muscles -- upward gaze due to its

entrapment . Injury to globe itself -- ophtho. consultation should be obtained on all

midface fractures patients

Limitation of mandibular movement secondary to zygomatic arch impingement on the coronoid process

Crepitation from air emphysema

Unequal pupilary level

Clinical features of Zygomatic Fractures

Intra-oral inspection

Ecchymosis in the upper buccal sulcus in the region of zyg. Buttress.

Anesthesia of teeth and gum.

Intra-oral palpation

Tenderness over zyg. Buttress.

Crepitus may be felt.

RADIOGRAPHS

Water's view : a PA projection w/ the head positioned at 27 degree angle to the vertical with the chin resting on the cassette

Submentovertex : "jug handle" Caldwell view : PA projection w/ the face at

a 15 degree angle to the cassette CT Scan : for more detail usually obtain axial

and coronal 3-5mm cuts

Water's view

CT Scan

Zygomatic arch fractures

May exist alone or with zygomatic bone or other facial bone fractures.

Specific clinical findings:

* Visible depression over the zyg. arch area.

* Limitation of mandibular movements.

* Classified as a- triple or V-shaped fracture

b- comminuted fractures

Zygomatic fractures

Radiographic examination:

Subnemto-vertial view. Occipito-mental view. Ct scan , axial cuts

Subnemto-vertical view

Zygomatic arch fractures

Comminuted fracture

Triple fracture

Treatment of Zygomatic Fractures

Treatment of Zygomatic Fractures

Zygomatic bone requires reduction for the following reasons:.

Globe displacement - enophthaimus / exophthaimus / diplopia

Alteration in facial contour Muscle/Fat/Nerve entrapment Mechanical restriction of mandibular movement Cosmetic.

Treatment of Zygomatic Fractures

Methods: Reduction alone. Reduction & fixation.

Reduction of Zygomatic Fractures

Methods of reduction: Closed reduction using

- Bristow’s elevator

- Rowe’s zygomatic elevator

* Open reduction ( surgical )

GELLIIE’S APPROACH

NONFIXATION Isolated arch fractures/minimally

displaced ZMC fractures -- no direct visualization

2-3cm incision in hairline below and parallel to anterior branch of temporal artery

To and through superficial temporalis fascia

Bristow’s elevator is passed medial to arch for elevation in a sweeping upward and outward direction

OTHER INDIRECT APPROACHES

Towel Clip : applied directly

Treatment of Zygomatic Fractures

OPEN REDUCTION TECHNIQUES Lateral brow incision subcilliary (blepheroplasty) incision Infraorbital crease incision Bicoronal / Hemicoronal flap

Treatment of Zygomatic Fractures

DIRECT FIXATION TECHNIQUES Wiring - 24 - 30 gauge stainless steel wire Mini bone plates

Trans osseous wiring

Wiring - 24 - 30 gauge stainless steel wire

Open reduction and transosseous wire fixation

Mini bone plates

Blow-out fractures

The classic blow-out fracture implies an intact orbital rim and a disruption of one of walls of the orbit.

It may be caused by a blow to the orbit by an object larger than the outer structure of the orbit producing a momentary increase in intra orbital pressure.

Blow-out fractures

This causes the weakest point of the orbit to give away, usually the orbital wall of the ethmoid or the roof of the maxillary sinus.

This type of fracture acts as safety valve to spare the globe.

Blow-out fractures

Clinical symptoms Circumorbital edema. Circumorbital ecchymosis. Ophthalmoplagia. Diplopia , (upper & lateral gaze) Enophthalmos.

Orbital floor support

ORBITAL FLOOR RECONSTRUCTION

Autograft --rib, iliac crest, calvaria, as well as ear or nose cartilage

Allograft --lyophilized dura, rib, iliac crest, cartilage

Alloplast --Teflon, Silastic, Ti-Mesh, and Gelfilm have been described