Download Midface injury

Oral and Maxillofacial Surgery
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Definition:
Mid-face
The area between
a superior plane
drawn through
the zygomaticofrontal sutures
tangential to the
base of the skull
and inferior
plane at the level
of the maxillary
dental occlussal
surface.
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Structures connection
(structures in relation)
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Orbit
Maxillary sinus
Nasal bone
Naso-orbital
ethmoid (NOE)
complex
Zygomatic
complex
Frontal bone and
sinus
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Vertical and horizontal pillars
•Area of strength
•Vertical and horizontal pillars
•Muscular attachment
•Area of weakness
•Sutures
•Lining tissues and air-filled cavities
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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
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Alveolar bone fracture
Involve block of
alveolar bone
with or without
 Intrusion of
teeth
 Extrusion of
teeth
 Luxation of teeth
 Fracture of teeth
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Le Fort’s fractures
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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
Ptrygoid laminae
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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
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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
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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.
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Signs and symptoms
although it is possible to distinguish between le fort II and III, the
signs and symptoms are almost similar
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Gross edema of soft tissue
Bilateral circumorbital
ecchymosis
Bilateral subconjunctival
hemorrahge
Obvious deformity of the
nose
Nasal bleeding and
obstruction
CSF leak rhinorrhea
Dish-face deformity
Limitation of ocular
movement
Possible diplopia and
enophthalmous
Retropostioning of the
maxilla with anterior open
bite
Lengthening of the face
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Difficulty in mouth opening
Mobility of the upper jaw
Occusional hematoma of
the palate
Cracked-pot sound on
percussion
Step deformity at infraorbiatal margin
Anasthesia of midface
Nasal bone moves with
mid-face as a whole
Tenderness and sepration
at FZ suture
Tenderness and deformity
of zygomatic arch
Depression of occular level
and pseudoptosis
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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
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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)
LeFort
40 %
I
15 %
II
10 %
III
10 %
Zygomatic arch
10 %
Alveolar process of maxilla
5%
Smash fractures
5%
Other
5%
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Diagnosis

Inspection
Extra-oral
(e.g. swelling, deformity, asymmetry
Leaks)
Intra-oral
(e.g. hematoma, occlusion)

Palpation
Step deformity, criptation, cracked pot sound, mobility
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Radiographical investigations
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Radiographical examination
Plain radiograph

Occipitomental
(10 or 30 degree)

Water’s view
Suitable for isolated orbital
fracture
Search line (Campbell’s line 1977)
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Radiographical examination
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Lateral skull view
OPG
Occlusal view of the
maxilla
Perapical views of
damaged teeth
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Radiographical examination
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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
enophthalmos
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Indications for treatment

Physical signs of a fracture of the maxilla.

Evidence of a fractured maxilla on imaging.
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Disruption of the occlusion of the teeth.
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Displacement of the maxilla.
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Post traumatic facial deformity.
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Indications for treatment

Fractured or displaced teeth.

Cerebrospinal fluid leak.
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Abnormal eye movement or restriction of
eye movement.
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Occlusion of the nasolacrimal duct.
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Sensory or motor nerve deficit.
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Other evidence of loss of function
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Aims of treatment

Relieve pain
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Restore function.
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Restore bone anatomy.
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Prevent infection
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Restore the dental occlusion
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Restore jaw movement at the earliest
possible stage
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Restore normal nerve function
Factors affecting the risk

Association with multiple injuries.
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Presence of uncontrolled haemorrhage
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Impairment of the airway.
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Presence of bone comminution
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Association with a dural tear.
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Association with a base of skull fracture.
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Factors affecting the risk

Presence of a pre-existing dentofacial
deformity.
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Time elapsed since the injury.
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Presence of a medical or surgical factor
which would delay general anesthesia
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Presence of any factor which would delay
healing. (eg nutritional deficiency or
alcoholism)
Stage of dental development (deciduous,
mixed or permanent dentition)
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Factors affecting the risk

Presence of fractured teeth.
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Total absence of teeth (edentulous)
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Inability of the patient to co-operate with
treatment.
Association with fractures of the mandible
especially bilateral fractures of the
condyles.
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Principles of treatment
Closed reduction may be appropriate in
cases
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Simple uncomplicated fractures
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Complex or comminuted fractures
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Medical or surgical contraindications to
open reduction
Maxillary fractures in children
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Open reduction may be appropriate
where
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Immediate or early jaw function is
desirable
Difficulty is encountered in reducing the
fracture by a closed method
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The fracture is unstable
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Definitive treatment

Reduction
Manual manipulation
Use of dis-impaction forceps
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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
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Immobilization within the tissue
Direct fixation
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Transosseous wiring at
fracture sites
Frontozygomatic sutures
Infrorbital margin
Midline of the palate
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Immobilization within the tissue
Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular
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Immobilization within the tissue
Support via the maxillary sinus by
filling materials
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Ribbon gauze
Balloon
Folly catheter
Polyethylene material
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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
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