Fractures Of The

Middle Third Of Facial

Skeleton
 Superiorly by line drawn across the skull from
zygomaticofrontal suture across frontonasal
and frontomaxillary sutures to the
zygomaticofrontal suture on the opposite
side.
 Inferiorly the occlusal plane of the upper
teeth or if the patient is edentulous , by the
alveolar ridge.
 Two maxillae
 Two zygomatic bones
 Two zygomatic process
of the temporal bones
 Two palatine bones
 Two nasal bones
 Two lacrimal bones
 The vomer
 The ethmoid and its
attached conchae
 Two inferior conchae
 The pterygoid plates of
the sphenoid bone
 Mid facial skeleton rarely fracture in
isolation.
 The bones are arranged in order that it will
withstand the forces of mastication from
below and provide protection in certain
areas for vital structures.
 The facial bones have very low tolerance to
impact forces.
 The nasal bones are least resistant
followed by zygomatic arch.
 Bones of the mid face act as cushion for
trauma directed towards the cranium.
 When the bones of the mid face are
removed it will be seen that the frontal
bone and body of the sphenoid bone form
an inclined plane which slopes downwards
and backwards from the frontal bone at an
angle of about 45 degree to the occlusal
plane of the upper teeth.
 Damage to the infraorbital and zygomatic
nerves may occur with zygomatic and Lefort
II fractures, giving rise the anesthesia or
paresthesia of the skin of the cheek and
upper lip.
 Cerebrospinal fluid rhinorrhoea may occurs
with Lefort II and Lefort III fractures & severe
fractures of nasal complex.
 The 6th cranial nerve is most frequently
involved in zygomatic, Lefort II, and Lefort III
fractures.
 Fracture of the orbital apex may result in
damage to optic nerve.
 Damage to the contents of superior orbital
fissure results in opthalmoplegia, dilation of
the pupil, anesthesia within the distribution
of the ophthalmic branch of the 5th cranial
nerve.
 Fracture involving the orbit may give rise
alteration in the position of globe of the eye.
 The level of the globe of the eye is normally
maintained by the suspensory ligament of
Lockwood which passes from its medial
attachment on the lacrimal bone to be
inserted laterally into Whitnall’s tubercle on
the inner aspect of zygomatic bone below the
FZ suture.
 If the floor of the orbit is fractured orbital
content may herniate through into the
maxillary sinus.
 The resulting entrapment of these tissues
may result in restriction of movement of
inferior rectus and inferior oblique muscle
with subsequent diplopia.
 Occlusion derangement most often
suggestive of fracture.
 As the mid face is pushed down the mandible
is forced open with bilateral gagging of the
molar teeth and the formation of anterior
open bite.
 Maxilla may be separated by a split of bony
palate in a line median palatal suture.
 Frequently involved in zygomatic complex
and Lefort I , Lefort II fractures.
 Results in the bleeding into the cavity and
herniation of the buccal pad of the fat.
 Radiograph show radiopacity within the
antrum which clear after about three weeks.
 Third part of the maxillary artery and its
terminal branches are closely associated with
fracture line of the Lefort I , II, III.

 Occasionally the artery or its greater palatine

branch is torn at pterygomaxillary fissure or
pterygopalatine canal resulting in severe life
threatening haemorrhage into nasophyranx.
General Management Of The
Patient With Midfacial Injury
 Immediate Treatment
Airway control
▪ The level of the consciousness is the most
important factor controlling the patency of the
airway.
▪ Place an unconscious patient on his side in the
position used routinely during recovery from a GA.
▪ Fully oriented patient want to sit up with the face
held forward.
▪ Clear the mouth and orophyranx by removing the
clotted blood, mucus, avulsed, loose, or broken
teeth.
▪ Consider endotracheal intubation when patient is
unconscious or with multiple injuries particularly of
head, face and chest.
Indication For Tracheostomy
In Maxillofacial Injuries
 Tracheostomy
▪ When prolonged artificial ventilation is necessary as in
severe head and chest injuries.
▪ To facilitate anesthesia for surgical repair in certain
major injuries.
▪ Following obstruction of the airway from laryngeal
edema, or direct injury to the base of the tongue &
orophyranx.
▪ Serious haemorrhage into the airway and when
secondary haemorrhage is the possibility.
▪ To ensure safe postoperative recovery after extensive
reparative surgery.
 Haemorrhage

▪ Severe haemorrhage is unusual despite of

extensive skeletal damage.
▪ Anterior nasal packing for mild to moderate
nasal bleeding.
▪ Posterior nasal packing for more profuse
haemorrhage into nasophyranx from
terminal branch of maxillary artery.
SHOCK

Acute circulatory collapse is

not a prominent feature of mid
face fracture if patient is
seriously shocked possibility
of more serious injury should
be suspected
Preliminary examination and
determination of priorities
▪ Examine the head for laceration , bony
damage and level of the consciousness.

▪ Examine the eyes, spine , the limbs, abdomen

and chest to quickly determine the treatment
priorities.
 History And Local
Examination
History
▪ Ask about loss of consciousness.
▪ Ask about any memory gap (retrograde amnesia
or anterograde amnesia).
▪ Ask about difficulty in breathing or swallowing
and headache or pain else where in the body.
▪ Medical history.
Local Examination

Inspection externally
▪ Look for the edema, Ecchymosis and soft
tissue laceration.

▪ Any obvious deformity, haemorrhage or CSF

leak.
Local Examination
Palpation

▪ Start at the back of the head and the cranium

to explore the wound and bony injuries.
▪ Next palpate zygomatic bone and arch and
around the rim of the orbit to note areas of
tenderness, step deformity and unnatural
mobility.
▪ Next palpate nasal complex in same manner.
▪ Examine the eye for vision, light reflex ,
diplopia and alteration in size of the pupil.
Local Examination

Inspection intra orally

▪ Gagging of the occlusion
▪ Derangement of the bite
▪ Lacerations
▪ Ecchymosis
▪ Damage to the teeth an alveolus
Local Examination

Palpation intra oral

▪ Look for the areas of tenderness, bony
irregularities, crepitus and mobility of the
teeth and alveolus.
▪ Manipulate the tooth bearing segment to
elicit un-natural mobility.
Soft tissue Laceration
Repair of soft tissue
laceration should be done as
early as possible before too
much edema has occurred, that
is within 1-8 hours of the
injury
Pain management

▪ Usually there is little pain

▪ Avoid giving powerful analgesic i.e. morphine
which depress the level of consciousness and
respiration.
▪ Diazepam 10mg I/V with pentazocine 15-
30mg are useful to relieve both pain and
cerebral irritation.
Control of infection

▪ Fracture of mid face are compound into the

mouth , nose and paranasal sinuses and often
associated damage to dura meter with risk of
meningitis.
▪ Patient should be given sulphadiazine 2g is
followed by1g 6 hourly and course continued
for at least 5 days or even longer as a
prophylaxis.
Cerebrospinal fluid
rhinorrhoea
▪ CSF rhinorrhoea should be assumed in all
Lefort II and Lefort III fractures and
nasoethmoidal complex fracture.

▪ In most instance the CSF leak arrest

spontaneously or result of reduction and
fixation of the fracture.
Clinical Diagnosis

▪ Tramline pattern

▪ Hollow effect on pillow

Detection of CSF

▪ Biochemical test
 Glucose oxidase stick
 Dextostix

▪ Ct scan
Lefort Classification Of
Mid Face Fracture
▪ Alphonse Guerin in 1886 described fracture of the tooth-bearing portion
of the maxilla without displacement, then in 1901 Rene Le Fort
investigated the facial skeleton of 35 cadavers that had subjected to a
variety of traumas then dissected and he found the typical three classes
of weak lines of the midface fractures.

▪ The mid face fractures is more complex than those produced by Le fort,
there is a modified Le fort fracture classification which includes
subdivisions to nearly cover the complex pattern of mid face fractures
 LEFORT I
• Also called Horizontal fracture, Guerin’s fracture ,
floating fracture, low level, subzygomatic fracture
• Separation of complete dentoalveolar part of the
maxilla
and the fracture is held only by means of soft tissue

• This is a horizontal fracture above the level of nasal floor

The fracture line extends backwards from the lateral
margin of the anterior nasal aperture below the
zygomatic buttress to cross the lower third of the
ptetygoid laminae. The 2nd line passes along the lateral
wall of the nose and the 3rd line through lower third of
the nasal septum to join the lateral fracture behind the
tuberosity
LEFORT I
 Signs and symptoms
▪ Slight swelling and edema of the lower part of
the face along with the upper lip swelling

▪ Ecchymosis in the labial and buccal vestibule,

as well as contusion of the skin of the upper lip
may be seen

▪ Bilateral nasal epistaxis may be observed

▪ Mobility of the upper dentoalveolar portion of

jaw, which is mobile to digital pressure
▪ Occlusion may be disturbed, difficult mastication

▪ Pain while speaking and moving the jaw

▪ Sometimes there will be upward displacement of

the entire fragment, locking it against the superior
intact structures, such a fracture is called as
impacted or telescopic fracture. Anterior open bite
may be seen in this case

▪ Percussion of maxillary teeth produces dull “

cracked cup “ sound
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
LEFORT II
• Also called pyramidal , subzygomatic fracture

• Force may be delivered at the level of nasal

bones

• This fracture runs from the thin middle area of the

nasal bones down either side , crossing the frontal
process of maxillae into the medial wall of each orbit.
Within each orbit, the fracture line crosses the lacrimal
Bone behind the lacrimal sac, before turning forward
to cross the infra-orbital margin slightly medial to or
Through the infra-orbital foramen. The fracture now
Extends downwards and backwards across the lateral
Wall of antrum below zygomaticomaxillary suture and
Divides the pterygoid laminae about halfway up.
Separation of the block from the base of the skull is
Completed via the nasal septum and may involve the
Floor of the anterior cranial fossa
Lefort II
Signs and symptoms
▪ There is a gross edema of the middle third of the
face known as ballooning or moon face. Edema sets
in within a short time of injury

▪ Presence of bilateral circumorbital edema and

ecchymosis. Rapid swelling of the eyelids makes
examination of the eyes difficult

▪ Bilateral subconjunctival hemorrhage confined to

medial half of the eye

▪ The bridge of the nose will be depressed (flat face).

Nasal disfigurement
▪ If there is impaction of the fragment against the cranial
base then shortening of the face with anterior open bite
will be seen

▪ If there is gross downward and backward displacement

of the fragement then elongation or lengthening of the
face will be seen with posterior gagging of the occlusion
with anterior open bite(Dish shaped face)

▪ Bilateral epistaxis may be present

▪ Difficulty in mastication and speech, due to derranged

occlusion may be seen

▪ Airway obstruction may be seen due to posterior and

downward displacement of the fragement impinging on
the dorsum of the tongue
▪ Surgical emphysema-crackling sensation transmitted to
the fingers doe to escape of air from the paranasal
sinuses is seen

▪ Step deformity at the infraorbital margins may be seen

▪ CSF leak may be present “Rhinorrhea”

▪ Anaesthesia and/or paraesthesia of the cheek is noted

LEFORT III
• Also called High level, transverse , supra-zygomatic
Fracture, craniofacial dysjunction

• The fracture runs from near the frontonasal sutures

Transversely backwards,parallel with the base of the
Skull and involves the full depth of the ethmoid bone
including the cribriform plate. within the orbit,the
fracture passes below the optic foramen into the
posterior limit of the inferior orbital fissure. from the
base of the inferior orbital fissure the fracture line
extends in two directions; backwards across the
pterygomaxillary fissure to fracture the roots of the
pterygoid laminae and laterally across the lateral wal
of the orbit separating the zygomatic bone from the
frontal bone. In this way the entire middle third of the
facial skeleton becomes detached from the cranial
base.
Lefort III
 Signs and symptoms
▪ Gross edema of the face,ballooning.’panda facies’
Within 24 to 48 hours

▪ Bilateral circumorbital edema/periorbital ecchymosis

and gross edema ‘racoon eyes’.gross circumorbital
edema will prevent eyes from opening

▪ Bilateral subconjunctival haemorrhage ,where

posterior limit will not seen,when patient is asked to
look medially
▪ There may be tenderness and separation at the
frantozygomatic sutures.this will lengthening of the face
and lowering of the ocular level.unilateral or bilateral
hooding of the eyes seen.

▪ Characteristic ‘dish face’ deformity.

▪ May be enophthalmos,diplopia or impairment of

vision,temporary blindness etc.

▪ Flatenning and widening,deviation of the nasal

bridge.

▪ Epistaxis, CSF rhinorrhea.

MANAGEMENT OF LEFORT
FRACTURES OF THE MID FACE
Reduction
Lefort I
▪ Finger manipulation alone for loose fractures. If
teeth are present reduced position is indicated
by the occlusion.
▪ For impacted fractures , manipulate the
fragments by grasping it with the pair of Rowe’s
disimpaction forcep.
▪ If fractured bone is firmly impacted, then expose
the fracture line through an incision in buccal
sulcus and mobilize it with an osteotome before
applying forcep
Reduction
(Rowe’s Disimpaction Forcep)
Reduction
(Rowe’s Disimpaction Forcep)
Reduction
Lefort II
▪ If the fracture is in one piece it may be reduce in
same manner as an impacted Lefort I fracture.
▪ The fragment should be moved firmly away from
the base of the skull until it is freely mobile.
▪ If there is coexisting Lefort I fracture then reduce
the tooth bearing segment with disimpaction
forcep and rest of the fragment with Asche’s &
Walsham’s forcep.
 Reduction
Lefort III
▪ It rarely occurs in isolation, rather frequently associated with
Lefort I, Lefort II or zygomatic and nasal complex fracture.
▪ Reduction is carried out in following order:
▪ Frontal & zygomatic fractures should be reduced first & fixed
under direct vision via coronal scalp flap for access.
▪ Next reduce the central mid face fracture via same
approach.
▪ Tooth bearing portion with Rowe’s Disimpaction forcep.
▪ After the main fragments of central block have been fixed
the naso-ethmoidal complex is treated.
Immobilization

▪ Internal Fixation
(immobilization within the tissues)

❑ External Fixation
(extra oral immobilization)
 Immobilization

▪ Internal fixation
 Direct osteosynthesis
 Tranosseous wiring at fracture site
 High level (frontozygomatic and frontonasal)
 Mid level (orbital rim &zygomatic buttress)
 Low level (alveolar & mid palatal)
 Miniplates
 Transfixation with krischner wire
 Transfacial
 Zygomatico septal
Tranosseous wiring
Lefort II & III
Reconstruction With
Miniplates
Immobilization

▪ Suspension wires to mandible

 frontal and central or lateral
 Circumzygomatic
 Zygomatic
 Infra-orbital
 Pyriform aperture.
▪ Support
 Antral pack
 Antral balloon
Circumzygomatic
Infra-orbital
Frontomandibular
Pyriform aperature
Immobilization
External Fixation
▪ Craniomandibular Fixation
 Box frame
 Halo frame
 Plaster of Paris head cap
▪ Craniomaxillary Fixation
 Supra-orbital pins
 Zygomatic pins
 Halo frame
▪ Suspension by cheek wires from halo frame or
head cap
Halo frame (extrenal
fixation )
Box frame (external fixation
)
Box frame (external fixation
)
Fracture of The Zygomatic
Complex
 Classification
Fracture of the Body of the
Zygomatic Complex involving
the Orbit
• Minimal or no displacement
• Inward and down ward displacement
• Outward displacement
• Comminution of the complex as whole
Zygomatic complex fracture
classification
Fracture zygomatic complex
 CLINICAL FINDINGS
ZYGOMATIC COMPLEX
FRACTURE
• Flattening of the cheek
• Swelling of the cheek
• Peiorbital Haematoma
• Circumorbital Ecchymosis
• Subconjuctival haemorrhage
• Epistaxis
 CLINICAL FINDINGS
ZYGOMATIC COMPLEX
FRACTURE

• Limitation of the ocular movement

• Ecchymosis and tenderness intra orally
over the zygomatic buttress.
• Diplopia
• Enophthalmos
• Lowering of pupil level
 CLINICAL FINDINGS
• Tenderness over the orbital rim an FZ
suture
• Step deformity of infraorbital margin
• Separation at FZ suture.
• Limitation of mandibular movement
• Anesthesia of cheek, temple, upper
teeth and gingiva
• Possible gagging of back teeth on back
side.
 Examination
• Flattening of the
cheek
Diplopia
Occipitomentalis View
 3 D CT Scan Showing
Fractured Zygomatic Complex
 Classification

Fracture Of The Zygomatic Arch

Alone Not Involving The Orbit.

• Minimal or no displacement

• V- type in fracture.

• Comminuted
Fracture of the zygomatic arch

Clinical Findings
• Extreme interference with mandibular
movement
• Visible depression of about 2.5cm over the
zygomatic arch.
Fracture zygomatic arch
 Management of zygomatic
complex fracture

Indication for reduction of zygomatic

complex fracture.
• To restore the normal contour of the
face
• To correct Diplopia
• To remove any interference with
mandibular movement
 Management
General Consideration
• Many zygomatic complex fracture are
stable after reduction without any form
of fixation.
• Recent fracture tend to be more stable
then those which are more then two
weeks old.
• In practice reduction can be achieved
up to six weeks after injury and some
times even longer.
 Management

Methods Of Closed Reduction

• Gillies Temporal Approach
• Intra Oral Approach
• Through Incision in Buccal Sulcus.
• Bone hook directly through stab incision
in the cheek.
Gillies Temporal Approach
 Management
Open Reduction And Fixation
(when repositioned bone is unstable )
Methods
• Transosseous wiring at the FZ suture line.
• Plating at FZ suture.
• Transosseous wiring at infra-orbital rim
• A combination of infra-orbital rim lateral wiring
• Fixation with pack in maxillary sinus
• Pin fixation from zygomatic bone to the supra-
orbital rim.
Transosseous At FZ Suture
Fracture at FZ suture
Transosseous At FZ Suture
Transosseous At FZ Suture
After closure
Fracture infra orbital rim
Transosseous At Infraorbital
Rim
Transosseous At Infraorbital
Rim
Fixation With Pack In Maxillary
Sinus
Purpose
• To support comminuted fracture of the
body of the zygomatic complex.

• To support the reconstituted

comminuted orbital floor fracture.
 Management

Fracture Of The Zygomatic Arch

If fractured alone the fragments should be

reduced via a gillies approach.
 SURGICAL APPROACHES
➢Open reduction with direct internal
fixation
➢Direct access to frontozygomatic
suture, orbital floor, infraorbital rims
OPEN REDUCTION

❖ Lateral brow incision

❖ lnfracilliary incision
❖ Infraorbital crease
incision
❖ Supratarsal fold
❖ "Crows Foot" incision
❖ Bicoronal / Hemicoronal
flap
Isolated Orbital Floor Fracture.
 Sign and symptoms
• Edema around the orbit
• Circumorbital and subconjuctival Ecchymosis
• Surgical emphysema due leakage air from
maxillary sinus
• Proptosis
• Paraesthesia within the distribution of the
infraorbital nerve.
• Diplopia
• Enophthalmos
• Tethering of extraoccular muscle (inferior
rectus , inf: oblique)
• Hanging drop sign in standard sinus view.
Forced Duction Test
Water projection
Orbital Floor Fracture
MANAGEMENT OF ISOLATED
ORBITAL FLOOR FRACTURE
 Management
Antral Packing
• Indicated when there is no actual bone loss
• Access via Caldwell-Luc operation
• Pack the sinus with 5cm ribbon gauze soaked
in whitehead’s varnish.
• Packing is usually left for 3 weeks or even
longer.
• Never pack into posteromedial-superior
aspect of the maxillary sinus which lies
beneath the optic foramen
 Management
Floor Construction With
Implant
• An incision is made in natural skin crease
immediately below the lid margin.
• The incision should not be extended too far
laterally as it may interfere with lymphatic
drainage.
• Dissect the skin and incise the orbicularis
oculi at slightly low level than original incision.
• Next incise the periosteum and cover the
bony gap with a 0.5mm thick Silastic or
Teflon.
Fractures of the nasal
complex
 Nasal complex fracture

• Most common of all facial fractures.

• Injuries may occur to other surrounding
bony structures.
• 3 types:
– Depressed
– Laterally displaced
– Nondisplaced
 Sign and Symptoms
• Bilateral Circumorbital Ecchymosis more marked on
medial aspect
• Subconjuctival Ecchymosis mainly confined to the
medial half
• Deviation of nose to one side
• Saddle type depression of the bridge
• Epistaxis
• Epiphora
• CSF leakage with complain of salty taste.
• Septal haematoma
• Mobility of nasal bones
• Step deformity and tenderness on palpation.
• Inc: in intercanthal distance
Nasal Fracture (deviation)
Nasal Fracture (Depression)

Nasal Complex Fracture

Traumatic Telecanthus
Nasal Complex Fracture
 Management Nasal Complex
Fracture
Reduction
▪ Walsham’s and Asche’s forceps are used for
manipulating the fragments.
▪ The unpadded blade of walsham’s forceps is
passed up the nostril and padded blade
externally. The fragments are manipulated into
their correct position.
▪ Next vomer & perpendicular plate of ethmoid
bone are reduced with asche’s forcep.
 Management Nasal Complex
Fracture
Reduction
▪ Next the finger and thumb of one hand are used
to compress the lacrimal bones and medial wall
of the orbit on each side to restore narrow bridge
of the nose.
▪ Finally pass the instrument to ensure that
patient has patent airway.
▪ If nasal complex is severely comminuted then
mould the shape of the nose between thumb
and fore finger.
 Management Nasal Complex
Fracture
Fixation
▪ Plaster-of-Paris splint
(for simple fracture)
▪ Lead plate splint
(for mobile nasal fracture)
▪ Nasal splint attached to the head frame.
(for flat nasal complex region).
Lead plate splint
Nasal splint attached by wire
to an anterior connecting rod
from a head frame
Post Operative Care
 Postoperative Care

• Immediate Postoperative Phase.

(when pt: recovering from the GA)
• Intermediate Phase
(before clinical bony union has
become established)
• Late Postoperative Phase
(removal of fixation, bite rehabilitation
and long term observation)
 Immediate Postoperative
Phase
• Experienced nurse should remain with the
patient until recovery is complete.

• Patient should be returned from theatre with

nasopharyngeal airway in position until pt:
recover consciousness.

• If IMF has been done, keep scissors, wire

cutter, screw driver etc, at patients bedside.
 Immediate Postoperative
Phase
• Pass suture through dorsum of the tongue while
patient is unconscious.

• Patient should be nursed lying on their sides

during recovery to enable saliva or oozing blood to
escape from mouth.

• An efficient suction apparatus must be at patient’s

bedside.

• If extra oral fixation have been applied, care

should be taken to prevent the pt: from damaging
the appliance.
 Intermediate Postoperative
Care

• General supervision
• Posture
• Sedation
• Prevention of infection
• Oral hygiene
• Feeding
 Late Postoperative Phase

• Testing of union
• Adjustment of occlusion
• Mobilization of the TMJ
• Anesthesia or paresthesia of the lip
• Teeth and supporting structure
 Postoperative Complication

Complication arising during primary

treatment.
• Misapplied fixation
• Infection
• Nerve damage
• Displaced teeth and foreign body
• Pulpitis
• Gingival and periodontal complication
• Drug interaction
 Postoperative Complication
Later Complication
• Malunion
• Delayed union
• Non-union
• Derangement of TMJ
• Sequestration of the bone
• Limitation of opening
• Bony deformity
• Ophthalmologic complication
• Neurological damage
• Scar