Maxillary Fracture: Deepak K Gupta

Maxillary fracture
Deepak K Gupta
Applied Anatomy
• Maxilla is composed of mainly 4 processes
– Frontal
– Zygomatic
– Alveolar
– Palatine
• Its largest part of middle third of the face and contributes
in the formation orbit, nasal cavity and hard palate.
• Its mainly composed of cancellous bone enclosed in a thin
layer of compact bone
• Force that are applied to the face are absorbed and
transmitted by buttress system, mainly of two types
• Vertical
• Horizontal
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Buttresses of Maxillofacial
Horizontal
Buttresses
1. Frontal Bar
2. orbital rims
3. Maxillary Alveolar
4. Mandibular alveolar
5. Inferior border of
mandible
1
2
Vertical buttress
1. Nasomaxillary,
2. Zygomaticomaxillary,
3. Pterygomaxillary
Classification of Fracture of maxilla
• Rene Le Fort classification (1901)
• Le Fort I
• Le Fort II
• Le Fort III
• Marciani modification of Le Fort
Le Fort I low maxillary fracture
Le Fort I (a) Le fort I - multiple segment
Le Fort II Pyramidal fracture
Le Fort II (a) le fort II + nasal
Le Fort II (b) le fort II (a) + ethmoid
Le Fort III Craniofacial dysjunstion
Le Fort III (a) Le Fort III + nasal fracture
Le Fort III (b) Le Fort III (a) + ethmoid
Le Fort IV Le Fort II or Le Fort III with cranial base
Le Fort IV (a) Le Fort IV with supraorbital rim
Le Fort IV (b) Le Fort IV + anterior cranial base
Le Fort IV (c) Le Fort IV (b) + le fort (a)
Le Fort Classification
• Based on low
energy impact
which is seldom
found separately
• Today due to
increased High
energy impact -
comminution and
combinations of
fracture type are
usually found
Le Fort I
• nasal septum to the
lateral pyriform rims,
travels horizontally
above the teeth
apices, crosses below
the
zygomaticomaxillary
junction, and
traverses the
pterygomaxillary
junction to interrupt
the pterygoid plates
Le Fort I : Guérin fractures OR Low Level
• Result from a force

of injury directed
low on the maxillary
alveolar rim in a
downward direction
from opposite jaw.
• Escapes diagnosis
Sign and symptom
• Sweeling of upper lip and
cheek
• Ecchymosis – maxillary buccal
sulcus
• Nasal block – oral breathing
• Eye or ocular sign are usually
absent
• Guerin sign
– Echymosis in palate – greater
palatine foramen bilaterally
Sign and symptom
• Occlusion
– Undisplaced incomplete fracture – no
disturbance to occlussion
– Displaced occlusion
• Anterior open bite : backward and downward
distraction of posterior maxilla – traction from
medial pterygoid muscle
• Posterior gagging of occlusion – threat to airway
• Teeth fracture
– Damage to the cusp of
individual teeth due to
impact from opposite
teeth
• Palatal fracture
• 8–15% of Le Fort fractures
• follow a sagittal or parasagittal
direction, splitting the maxilla
longitudinally close to the
midline
• exit anteriorly between the
central incisors, or between
the lateral incisor and the
canine tooth
• Bilateral epistaxis or nasal bleeding may be
observed
• Pain while speaking and moving the jaw upper
dentoalveolar portion of the jaw, which is
frequently mobile to digital pressure
• Cracked pot sound
• Floating maxilla
• Palpation
– Step deformity along the piriform aperture,
buccal sulcus and tuberosity region
Le Fort I
Le Fort II/Pyramidal fracture
• Starts from nasal bridge at or below the nasofrontal suture through the
frontal processes of the maxilla,
• Inferolaterally through the lacrimal bones and inferior orbital floor and
rim through or near the inferior orbital foramen, and inferiorly through
the anterior wall of the maxillary sinus;
• It then travels under the zygoma, across the pterygomaxillary fissure,
and through the pterygoid plates
Clinical feature
• gross edema of the middle third of the face known as
ballooning or moon face
• bilateral circumorbital edema and ecchymosis (Black
eye)
• Bilateral subconjunctival hemorrhage - medial half
• Bridge of the nose will be depressed (flat face)
• Anterior open bite - impaction of the fragment
• Gross downward and backward displacement of the
fragment Posterior gagging of the occlusion with -
anterior open bite (Dish-shaped face)
Clinical Feature
• Pseudotelecanthus: swelling over the nasal bridge
illusion of telecanthus, true telecanthus on the
involvement of NOE complex
• Bilateral epistaxis
• Difficulty in mastication, and speech
• Loss of occlusion may be seen
• CSF leak may be present
• Step deformity at the infraorbital margins
• Anesthesia and/or paresthesia of the cheek is
noted
Le Fort III fractures (transverse)
• craniofacial dysjunctions
• Anteriorly: nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of
the orbit through the nasolacrimal groove and ethmoid bones.
• The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic
canal.
• Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and
continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and
the zygomatic arch.
• Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the
ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the
sphenoid.
Clinical feature
• high level fracture
• Lateral direction with a severe impact
• Clinically this fracture appears similar to the
LeFort II fracture, but close examination will
demonstrate a more serious condition.
• After stabilizing the head and then gripping of
the maxillary teeth with one hand and simple
manipulation, will confirm complete movement
of the middle third of the face.
• Mobility of whole skeleton as a single block can
be felt
Signs and symptom
• Gross edema of the face, ballooning. “Panda
facies” within 24 to 48 hours
• Bilateral circumorbital/periorbital ecchymosis
and gross edema ’Racoon eye
• Gross circumorbital edema will prevent eyes from
opening
• Bilateral subconjunctival hemorrhage
• tenderness and separation at the
frontozygomatic sutures.
Signs and symptom
• Characteristic ‘dish face’ deformity
• enophthalmos,
• diplopia or
• impairment of vision, temporary blindness,
• Flattening and widening, deviation of the
nasal bridge.
• Epistaxis, CSF rhinorrhea
Investigation
• CT-scan is best option for studying mid-facial
fracture but plain radiograph may be helfull
too.
• Radiographic examination
– Water’s view: PA view with cephaled angulation
– Caldwell view : PA view
– Lateral view
– Submentovertex view:
Waters’ view: Le Fort I fracture
CT scan (coronal view) documenting a
Le Fort I fracture in more detail
CT scan, axial view of a Le Fort II fracture, shows the fracture
line through anterior and posterior maxillary sinus walls
CT scan, axial view of a Le Fort II fracture, shows the fracture line
through both infraorbital rims and zygomatic arch on the right
CT scan, coronal view, shows the fracture at Le Fort III level on
the right and Le Fort II level bilaterally
CT scan; 3-D reconstruction of a
panfacial fracture
Management of Le Fort Fractures
• Timings of surgery
– Controversial issue
– Delayed repair (7-14 days)
• manipulation of bones and soft tissue easier –
suppression of edema.
• risk of fibrosis and healing is there
• Unstable patient – Haemodynamically unstable and
increased intracranial pressure ICP
– Immediate: only in stable patient
Surgical approaches: Le Fort I
• Transoral vestibular
incision
– mobile mucosa 5–10 mm
above the attached gingiva
around the maxillary arch,
leaving a “flange” for
easier suturing
– crestal incision in
edentulous patients
• facial degloving : irregular
fracture
Alar-cinch technique
Identify and reposition the

alar base with a suture to
avoid lateral position of
the alae bases
Reduction
• Loosely mobile : Finger
manipulation
• Impacted : Rowe’s William forceps
– Padded blade is inserted inside the
mouth and unpadded in nostril
– Standing from behind, grasping the
two forceps, fracture segment is
manipulated
• Firmly impacted : fracture line
should be exposed and mobilised
using osteotome and disimpacted
forceps
• Split Palate: firstly two palatal
halves are approximated by
traction applied by HAYTON-
WILLIAM forceps and then with
Rowe’s William forceps
Fixation
• Indirect
– Suspension wire
– MMF for 4-6 weeks
• Direct
– Miniplate : Stabilization
with L-shaped miniplates
(1.5 or 2.0), Fixation with at
least two screws on either
side of the fracture line in
order to avoid rotational
instability
– Transosseous wire fixation –
buttress bone (lateral
piriform rim and
zygomaticomaxillary)
Fixation for palatal split
• Stabilization of Le Fort
fracture as described
earlier
• The additional sagittal
fracture is stabilized
subnasally with a
miniplate 1.5 or 2.0
• Fixation of the palatal
fracture with a miniplate
Le Fort I fracture with comminution on
both sides
Stabilization with longer miniplates bridging the areas of
comminution. Reconstruction and stabilization of the right
anterior maxillary sinus wall with a titanium mesh
In situations with bone loss in buttress areas, bone grafts,
often in combination with miniplate fixation, should be used to
bridge the defect.
Surgical approaches: Le Fort II and III
• choice of approach
depends
– fracture pattern
– amount of displacement,
– other accompanying
fractures
– surgeon’s preference
• Coronal approach
– cutaneous incision is
made from the helix root
on one side to the vertex
of the skull and then to
the contralateral helical
root
• Modifications
– the sinusoidal or saw-tooth
stealth incision,
– extension of the incision
behind the pinna in the
postauricular area instead of
the preauricular region
– hemicoronal
• frontal branch of
the facial nerve by
transection of the
superficial layer
• surgical dissection
and release of the
supraorbital nerve
is required https://www.facebook.com/notesdental
Upper blepharoplasty
• zygomaticofrontal
suture areas are
exposed through the
lateral portion
• disadvantage of
limited exposure,
making a symmetrical
control of reduction
impossible
• hemicoronal
approaches should be
avoided.
Subciliary and mid-eyelid incision
(lateral view).
Reduction and fixation of infraorbital
rim
Orbital floor reconstruction
Less risk to cornea and relatively
quick
Risk of ectropian and visible scar
Transconjunctival incision (lateral
view).
• Scarless and doesn’t
create ectropion
(lower eyelid turns
outwards)
• With lateral
canthotomy it can be
used to approach
frontozygomatic
suture too
Mid-eyelid incision Exposure of the
infraorbital rim through
(frontal view) mid-eyelid incision
Reduction
• Done in a similar as in Le Fort I using ROWE’S
Williams forceps but care should be taken as it
involves base of skull
• Ash’s or Walshman’s forceps for nasal septum
may be used
Fixation
It may be direct or indirect means.
Direct: miniplate, Transosseous wiring
at ZM buttress, infraorbital rim and
frontonasal junction
Indirect: MMF for 4-6 weeks
The infraorbital and NOE area are

stabilized with miniplates 1.3.
Zygomaticomaxillary buttresses are
stabilized with miniplates 2.0.
Reconstruction and fixation of outer

facial frame as the first step during
repair of a Le Fort III fracture.
• Le Fort III
fracture in
combination
with zygomatico-
orbital fracture
on the left and
typical occlusal
disturbance
• Fixation of Le
Fort III and
zygomatico-
orbital fracture
with miniplates
2.0 and 1.3. The
patient is in MMF
during surgery
only
• Fixation of Le
Fort I, II, and III
fractures with
miniplates 2.0
and 1.3.
• On the left, a
bone graft is
covering a bony
defect at the
zygomaticomax
illary buttress
area.
Aftercare
• Evaluation of vision
– as soon as they are awakened from anesthesia
– regular intervals until they are discharged from the
hospital
• Postoperative positioning : upright position - improve
periorbital edema and pain
• Nose-blowing: avoided for 10 days - orbital
emphysema
• Medication : Nasal decongestant, Antibiotics,
Analgesia, Steroids, Ophthalmic ointment excluding
NSAID’S and aspirin
• Ophthalmological examination
• Postoperative imaging: 3-D imaging (CT, cone beam)
Afercare
• Wound care: suture removal within 5 days, ice packs, avoid sun
exposure
• Diet
• Soft diet: after healing of the maxillary vestibular incision.
• Intranasal feeding: oral bone exposure and soft-tissue defects.
• liquid diet : Patients in MMF
• Clinical follow-up: complexity of the surgery
• Eye movement exercises
• Oral hygiene : use of soft tooth brush and oral rinse tds
• MMF: duration of MMF is controversial and is dependent on
– Fracture morphology
– Type and stability of fixation (including palatal splints)
– Dentition
– Coexistence of mandibular fractures
– Premorbid occlusion
Complication of Mid-face fracture
• Early • Late
– Extensive Hemorrhage – Palpable Hadware
– Airway Obstruction – Non-Union / Malunion
– Infection – Plate Exposure
– CSF Leak – Lacrimal System obstruction
– Blindness – V2 Anesthesia
– Devitalized Teeth
– Extra-Occular Muscle
Imbalance
– Diplopia
– Enophthalmos
– Orbital Dystopia
– Change In Facial Appearance
– Nasal Obstruction
– Malocclusion
Refrences
• Principles of Internal Fixation of the Craniomaxillofacial
Skeleton - Trauma and Orthognathic Surgery by AO
foundation
• Textbook of oral and maxillofacial surgery 2nd edition: S
M Balaji
• Text book of oral and maxillofacial surgery 3rd
edition_neelima Mallik
• Contemporary oral and maxillofacial surgery
_hupp_ellis_tucker
• clinical handbook of oral and maxillofacial
surgery_lashkins
• Netter’s Atlas version 5.1
THANKS……
Feedback if any : dr.dkg07@gmail.com
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Maxillary Fracture: Deepak K Gupta

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Maxillary fracture

• Result from a force

Identify and reposition the

The infraorbital and NOE area are

Reconstruction and fixation of outer

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