FRACTURE MAXILLA

DR SHAMEEJ MUHAMED KV
SENIOR RESIDENT
DEPARTMENT OF NEUROSURGERY , GMC CALICUT
 INTRODUCTION

• 2nd largest bone of face

• 2 maxillae forms whole of upper jaw

• Each maxilla contributes in formation of

1. Face
2. Nose
3. Mouth
4. Orbit
5. Infratemporal fossa
6. Pterygopalatine fossa
 FEATURES OF MAXILLA

Each maxilla has –

1. Abody
2. 4 processes – frontal
zygomatic
alveolar
palatine
BODY OF MAXILLA
• Shape – pyramidal
• It has –
• 1. Base – directed medially at nasal surface
• 2. Apex - directed laterally at zygomatic process
• 3. 4 surfaces – anterior / facial
posterior / infratemporal
medial / nasal
superior / orbital
• Encloses a cavity – maxillary sinus
ANTERIOR / FACIAL SURFACE
• Directs laterally
• Incisive fossa -depressor septi
• Nasalis – superolateral, along nasal notch
• Canine fossa – levator anguli oris
• Infraorbital foramen
• levator labii superioris
• Medially – the nasal notch & anterior nasal spine
 POSTERIOR / INFRATEMPORAL SURFACE

 Concave
 Directed – backward & laterally
Forms – anterior wall of infratemporal
fossa
Separated from anterior surface by zygomatic process & zygomatico
maxillary ridge
Posteroinferiorly – maxillary tuberosity &
superficial head of medial pterygoid
muscle
SUPERIOR / ORBITAL SURFACE
• Smooth, triangular & slightly concave
• Forms – Greater Part Of Floor Of Orbit
• Anterior border forms – part of inferior orbital margin
• continues with lacrymal crest of frontal process
Posterior border – smooth & rounded
• Forms most anterior margin of inferior orbital fissure
• In middle – infraorbital groove
Medial border – Anteriorly lacrymal notch, converted into
nasolacrimal canal
• Behind the notch, articulation with –
Lacrymal
Labrynth of ethmoid
Orbital process of palatine bone
 THE MEDIAL /NASAL SURFACE

 Part of lateral wall of nose

 Posterosuperiorly – maxillary hiatus
 Above the hiatus – air sinuses
 Below the hiatus – anterior part of inferior meatus
Behind the hiatus – articulates with perpendicular plate of palatine
bone & encloses greater & lesser palatine canals
Infront of the hiatus – nasolacrymal groove articulates with
descending process of lacrymal bone & lacrymal process of inferior nasal
concha to forms nasolacrymal canal
• More anteriorly – conchal creast for articulation with inferior nasal concha.
• Above the conchal crest – atrium of middle meatus.
 PROCESSES OF MAXILLA

• 1. FRONTAL
• 2. ZYGOMATIC
• 3. ALVEOLAR
• 4. PALATINE
FRONTAL PROCESS
Projects upward & backwards to
articulate
above – nasal margin of frontal bone
infront – nasal bone
behind – lacrymal bone
Lateral surface – divided by anterior
lacrymal crest into anterior smooth &
posterior grooved
Anterior lacrymal crest gives attachment
to lacrymal fascia & medial palpebral
ligament
• Medial surface – forms lateral
wall of nose
• from above downwards –
- Uppermost roughened area
for articulation with ethmoid
-2. Ethmoidal crest – a
horizontal ridge, articulates with
middle nasal concha
-Below the ethmoidal crest-
atrium of middle meatus
ZYGOMATIC PROCESS
 Pyramidal lateral projection
 Anterior, posterior & superior surfaces converge here
 Superiorly – rough, to articulate with zygomatic bone
ALVEOLAR PROCESS
• Forms half of alveolar arch
 Bears socket for maxillary teeth
 In adults = 8 sockets
PALATINE PROCESS
• Thick horizontal plate
• Projecting medially
• Forms largest part of roof & floor
• Inferior surface – concave & forms anterior 3/4th of bony hard palate.
• Posterolaterally –greater & lesser palatine foremen
• Superior surface –concave from side to side & forms floor of nasal
cavity.
ARTICULATIONS OF MAXILLA
• Superiorly – 3 bones
1. Frontal
2. Nasal
3. Lacrymal
• Laterally – 1 bone
1. Zygomatic bone
• Medially – 5 bones
1. Ethmoid
2. Inferior nasal concha
3. Vomer
4. Palatine
5. Opposite maxilla
• D Orbit, medial wall
• E orbit, lateral wall
• F Suture between sphenoid and zygomatic
bones
• Nasomaxillary suture
• 1 Globe
• 2 Ethmoid sinus
• 3 Sphenoid sinus
• 4 Nasal bone
• 5 Maxilla, frontal process
• 6 Orbit, lateral rim
• 7 Sphenoid bone
• 8 Optic foramen
 • F Groove for infraorbital nerve
• G Maxillary sinus, posterolateral
wall
• 5 Maxilla, frontal process
• 9 Maxillary sinus
• 10 Zygomatic arch
• 11 Pterygoid bone
• 12 Nasolacrimal duct
• 13 Mandible, condyle
Clear maxillary sinuses can almost rules out certain fractures such as LeFort, blowout fractures,zmc #
 • H Maxillary sinus, anterior wall
• I Maxillary sinus, medial wall
• J Medial pterygoid plate
• K Lateral pterygoid plate
• 9 Maxillary sinus
• 14 Mandible, ramus

Fracture of the pterygoid plates may represent LeFort fracture

Buttresses of Maxillofacial
• Force that are applied to the face are absorbed and transmitted by
buttress system, mainly of two types
• Vertical
• Horizontal
Horizontal Buttresses
• 1. Frontal Bar
• 2. orbital rims
• 3. Maxillary Alveolar
• 4. Mandibular alveolar
• 5. Inferior border of mandible
 Vertical buttress

• 1. Nasomaxillary,
• 2. Zygomaticomaxillary
• 3. Pterygomaxillary
• 4. mandibular
 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

Ia - Low maxillary fracture/multiple segments
• Le Fort II - Pyramidal fracture
IIa - Pyramidal and nasal fracture
IIb - Pyramidal and NOE fracture
• Le Fort III - Craniofacial disjunction
IIIa - Craniofacial disjunction and nasal fracture
• IIIb - Craniofacial disjunction and NOE fracture.
• Le Fort IV - LeFort II or III fracture &cranial base fracture
IV a - + Supraorbital rim fracture
IV b - + Anterior cranial fossa & supraorbital rim fracture
IV c - + Anterior cranial fossa & orbital wall fracture
 LE FORT FRACTURES
• Among the most severe fractures seen in face and associated with
high-energy trauma
• Named after René LeFort, a French physician, who studied facial
fractures in cadavers. Result was published in 1901
• Key facts -
In each type, there is a partial or complete separation of maxilla
from the remainder of the facial skeleton
All LeFort fractures must extend through posterior face, transects
the pterygoid processes
Any combination of LeFort I, II, and III patterns can occur
ETIOLOGY &EPIDEMIOLOGY
• Road traffic accidents (most common) -40%
• Industrial accidents - 10 %
• Assault -15%
• Sports - 25 %
• Fall - 10 %
•Most maxillary fractures occur in young men aged
between 16 to 40 years.
• Peak age- 21 - 25 years
• Male : Female - 4:1
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
• Escapes diagnosis
MOI--- Direct horizontal or angular blow at the level of upper teeth but below the
anterior nasal spine = Le Fort I or horizontal maxillary fracture
 LE FORT I
• Fracture line passes fron 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
• Alsp known as floating palate-
seprates teeth from upper face
Sign and symptom
• Swelling 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
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
•Cracked pot sound
•Floating maxilla
•Palpation
Step deformity along the piriform aperture, buccal sulcus and
tuberosity region
Le Fort II/Pyramidal fracture
• Starts from nasal bridge at or
below the nasofrontal suture
through the frontal processes of
the maxilla,
• •Infero laterally 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
Horizontal impacts along the Frankfort plane = Le Fort II fracture
pyramidal fracture
Sign and symptom
• 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)
• 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 or paresthesia of the cheek is noted
LE FORT III
• Craniofacial Dysjunctions
• This fracture separates calvaria (skull) from the facial bones.
• Most severe of all LeFort fractures
•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
supero-laterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic
arch.
• From this point , fracture descends across the upper posterior aspect of maxillae in the region of
sphenopalatine fossa and upper limit of pterygomaxillary fissures and fractures the roots of pterygoid
laminae at its base.
•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 pterygoidplates to the base of the sphenoid.
Impact on the nasion at 30-60 degree above the horizontal = Le Fort III fracture (craniofacial disjunction)
FEATURES
• high level fracture
•Lateral direction with a severe impact
•Clinically this fracture appears similar to the LeFortII 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
Sign 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.
• 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 help full too.
•Radiographic examination
–Water’s view: PA view with cephalad angulation
–Caldwell view : PA view
–Lateral view
–Submentovertex view:
CT scan (coronal view) documenting a Le Fort
I fracture
 LE FORT II
CT scan, axial view of a Le Fort II
fracture, shows the fracture line
through anterior and posterior maxillary
sinus
CT scan, axial view of a Le Fort II
fracture, shows the fracture line
through both infraorbital rims and
zygomatic arch on the right
LE FORT III
MANAGEMENT
Timings of surgery
emergencies involving panfacial fractures require immediate
surgery
If no such medical emergencies surgery may be delayed
Delayed repair (7-14 days)
•manipulation of bones and soft tissue easier –suppression of edema.
•risk of fibrosis and healing is there
• Principles of management
REDUCTION
FIXATION
IMMOBILIZATION
DEFENITIVE MANAGEMENT –LE FORT I FRACTURE

SURGICAL APPROACH- MAXILLARY REDUCTION- ROWE OR HAYTON

VESTIBULAR WILLIAMS FORCEP
FIXATION- 4-point fixation with IMMOBILISATION-
MINIPLATE. MAXILLOMANDIBULAR FIXATION(MMF)
 LE FORT II

SURGICAL APPROACH Coronal Approach

A– Subciliary incision B – Sub tarsal incision

C - Infraorbital incision D - Extension of Subciliary
REDUCTION- ROWE OR HAYTON
WILLIAMS FORCEP FIXATION- 3-POINT fixation
LE FORT III

CORONAL APPROACH PREAURICULAR APPROACH

A . LATERAL EYEBROW APPROACH
B. UPPER-EYELID APPROACH GLABELLA APPROACH
• REDUCTION- ROWE OR HAYTON
WILLIAMS FORCEP
• FIXATION- 3-point fixation
• IMMOBILISATION-
Maxillomandibular Fixation if
required
THANK YOU