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 Midface Fractures

Moderator: Dr. Rajay AD

Kamath
Dr. Subha Lakshmi
Presenter: Dr. Jomi Porinchu
 Contents
PART I
Surgical Anatomy
Etiology and History
Classification
Clinical features
PART II
Management of a trauma patient
Complications
Case presentation
Introduction
SURGICAL ANATOMY
Mid face
Bones of Middle Third of face
Common sutural fracture sites
Physical characteristics of mid-facial
skeleton
Physical characteristics of mid-facial
skeleton
Facial buttress system
 Superficial struts Deep strut
Horizontal Upper Roof of the orbit, ethmoid Lesser wing of
strut air cells, cribriform plate sphenoid bone
and roof of
sphenoid sinus
Middle Floor of the orbit and
zygomatic arch
Lower Alveolar process of
maxillae, floor of the nose
and hard palate
Vertical Lateral Orbital process of the Greater wing of
strut frontal bone and zygomatic sphenoid
bone , lateral wall of the
maxillae

Medial lamina papyracea,medial Lateral wall of

wall of the maxillary sinus , sphenoid sinus
nasal bones , nasal septum
Inferior Nasal septum Posterior wall of
the maxillary
Imaging of facial trauma ; OMFSCNA Nov 2001
sinuses and
pterygoid
Structures in the way
Musculature
Superficial Musculoaponeurotic
System
 IMPORTANT
BLOOD VESSELS

3rd part of maxillary artery

life threatening
hemorrhage into
nasopharynx

post nasal pack

Greater palatine vessels :

(GUERINS SIGN)
 Etiology of mid facial
injuries
Typical causes:
- Direct violence
- Indirect violence
- Crush injuries
. Automobile accidents RTA
. Air crash
. Mining accidents
- High velocity missiles
History
Smith Papyrus 2500BC
Charles Fredrick William
Reiche 1822
Carl Ferdinand van Graffe
1823
Bernhard RK von
Langenbeck 1859
David Cheever 1867
Otto Lanz 1893
Rene Le Fort 1901
CLASSIFICATION
 Le Fort fractures
Rene LeFort 1901 in cadaver skulls
Etude expermentale sur les fractures de la machoire
superieure
Based on the most superior level
Frequently different levels on either side
Le Fort I
Le Fort II
Le Fort III
LeFort I, Low Level or Guerin Type
Fracture :
LeFort II or Pyramidal
Fracture
LE FORT III OR CRANIOFACIAL
DYSJUNCTION
 Deficiencies of Le Fort
classification
Failed to adequately account for
Fractures at multiple levels.
Asymmetric fracture patterns.
Separation of major fragments
Comminution of vulnerable areas as
well as concurrent anterior fossa and
mandibular fractures.
Modified Le Fort Classification
ERICH CLASSIFICATION -
1942
HORIZONTA
L

PYRAMIDAL

TRANSVERS
E
 Relationship of fracture to
Zygomatic Bone
Subzygomatic fractures
Suprazygomatic fractures

Depending on level of Fracture line

Low level fractures
Mid level fractures
High level fractures
 Krugers General Classification

Simple or
closed
Compound
or open
Comminuted
Complicated
or complex
Impacted
Greenstick
Pathological
ROWE AND WILLIAMS CLASSIFICATION
-1985
A. FRACTURES NOT INVOLVING OCCLUSION :

I. Central Region :
a. Fractures of the nasal bones/nasal septum.
- Lateral nasal injuries
- Anterior nasal injuries
b. Fractures of frontal process of maxilla
c. Nasoethmoidal fractures

d. Fractures of type (a), (b) and (c) extending into the

frontal
bone (frontoorbitonasal dislocation).
II. Lateral region:
Fractures involving the zygomatic bone, arch and maxilla
excluding dentoalveolar component.

B. FRACTURES INVOLVING OCCLUSION :

Dentoalveolar
Subzygomatic
- Lefort I (low level or Guerin)
- Lefort II (Pyramidal Fracture)
Suprazygomatic
Donat, Endress,
Mathog
 Palatal fractures

Classification
Type I Alveolar fracture
Ia Anterior alveolus
Ib Posterolateral
alveolus
Type II Mid line split
Type III Parasagittal fracture
Type IV Paraalveolar fracture
Type V Complex/ comminuted
fracture
Type VI Transverse
 Medial Maxillary
Fractures

Involving the
-lateral margin of the piriform
aperture
- the maxillary frontal process
-medial aspect of the
infraorbital rim.

Yoshioka N, Tomita S, Nishikawa H, Arakawa A, Sesaki S, Medial maxillary fractures

revisted, British Journal of Plastic Surgery (2014), doi: 10.1016/j.bjps.2013.12.028
CLINICAL FEATURES AND
EXAMINATION
 Le-fort I Fracture

Ecchymosis in Labial & Buccal Vestibule

Mobile maxilla Low level
Anterior Open Bite
Loose or fractured maxillary incisors
Cracked Pot sound
Impacted fracture
Guerins sign.
Le-fort I Le-Fort II Le-fort III
 Le-fort II Fracture
Gross oedema of the middle third
of facial skeleton.
(moon face/ballooning)
B/L Circumorbital edema &
ecchymosis : Raccoon's eye sign
B/L Subconjuctival hemorrhage
Enophthalmos , Diplopia
Bilateral epistaxis
Cerebrospinal fluid leak
Bridge of nose depressed -Flat
face
Anesthesia / paraesthesia of
cheek
Surgical Emphysema
Le-fort I Le-Fort II Le-fort III
 Intra-oral Findings

Molar gagging
Anterior open bite

Fractured teeth

Tenderness & step -

zygomatic buttress
 Le-fort III Fracture
panda facies within 24 to 48 hours
B/L circumorbital edema and subconjunctival
hem.
Tenderness F Z sutures
Dish face
Bilateral hooding of eye
Lowered ocular level
Enophthalmos/ diplopia / impaired vision/
transient blindness
Flattening & widening / deviated nasal bridge
Epistaxis / CSF rhinorrhoea
 CSF RHINORRHEA (25-50% of LeFort II and III)

Tramline flow of CSF

Blood only
Le-fort I Le-Fort II Le-fort III
 References.

Grants Atlas of anatomy 12th edition

Maxillofacial Surgery , vol.1, 2nd edition. Peter Ward Booth

Oral & Maxillofacial Trauma, vol.1 & 2, 3 rd edition.- Fonseca

Rowe & Williams Maxillofacial Injuries, vol.1

Killeys Fractures of Middle 3rd of Facial skeleton 5th ED. - Peter Banks

Petersons principles of oral and maxillofacial surgery Vol 1 Michael Miloro.

Manual of internal fixation in the cranio-facial skeleton. Techniques recommended

by the AO/ASIF maxillofacial group. Joachim Prein

Surgical anatomy of the face. Wayne F Larrabee et al.

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