BY

DR JAHANGIR HAMMAD
BDS ,FCPS
 Le Fort’s classification (1901)
 Le Fort I, II, III
 Erich’s classification (1942)
 Horizontal, pyramidal, transverse
 Classification based on relationship of fracture line to
zygomatic bone
 Subzygomatic, suprazygomatic
 Classification based on level of fracture line
 Low, mid, high level fractures
 Rene LeFort 1901 in cadaver skulls
 Frequently different levels on either side
 LeFort I
 LeFort II
 LeFort III
From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian
Publishing Company 1988, pg76.
 Le fort I – low maxillary #s
 Ia – low maxillary #s/multiple segments
 Le fort II – pyramidal #s
 IIa - Pyramidal and nasal #s
 IIb – pyramidal and naso-orbito-ethmoidal complex #s
 Le fort III – craniofacial dysjunction
 IIIa – craniofacial dysjunction and nasal #
 IIIb – craniofacial dysjunction and NOE #
 Le fort IV – le fort II or III with cranial base #
 IV a - +supraorbital rim #
 IVb - +anterior cranial fossa and supra orbital rim #
 IVc - +anterior cranial fossa and orbital wall #
From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg
1993;51:962.
 # not involving teeth and alveolus
 Central region
 # of the nasal bone and/or the nasal septum
 # of the frontal process of the maxilla
 # of the above which extend into the ethmoid bone (naso-
ethmoid #s)
 # of the above which extend into the frontal bone (fronto-orbito-
nasal #s)
 Lateral region
 #s involving the zygomatic bone, arch, and maxilla (zygomatic
complex #s)
 #s involving the teeth and alveolar bone

 Dento alveolar
 Subzygomatic
 Le fort I
 Le fort II
 Suprazygomatic
 Le fort III
 Aka horizontal/guerin’s/ floating/ low level/
subzygomatic fracture
 # line – commences at a point on the lateral margin of
the nasal aperture, passes above the nasal floor,
laterally above the canine fossa and traverses the
lateral antral wall, dipping down below the zygomatic
buttress and then inclines upward and posteriorly
across the pterygomaxillary fissure to fracture the
lower 1/3rd of the pterygoid laminae.
 Typically bilateral, with fracture of lower third of nasal
septum, but may be unilateral
 May occur as a single entity or in association with Le
Fort II & III #s
 Usually caused by violent force applied over a more
extensive area above the level of the teeth
 May also be caused by a blow to the lower jaw
 Slight swelling of lower part of face+upper lip
 Ecchymosis in labial and buccal vestibule, contusion
of skin of upper lip, laceration of upper lip and intra
oral mucosa
 Bilateral epistaxis or nasal bleeding
 Mobility of upper dentoalveolar portion of the jaw
 Disturbed occlusion & difficulty in mastication
 Pain while speaking and moving jaw
 Cracked pot percussion note of maxillary teeth
 Fracture of the cusps of the cheek teeth
 Impaction of entire fragment, giving a classical open
bite
 0° occipitomental (0° OM)
 30° occipitomental (30° OM)
 True lateral skull
1 Frontal sinus
2 Orbit
3 Maxillary sinus
4 Nasal septum
5 Nasal cavity
6 Hard palate
 Aka pyramidal/ subzygomatic fractures
 # line runs below frontonasal suture from the thin
middle area of the nasal bones down on either side,
crossing the frontal process of the maxillae into the
medial wall of each orbit, and passing across lacrimal
bones immediately behind the lacrimal sac. From this
point, it passes downward, forward and laterally
crossing the inferior orbital margin slightly medial or
through the infraorbital foramen.
 It then runs downwards and backwards across the
lateral wall of the antrum below the ZM suture, and
divides the pterygoid lamina at its middle third
 Seperation of the block of the midface from the base of
the skull is completed via the nasal septum and may
involve the floor of the anterior cranial fossa
 Usually caused by a violent force in an anterior
direction sustained by the central region of the middle
1/3rd of the facial skeleton over an area extending from
the glabella to the alveolar margin
 Force may be delivered at the level of the nasal bones
 Ballooning or moon face
 Bilateral circumorbital oedema and ecchymosis
 Bilateral subconjuctival hemorrhage confined to the
medial 1/3rd of the eye and enopthalmos
 Depressed nasal bridge
 Shortening of the face with anterior open bite
 Dish shaped face
 Bilateral epistaxis
 Masticatory and speech difficulty
 Loss of occlusion
 Airway obstruction
 Surgical emphysema
 CSF leak
 Step deformity of infraorbital margins
 Anaesthesia &/or paresthesia of the cheeck
 History
 Examination
 Labs
 RNI
 Imaging
 0° occipitomental (0° OM)
 30° occipitomental (30° OM)
 True lateral skull
 Aka transverse / suprazygomatic/high level fracture
 # line runs from near the Fronto nasal suture 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 # line passes
below the optic foramen into the posterior limit of the
inferior orbital fissure.
 From here, it extends in 2 directions:
 Posteriorly across the Pterygo maxillary fissure to # the root
of the pterygoid laminae
 Anteriorly across the lateral wall of the orbit seperating the
zygomatic bone from the frontal bone
 Usually caused by trauma inflicted over a wide area
at the orbital level
 Force is usually applied from a lateral direction with
severe impact
 Initial impact is taken by the zygomatic bone,
resulting in depressed fracture
 Because of the severe impact, the entire middle face
thus hinges about the fragile ethmoid bone and the
impact will be transmitted on the contralateral side
resulting in laterally displaced zygomatic # of the
opposite side (craniofacial dysjunction)
 Mobility of the entire middle facial skeleton as a
block can be felt on gentle manipulation
 Panda facies within 24 hours
 Racoon eyes
 Bilateral subconjuctival haemorrhage without
posterior limit
 Tenderness and separation at FZ sutures causing
lengthening of the face and lowering of the ocular
level
 Unilateral or bilateral hooding of the eyes
 Dish face deformity
 Enopthalmos, diplopia od impairment of vision,
blindness
 Epistaxis, CSF rhinorrhoea
 Flattening, widening and deviation of the nasal
bridge
 Posterior gagging, anterior open bite
 Lateral displacement of midline in upper jaw
 Gagging of occlusion of molars at one side and
posterior open bite at the other side due
RACOON EYES
 0° occipitomental (0° OM)
 30° occipitomental (30° OM)
 True lateral skull (brow-up)
 Coronal section tomography
 CT +/- 3-D reconstruction
 Cause of Fracture
 Degree of Force
 Specific Symptoms
 Time since injury
 Allergies
 Medications
 Etc.
 Symmetry/Deformity  Visual disturbances
 Lacerations/Abrasions/  Diplopia
 Reflexes
 Ecchymoses  Extraocular muscle function
 Palpable step deformities  Acuity
 Orbital rims  Fields
 Zygomatic arches  Intranasal Inspection
 Nose
 Hematoma
 Frontal Bones
 Airway Obstruction
 Mandibular borders
 CSF rhinorrhea
 Movement of dental arches
 Facial movement
 Fractured/Avulsed/Mobile (including jaw excursions)
teeth
 Facial sensation
 Physical signs of a fracture of the maxilla.

 Evidence of a fractured maxilla on imaging.

 Disruption of the occlusion of the teeth.

 Displacement of the maxilla.

 Post traumatic facial deformity.

60
 Fractured or displaced teeth.

 Cerebrospinal fluid leak.

 Abnormal eye movement or restriction of eye

movement.

 Occlusion of the nasolacrimal duct.

 Sensory or motor nerve deficit.

 Other evidence of loss of function

61
 Relieve pain

 Restore function.

 Restore bone anatomy.

 Prevent infection

 Restore the dental occlusion

 Restore jaw movement at the earliest possible stage

 Restore normal nerve function

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 Association with multiple injuries.

 Presence of uncontrolled haemorrhage

 Impairment of the airway.

 Presence of bone comminution

 Association with a dural tear.

 Association with a base of skull fracture.

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 Presence of a pre-existing dentofacial deformity.

 Time elapsed since the injury.

 Presence of a medical or surgical factor which would

delay general anesthesia

 Presence of any factor which would delay healing.

(eg nutritional deficiency or alcoholism)

 Stage of dental development (deciduous, mixed or

permanent dentition)

64
 Presence of fractured teeth.

 Total absence of teeth (edentulous)

 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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 CLOSED REDUCTION

 OPEN REDUCTION
Closed reduction may be appropriate in cases

 Simple uncomplicated fractures

 Complex or comminuted fractures

 Medical or surgical contraindications to open reduction

 Maxillary fractures in children

68
Open reduction may be appropriate where

 Immediate or early jaw function is desirable

 Difficulty is encountered in reducing the

fracture by a closed method

 The fracture is unstable

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 Reduction

Manual manipulation

Use of dis-impaction forceps

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Extraoral fixation

Craniomandibular fixation
Box-frame (pin fixation)
Halo-frame
Plaster of paries headcap

Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame

72
Direct fixation

 Transosseous wiring at
fracture sites
 Frontozygomatic sutures
 Infrorbital margin
 Midline of the palate

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74
Internal-wire suspension

Circumzygomatico-mandibular

Infraorbital border-mandibular

Frontomandibular

Pyriform fossa-mandibular

75
 Support via the maxillary sinus by filling materials
 Ribbon gauze
 Balloon
 Folly catheter
 Polyethylene material

76
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

77
 Zygomatic or malar fracture are the terms commonly used
to described fractures that involve the lateral one third of
the middle face.
 Other names for this fracture are:
1. Zygomatico-maxillary complex.
2. Zygomatico-maxillary compound
3. . Zygomatico orbital.
4. Zygomatic complex.
5. Malar.
6. Trimalar.
7. Tripod.
. Second in frequency after nasal fractures. The high
incidence of zygoma fractures probably relates to the
prominent position of zygoma within the facial
skeleton.
 The incidence, cause, age, and sex predilection of
zygomatic injuries vary, depending largely on the
Social, Economical, Political and Educational Status of
the population
 Male : Female – 4:1
 Age - Second and Third decades of life.
 Bilateral fractures –less than 4%in 2067 cases (Ellis et
al) ZMC
 Anatomy
Star-shape like with four processes
 Frontal process
 Temporal process
 Buttress
 Orbital floor (Maxilla and GWSB)

Temporal fascia and muscle

Masseter muscle
82
 Four sutures involved in
Zygomaticomaxillary Complex
Fractures

1. Zygomaticonfrontal Suture
2. Zygomaticomaxillary Suture
3. Zygomaticotemporal Suture
4. Zygomaticosphenoid Suture
The malar bone represent
a strong bone on fragile
supports, and it is for
this reason that, though
the body of the bone is
rarely broken, the four
processes- frontal,
orbital, maxillary and
zygomatic are frequent
sites of fracture.
Zygomatic bone fractured as a block
near its principle three suture lines
HD Gillies, TP Kilner and D Stone, and often displaces inwards to a
1927
greater or lesser extent. 84
 To protect the globe of the eye.
 To give origin to the masseter muscle.
 To transmit part of the masticatory forces to the
cranium.
 To absorb forces of an impact before it reaches brain.
 FRACTURES OF ZYGOMA
1. MINIMAL OR NO DISPLACEMENT
2. INWARD AND DOWNWARD DISPLACEMENT
3. INWARD AND POSTERIOR DISPLACEMENT
4. OUTWARD DISPLACEMENT
5. COMMUINATION OF THE WHOLE COMPLEX
 ARCH FRACTURES
1. MINIMAL OR NO DISPLACEMENT
2. V – TYPE IN FRACTURE
3. COMMINUTED
 Periorbital ecchymosis and edema

 Flattening of the malar prominence

 Flattening over the zygomatic arch

 Pain and tenderness on palpation

 Ecchymosis of the maxillary buccal sulcus

 Deformity at the zygomatic buttress of the

maxilla

 Deformity at the orbital margin

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 Trismus
 Abnormal nerve sensibility
 Epistaxis
 Subconjunctival ecchymosis
 Crepitation from air
emphysema
 Displacement of palpebral
fissure (pseudoptosis)
 Unequal pupillary levels
 Diplopia
 enophthalmos

91
 Inspection

 Palpation

 Visual examination
 Eye movement
 Diplopia
 Pupil reaction

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Nothing is more valuable to the surgeon in
determining the extent of injury and the
position of the fragments-both before and
after operation- than a good skiagram
(radiograph)

HD Gillies, TP Kilner and D Stone, 1927

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 Occipitomental view

(Posterioanterior oblique)

 (water’s view)

97
  submentovertex

Recommended for isolated

zygomatic arch fracture

99
Timing:
 As early as possible unless there are ophthalmic,
cranial or medical complications

 Preiorbital edema and ecchymosis obscure the fine

details of the fracture, intervention can be
postponed but not more than a week

Indications:

•Diplopia
•Restriction of mandibular movement
•Restoration of normal contour
•Restoration of normal skeletal protection for the eye
101
 Temporal approach (Gillies et al
1927)

Suitable for isolated

zygomatic fracture with
good stability afterwards
102
 Percutaneous approach (malar hook,
Carroll-Girard bone screw)

Suitable for displaced zygomatic

fracture with high
Stability after reduction
103
 Buccal sulcus
approach (Keen
1909)

 Elevation from
eyebrow approach
(the same principle of Gillies
approach)

104
 Transosseous wiring at
 Frontozygomatic suture
 Infraorbial rim

Surgery:

•Lateral eyebrow incision

•Infraorbital approach
105
 Rigid fixation using plate and screws at
 Frontozygomatic suture
 Infraorbial rim
 Inferior buttress of the zygoma

Surgery:

•Lateral eyebrow incision

•Infraorbial approach
•Subciliary (blepharoplasty) incision
•Mid-lower lid incision
•Transconjunctival approach
106
Points of fixation:

Lateral Buttress of Infraorbital

orbital rim zygoma rim and
buttress 107
 Kirschener wire

 Pin fixation

 Antral pack

108