Type of fracture Involves
I. Le Fort I 1. anterior and lateral walls of the maxillary sinus
fracture (also 2. lateral nasal walls
called Guerin 3. pterygoid plates at the junction of the lower one-third with the
fracture or low- upper two third.
level fracture), ❖ A unilateral maxillary fracture may also occur, with the fracture
floating maxilla coursing through the palatal suture line or adjacent to it.
II. Le Fort II 1. Frontonasal suture
fracture is also 2. Nasal and lacrimal bones
referred to as a 3. Infraorbital rim in the region of the zygomaticomaxillary
pyramidal or suture
sub-zygomatic 4. Maxilla
fracture. 5. Pterygoid plates half way.
❖ It can be unilateral or bilateral.
III. Le Fort III it starts at the frontonasal suture, runs through the frontomaxillary
fracture is also suture, over the lacrimal bone, the lamina papyracea of the ethomoid
called bone and towards the optic foramen to reach the inferior orbital
craniofacial fissure
disjunction
The fracture line divides into two lines:
♦ One line passes around the frontozygomatic suture to
separate the zygomatic bone from the frontal bone.
♦ The other line passes posteriorly to fracture the pterygoid
plates at the root, thus separating them from the cranial base.
maxillary sinus
pterygoid plate
Clinical features
Le Fort I Le Fort II Le Fort III
‘Cracked pot’ ‘Cracked pot’ sound on ‘Cracked pot’ sound on
percussion sound from tapping teeth. tapping teeth.
upper teeth
(CSF) rhinorrhea may be CSF leakage due to the
encountered as the result of a involvement of the
dural tear, although a cribriform plate leading to
classical Le Fort II fracture dural tear and CSF
does not include the cribriform rhinorrhea.
plate of ethmoid so CSF
rhinorrhea does not take
place, unless there is
associated fracture of
cribriform plate of ethmoid.
Hypoesthesia of the Hypoesthesia of the
infraorbital nerve may infraorbital nerve is also
be caused by the rapid common because of direct
development of edema. trauma or rapid edema
formation.
Palatal ecchymosis Edema is often present Facial edema.
(Guerin sign) is usually overlying the fracture sites.
noted
Ecchymosis & Bilateral cirumorbital edema Classic dish face deformity
tenderness of the & ecchymosis & & mobility of the
zygomaticomaxillary subconjunctival hemorrhage zygomaticomaxillary
buttress area. Possible diplopia & complex. As the facial
enophthalmos in severe bones are disarticulated
cases. from the cranial base the
elongation of the face
takes place leading to long
face.
Fractured cusps of teeth Step deformity in the There may be gagging of the
infraorbital rim. occlusion in the molar
area.
Malocclusion and Tenderness over the nasal
mobility of whole of bridge area & possible nasal
dentoalveolar segment of deformity.
upper jaw. Epistaxis is common.
Malocclusion is often present
in the form of an anterior
open bite & gagging of
posterior teeth.
Difficulty in opening mouth,
and sometimes inability to
move the lower jaw
Mobility of the upper jaw.
Plain radiographs have only limited role, and they are indicated when three-
dimensional imaging (CT scan) is not available, these may include:
Occipitomental -Two projections angled at 10∘ and one at 30∘ are desirable.
projection (Water's - demonstrate uncomplicated middle third fractures with
view) enough detail to determine a treatment plan.
-For interpretation of occipitomental radiographs, systematic
examination along lines where bone disjunction can be expected if
a fracture has occurred.
-To facilitate interpretation, 5 curved lines (Campbell-Trapnell
lines) are frequently used.
-demonstrate the major areas of fracture discontinuity including
the zygomaticofrontal buttress, the inferior orbital rim and
zygomaticofrontal suture in addition to haziness of the
maxillary sinus due to hemorrhage.
Lateral projection
Le Fort type fractures at each level (I, II and III) can be detected on
this view where the fracture line can be seen passing across the
pterygoid plates.
It is often the only plain view that clearly demonstrates a Le Fort
I fracture.
It also aids recognition and assessment of any extension of
fractures into the frontal sinus.
CT scan
A CT scan or cone beam CT (CBCT) with multiplanar and 3-D
reconstruction is indicated for visualization and delineation of
the magnitude and comminution of the midfacial fractures and
for the identification of adjacent fractures, such as those of the
maxilla, the naso-orbito-ethmoidal complex and the skull
base.
Type of Fracture Features
Le fort I • Floating maxilla/Guerin’s fracture/Horizontal
fracture of maxilla/Low level fracture/
Telescopic fracture
• Bleeding into maxillary antrum (sinus)
Le fort II • Pyramidal fracture/ Infrazygomatic fracture
• Panda facies
• CSF rhinorrhoea
Le fort III • Craniofacial dysjunction/ high level fracture/
suprazygomatic fracture
• Crack pot sound on tapping teeth
• CSF rhinorrhoea
• Hooding of eyes
• Racoon eyes
• Circumorbital ecchymosis
Naso-ethmoidal • CSF rhinorrhoea(comminuted cribriform plate of
fracture, ethmoid)
Le fort II & le fort III • Tramline effect & halo on pillow effect are
diagnostic signs of CSF rhinorrhoea
Le fort II & III • Moon facies
zygomatic complex
fractures
Flattening & Swelling of the
cheek
Limitation of mouth
opening
Anesthesia of cheek,
temple, upper teeth and
gingiva
Periorbital (circumorbital)
ecchymosis and edema
Sub-conjunctival
hemorrhage
Epistaxis
Crepitation from air
emphysema
Tenderness and palpable
separation at
frontozygomatic suture
Step deformity and
tenderness of infraorbital
margin
Ecchymosis and
tenderness intra-orally over
zygomatic buttress
Limitation of ocular
movement
Diplopia
Enophthalmos
Displacement of the
palpebral fissure and
unequal pupillary levels
Instrument Use
Walsham’s forceps to manipulate the nasal & frontal process of the maxilla
the external blade padded with rubber or plastic tubing.
Asche’s forceps to manipulate the vomer & perpendicular plate of the
ethmoid bone.
Rowe’s disimpaction To manipulate the fracture into place
forceps & Hayton Williams To complete the reduction
forceps
Fine toothed dissecting are inserted under the globe of the eye via the inferior
forceps conjunctival fornix, and the insertion of the inferior rectus
is gently grasped enabling the globe to be forcibly rotated
upwards and its freedom of movement compared with the
opposite side.
Rowe's or Bristow's To elevate fractured zygomatic bone
elevator
Fine toothed dissecting forceps
Classification of mandibular fractures
Classification Types/Sites
Type of Fracture Simple/Closed single fracture without external environment.
Compound/Opened fracture that extends into external
environment through skin, mucosa, or
periodontal membrane.
Comminuted bone is fragmented into multiple pieces.
Greenstick only one cortex of the bone is “broken” with
the other cortex being “bent”, it is found
“exclusively” in children.
Pathologic Caused by pre-existing pathological condition
of bone (such as osteomyelitis, neoplasms or
generalized skeletal disease) that leads to
fracture from minimal trauma
Complicated/Complex Fractures associated with the damage to the
important vital structures complicating the
treatment, as well as prognosis, including the
severely atrophied mandible
Single There is only one fracture line in the
mandible.
Multiple There are two or more distinct fracture lines
in the mandible that do not connect with each
other.
Anatomic Site Dentoalveolar
Condylar 30%
Coronoid 2%
Ramus 3%
Angle 5%
Body (molar/premolar) 25%
Symphysis/Para- 15%
symphysis
Tendency to Favorable when the muscles tend to pull the fragments
Displace together (minimizing displacement)
Unfavorable when they are significantly displaced by the
muscles.
Image Use
Panoramic radiograph (OPG) best single overall view of the mandible, including the
condyles.
Posteroanterior (PA) view Often used in combination with the OPG to provide a
complete view of the mandible.
Oblique lateral views PA with Left and right oblique lateral views can be taken if
an OPG is not available.
30° Townes projection This view is useful when the condylar head is obscured in
the PA view by superimposition of the Skull base & mastoid
process, as it demonstrates the condylar region and
posterior fossa of the skull.
A reverse Townes projection may also be used.
Occlusal view midline fractures with minimal displacement.
CT scan While not routinely used for isolated mandibular fractures,
CT scans are helpful in cases with complicating factors like
significant comminution or for detailed assessment of
displaced condylar fractures.
Closed & Open treatment of mandibular fracture
The main indications of closed The main indications for open
treatment: treatment:
1. Non-displaced favorable 1. Displaced unfavorable
fractures. fractures.
2. Limited resources and 2. Multiple fractures of the
facilities for open treatment. facial bones
3. Medically compromised 3. Fractures of an edentulous
patients where conservative mandible with severe
line of treatment is required. displacement.
4. Grossly infected fractures. 4. Delay of treatment and
interposition of soft tissue
5. Pediatric fractures with between non-contacting
mixed dentition phase. displaced fracture fragments.
6. Edentulous fractures. 5. Special systemic
conditions contraindicating
IMF.
Closed treatment is contraindicated in some conditions e.g.
Epilepsy
Chronic respiratory diseases
Incompliant patient
Chronic alcohol or drug abuse
Methods of immobilization in closed treatment
Bonded Interdenta Arch bars: Cap IMF Dentures External
orthodontic l wiring: splints screws or pin fixation
brackets: : : Gunning-
type
splints
only indicated edentulou indicated in
light wires or applicable where the s jaw special
intermaxillar when the patient fractures, conditions,
y patient has has an such as
elastic a insufficien infected
bands. complete, t number fractures,
or almost of suitably fractures
complete, shaped caused by
number of teeth or gunshot
suitably when a injuries or
shaped direct pathologica
teeth linkage l fractures.
across the
fracture is
required.
0.5 mm
soft
stainless
wire is
usually
used.
Methods of immobilization in opened treatment
Interosseous Miniplates Three- Non Compression Lag screws
or (miniaturized dimensional compression plates
Transosseous plates) titanium rigid plates
wiring miniplates (Reconstruction
plates)
The most mainly used in Perpendicularly
common the management Across the
form of of infected, fracture line
internal severely ideal for
fixation parasymphyseal
comminuted and symphyseal
fractures, in fractures, but it
fractures where becomes
there are technically more
difficult in body
continuity or angle
defects, and in
fractures in fractures
which delayed because the risk
of damage to the
union or non- inferior
union has
occurred. alveolar nerve
increases.
ORIF of condylar fractures
Absolute indications: Relative indications:
1. Displacement of condyle into middle 1. Bilateral fracture with associated mid-
cranial fossa. face fracture (particularly where one
condylar fracture is dislocated or
2. Impossibility of restoring occlusion angulated).
with closed treatment.
2. Bilateral fracture with severe open bite
3. Lateral extra-capsular displacement. deformity.
4. Invasion by foreign body (e.g. missile).
3. Unilateral fracture with dislocation,
overlap or significant angulation of the
condylar head.
4. When IMF is contraindicated for
medical reasons.
Removal of Teeth in the line of fracture
Absolute indications Relative indications
1. Longitudinal fracture involving the root. 1. Functionless tooth that would probably
2. Dislocation or subluxation of the tooth eventually be removed.
from its socket. 2. Advanced caries.
3. Presence of periapical infection. 3. Doubtful teeth that could be added to
4. Advanced periodontal disease. existing dentures.
5. Already infected fracture line.
6. Acute pericoronitis.
7. Where a displaced tooth prevents
reduction of the fracture.
