Good Morning One and
All
WELCOME
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/[Link].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.
THROUGH
TR
P
M
IA
H UI
L
TR
S
Thank you all for patient hearing
