MID-FACE FRACTURE

• GUIDED BY;

DR.PANKAJAKSHI BAI(MDS)
DR.JAYENDRA PUROHIT(MDS)
DR.NIKILKUMAR JAIN(MDS)

PRESENTED BY;
SUCHAK SHRADDHA
 FRACTURE OF MIDDLE-THIRD OF THE
FACIAL SKELETON
• FRACTURE-It is defined as a sudden break in
the continuity of bone and it may be complete
or incomplete.
 MIDDLE-THIRD OF FACIAL SKELETON
• Middle third of facial skeleton is defined as an
area bounded superiorly by a line drawn across
the skull from the zygomaticofrontal suture of
one side ,across the frontonasal suture and
frontomaxillary suture to the zygomaticofrontal
suture on the opposite side, and inferiorly by
the occlusal plane of upper teeth, or if the
patient is edentulous by the upper alveolar
ridge.
BONES CONSTITUTING THE MIDDLE –
THIRD OF FACE
• Two maxilla
• Two palatine bones
• Two zygomatic bones and
their temporal process
• Two zygomatic process of
temporal bone
• Two nasal bones
• Two lacrimal bones
• The ethmoid bone and its
attached conchae-unpaired
• Two inferior conchae
• Two pterygoid plates of
sphenoid
• The vomer -unpaired
 CLASSIFICATION
• Classification mainly helpful for
communication purpose.
• Classification based on experimental studies
carried out by a French surgeon, Rene Lefort
in 1901.
1) RENE LEFORT IN 1901
LEFORT I
LEFORT II
LEFORT III

2) ERICH’S CLASSIFICATION
HORIZONTAL
PYRAMIDAL
TRANSVERSE

3) DEPENDING ON THE RELATIONSHIP OF FRACTURE

LINE TO ZYGOMATIC BONE
SUBZYGOMATIC
SUPRAZYGOMATIC
4) DEPENDING ON THE LEVEL OF FRACTURE
LINE
LOW LEVEL
HIGH LEVEL

5) ROWE AND WILLIAM’S CLASSIFICATION

FRACTURE INVOLVING OCCLUSION
FRACTURE NOT IMVOLVING OCCLUSION
 FRACTURE NOT INVOLVING
OCCLUSION
• CENTRAL REGION • LATERAL REGION

a) Fracture of nasal bone

and /or nasal septum a) Fracture involving
b) Fracture of frontal zygomatic bone,arch
process and
c) Fracture of type a and b maxilla(zygomaticoma
extending into the
ethmoid bone xillary complex)
d) Fracture of type a,b and excluding the
c which extend into dentoalveolar
frontal bone. component.
 FRACTURE INVOLVING OCCLUSION
a) Dentoalveolar

b) Subzygomatic fracture
LEFORT I
LEFORT II

c) Suprazygomatic
LEFORT III
 MODIFICATION OF LEFORT’S FRACTURE
CLASSIFICATION BY MARCIANI IN 1993
LEFORT I-Low maxillary fracture
low maxillary fracture/multiple segments

LEFORT II-pyramidal fracture

IIa- pyramidal+nasal fracture
IIb-pyramidal+NOE#

LEFORT III-cranifacial dysjunction

IIIa-craniofacial dysjunction +nasal#
IIIb-craniofacial dysjunction+NOE#

LEFORT IV-LEFORT II OR LEFORT III and cranial base fracture

IVa+supraorbital rim#
IVb+supraorbital rim#+anterior cranial base
IVc+anterior cranial base+orbital wall#
 LEFORT I FRACTURE
• LOW LEVEL
• HORIZONTAL FRACTURE
• GUREIN FRACTURE
• FLOATING FRACTURE
As there is separation of complete dentoalveolar
part of maxilla (pterygomaxillary dysjunction)
and the fracture segment is held only by means
of soft tissue.
 LEFORT I FRACTURE PATTERN
• The fracture line commences at a point on
the lateral margin of nasal aperture,

• Passes above the nasal floor,

• Laterally above the canine fossa and

• Transverse the lateral antral wall,

• Dipping down below the zygomatic buttress and
then incline upward and posteriorly across the
pterygomaxillary fissure to fracture pterygoid
laminae at junction of their lower one third and
upper two third .

• It is completed by joining the middle part of

nasal septum to pterygomaxillary fissure.

• The typical lefort fracture is always bilateral

,with fracture of lower third of nasal septum.

• It can be unilateral also.

 CLINICAL FEATURES

EDEMA AND SWELLING IN LOWER UPPER LIP SWELLING

PART OF FACE
Ecchymosis in labial vestibule
Laceration of lip
Bilateral epistaxis
Mobility of upper dentoalveolar
portion of jaw
 Occlusion may be disturbed
• Anterior open bite due to premature contact
of posterior teeth known as gagging of
occlusion.
Eccymosis in greater palatine foramen
region –GUREIN SIGN
PRESENCE OF MIDLINE SPLIT OF
PALATE
 OTHER CLINICAL FEATURES
• Percussion of maxillary teeth produces dull ‘cracked
cup ‘ sound.

• Difficulty in mastication

• Pain while speaking and moving the jaw.

• Sometimes there may be upward displacement of

the entire fragment,locking it against the superior
intact structures ,such a fracture is called impacted
or telescopic fracture.
 LEFORT II FRACTURE
• PYRAMIDAL FRACTURE
• SUBZYGOMATIC
 LEFORT II FRACTURE PATTERN
• The fracture line runs below frontonasal suture
from thin middle area of nasal bone on either side
,

• Crossing the frontal process of maxilla into the

medial wall of each orbit,

• Passing across the lacrimal bone immediately

behind the lacrimal sac.

• From this point, it passes downward ,forward and

laterally ,crossing the inferior orbital margin in the
region of zygomaticomaxillary suture.
• It may or may not involve the infraorbital foramen.

• It then run downward and forward and laterally to

traverse the lateral antral wall,just medial to
zygomaticomaxillay suture line.

• Dipping down below zygomatic buttress and incline

upward and posteriorly across the pterygomaxillary
fissure and fracture the pterygoid laminae about
half wayup.

• Separation of entire block from the base of the

skull is completed via the nasal septum and may
involve the floor of anterior cranial fossa.
 GROSS EDEMA OF MIDDLE THIRD OF FACE-
BALLONING OR MOON FACE OR “PANDA FACIES
BILATERAL CIRCUMORBITAL EDEMA
AND ECCYMOSIS –”RACOON FACIES”
SUBCONJUCTIVAL HAEMORRHAGE
DISH SHAPED FACE
CSF LEAK
STEP DEFORMITY IN INFRAORBITAL
MARGINS
EPISTAXIS
OEDEMA OF CONJUNCTIVA
OTHER OCULAR CHANGES
ENOPHTHALMOS
DIPLOPIA
PERIORBITAL ECCHMOSIS
PTOSIS
BATTLE’S SIGN
WIDENING OF INTERCANTHAL
DISTANCE
CULLEN’S SIGN-SUBLINGUAL
HEMATOMA
 LEFORT III FRACTURE
• TRANSVERSE FRACTURE
• SUPRAZYGOMATIC FRACTURE
• HIGH LEVEL FRACTURE
• CRANIFACIAL DYSJUNCTION
 LEFORT III FRACTURE PATTERN
• The fracture line passes near the frontonasal
suture ,runs transversely ,backward, parallel to
base of skull to full depth of ethmoid bone
including the cribriform plate.

• Within the orbit ,below the optic foramen into

posterior limit of inferior orbital fissure.

• The fracture line reaches the optic foramen which

is surrounded by a dense ring of bone.
• The fracture line gets deflected downward and
laterally to reach medial aspect of posterior limit of
inferior orbital fissure.

• From the base of inferior orbital fissure ,the fracture

line extends in 2 directions

1) Backward across the maxillary fissure to fracture

the roots of pterygoid laminae.

2) Laterally across the lateral wall of orbit separating

the zygomatic bone from frontal bone.

Entire middle third of facial skeleton is detached from

skull bone
HOODING OF EYE
 OTHER CLINICAL FEATURES
• There may be tenderness and separation of
frrontonasal suture.this produce lengthening of
face and lowering of ocular level.

• If the fracture line passes above the whitnall’s

tubercle ,there will be lowering of the level of
the eye .this can be seen by comparing the
pupillary level .
 SEQUENCE OF TREATMENT OF
PANFACIAL TRAUMA /FRACTURE
• Necrotic debris to be removed.

• Mandibular fracture if present to be addressed.

• Intraoral laceration to be addressed.

• Maxillary fracture reduced and placed in IMF.

• Zygomatic injuries if present is addressed .

• Frontozygomatic suture is exposed ,reduced and fixed.

• Zygomaticomaxillary suture and floor of orbit are repaired

• Nasal injury and nasoethmoid injury is addressed.

• The last to be repaired are the laceration of skin.

 GENERAL MANAGEMENT
• Immediate treatment
• Preliminary examination and determination of
priorities.
• History of local exmination
• Inspection-externally
intraoral
• Palpation
• Control of pain
• Control of infection
• Radigraphic examination
• Definitive treatment
 RADIGRAPHIC EXAMINATION
FOR THE MID-FACE-
15and 30 degree occipitomental view
submentovertex view
occlusal view
PA view –waters projection

FOR THE CRANIAL VAULT

lateral view
occipitofrontal -25 degree
townes projection (fronto-occipital)
 PRINCIPLES OF MANAGEMENT
• REDUCTION-Restoration of a fractured fragments
to their original anatomical position.

• FIXATION-After reduction the fractured fragments

are fixed,in their anatomical realationship to
prevent displacement and achieve proper
approximation.

• IMMOBILIZATION-During this phase ,fixation device

is ratained to stabilize the reduced fragments , until
clinical bi=ony union takes place.
 REDUCTION

CLOSED OPEN

BY MANIPULATION
BY INCISION
TRACTION

1-DIGITAL OR HAND BONE

ELASTIC EXPOSURE
2-ACCORDING TO DINGMAN AND
HARDING TRACTION
3-ACCORDING TO PRO[ESCUS AND REDUCTION
BURLIBASA
4-REDUCTION USING SPECIAL
INSTRUMENTS
 MANUAL REDUCTION
• INDICATION

• When fracture fragments are not impacted

• Non displaced favourable fracture
• Fresh fracture
• Edentulous maxillary fracture
• In children with developing dentition
 METHODS OF REDUCTION
1) SIMPLE MANIPULATION BY HAND
• It is possible in fresh fractures
• With help of finger and thumb
• Fix 2 double wire encircling the 1st and 2nd
molars and twisting them on either side

2) DINGMAN AND HARDING IN 1951

They suggested the use of impression compound
.
3) PROPESCUS AND BURLIBASA IN 1966
Reduction by –rubber dam
-long ribbon
strip gauze
rubber catheter
4) REDUCTION BY USING SPECIAL INSTRUMENTS

ROWE’S MAXILLARY DISIMPACTION FORCEPS

HAYTON’S WILLIAM DISIMPACTION FORCEPS

REDUCTION BY TRACTION-INTRAORAL
-EXTRAORAL
INSTRUMENTS
 OPEN REDUCTION
• INDICATION-firmly impacted,displaced
fracture,fracture of edentulous maxilla,specific
systemic condition contraindicating IMF,multiple
fracture.

• TECHNIQUE-vestibular incision 1st molar to 1st molar

region-refection of flap-fracture line is exposed –
osteotome inserted to mobilize the fragment-
disimpaction forcep is used-temporary IMF
 FIXATION
1) INTERNAL FIXATION

a) DIRECT OSTEOSYNTHESIS
Miniplates and screws
Tranosseous wiring
Transfixation and kirschiner wire

b) SUSPENSION WIRES TO MANDIBLE( ADAM’S SUSPENSORY WIRES)

Frontal
Circumzygomatic
Zygomatic
Infraorbital
Pyriform aperture
Circumpalatal

c) SUPPORT
Antral pack
Antral ballon
2) EXTERNAL FIXATION

a) CRANIOMANDIBULAR
Box frame
Haloframe
Plaster of paris headcap

b) CRANIOMAXILLARY
Supraorbital pins
Zygomatic pins
Halo frame
Levant frame

c) SUSPENSION BY CHEEK WIRES FROM HALOFRAME/HEADCAP

 INTERNAL FIXATION
A- DIRECT OSTEOSYNTHESIS
TRANSOSSEOUS OR INTRAOSSEOUS WIRING
Wire osteosynthesis : oldest , simplest most popular method.
Sites for lefort I: alveolar
midpalatal
zygomaticofrontal
zygomaticomaxillary
palatal process
frontonasal process
Sites for LEFORT II: orbital rim
zygomatic buttress.
TRANSOSSEOUS
• The fracture line is reduced

• Fracture fragments are approximated in there normal anatomic

position.

• Holes are drilled on either sides of fracture line

• 26 or 28 gauge wire stainless steel wire is passed to interconnect

the holes and both the end of the wires are grasped on the outer
cortex twisted, cut and finished.

• IMF done for period of 4 to 6 weeks.

• DRAWBACKS: 1) IMF always needed.

2) there is no three dimensional stability to the fragment.
3) delayed healing because of micro movement at the fracture site.
 TRANSFIXATION: kirschner wires or
steinmann pins may be inserted
• From zygoma to zygoma
• From zygoma to maxilla

• MINIPLATE OSTEOSYNTHESIS
• ( non compression monocortical screw system)
• Developed in frame by michelet in 1978 & made popular by champy in
1975
• AIM:
To attain a functionally oriented fracture adaptation
Application of plate to the region of traction side of bone.
THERAPEUTIC PRINCIPLE:fixation by stability
stability is achieved by a perfect anatomic
reduction &
Intrafragmentary approximation without compression.
TRANSFIXATION
 SUSPENSION WIRES:
• Principle of internal wire suspension first described by ADAMS in
1943
• Also called ADAMS suspension wires.
• It can be used in cases of scalp injuries
• Minimum armamentarium
• Simple procedure
• Various areas for direct suspension of wires
• 1) pyriform fossa
• 2) zygomatic arch
• 3) zygomatic buttress
• 4)infraorbital rim
• 5) zygomatic process of frontal bone
SUSPENSION WIRING
• FOR LEFORT II FRACTURE
• SITES: circumzygomatic suspension
pyriform fossa suspension
infraorbital suspension
• FOR LEFORT II FRACTURE:
circumzygomatic suspension
Lateral frontal suspension
Infraorbital suspension
 SUPPORT:ANTRAL PACK AND
BALLON CATHETER
 ANTRAL PACK
• A long strip of half inch ribbon gauze socked in betadine or iododoform
&lubricated with vaseline is used to pack the antrum.

• Packing should be started at the back of the floor & laid in anteroposterior
direction.

• Care is taken not to force the pack tightly at the floor of the orbit , but
adjusted in such a way that the ocular level is brought to normaly.

• The last end of the pack either may be brought out through the corner of the
incision intraorally or through the nose, via nasal antrostomy.

• Pack is not retained for more than 2 months

 BALLON CATHETER

• Shea & anthony in 1952 devised a balloon for the purpose of supporting the comminuted
orbital floor .

• Recently the use of FOLEY’S CATHETER no 16 or 18 is recommended.

• the preliminary procedure is same as described for the insertion of an antral pack.

• Nasal antrostomy is performed and a curved hemostate is passed from the antrum into the
nasal antrostomy.

• The tips of the hemostat is opened to grasp the tip of foley ‘s catheter and the hemostat is
pulled into the antrum .

• The position of the catheter is adjusted in the antral cavity .

• The 20 ml of sterile saline is inserted into the rubber stopper of the cathter and the balloon
slowly inflated under direct vision , until a satisfactory reduction has been achevied.

• The balloon kept for 1 to 2 weeks and then removed , after deflating by emptying the saline,
through the nose.
 EXTERNAL FIXATION:
• CRANIOMAXILLARY: fixation between the skull & maxillary arch is
termed as craniomaxillary fixation.

• The stable skull bone serves as a point of fixation for the fracture of
facial skeleton.

• Here fixation of mobile maxillary segment to the stable cranium.

• Connectors are placed on the arch bars which connect the maxillary
arch to the external head gear.

• E.G. HALO FRAME OR LEVANT FRAME

• Directly secured to the skull by multiple screw pins inserted into the
external cortex of skull.
CRANIOMAXILLARY
• CRANIOMANDIBULAR FIXATION:

Fixation between the mandibular arch and skull is termed as

craniomandibular fixation.

• the fracture area of the middle third of the face is sandwiched

between intact skull and rigid mandible .

• It can be achieved by :
• connecting a mandibular splint to a plaster of paris head cap via an
anterior projecting bar and vertical rod ,

• bilateral transbuccal wires from the head caps to a mandibular arch

bar .

• Halo frame can be used as fixed anchorage point in both

cranoimaxillary or craniomandibular fixation method.
 IMMOBILIZATION
• Immobilization is done to stable skeletal
segments of the skull.
• It should be maintain for approximately 6-8
weeks
• IMF MAINTAINED- until occlusal disturbances
can no longer results i.e 3-4 weeks
• In case of miniplates osteosynthesis –no need
for IMF.
 COMPLICATION
• Inadequately reduced fracture-facial defomity
• Obstruction of nasolacrimal.
• Epiphora
• Dacrocystitis
• Late enophthamos due expansion of orbital volume.
• Stabismus
• Ptosis and diplopia
• Fracture involving cribriform plate of ethmoid may result in
anosmia.
• Non-union
• Meningitis