Oral and Maxillofacial Surgery

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 Mid-face
Definition:
The area between
a superior plane
drawn through
the zygomatico-
frontal sutures
tangential to the
base of the skull
and inferior
plane at the level
of the maxillary
dental occlussal
surface.
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 Structures connection
(structures in relation)

 Orbit
 Maxillary sinus
 Nasal bone
 Naso-orbital
ethmoid (NOE)
complex
 Zygomatic
complex
 Frontal bone and
sinus 3
 Vertical and horizontal pillars

•Area of strength
•Vertical and horizontal pillars
•Muscular attachment
•Area of weakness
•Sutures
•Lining tissues and air-filled cavities 4
 Pattern of fractures
of mid-face skeleton
 Alveolar fracture and dental fracture

 Le Fort ‘s fracture ((french surgeon Rane Le Fort

1901)

 Naso-orbital ethmoid fracture

 Zygomatic complex and arch fracture

 Frontal sinus and bone fracture

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 Alveolar bone fracture
Involve block of
alveolar bone
with or without
 Intrusion of

teeth
 Extrusion of
teeth
 Luxation of teeth

 Fracture of teeth

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 Le Fort’s fractures
 Le Fort I (low
level or Guerian
fracture)
 Unilateral/ bilateral
Horizontal fracture
through the maxilla
above the level of
the nasasl floor and
alveolar
process(apertura piriforma,deasupra
apexurilor dentare,fosa canina,creasta zigomatico-
alveolara,tuberozitatea maxilara si 1/3 inferioara a
apofizelor pterigoide)

Piriform rims
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 Anterior maxilla
 Zygomatic buttresses
 Signs and symptoms
 Slight swelling of upper lip

 Ecchymosis in upper lip sulcus

 Hematoma intra-orally over zygoma and in palate

 Disturbed occlusion

 Mobility of teeth of the involved segment of maxilla

 Combination of soft tissue laceration

 Exposure of nares and the maxillary antra in case of

gross injury

 Impacted type of fracture is oftenly not mobile and

teeth cusps(varfuri) may be damaged

 Cracked-pot percussion of upper teeth 8

 Le Fort’s fractures

 Le Fort II
(pyramidal or subzygomatic)
Separation of NF suture,
medial orbital walls (lacrimal
bone), inferior orbital floor
and rim (adjacent to
infrorbital canal and
foramen), anterior maxilla
below zygomatic buttress
and ptrygoid laminae about
halfway up.(Linia de fractura are traiect oblic in
jos si inspoi prin: oase nazale,os lacrimal,apofiza ascendenta a
maxilarului,rebordul orbital la nivelul gaurii infraorbitale(podeaua
orbitei ramane integra),peretele antero-lateral al sinusului
maxilar,1/3 mijlocie a apofizelor pterigoide,peretele lateral al fosei
nazale,vomerul,septul nazal cartilaginos.)

Separation of the block from the base of skull is completed

via the nasal septum and may involve the floor of the
anterior cranial fossa 9
 LeFort’s fractures

 LeFort III
(cranifacial dysjunction, high
transverse, suprazygomatic)
Separation of NF suture, medial
orbital walls (involve the depth of
the ethmoid bone and cribriform
plate, pass below optic foramen
and cross the inferior orbital
fissur), inferior orbital floor,
lateral orbital wall, ZF suture,
zygomatic arch, suprazygomatic to
the root of ptrygoid plate.(Linia de fractura
are traiect oblic in jos si inapoi prin:oasele nazale la nivelul suturii
naso-frontale,os lacrimal,apofiza ascendenta a maxilarului,suprafata
orbitala a etmoidului,peretele inferior al orbitei(pana la sutura sfeno-
maxilara),peretele extern al orbitei(prin sutura fronto-malara),apofiza
pterigoida in 1/3 superioara,arcada temporo-zigomatica,lama
perpendiculara a etmoidului,vomerul. )

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Signs and symptoms
although it is possible to distinguish between le fort II and III, the
signs and symptoms are almost similar
 Gross edema of soft tissue
 Bilateral circumorbital
ecchymosis
 Bilateral subconjunctival
hemorrahge
 Obvious deformity of the
nose
 Nasal bleeding and
obstruction
 CSF leak rhinorrhea
 Dish-face deformity
 Limitation of ocular
movement
 Possible diplopia and
enophthalmous
 Retropostioning of the
maxilla with anterior open
bite
 Lengthening(alungirea)of
the face
 Difficulty in mouth opening
 Mobility of the upper jaw
 Occusional hematoma of
the palate
 Cracked-pot sound on
percussion
 Step deformity at infra-
orbiatal margin
 Anasthesia of midface
 Nasal bone moves with
mid-face as a whole
 Tenderness and sepration
at FZ suture
 Tenderness and deformity
of zygomatic arch
 Depression of occular level
and pseudoptosis
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 Bowerman classification of midface-fracture
(1994)
 Fracture not involving the occlusion
• Central region
 Nasal bone/ septum (lateral, anterior injuries)
 Frontal process of the maxilla

 Nasoethmoid
 Fronto-orbito-nasal dislocation

• Lateral region (zygomatic complex EX dento alveolar

frcature

 Fracture involving the occlusion

• Dento alveolar

• Subzygomatic:
 Le Fort’s (I, II)

• Supra zygomatic:
 Le Fort III

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These fractures may occur unilaterally or bilaterally, with separation
of maxillary midline and or extension to frontal or temporal bone
 Prevalence of mid-face fractures
Fracture Type Prevalence

Zygomaticomaxillary complex (tripod fracture) 40 %

I 15 %
LeFort II 10 %
III 10 %
Zygomatic arch 10 %
Alveolar process of maxilla 5%
Smash fractures 5%
Other 5%
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 Diagnosis
 Inspection
Extra-oral
(e.g. swelling, deformity, asymmetry
Leaks)
Intra-oral
(e.g. hematoma, occlusion)

 Palpation
Step deformity, criptation, cracked pot sound, mobility

 Radiographical investigations
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 Radiographical examination
Plain radiograph

 Occipitomental
(10 or 30 degree)

 Water’s view
Suitable for isolated orbital
fracture
Search line (Campbell’s line 1977)

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 Radiographical examination

 Lateral skull view

 OPG
 Occlusal view of the
maxilla
 Perapical views of
damaged teeth

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 Radiographical examination

 CT scan
 3-D CT imaging

• Coronal sections
• Axial sections

1. Whenever intracranial damage and

frontal sinus are suspected
2. Extensive fracture that involves
nasoethmoid complex or orbital
region
3. Orbital trauma to evaluate the
degree of orbital injury and
enophthalmos 17
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 Indications for treatment

 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.

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 Indications for treatment

 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

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 Aims of treatment
 Relieve pain

 Restore function.

 Restore bone anatomy.

 Prevent infection

 Restore the dental occlusion

 Restore jaw movement at the earliest

possible stage
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 Restore normal nerve function

 Factors affecting the risk

 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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 Factors affecting the risk

 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)
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 Factors affecting the risk

 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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 Principles of treatment
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

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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 26

 Definitive treatment
 Reduction

Manual manipulation

Use of dis-impaction forceps

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 Fixation and immobilization

Extraoral fixation

Craniomandibular fixation
Box-frame (pin fixation)(cadru extern)
Halo-frame(coroana)
(ghips)Plaster of paries headcap

Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame
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Immobilization within the tissue
Direct fixation

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

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 Immobilization within the tissue

Internal-wire suspension

Circumzygomatico-mandibular

Infraorbital border-mandibular

Frontomandibular

Pyriform fossa-mandibular

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 Immobilization within the tissue

Support via the maxillary sinus by

filling materials
• Ribbon gauze
• Balloon
• Folly catheter
• Polyethylene material

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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

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