FRACTURES OF THE MIDDLE THIRD OF THE FACIAL SKELETONABDUL KARIM SHARIF, MD, PGD

School of Dentistry, Ghalib UniversityKabul, AfghanistanOctober 2015

Bones constituting the Middle Third of the Face

• Maxilla (2)• Palatine bones (2)• Zygoma (2)• Zygomatic Processes of Temporal bone (2)• Nasal bone (2) • Lacrimal bones (2)• Ethmoid and its attached conchae (1)• Inferior conchae (2)• Pterygoid plates of sphenoid (2)• Vomer (1)

Physical Characteristics of the Midfacial Skeleton

• Made up of considerable number of bones – rarely fractured in isolation

• All the bones are comparatively fragile, articulate in a most complex fashion

• Greatest portion is maxilla• Capable to absorb force and transmit to the adjacent articulating

bones• Acts as a cushion for the trauma directed to the cranium

• Middle third is anatomically complicated – Generally comminuted fractures

Classification of Fractures of the Middle Third of the Facial Skeleton

• Rene LeFort – 1901 – Paris • LeFort I• LeFort II• LeFort III

Classification of Fractures of the Middle Third of the Facial Skeleton …

• Erich’s – 1942 – Direction of fracture line• Horizontal Fracture• Pyramidal Fracture• Transverse Fracture

• Depending on the relationship of the fracture line to the zygomatic bone;• Subzygomatic Fracture• Suprazygomatic Fracture

Classification of Fractures of the Middle Third of the Facial Skeleton …

• Depending of the level of a fracture line:• Low level fracture • Mid level fracture• High level fracture

Classification of Fractures of the Middle Third of the Facial Skeleton …

LeFort I Fracture• Low Level Fracture• Subzygomatic Fracture• Guerin’s Fracture• Floating Maxilla• Horizontal Fracture of the Maxilla

LeFort I Fracture• Separation of complete

dentoalveolar part of the maxilla (pterygomaxillary dysjunction)

• Fractured fragment held by the means soft tissues

• Fractured fragment is freely moblie

• A violent force applied over a more extensive are, above the level of the teeth

• Commences at the anterior nasal aperture passes above the nasal floor passes laterally above the canine fossa and traverses the lateral antral wall passes below the zygomatic buttress to the pterygomaxillary fissure and fractures the pterygoid lamina at the junction of their lower third and upper two-thirds.

• Line of fracture is the same at the opposite side

LeFort I Fracture (Fracture Line)

• Slight swelling and edema of the lower part of the face along with the upper lip swelling (gross edema not present)

• Ecchymosis in the labial and buccal vestibule• Contusion of the skin of the upper lip may be seen• Bilateral epistaxis

LeFort I Fracture (Signs and Symptoms)

LeFort I Fracture (Signs and Symptoms) …

• Mobility of the upper dentoalveolar portion of the jaw to digital pressure

• Disturbed occlusion• Pain while speaking and moving the jaw• Sometimes upward displacement of the entire fragment –

anterior open bite• Percussion to maxillary teeth – dull cracked up sound

LeFort I Treatment• Bone Plate• Circumzygomatic Wiring (IMF + Zygomatic arch

suspension)

Zygomatic Arch Suspension (Circumzygomatic Wiring) + IMF

Zygomatic Arch Suspension (Circumzygomatic Wiring) + IMF

LeFort II Fracture• Mid level fracture• Pyramidal Fracture• Subzygomatic fracture

LeFort II Fracture• Violent force applied from anterior direction on the central

region of middle third of the facial skeleton.• Force delivered at the level of the nasal bone

LeFort II Fracture (Fracture Line)• Starts below the

nasofrontal suture crosses the frontal processes of maxilla on either side passes anteriorly across the lacrimal bones immediately anterior to the nasolacrimal canal passes downward, forward and laterally crossing the inferior orbital margin in the region of zygomaticomaxillary suture crosses the lateral wall of antrum rest as LeFort I

LeFort II Fracture (Signs and Symptoms)

• Ballooning or Moon Face• Circumorbital edema and ecchymosis (Black Eye)• Bilateral subconjunctival hemorrhage (Middle half of the eye) • Flat face (Nasal depression or disfigurement)• Bilateral epistaxis• Difficulty in mastication and speech

LeFort II Fracture (Signs and Symptoms)

• Shortening of the face, anterior open bite• Elongation of the face (Dish-shaped face)• Loss of occlusion• Airway obstruction• CSF leakage• Step deformity at the infraorbital margins may be seen• Anesthesia/paresthesia of the cheek

LeFort II Fracture (Treatment)• Zygomatic Arch Suspension or Frontal Bone Suspension• Intraosseous wiring may be done at infraorbital margins

LeFort III Fracture• Transverse fracture• Suprazygomatic fracture• High level fracture• Craniofacial dysjunction

LeFort III Fracture• The line of fracture extends above the zygomatic bones

on both sides as a result of trauma being inflicted over a wider area, at the orbital level

LeFort III Fracture (Fracture Line)• Starts at naso frontal

suture crosses nasal bone and the frontal process of the maxilla upper limit of the lacrimal bones continues posteriorly and crosses the thin orbital plates traverses the lateral orbital wall.

LeFort III Fracture (Signs and Symptoms)• Clinically similar to the LeFort II, but close examination demonstrates LeFort III• Gross edema of the face, balooning. “Panda Facies”, 24 –

48 hrs• Bilateral Circumorbital ecchymosis and gross edema

(Racoon Eye)• Bilateral subconjunctival hemorrhage (Posterior limit will not be seen)

LeFort III Fracture (Signs and Symptoms)

• Tenderness and separation at the frontozygomatic sutures• Lengthening of the face• Lowering the ocular level

• Characteristic “dish face” deformity• May be enophthalmous, diplopia or impairment of vision,

temporary blindness …• Flattening and widening and deviation of the nasal bridge• Epistaxis, CSF rhinorrhea

Treatment• Intraosseous wiring at zygomaticofrontal sutures +

Frontomalar suspension wiring• Intraosseous wiring at the infraorbital margin, if step

deformity exists

QUESTIONS … ?