Mid Face Fractures / orthodontic courses by Indian dental academy

MIDFACE FRACTURESMIDFACE FRACTURES INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.comwww.indiandentalacademy.com

IntroductionIntroduction

Upper 1/3Upper 1/3rd rd

Middle 1/3Middle 1/3rd rd

Lower 1/3Lower 1/3rd rd


MidFaceMidFace MaxillaeMaxillae Palatine bones Palatine bones Zygomatic bonesZygomatic bones Zygomatic processes of Zygomatic processes of temporal bonestemporal bones nasal bonesnasal bones lacrimal boneslacrimal bonesVomerVomerEthmoid bones & it’s Ethmoid bones & it’s conchaconcha inf. Turbinatesinf. TurbinatesPterygoid plates of Pterygoid plates of sphenoidsphenoid


Surgical AnatomySurgical Anatomy

Central midface : Central midface : Crumple ZoneCrumple Zone

Complex ArticulationComplex Articulation

Protects brain and Protects brain and skull skull


Articulation with Articulation with Skull BaseSkull Base


Areas of WeaknessAreas of Weakness

Developmental Developmental SuturesSutures

Air filled spaces Air filled spaces

Neurovascular Neurovascular bundlebundle


Areas of StrengthAreas of StrengthThickened BonesThickened BonesHigher ratio of cortical:cancellousHigher ratio of cortical:cancellousAnalogus to architectural concepts of supportAnalogus to architectural concepts of supportSicher & Tandler in 1928Sicher & Tandler in 1928


Vertical ButtressesVertical Buttresses

Anterior / Nasomaxillary pillarsAnterior / Nasomaxillary pillarsMiddle / Zygomatico-maxillary pillarsMiddle / Zygomatico-maxillary pillarsPosterior/ Pterygomaxillary pillarsPosterior/ Pterygomaxillary pillars


Horizontal ButtressesHorizontal Buttresses

Supra-Orbital Rims with Frontal Supra-Orbital Rims with Frontal bonesbonesInfra-Orbital RimsInfra-Orbital RimsAlveolar ProcessAlveolar Process


Muscular AttachmentMuscular Attachment

Static structureStatic structureMuscles of Muscles of masticationmasticationExtra-ocular Extra-ocular musclesmusclesBuccinatorBuccinatorFacial mimetic Facial mimetic musclesmuscles


ClassificationClassification


FRACTURES NOT INVOVING FRACTURES NOT INVOVING OCCLUSIONOCCLUSION

A. CENTRAL REGIONA. CENTRAL REGION Fractures of the nasal bones and / or nasal Fractures of the nasal bones and / or nasal septum - lateral nasal injuries septum - lateral nasal injuries

- anterior nasal injuries- anterior nasal injuries

Fractures of the frontal process of the maxilla Fractures of the frontal process of the maxilla

Fractures of (1) and (2) which extend into the Fractures of (1) and (2) which extend into the ethmoid bone ( nasoethmoid)ethmoid bone ( nasoethmoid)

Fractures of types (1), (2) and (3) which extend Fractures of types (1), (2) and (3) which extend into the frontal bone (fronto- orbito- nasal into the frontal bone (fronto- orbito- nasal dislocation)dislocation)


B. LATERAL REGIONB. LATERAL REGION

Fractures involving the zygomatic bone, Fractures involving the zygomatic bone,

Zygomatic arch andZygomatic arch and

maxilla maxilla

(zygomatic complex) excluding the dento-alveolar component (zygomatic complex) excluding the dento-alveolar component


FRACTURES INVOLVING FRACTURES INVOLVING OCCLUSIONOCCLUSION

Dento alveolar Dento alveolar

Subzygomatic :Subzygomatic :

-- Le Fort I ( low level)-- Le Fort I ( low level)

-- Le Fort II (pyramidal)-- Le Fort II (pyramidal)

Suprazygomatic Suprazygomatic

--Le Fort III (High-level)--Le Fort III (High-level)www.indiandentalacademy.comwww.indiandentalacademy.com

Rowe & William’s (1985)Rowe & William’s (1985)

FRACTURES NOT INVOVING THE FRACTURES NOT INVOVING THE

DENTOALVEOLAR COMPONENTDENTOALVEOLAR COMPONENT

FRACTURES INVOLVING THE DENTOALVEOLAR FRACTURES INVOLVING THE DENTOALVEOLAR

COMPONENTCOMPONENT


ClassificationClassificationAlphonse Guerin ( 1888)Alphonse Guerin ( 1888)Rene LeFort (1901)Rene LeFort (1901) Experimental cadaveric studiesExperimental cadaveric studies # along the lines of weakness# along the lines of weakness Assault from frontal / lateral impactAssault from frontal / lateral impact Avoided areas of strengthAvoided areas of strength

LeFort ILeFort I LeFort IILeFort II LeFort IIILeFort III


Le Fort ILe Fort IGuerin #,Floating #Guerin #,Floating #

Fracture extends Fracture extends transversely above transversely above level of teethlevel of teethTraumatic force Traumatic force directed directed to the lower maxillary to the lower maxillary region regionB/L or U/LB/L or U/LU/L: auxillary # : U/L: auxillary # : midline of the midline of the palatepalatewww.indiandentalacademy.comwww.indiandentalacademy.com

MAXILLOFACIAL INJURIESMAXILLOFACIAL INJURIESMIDFACE FRACTURES

Le-Fort I Fracture(Guerin # / Low level # / Floating #)

Nasal floor Pyriform rim Zygomatic buttress Pterygoid lamella Lateral wall nose Nasal septum tuberosity


Le Fort II: Le Fort II: Pyramidal #Pyramidal #

Begins above level Begins above level of teethof teetha violent force to the a violent force to the central region of the central region of the midmidCentral portion Central portion mobilized mobilized independentlyindependentlyPa Skull- Pyramidal Pa Skull- Pyramidal shaped.shaped.


MAXILLOFACIAL INJURIESMAXILLOFACIAL INJURIESMIDFACE FRACTURES

Le-Fort II Fracture( Pyramidal # / Subzygomatic # )

Nasal bone Frontal bone Orbit Lacrimal bone Infraorbital foramen Maxillary antrum ZM suture


Le Fort III:Le Fort III: Craniofacial DysjunctionCraniofacial Dysjunction

Fracture extends through Fracture extends through zygomatic archzygomatic archEntire midface separated & Entire midface separated & suspended solely by soft suspended solely by soft tissuestissueswww.indiandentalacademy.comwww.indiandentalacademy.com

MAXILLOFACIAL INJURIESMAXILLOFACIAL INJURIES

GK / MAXFACGK / MAXFACSDM DHARWADSDM DHARWAD

MIDFACE FRACTURESLe-Fort III Fracture

( High transverse/Suprazygomatic/Craniofacial disarticulation)

Fronto-nasal suture Ethmoid cribriform plate Frontal process maxilla Medial wall orbit Optic foramen Inferior orbital fissure Pterygoid lamella Lateral wall of orbit Z-F

suturewww.indiandentalacademy.comwww.indiandentalacademy.com

These fractures may occur unilaterally or These fractures may occur unilaterally or

may be associated independently with a may be associated independently with a

fracture of the zygomatic complexfracture of the zygomatic complex

There may be midline separation of the There may be midline separation of the

maxilla and / or extension of the fracture maxilla and / or extension of the fracture

pattern into the frontal or temporal bones pattern into the frontal or temporal bones www.indiandentalacademy.comwww.indiandentalacademy.com

Factors influencing displacementFactors influencing displacementDegree of forceDegree of force

Direction of forceDirection of force

Resistance to the force offered by the facial Resistance to the force offered by the facial

bonesbones

Point of application of forcePoint of application of force

Cross sectional area of objectCross sectional area of object

Attached musclesAttached muscleswww.indiandentalacademy.comwww.indiandentalacademy.com

Diagnosis of Maxillofacial InjuriesDiagnosis of Maxillofacial Injuries

InspectionInspectionPalpationPalpationDiagnostic ImagingDiagnostic Imaging Plain RadiographsPlain Radiographs CT -Axial section -Coronal sectionCT -Axial section -Coronal section


Local clinical examinationLocal clinical examinationgently clean up the facegently clean up the faceInspectionInspectionPalpationPalpationDiagnostic ImagingDiagnostic Imaging

Extra oral examinationExtra oral examination

Lacerations or injury over headLacerations or injury over headCheck for edema, ecchymosis (periorbital, Check for edema, ecchymosis (periorbital, conjunctival, scleral) and soft tissue lacerationsconjunctival, scleral) and soft tissue lacerationsAny obvious bony deformities, haemorrhage, Any obvious bony deformities, haemorrhage, epistaxis or otorrhoea, rhinorrhoeaepistaxis or otorrhoea, rhinorrhoea

occular involvementoccular involvement www.indiandentalacademy.comwww.indiandentalacademy.com

PalpationPalpation

It should begin at the back of the neck and It should begin at the back of the neck and cranium, Upper face,the zygomatic arch ,bone cranium, Upper face,the zygomatic arch ,bone and orbitand orbit

Ares of tenderness, deformities notedAres of tenderness, deformities noted

Step deformity,subcutaneous emphysema Step deformity,subcutaneous emphysema

Mobility of maxillaMobility of maxilla

Eyelids separated and vision tested, check forEyelids separated and vision tested, check for diplopia, light reflexdiplopia, light reflex

Check for ParaesthesiaCheck for Paraesthesiawww.indiandentalacademy.comwww.indiandentalacademy.com

Intra oral examinationIntra oral examination

Derangement of occlusion, gagging of Derangement of occlusion, gagging of

occlusion, lacerations, ecchymosisocclusion, lacerations, ecchymosis

PalpationPalpation

Areas of tenderness, bony irregularities, Areas of tenderness, bony irregularities,

crepitus mobility of teeth notedcrepitus mobility of teeth noted

Examination of teethExamination of teeth

Pharynx evaluated for laceration & bleedingPharynx evaluated for laceration & bleedingwww.indiandentalacademy.comwww.indiandentalacademy.com

Clinical FeaturesClinical FeaturesLeFort - ILeFort - I

Swelling of the upper lipSwelling of the upper lip

Ecchymosis present in the buccal sulcus Ecchymosis present in the buccal sulcus beneath each zygomatic archbeneath each zygomatic arch

Patient keeping thePatient keeping the

mouth slightly openmouth slightly open

Occlusion derrangedOcclusion derranged

Midline split of the palateMidline split of the palate

Subluxation of teethSubluxation of teeth


The impacted Le Fort I fracture (Telescoping The impacted Le Fort I fracture (Telescoping

fracture) –difficult to diagnose – ‘grating fracture) –difficult to diagnose – ‘grating

sound’sound’

Percussion ‘cracked pot’ sound Percussion ‘cracked pot’ sound

Haemorrhage in the maxillary sinusesHaemorrhage in the maxillary sinuses


LeFort - II / IIILeFort - II / IIISwelling Swelling : gross; (moon face) eyelids : gross; (moon face) eyelids conjunctivaconjunctivaEcchymosis : bilateral circum-orbital Ecchymosis : bilateral circum-orbital

(panda face/raccoon face)(panda face/raccoon face) : subconjunctival: subconjunctivalChemosisChemosis Infra orbital stepInfra orbital step (Le Fort II)(Le Fort II)Nasal deformityNasal deformity


Retropositioning of maxilla : Deranged Retropositioning of maxilla : Deranged

occlusion : post gagging : V. Docclusion : post gagging : V. D

Mobility of midfaceMobility of midface

Hematoma on palateHematoma on palate

Dish faceDish face

Loss of function: Loss of function:

Diplopia? AnosmiaDiplopia? Anosmia

Nares filled with clotted bloodNares filled with clotted blood

Emphysema, Epiphora, Emphysema, Epiphora,

CSF Rhinorrhea,Hooding of eyeCSF Rhinorrhea,Hooding of eyewww.indiandentalacademy.comwww.indiandentalacademy.com

LeFort - IILeFort - IINo alteration of pupillary levelNo alteration of pupillary levelHaematoma in the upper buccal sulcusHaematoma in the upper buccal sulcusStep deformity : infra orbital marginsStep deformity : infra orbital marginsLimitation of orbital movement with diplopia Limitation of orbital movement with diplopia and enopthalmosand enopthalmosAnaesthesia or Paraesthesia of the cheekAnaesthesia or Paraesthesia of the cheekGagging of occlusion and retro-positioning of Gagging of occlusion and retro-positioning of the maxillathe maxilla

On manipulation: movement being detected at On manipulation: movement being detected at the infra orbital margins and nasal bridgethe infra orbital margins and nasal bridge


LeFort - IIILeFort - IIILenghtening of the faceLenghtening of the faceAlteration of the occular level Alteration of the occular level unilateral or bilateral unilateral or bilateral hooding hooding of the eyeof the eye# of the zygomatic arch :# of the zygomatic arch :flattening of the zygomatic complex flattening of the zygomatic complex Tenderness and deformity over the zygomatic archTenderness and deformity over the zygomatic archTenderness and separation at the F-ZsutureTenderness and separation at the F-ZsutureMobility of the whole facial skeleton as a single Mobility of the whole facial skeleton as a single blockblock

Gagging of occlusion in the molar areaGagging of occlusion in the molar area

Disruption of the cribriform plate :CSF rhinnorhoea Disruption of the cribriform plate :CSF rhinnorhoea www.indiandentalacademy.comwww.indiandentalacademy.com

Radiographic EvaluationRadiographic Evaluation

Plain Radiographs :Plain Radiographs : P - A skullP - A skull PNSPNS Lateral skull Lateral skull CT ScanCT Scan Axial & Coronal sectionsAxial & Coronal sections


PNS viewPNS view


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Mid Face Fractures / orthodontic courses by Indian dental academy

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