MIDFACE FRACTURES. Midface fractures Fractures of the middle third may be subdivided into: Dento-alveolar fractures. Fractures of the maxilla. Fractures

MIDFACE FRACTURES

Midface fracturesFractures of the middle third may be subdivided into:Dento-alveolar fractures.Fractures of the maxilla.Fractures of the zygomatic bone & arch.Blow out fractures.Nasal-orbital-ethmoidal fractures.

Dento-alveolar fractures It consists of fracture, subluxation, or avulsion of the teeth with or without an associated fracture of the alveolus, and they may occur as a clinical entity or in conjunction with any other type of fracture.

FRACTURES OF THE MAXILLA

Fractures of the maxillaClassificationThe Le Fort classification defines the weakest areas of the midface complex when it is assaulted from a frontal directions at a different levels into :Le Fort type ILe Fort type IILe Fort type III

LeFort Classification*

Le Forte type I fractureFracture lines

Le Fort type IIt results from a force delivered above the level of the teeth.

The fracture courses from the lateral border of the pyriform aperture

Le Fort type Iabove the canine eminence lateral antral wall behind the maxillary tuberosity across the lower third of the ptergoid plate.The nasal septum may be fractured

Le Fort type I fractures* It may be unilateral or bilateral* It may occur single or in conjunction of with Le Fort type II or III fractures.*The clinical findings may be largely masked by more severe fractures.* Caused by blow with a sharp object above the apices of the teeth.

Clinical findings in Le Forte I fractureslow level or Guerin type

Le Fort type I fracturesClinical findings: Extra-orallySwelling of the upper lip.Soft tissue laceration.Open mouth to accommodate the displaced dento-alveolar portion.Epistaxis.

Le Fort type I fracturesClinical findings: Intra-orallyMalocclusion.

Mobility of tooth bearing portion.Ecchymosis of the buccal sulcus.Dull sound on percussion.

Le Forte type II fracturesFracture lines

Le Fort type IIIt results from a force delivered at a level of the nasal bones.The fracture line occurs along the nasofrontal suture lacrimal bone across the infra- orbital rim in the region of the zygomatico-maxillary suture

Le Fort type II above the canine eminence inferiorly and distally along the lateral antral wall, but at a higher level than Le Fort type I across the pterygoid plate at its middle.

Clinical findings in Le Forte II fracturesSub-zygomatic fracturePyramidal fracture

Le Fort type II fracturesClinical Findings: Extraorally- Ballooning of the face.- Lenghtenening of the face- Circumorbital ecchymosis- Subconjunctival Hg.EpistaxisDipobia (cont)

Le Fort type II fracturesClinical Findings: (cont) Extraorally- EnophthalmosCSF rhinorrhoeaStep deformity in the lower border of the orbitIntact zygomatic bone & arch

Le Fort type II fracturesClinical Findings: IntraorallyMalocclusionGagging of the posterior teeth and anterior open biteMobility of the maxillaEcchymosis of the sulucs

Le Forte type III fracturesFracture lines

Le Fort type IIIThe fracture is caused by a force at the orbital level , the resultant fracture is craniofacial dysjunction.It is called :high level fracture or supra-zygomatic fracture

Le Fort type III The fracture line courses through the zygoma-ticotemporal and zygomaticofrontal sutures lateral orbital wall inferior orbital fissure medially to the naso-frontal suture fractures the pterygoid plate at its base.

Clinical findings in Le Forte III fracturesSupra-zygomatic fracture High level

Le Fort type III fracturesClinical Findings Extraorally- Severe edema of the face ballooning- Lengthening of the face- Flattening of the cheek- Circumorbital ecchymosis- Subconjunctival Hg

Le Fort type III fracturesClinical Findings (cont) ExtraorallyEpistaxisEnophthalmosCSF rhinorrhoea

Le Fort type III fracturesClinical Findings IntraorallyGagging of the posterior teeth and anterior open biteEcchymosis and Hg of the buccal sulcusMobility of the maxillaMandibular interference

Radiology for maxillary fractures

Occipto-mental viewCT scan

Occipto-mental view

Occipto-mental view

Computerized tomography

TYPES * Axial scan * Coronal scan * 3/D CT

imagingAxial scan

Computerized tomographyAxial scan

Computerized tomographyAxial scan

Coronal scanAxial scan

Coronal scan Axial scan

3/D Computerized tomography

Treatment of the maxillary fractures First aid treatmentPreliminary treatmentDefinitive treatment

Treatment of the maxillary fractures REDUCTIONIMMOBILIZATION

Treatment of the maxillary fracturesREDUCTION * Digital pressure * The use of Rowes forceps , Hayton- Wiliams disimpac- tion forceps. * Surgical

Rowes Desimpaction Forceps*

Maxillary fracturesImmobilizationMethodsMMFInternal fixationSkeletal suspensionSupportExternal fixation

Maxillary fracturesImmobilization

Circumzygomatic suspension Obwegeser technique

Maxillary suspension

1- Frontal susp.2- Pyriform fossa susp.3- Infraorbital rim susp.4- Circumzygomatic susp.

Antral support

Treatment of unilateral Le Fort type I fracturesClosed reduction & fixation * Digital pressure. * Arch bar tightened in the unfractured side and loose in the fractured side. * Adjust occlusion, tighten the fractured side then secure MMF.

Treatment of unilateral Le Fort type I fracturesB) Open reduction & fixation * Cases of unstable fractures. * Arch bars are prepared * Sulcus incision to expose the fracture site in canine & buttress regions * Transosseous wiring or miniplates are used for fixation.

Transosseous wiring

Sulcus incisionFracture exposureReductionDrilling wholes24-26 guage wire is used

Treatment of bilateral Le Fort type I fracturesReduction closed or openImmobilization suspension or internal fixation

Treatment of Le Fort type Il fracturesReduction closed or openImmobilization suspension or internal fixation

Treatment of Le Fort type Ill fracturesReductionImmobilization suspension or internal fixation

Zygomatic complex fractures

Zygomatic complex fracturesSecond most common fracture of the facial bones behind nasal bone fractures Zygoma forms prominence of cheek which subsequently contributes to frequency of fractures Major contact areas are with the maxilla and frontal bones Also forms portion of lateral wall and floor of the orbit

ARTICULATIONSFrontozygomatic Zygomaticotemporal Zygomaticomaxillary

Foramina

Foramen allows for passage of zygomaticofacial and zygomaticotemporal nerves of V2 that supply sensation to cheek and anterior temple Infraorbital N. Of V2 courses the floor of the orbit and exits the infraorbital foramen or notch

COMMON FRACTURE SITES

Frontozygomatic suture Infraorbital rim Junction of the zygomatic arch and temporal bones Orbital floor Maxillary buttress

Classification of Zygomatic Fractures

Clinical features of Zygomatic Fractures

Clinical features of Zygomatic FracturesCommon clinical features:EdemaCircumorbital ecchymosisSubconjunctival hemorrageMalar depression Step defect at infraorbital rim Step defect at frontozygomatic suture Epistaxis

Clinical features of Zygomatic FracturesStep defect at zygomatic buttress of maxilla intraorally Ecchymosis at maxillary buttress region V2/infraorbital nerve paraesthesia or anesthesia

Clinical features of Zygomatic Fractures LESS COMMON FINDINGSEnopthalmos or Proptosis Diplopia (monocular vs. binocular) Decreased mobility of extraocular muscles -- upward gaze due to its entrapment .Injury to globe itself -- ophtho. consultation should be obtained on all midface fractures patients

Limitation of mandibular movement secondary to zygomatic arch impingement on the coronoid process Crepitation from air emphysema Unequal pupilary level

Clinical features of Zygomatic FracturesIntra-oral inspectionEcchymosis in the upper buccal sulcus in the region of zyg. Buttress.Anesthesia of teeth and gum.Intra-oral palpationTenderness over zyg. Buttress.Crepitus may be felt.

RADIOGRAPHSWater's view : a PA projection w/ the head positioned at 27 degree angle to the vertical with the chin resting on the cassette Submentovertex : "jug handle" Caldwell view : PA projection w/ the face at a 15 degree angle to the cassette CT Scan : for more detail usually obtain axial and coronal 3-5mm cuts

Water's view

CT Scan

Zygomatic arch fracturesMay exist alone or with zygomatic bone or other facial bone fractures.Specific clinical findings:* Visible depression over the zyg. arch area.* Limitation of mandibular movements.* Classified as a- triple or V-shaped fracture b- comminuted fractures

Zygomatic fractures

Radiographic examination:

Subnemto-vertial view.Occipito-mental view.Ct scan , axial cuts

Subnemto-vertical view

Zygomatic arch fractures Comminuted fracture

Triple fracture

Treatment of Zygomatic Fractures

Treatment of Zygomatic FracturesZygomatic bone requires reduct