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MAXILLARY FRACTURES

LEFORT - AP VIEW

Midface FracturesMidface Fractures

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Le Fort’s fracturesLe Fort I (low level

or Guerian fracture)

Unilateral/ bilateral Horizontal fracture

through the maxilla above the level of the

nasasl floor and alveolar process

Piriform rimsAnterior maxillaZygomatic buttressesPtrygoid laminae

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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

Impacted type of fracture is oftenly not mobile and teeth cusps may be damaged

Lé Fort I

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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.

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

Lé Fort II

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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.

Le Fort 3 and mastication problem

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Signs and symptomsalthough 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 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

Inspection

Palpation

Diagnostic Imaging

Plain films

CT

DIAGNOSIS OF MAXILLOFACIAL INJURIES

INSPECTION

Sublingual ecchymosisSublingual ecchymosis Step defects, ridgediscontinuity, malocclusionStep defects, ridgediscontinuity, malocclusion

PALPATION

“Step” Defect

Crepitus

Bony segments

Subcutaneous emphysema

Mobility

DIAGNOSIS OF MAXILLOFACIAL INJURIES

FACIAL EXAMINATIONPALPATION OF MIDFACE/BRIDGE OF NOSE

FACIAL EXAMINATIONORBITS EVALUATION

FACIAL EXAMINATIONOrbits evaluated

Periorbital edema and ecchymosis

Gross visual acuity determined

Diplopia

Pupillary size & shape

Subconjunctival hemorrhage

FACIAL EXAMINATION

Orbits evaluatedLid lacerations

Attachment of medial canthal tendon

Rounding of lacrimal lake

Increased intercanthal distance

Epiphora

Prompt Ophthamology consult

FACIAL EXAMINATIONEvaluate mandibular

openingPalpation of buccal vestibule

Crepitus of lateral antral wallOcclusion evaluated

Absence and quality

of dentition notedEcchymosis common finding

Pharynx evaluated for laceration & bleeding

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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

Restore normal nerve function

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Factors affecting the risk

Association with multiple injuries.

Presence of uncontrolled haemorrhage

Impairment of the airway.

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

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Definitive treatment

Reduction

Manual manipulation

Use of dis-impaction forceps

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Fixation and immobilization

Extraoral fixation

Craniomandibular fixationBox-frame (pin fixation)Halo-framePlaster of paries headcap

Craniomaxillary fixationSupra-orbital pinsZygomatic pinsHalo-frame

Cont: Management

Techniques

Plate Fixation (Miniplates) Interosseous Wire Fixation Bone Grafts

Management by Le Fort Classification

Le Fort I: reduced digitally, MMF, fixation of ZM Le Fort II: stabilization of the ZM buttress, MMF , nasofrontal

process and inferior orbital rim.

Le Fort III: usually requires coronal flap for adequate exposure for exploration and miniplate fixation

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