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Oral and Maxillofacial Surgery

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Mid-faceMid-faceDefinition:Definition:

The area between The area between a superior plane a superior plane drawn through drawn through

the zygomatico-the zygomatico-frontal sutures frontal sutures

tangential to the tangential to the base of the skull base of the skull

and inferior and inferior plane at the level plane at the level of the maxillary of the maxillary dental occlussal dental occlussal

surface.surface.

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Structures connectionStructures connection(structures in relation)(structures in relation)

OrbitOrbit Maxillary sinusMaxillary sinus Nasal boneNasal bone Naso-orbital Naso-orbital

ethmoid (NOE) ethmoid (NOE) complexcomplex

Zygomatic Zygomatic complexcomplex

Frontal bone and Frontal bone and sinussinus

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Vertical and horizontal pillarsVertical and horizontal pillars

•Area of strength•Vertical and horizontal pillars •Muscular attachment

•Area of weakness •Sutures•Lining tissues and air-filled cavities

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Pattern of fracturesPattern of fracturesof mid-face skeletonof mid-face skeleton

Alveolar fracture and dental fractureAlveolar fracture and dental fracture

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

Fort 1901)Fort 1901)

Naso-orbital ethmoid fractureNaso-orbital ethmoid fracture

Zygomatic complex and arch fractureZygomatic complex and arch fracture

Frontal sinus and bone fractureFrontal sinus and bone fracture

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Alveolar bone fractureAlveolar bone fracture

Involve block of Involve block of alveolar bone alveolar bone with or withoutwith or without

Intrusion of Intrusion of teethteeth

Extrusion of Extrusion of teethteeth

Luxation of teethLuxation of teeth Fracture of teethFracture of teeth

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Le Fort’s fracturesLe Fort’s fractures Le Fort I (low Le Fort I (low

level or Guerian level or Guerian fracture)fracture)

Unilateral/ bilateralUnilateral/ bilateral

Horizontal fracture Horizontal fracture through the maxilla through the maxilla above the level of above the level of

the nasasl floor and the nasasl floor and alveolar processalveolar process

Piriform rimsPiriform rims Anterior maxillaAnterior maxilla Zygomatic buttressesZygomatic buttresses Ptrygoid laminaePtrygoid laminae

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Signs and symptomsSigns and symptoms Slight swelling of upper lipSlight swelling of upper lip

Ecchymosis in upper lip sulcusEcchymosis in upper lip sulcus

Hematoma intra-orally over zygoma and in palateHematoma intra-orally over zygoma and in palate

Disturbed occlusionDisturbed occlusion

Mobility of teeth of the involved segment of maxillaMobility of teeth of the involved segment of maxilla

Combination of soft tissue lacerationCombination of soft tissue laceration

Exposure of nares and the maxillary antra in case of Exposure of nares and the maxillary antra in case of gross injurygross injury

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

Cracked-pot percussion of upper teethCracked-pot percussion of upper teeth

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Le Fort’s fracturesLe Fort’s fractures

Le Fort IILe Fort II (pyramidal or subzygomatic)(pyramidal or subzygomatic)

Separation of NF suture, Separation of NF suture, medial orbital walls medial orbital walls (lacrimal bone), inferior (lacrimal bone), inferior orbital floor and rim orbital floor and rim (adjacent to infrorbital (adjacent to infrorbital canal and foramen), canal and foramen), anterior maxilla below anterior maxilla below zygomatic buttress and zygomatic buttress and ptrygoid laminae about ptrygoid laminae about halfway up.halfway up.

Separation of the block from the base of skull is completed Separation of the block from the base of skull is completed via the nasal septum and may involve the floor of the via the nasal septum and may involve the floor of the anterior cranial fossaanterior cranial fossa

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LeFort’s fracturesLeFort’s fractures

LeFort III LeFort III (cranifacial dysjunction, high (cranifacial dysjunction, high

transverse, suprazygomatic)transverse, suprazygomatic)

Separation of NF suture, Separation of NF suture, medial orbital walls (involve medial orbital walls (involve

the depth of the ethmoid the depth of the ethmoid bone and cribriform plate, bone and cribriform plate,

pass below optic foramen and pass below optic foramen and cross the inferior orbital cross the inferior orbital

fissur), inferior orbital floor, fissur), inferior orbital floor, lateral orbital wall, ZF suture, lateral orbital wall, ZF suture,

zygomatic arch, zygomatic arch, suprazygomatic to the root of suprazygomatic to the root of

ptrygoid plate.ptrygoid plate.

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Signs and symptomsSigns and symptomsalthough it is possible to distinguish between le fort II and III, the although it is possible to distinguish between le fort II and III, the signs and symptoms are almost similarsigns and symptoms are almost similar

Gross edema of soft tissueGross edema of soft tissue Bilateral circumorbital Bilateral circumorbital

ecchymosisecchymosis Bilateral subconjunctival Bilateral subconjunctival

hemorrahgehemorrahge Obvious deformity of the Obvious deformity of the

nosenose Nasal bleeding and Nasal bleeding and

obstructionobstruction CSF leak rhinorrheaCSF leak rhinorrhea Dish-face deformityDish-face deformity Limitation of ocular Limitation of ocular

movementmovement Possible diplopia and Possible diplopia and

enophthalmousenophthalmous Retropostioning of the Retropostioning of the

maxilla with anterior open maxilla with anterior open bitebite

Lengthening of the faceLengthening of the face

Difficulty in mouth openingDifficulty in mouth opening Mobility of the upper jawMobility of the upper jaw Occusional hematoma of Occusional hematoma of

the palatethe palate Cracked-pot sound on Cracked-pot sound on

percussionpercussion Step deformity at infra-Step deformity at infra-

orbiatal marginorbiatal margin Anasthesia of midfaceAnasthesia of midface Nasal bone moves with Nasal bone moves with

mid-face as a wholemid-face as a whole Tenderness and sepration Tenderness and sepration

at FZ sutureat FZ suture Tenderness and deformity Tenderness and deformity

of zygomatic archof zygomatic arch Depression of occular level Depression of occular level

and pseudoptosisand pseudoptosis

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Bowerman classification of midface-fracture Bowerman classification of midface-fracture (1994)(1994)

Fracture not involving the occlusionFracture not involving the occlusion• Central regionCentral region

Nasal bone/ septum (lateral, anterior injuries)Nasal bone/ septum (lateral, anterior injuries) Frontal process of the maxillaFrontal process of the maxilla NasoethmoidNasoethmoid Fronto-orbito-nasal dislocationFronto-orbito-nasal dislocation

• Lateral region (zygomatic complex EX dento alveolar Lateral region (zygomatic complex EX dento alveolar frcaturefrcature

Fracture involving the occlusionFracture involving the occlusion• Dento alveolarDento alveolar

• Subzygomatic:Subzygomatic: Le Fort’s (I, II)Le Fort’s (I, II)

• Supra zygomatic: Supra zygomatic: Le Fort IIILe Fort III

These fractures may occur unilaterally or bilaterally, with separation of maxillary midline and or extension to frontal or temporal bone

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Prevalence of mid-face fracturesPrevalence of mid-face fractures

Fracture TypeFracture Type PrevalencePrevalence

Zygomaticomaxillary complex (tripod fracture)Zygomaticomaxillary complex (tripod fracture) 40 %40 %

LeFortLeFort

II 15 %15 %

IIII 10 %10 %

IIIIII 10 %10 %

Zygomatic archZygomatic arch 10 %10 %

Alveolar process of maxillaAlveolar process of maxilla 5 %5 %

Smash fracturesSmash fractures 5 %5 %

OtherOther 5 %5 %

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Diagnosis Diagnosis

InspectionInspection Extra-oral Extra-oral (e.g. swelling, deformity, asymmetry(e.g. swelling, deformity, asymmetryLeaks) Leaks)

Intra-oralIntra-oral(e.g. hematoma, occlusion)(e.g. hematoma, occlusion)

PalpationPalpationStep deformity, criptation, cracked pot sound, mobilityStep deformity, criptation, cracked pot sound, mobility

Radiographical investigationsRadiographical investigations

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Radiographical examinationRadiographical examinationPlain radiographPlain radiograph

OccipitomentalOccipitomental

(10 or 30 degree)(10 or 30 degree) Water’s viewWater’s viewSuitable for isolated orbital Suitable for isolated orbital

fracturefractureSearch line (Campbell’s line 1977)

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Radiographical examinationRadiographical examination

Lateral skull viewLateral skull view OPGOPG Occlusal view of the Occlusal view of the

maxillamaxilla Perapical views of Perapical views of

damaged teethdamaged teeth

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Radiographical examinationRadiographical examination

CT scanCT scan 3-D CT imaging3-D CT imaging

• Coronal sectionsCoronal sections• Axial sectionsAxial 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

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Indications for treatmentIndications for treatment

Physical signs of a fracture of the maxilla.Physical signs of a fracture of the maxilla.

Evidence of a fractured maxilla on imaging.Evidence of a fractured maxilla on imaging.

Disruption of the occlusion of the teeth.Disruption of the occlusion of the teeth.

Displacement of the maxilla.Displacement of the maxilla.

Post traumatic facial deformity.Post traumatic facial deformity.

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Indications for treatmentIndications for treatment

Fractured or displaced teeth.Fractured or displaced teeth.

Cerebrospinal fluid leak.Cerebrospinal fluid leak.

Abnormal eye movement or restriction of Abnormal eye movement or restriction of eye movement.eye movement.

Occlusion of the nasolacrimal duct.Occlusion of the nasolacrimal duct.

Sensory or motor nerve deficit.Sensory or motor nerve deficit.

Other evidence of loss of functionOther evidence of loss of function

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Aims of treatmentAims of treatment Relieve painRelieve pain

Restore function.Restore function.

Restore bone anatomy.Restore bone anatomy.

Prevent infectionPrevent infection

Restore the dental occlusionRestore the dental occlusion

Restore jaw movement at the earliest Restore jaw movement at the earliest possible stagepossible stage

Restore normal nerve functionRestore normal nerve function

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Factors affecting the riskFactors affecting the risk

Association with multiple injuries.Association with multiple injuries.

Presence of uncontrolled haemorrhagePresence of uncontrolled haemorrhage

Impairment of the airway.Impairment of the airway.

Presence of bone comminutionPresence of bone comminution

Association with a dural tear.Association with a dural tear.

Association with a base of skull fracture.Association with a base of skull fracture.

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Factors affecting the riskFactors affecting the risk

Presence of a pre-existing dentofacial Presence of a pre-existing dentofacial deformity.deformity.

Time elapsed since the injury.Time elapsed since the injury.

Presence of a medical or surgical factor Presence of a medical or surgical factor which would delay general anesthesiawhich would delay general anesthesia

Presence of any factor which would delay Presence of any factor which would delay healing. (eg nutritional deficiency or healing. (eg nutritional deficiency or alcoholism)alcoholism)

Stage of dental development (deciduous, Stage of dental development (deciduous, mixed or permanent dentition)mixed or permanent dentition)

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Factors affecting the riskFactors affecting the risk

Presence of fractured teeth.Presence of fractured teeth.

Total absence of teeth (edentulous)Total absence of teeth (edentulous)

Inability of the patient to co-operate with Inability of the patient to co-operate with treatment.treatment.

Association with fractures of the mandible Association with fractures of the mandible especially bilateral fractures of the especially bilateral fractures of the condyles.condyles.

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Principles of treatment Principles of treatment

Closed reduction may be appropriate in Closed reduction may be appropriate in casescases

Simple uncomplicated fracturesSimple uncomplicated fractures

Complex or comminuted fracturesComplex or comminuted fractures

Medical or surgical contraindications Medical or surgical contraindications to open reductionto open reduction

Maxillary fractures in childrenMaxillary fractures in children

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Open reduction may be appropriate Open reduction may be appropriate wherewhere

Immediate or early jaw function is Immediate or early jaw function is desirabledesirable

Difficulty is encountered in reducing the Difficulty is encountered in reducing the

fracture by a closed methodfracture by a closed method

The fracture is unstableThe fracture is unstable

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Definitive treatmentDefinitive treatment

ReductionReduction

Manual manipulationManual manipulation

Use of dis-impaction forcepsUse of dis-impaction forceps

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Fixation and immobilizationFixation and immobilization

Extraoral fixationExtraoral fixation

Craniomandibular fixationCraniomandibular fixationBox-frame (pin fixation)Box-frame (pin fixation)

Halo-frameHalo-frame

Plaster of paries headcapPlaster of paries headcap

Craniomaxillary fixationCraniomaxillary fixationSupra-orbital pinsSupra-orbital pins

Zygomatic pinsZygomatic pins

Halo-frameHalo-frame

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Immobilization within the tissueImmobilization within the tissueDirect fixationDirect fixation

Transosseous wiring at Transosseous wiring at

fracture sitesfracture sites Frontozygomatic suturesFrontozygomatic sutures Infrorbital marginInfrorbital margin Midline of the palateMidline of the palate

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Immobilization within the tissueImmobilization within the tissue

Internal-wire suspensionInternal-wire suspension

Circumzygomatico-mandibularCircumzygomatico-mandibular

Infraorbital border-mandibularInfraorbital border-mandibular

FrontomandibularFrontomandibular

Pyriform fossa-mandibularPyriform fossa-mandibular

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Immobilization within the tissueImmobilization within the tissue

Support via the maxillary sinus by Support via the maxillary sinus by filling materialsfilling materials

• Ribbon gauzeRibbon gauze• BalloonBalloon• Folly catheterFolly catheter• Polyethylene materialPolyethylene material

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Length of the hospital stay will depend Length of the hospital stay will depend on a number of factors including:on a number of factors including:

• Presence of other injuriesPresence of other injuries

• Age and medical status of the patientAge and medical status of the patient

• Severity of the injurySeverity of the injury

• Technique employed in the reduction and Technique employed in the reduction and fixation of the fracturefixation of the fracture

• Presence or absence of medical or Presence or absence of medical or surgical complicationssurgical complications

• Social circumstances of the patient Social circumstances of the patient

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