1. Oral and Maxillofacial Surgery
MANAGEMENT OF FACIAL TRAUMA
Mid-face Injury
Oral and Maxillofacial Surgery

2. Mid-face
Definition:
The area between a superior plane drawn through the zygomatico-frontal sutures tangential to the base of the skull and inferior plane at the level of the maxillary dental occlussal surface.

3. Structures connection (structures in relation)
Orbit
Maxillary sinus
Nasal bone
Naso-orbital ethmoid (NOE) complex
Zygomatic complex
Frontal bone and sinus

4. Vertical and horizontal pillars
Area of strength
Vertical and horizontal pillars
Muscular attachment
Area of weakness
Sutures
Lining tissues and air-filled cavities

5. Pattern of fractures of mid-face skeleton
Alveolar fracture and dental fracture
Le Fort ‘s fracture ((french surgeon Rane Le Fort 1901)
Naso-orbital ethmoid fracture
Zygomatic complex and arch fracture
Frontal sinus and bone fracture

6. Alveolar bone fracture
Involve block of alveolar bone with or without
Intrusion of teeth
Extrusion of teeth
Luxation of teeth
Fracture of teeth

7. Le Fort’s fractures Le 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 rims
Anterior maxilla
Zygomatic buttresses
Ptrygoid laminae

8. 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
Exposure of nares and the maxillary antra in case of gross injury
Impacted type of fracture is oftenly not mobile and teeth cusps may be damaged
Cracked-pot percussion of upper teeth

9. 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

10. 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.

11. Signs and symptoms although 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

12. Bowerman classification of midface-fracture (1994)
Fracture not involving the occlusion
Central region
Nasal bone/ septum (lateral, anterior injuries)
Frontal process of the maxilla
Nasoethmoid
Fronto-orbito-nasal dislocation
Lateral region (zygomatic complex EX dento alveolar frcature
Fracture involving the occlusion
Dento alveolar
Subzygomatic:
Le Fort’s (I, II)
Supra zygomatic:
Le Fort III
These fractures may occur unilaterally or bilaterally, with separation of maxillary midline and or extension to frontal or temporal bone

13. Prevalence of mid-face fractures
Fracture Type
Prevalence
Zygomaticomaxillary complex (tripod fracture)
40 %
LeFort I
15 % II
10 %
III
Zygomatic arch
Alveolar process of maxilla
5 %
Smash fractures
Other

14. Diagnosis Inspection Extra-oral Intra-oral Palpation
(e.g. swelling, deformity, asymmetry
Leaks)
Intra-oral
(e.g. hematoma, occlusion)
Palpation
Step deformity, criptation, cracked pot sound, mobility
Radiographical investigations

15. Radiographical examination
Plain radiograph
Occipitomental
(10 or 30 degree)
Water’s view
Suitable for isolated orbital fracture
Search line (Campbell’s line 1977)

16. Radiographical examination
Lateral skull view
OPG
Occlusal view of the maxilla
Perapical views of damaged teeth

17. Radiographical examination
CT scan
3-D CT imaging
Coronal sections
Axial sections
Whenever intracranial damage and frontal sinus are suspected
Extensive fracture that involves nasoethmoid complex or orbital region
Orbital trauma to evaluate the degree of orbital injury and enophthalmos

19. 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.

20. 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

21. 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

22. Factors affecting the risk
Association with multiple injuries.
Presence of uncontrolled haemorrhage
Impairment of the airway.
Presence of bone comminution
Association with a dural tear.
Association with a base of skull fracture.

23. 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)

24. 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.

25. 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

26. 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

27. Definitive treatment Reduction Manual manipulation
Use of dis-impaction forceps

28. Fixation and immobilization
Extraoral fixation
Craniomandibular fixation
Box-frame (pin fixation)
Halo-frame
Plaster of paries headcap
Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins

29. Immobilization within the tissue
Direct fixation
Transosseous wiring at
fracture sites
Frontozygomatic sutures
Infrorbital margin
Midline of the palate

30. Immobilization within the tissue
Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular

31. Immobilization within the tissue
Support via the maxillary sinus by filling materials
Ribbon gauze
Balloon
Folly catheter
Polyethylene material

32. Length of the hospital stay will depend on a number of factors including:
Presence of other injuries
Age and medical status of the patient
Severity of the injury
Technique employed in the reduction and fixation of the fracture
Presence or absence of medical or surgical complications
Social circumstances of the patient

33. that's it for today