Maxillofacial Surgery Dental Students Fifth Year First semester Lecture Name maxillofacial trauma part 2 Al Azhar University Gaza Palestine Dr. Lama El Banna

1. 1

2. MIDDLE THIRD OF THE FACIAL
SKELETON
• Middle third of the facial skeleton is defined as an area bounded
superiorly by a line drawn across the skull from the
zygomaticofrontal suture of one side, across the frontonasal and
frontomaxillary sutures to the zygomaticofrontal suture on the
opposite side, and inferiorly by the occlusal plane of the upper
teeth, or, if the patient is edentulous, by the upper alveolar ridge.
• Posteriorly, the region is demarcated by the sphenoethmoidal
junction, but includes the free margin of the pterygoid laminae of
the sphenoid bone inferiorly.
2

3. 3

4. BONES CONSTITUTING THE MIDDLE
THIRD OF THE FACE
These are eight paired bones and two unpaired bones constituting the middle third of the
face.
1. The two maxillae.
2. The two palatine bones.
3. The two zygomatic bones and their temporal processes.
4. The two zygomatic processes of temporal bones.
5. The two nasal bones.
6. The two lacrimal bones.
7. The ethmoid bone and its attached conchaeunpaired.
8. The two inferior conchae.
9. The two pterygoid plates of the sphenoid.
10. The vomer—unpaired.
4

5. APPLIED ANATOMY OF THE
MAXILLA
• Maxilla forms the largest part of middle third of the face and contributes to
the formation of the orbit, nasal cavities and hard palate.
• The body of each maxilla is hollowed or pneumatised by the presence of
maxillary sinus. The maxillae have four processes: frontal, zygomatic,
alveolar and palatine.
• The maxillae are designed to absorb the masticatory forces.
• The midface acts as a ‘matchbox’ located below and ahead of the brain.
When the midface experiences force due to a blow or fall, it can easily
crumble due to the bones being fragile. These fragile bones are surrounded
by thicker bones of the facial buttress system responsible for strength and
stability.
5

6. 6
Pictorial depiction of strength of the bones of
skull and face.

7. COMPARISON OF THE MIDFACE TO A
‘MATCHBOX’
7

8. • The midface skeleton consists of cancellous segments enclosed
within a thin layer of compact bone and reinforced by a tough
frame of ‘buttresses’ (structural pillars).
• Forces that are applied to the face are absorbed and transmitted
by the buttress system. These buttresses are of two types,
vertical and horizontal buttresses.
• Masticatory forces are transmitted to the skull base primarily
through the vertical buttresses, which are joined and additionally
supported by the horizontal buttresses. The buttress help to
determine the areas of fracture and stabilisation.
8

9. 9
The bony pillars of the face.

10. • The midface is anchored to the cranium through this
framework:
Vertical buttresses: Nasomaxillary sutures,
zygomaticomaxillary sutures and pterygomaxillary junction.
Horizontal buttresses: Frontal bar, orbital rims,
zygomatic processes of temporal bone, maxillary alveolus
and palate and serrated edges of greater wing of the
sphenoid.
10

11. 11
Skeletal buttresses of the face. (A) Horizontal
buttresses. (B) Vertical buttresses. (C) Angulation of
the frontal bone and sphenoid to the occlusal plane.

12. CLASSIFICATION OF FRACTURES
OF MAXILLA
• There is more tendency of fracture in areas of stress
concentration and areas of weakness. Based on these factors, Le
Fort in 1901 described the classical patterns of facial fractures,
occurring through the junctions of horizontal and vertical
buttresses, at suture lines and thinner segments of bone.
• The fractures of the midface are not always classical as
mentioned by Le Fort, because of the complex nature of force
causing fracture. Fractures may be isolated or combinations.
They may be unilateral or bilateral Le Fort fracture.
12

13. FRACTURES OF MIDFACE:
CLASSIFICATION
1. In 1901, Rene Le Fort, based on his experimental work with
cadavers, classified maxillary fractures according to the level of
injury as:
a. Le Fort I
b. Le Fort II
c. Le Fort III
13

14. 2. Marciani modification (1993)
a. Le Fort I: Low maxillary fracture
b. Le Fort Ia: Low maxillary fracture/multiple segments
c. Le Fort II: Pyramidal fractures
d. Le Fort IIa: Pyramidal and nasal fractures
e. Le Fort IIb: Pyramidal and NOE fractures
f. Le Fort III: Craniofacial dysjunction
g. Le Fort IIIa: Craniofacial dysjunction and nasal fractures
h. Le Fort IIIb: Craniofacial dysjunction and NOE fractures
i. Le Fort IV: Le Fort II or III fractures and cranial base fractures
j. Le Fort IVa: Le Fort II or III fractures and cranial base fractures + supraorbital rim
fractures
k. Le Fort IVb: Le Fort II or III fractures and cranial base fractures + anterior cranial base
l. Le Fort IVc: Le Fort II or III fractures and cranial base fractures + anterior cranial fossa
and orbital wall fractures
14

15. 3. Hendrickson classification of palate fracture (1998)
a. Type I: Alveolar
- Ia: Anterior alveolar (incisor)
- Ib: Posterior alveolar (premolar molar)
b. Type II: Sagittal
c. Type III: Parasagittal
d. Type IV: Para alveolar
e. Type V: Complex
f. Type VI: Transverse
15

16. a. Fractures not involving the occlusion
- Central region
i. Fractures of the nasal bones and/or
nasal septum
• Lateral nasal injuries
• Anterior nasal injuries
ii. Fractures of the frontal process of the
maxilla
iii. Fractures of type (a) and (b) which
extend into the ethmoid bone
(nasoethmoid)
iv. Fractures of type (a), (b) and (c) which
extend into the frontal bone
- Lateral region: Fractures involving the
zygomatic bone, arch and maxilla
(zygomatic complex) excluding the
dentoalveolar component
b. Fractures involving the occlusion
- Dentoalveolar
- Subzygomatic
i. Le Fort I (low level or Guerin)
ii. Le Fort II (pyramidal)
- Suprazygomatic
i. Le Fort III (high level or
craniofacial dysjunction)
16
4. According to Rowe and Williams (1985)

17. LE FORT FRACTURES
• The classic description of the Le Fort fractures has been
principally based on the work of Rene Le Fort (1901),
who classified the fractures by his experiments.
• Low velocity forces were used to produce fracture
patterns, which are now known as Le Fort I, II, III and IV
(Marciani).
• However, there exists combination of fracture patterns
with extension into the nasoethmoid and orbital regions. It
is to be remembered that maxilla is a paired bone as right
and left.
17

18. 18
Fractures of the middle third of the face:
(1)Horizontal or Guerin or LeFort I fracture,
(2)Pyramidal or LeFort II fracture,
(3)Craniofacial dysjunction, transverse or LeFort III fracture
(1) (2) (3)

19. • So, a combination of Le Fort fractures is more common
than the classic description as by Rene Le Fort, for
example right Le Fort II and left Le Fort I fracture maxillae
or different fracture lines on the same maxilla as right
maxillary combined Le Fort I and II fracture patterns.
• Clinical diagnosis is more classically determined by
meticulous examination through radiograph and CT scan
helps in treatment planning.
19

20. 20
(A) Right Le Fort II and left Le
Fort I.
(B) Right Le Fort II and left Le
Fort III.

21. LE FORT I (LOW LEVEL OR GUERIN
FRACTURES/FLOATING MAXILLA)
• This is a horizontal fracture above the level of the nasal floor including the
dental component.
• Fracture line: The fracture line extends backwards along the maxilla from the
pyriform fossa.
Laterally—lateral margin of the anterior nasal aperture—lateral wall of
maxillary sinus below the zygomatic buttress—the lower one-third of the
pterygoid laminae and associated palatine bone.
Medially—lower third of the nasal septum—lateral margin of the anterior
nasal aperture (the lateral wall of the nose) proceeding posteriorly to join the
lateral fracture behind the tuberosity.
21

22. 22
Le Fort I fracture line.

23. Force
•This type of fracture results from application of
horizontal force just above the apices of the
maxillary teeth.
•A Le Fort I fracture, which often escapes diagnosis
is the one, which results due to transmission of
blow from the opposite jaw, which is often
impacted.
23

24. SIGNS AND SYMPTOMS
Swelling of the upper lip and cheeks.
 Ecchymosis present in the maxillary buccal sulcus from
shearing of soft tissue or periosteal tear.
 Nasal block: Mucosal tear in maxillary/ethmoid sinus
may induce bleeding causing a nasal block forcing the
patient to undergo oral breathing.
 Eye or ocular signs are usually absent.
24

25. 25
Swelling of upper lip and cheek in
association with Le Fort I fracture.

26. 26
Buccal ecchymosis of Le Fort I
fracture of maxilla.

27. 27
Nasal block from haemorrhage due to
nasal mucosal tear in Le Fort fracture.

28.  Guerin sign: Ecchymosis in the palate in the area of
greater palatine foramen bilaterally is a classic finding of
Le Fort I fracture though not seen in all cases.
 Occlusion: Undisplaced incomplete LeFort I fractures
usually cause no occlusal disturbance. But complete Le
Fort I fractures classically show varying degrees of
anterior open bite. This is from backward and downward
distraction of posterior maxilla resulting from inferior
traction of the medial pterygoid muscle towards the
mobile maxillary fragment. This posterior gagging of
occlusion is a potential threat to airway.
28

29. 29
Mild derangement in occlusion
associated with LeFort I fracture.

30.  Teeth fracture: Due to impaction of the mandibular teeth against the maxillary
counterpart, damage to the cusp of individual maxillary teeth may be seen.
 Palatal fracture: Commonly midpalatal split is associated with Le Fort I evident as
linear mucosal tear in midpalate. The associated palatal fracture could be any of the
Hendrickson classification patterns with or without oronasal communication
depending on the amount of separation between the fragments from the effect of
bilateral medial pterygoid. With Le Fort I, the teeth and maxilla will move, but the
nose and upper face will stay fixed.
 Cracked-pot sound: Percussion of the maxillary teeth results in distinctive
‘cracked-pot sound’, similar to the sound produced when a cracked China pot is
tapped with a spoon.
 Floating maxilla: Mobility of the dentulous segment of the maxilla.
 Palpation reveals tenderness and step deformity along the pyriform aperture,
buccal sulcus and tuberosity regions.
30

31. 31
Teeth fracture and posterior open bite on right
side following Le Fort I maxillary fracture.

32. 32
Parasagittal palatal fracture
associated with Le Fort I fracture.

33. LE FORT II FRACTURES
(PYRAMIDAL FRACTURES)
• Le Fort II fracture is a pyramid-shaped fracture, when involving both maxilla.
Fracture line
• This fracture runs
• anteriorly—thin middle area of the nasal bones or frontonasal junction crossing the
frontal processes of the maxillae, into the medial wall of each orbit, crosses the
lacrimal bone behind the lacrimal sac— turns forward to cross the infraorbital
margin—slightly medial to or through the infraorbital foramen—extends downwards
and backwards across the lateral wall of the antrum—below the
zygomaticomaxillary suture—middle one-third of the pterygoid laminae horizontally.
• Posteromedially—separation of the block from the base of the skull is completed
via the nasal septum and may involve the floor of the anterior cranial fossa.
33

34. 34
Le Fort II fracture line.

35. Force
• Le Fort II fracture is a result of force applied near the level
of the nasal bones.
35

36. SIGNS AND SYMPTOMS
• Swelling: Gross oedema of the middle third of the face gives an
appearance of ‘moon facies’’ to the patient.
• Subcutaneous emphysema is sometimes evident by crepitus felt
on palpation. This is due to direct communication between the
sinus cavities and the soft tissues of the face.
• Telecanthus: Commonly the swelling over the nasal bridge may
give illusion of telecanthus (pseudotelecanthus) and true
telecanthus when associated with naso-orbito-ethmoid fracture.
• Epistaxis, epiphora are common especially in displaced fracture
of maxilla involving or impinging the lacrimal sac or nasolacrimal
duct.
36

37. 37
Moon facies from gross oedema and subcutaneous
emphysema of middle third of face with pseudo
telecanthus and epistaxis.

38.  Bilateral circumorbital or periorbital oedema, ecchymosis giving an
appearance of ‘raccoon eyes’ is seen in both Le Fort II and Le Fort III
fractures.
 Subconjunctival haemorrhage develops rapidly and is restricted to medial
aspect of eyeball though not always. The differentiating factor is the
subconjunctival haemorrhage of Le Fort II maxillary fracture, which has its
posterior limit demarcated laterally; whereas this demarcation is lost in Le
Fort III zygomaticomaxillary complex fractures.
 Chemosis or oedema of conjunctiva is a common finding.
 CSF rhinorrhoea may be present but not always as in Le Fort III fractures.
 Enophthalmos, limitation in ocular mobility from muscle entrapment and
diplopia are possible findings as the fracture line involves the medial wall and
medial floor of orbit.
38

39. 39
Characteristic raccoon eyes of Le Fort II and III
periorbital edema and ecchymosis.

40.  Anaesthesia or paraesthesia of the cheek as a result of injury to
the infraorbital nerve due to the fracture of the inferior orbital rim.
 Step deformity at the infraorbital rims or nasofrontal junction is
noticed. Zygoma and arch are intact, no loss of malar prominence
unless associated with zygomaticomaxillary complex fractures.
 Ecchymosis or haematoma is seen in the buccal sulcus opposite
to the maxillary first and second molar teeth as a result of fracture
at the zygomatic buttress or in palate in association with greater
palatine arterial damage.
 Sometimes massive nasal or pharyngeal haemorrhage occurs
causing upper airway obstruction. Nasal packing or other means
of surgical intervention is done immediately.
40

41. 41
Palatal ecchymosis in Le Fort II maxillary
fracture (Guerin sign).

42.  Midline or paramedian split of the palate is common with Le Fort
II seen as mucosal tear with oronasal communication.
 Retropositioning of the whole maxilla and gagging of the
occlusion are seen creating anterior open bite. Class III
malocclusion may be seen in anterior force impacting the maxilla
creating a dish face deformity. Lengthening of face occurs due to
separation of middle third from the skull base.
 When maxillary alveolus is grasped anteriorly, the midfacial
skeleton moves as a pyramid and the movement can be detected
at the infraorbital margin and the nasal bridge.
 Palpation of vestibule reveals tenderness with step deformity at
zygomaticomaxillary buttress regions.
42

43. 43
Midpalatal split in association with
Le Fort II fracture

44. 44
Class III jaw position and anterior open bite
following Le Fort II and NOE fractures.

45. LE FORT III FRACTURES (SUPRAZYGOMATIC
FRACTURE OR CRANIOFACIAL
DYSJUNCTION)
• Le Fort III fractures are usually a component of panfacial
fractures resulting from high velocity trauma.
• They rarely occur in isolation and are usually
accompanied by skull base fractures and complex Le Fort
I, II and III fractures.
• Fracture line extends from
Anteriorly: The frontonasal suture—transversely
backwards, parallel with base of the skull, to full depth of
the ethmoid bone including the cribriform plate.
45

46. Posteromedially: Within the orbit—the fracture passes below the
optic foramen into the posterior limit of the inferior orbital fissure.
From the base of the inferior orbital fissure, the fracture line
extends in two directions:
i. Backwards across the maxillary fissure to fracture the roots
of the pterygoid laminae
ii. Laterally across the lateral wall of the orbit separating the
zygomatic bone from the frontal bone
Posterolaterally: From the orbit—inferior orbital fissure—lateral
wall of orbit into the frontozygomatic suture. In addition, fracture
of the zygomatic arch is an integral part of Le Fort III completing
the separation of facial bones from cranium. In this way, the entire
middle third of the facial skeleton becomes detached from the
cranial base.
46

47. 47
Le Fort III fracture
lines depicted in a CT.

48. Force:
• The force causing the fracture is at the level of the orbit. The force
is mainly through the lateral orbit, which is contrary to that of Le
Fort II.
48

49. SIGNS AND SYMPTOMS
• All the clinical findings of Le Fort II will be present. In addition,
Characteristic raccoon eyes, ‘dish face’ deformity (concave profile) with
lengthening of the face.
‘Hooding of eyes’ may be seen due to separation of the frontozygomatic
suture causing loss of support to the suspensory ligament of Lockwood and
all attachments to Whitnall tubercle.
Enophthalmos, hypoglobus, diplopia with altered canthal position (slant).
Subconjunctival haemorrhage involving entire eye with no posterior limit
seen.
Saddle nose deformity commonly with associated naso-orbito-ethmoid
fracture.
49

50. 50
Typical dish face appearance with retruded
maxilla —Le Fort III maxillary fracture

51. 51
Hooding of eyes, left eye enophthalmos, hypoglobus and
altered canthal position with restricted mouth opening.

52.  CSF rhinorrhoea.
 CSF otorrhoea in associated skull base fractures.
 Loss of lateral facial projection from zygomatic arch fractures.
 Decreased mouth opening from zygoma impinging coronoid process and
severe posterior gagging of teeth from midface inferior distraction from
muscle (medial/lateral pterygoid, masseter) pull.
 Occlusion—deranged with severe anterior open bite, class III malocclusion,
commonly associated with teeth or dentoalveolar fractures. When lateral
displacement has taken place tilting of the occlusal plane and gagging of one
side is seen.
 Posterior nasal bleed or pharyngeal bleed from nasopharyngeal tear
commonly requiring intervention to arrest bleeding.
52

53. 53
CSF rhinorrhoea in Le Fort III fracture.

54.  Mobility of entire midfacial skeleton as a single unit
maxillary mobility with simultaneous mobility felt at both
frontozygomatic regions and nasal bridge.
 Tenderness and step deformity will be palpable at
bilateral lateral orbital rims, zygomatic arch deformity and
nasal bridge.
54

55. Maxillary fractures are distinguished
into le fort I, II and III based on the
classical mobility
Step 1: Left palm is placed over the forehead, with the thumb over right lateral orbital rim
(frontozygomatic junction), index finger over left frontozygomatic junction or alternatively the
frontonasal junction can also be assessed simultaneously.
Step 2: The maxilla is grasped firmly at the anterior portion of alveolus and not the teeth. The
maxilla is checked for mobility with concurrent mobility in bilateral frontozygomatic junction.
Step 3: Frontonasal junction at the root of nose is grasped with left thumb and index finger
while palm stabilises the cranium at forehead.
Step 4: Repeat step 2 checking for dental segment maxilla mobility with concurrent mobility
in frontonasal junction.
Step 5: Place two fingers as of left hand one on each infraorbital rim, all the time palm
stabilises the cranium at forehead.
Step 6: Repeat step 2 and check for concurrent mobility felt at both infraorbital rims.
55

56. 56
Clinical examination of maxillary fractures:
(A–B) Step 1 , (C–D) Step 2, (E) Step 3 and 4, (F) Step 5.

57. COMPARISON OF SITE OF MOBILITY
EVIDENT IN DIFFERENT FRACTURE
LEVELS
57

58. Le Fort I Le Fort II Le Fort III
 Swelling in upper lip and
cheek
 Ecchymosis of maxillary buccal
sulcus
 Nasal block
 Guerin sign
 Teeth fracture
 Palatal fracture
 Cracked pot sound
 Floating maxilla
 Oedema of midface: Moon facies
 Subcutaneous emphysema
 Telecanthus/pseudotelecanthus
 Epistaxis/epiphora
 Bilateral circumorbital oedema:
 Raccoons eye
 Subconjunctival haemorrhage
 Chemosis/oedema of conjunctiva
 CSF rhinorrhea
 Enophthalmos
 Anesthesia/paraesthesia of
 cheek
 Step deformity of infraorbital rim
 Gagging of occlusion with anterior
open bite
 Midline or paramedian split of the
palate
 Airway obstruction
 Dish face deformity of face
 Raccoon eyes, Hooding of eye
 Enophthalmos,
 hypoglobus, diplopia
 Subconjunctival
 haemorrhage
 Saddle nose deformity
 CSF rhinorrhoea/CSF
 otorrhea
 Craniofacial dysjunction
 Posterior gagging of
 occlusion, anterior open bite
 Posterior nasal bleed
 Mobility of entire midfacial
 skeleton
 Decreased mouth opening
58

59. FRACTURES OF THE ZYGOMATIC
COMPLEX
• The zygomatic bone usually fractures in the region of
the zygomaticofrontal suture, the zygomaticotemporal
suture and the zygomaticomaxillary suture. It is unusual
for the zygomatic bone itself to be fractured, but in
extreme violence, the bone may be comminuted or split
across. The isolated zygomatic arch fracture may occur
without displacement of the zygomatic bone.
59

60. 60

61. CLASSIFICATION OF THE ZYGOMATIC COMPLEX
FRACTURE (ROWE AND KILLEY 1968)
Type I : No significant displacement
Type II : Fractures of the zygomatic arch
Type III : Rotation around the vertical axis
a. Inward displacement of orbital rim
b. Outward displacement of orbital rim
Type IV : Rotation around the longitudinal
axis
a. Medial displacement of the frontal
process
b. Lateral displacement of frontal process
Type V : Displacement of the complex en bloc
a. Medial
b. Inferior
c. Lateral (rare)
Type VI : Displacement of the orbitoantral
partition
a. Inferiorly
b. Superiorly (rare)
Type VII : Displacement of orbital rim
segments
Type VIII : Complex comminuted fractures.
61

62. 62
Fractures of the zygomatic complex: (1) Group I: No significant displacement,
(2) Group II: Zygomatic arch fracture, (3) Group III: Unrotated body fracture,
(4) Group IV: Medially rotated body fractures (a) outward at zygomatic
prominence (b) inward at zygomaticofrontal suture

63. 63
Fractures of the zygomatic complex: (5) Group V:Laterally rotated body
fractures (a) upward at infraorbital margin (b) outward at zygomaticofrontal
suture, (6) Complex fractures, (7 and 8) Directions of force

64. 64

65. 65
Oblique fracture of the zygomatic arch as a component of a zygomatico
maxillary complex fracture. The zygomatic process of the temporal bone
just has a greenstick fracture and is displaced medially. The body of the
zygomatic bone, with its temporal process, is rotated.

66. SIGNS AND SYMPTOMS
1. Flattening of the injured cheek (possibly masked by swelling)—most common
displacement of the complex is inward.
2. Unilateral epistaxis may be present.
3. Circumorbital ecchymosis will develop after few hours from effusion of blood into
the surrounding tissues. Circumorbital oedema can be quite gross.
4. Subconjunctival haemorrhage will be observed at the outer canthus, if the
patient is asked to look medially, the posterior limit of the effusion cannot be
defined.
66

67. 5. Depression of the ocular level/limitation of ocular movement may be seen.
6. Proptosis of the eye may be seen due to retrobulbar haemorrhage.
7. Patient may complain of diplopia and/or blurring of vision.
8. Anaesthesia of the cheek, nose and lip may be present.
9. Oedema of the cheek and eyelids. Traumatic emphysema can often be detected
in the infraorbital region, if air escapes into the tissues from the maxillary sinus.
10. Step deformity of the infraorbital margin.
11. Limitation of mandibular movement.
12. Ecchymosis and tenderness in the upper buccal sulcus, change in sensation of
the teeth and gums.
13. Enophthalmos may be seen.
67

68. 68

69. FRACTURE OF THE FLOOR OF THE
ORBIT (BLOW-OUT FRACTURE)
• True blow-out fracture occurs as a result of direct trauma to
the orbit with an object larger than the globe size (cricket ball
injury).
• Here primarily there is an increase in hydraulic pressure
within the orbit resulting from compression of the orbital
contents.
• In addition, forces acting on the bone play a part. The
fractured orbital floor gives way into the maxillary sinus. At the
same time, orbital fatty tissue and sometimes muscles,
(inferior rectus and inferior oblique) prolapse into the sinus
like a hernia.
69

70. 70
Blow-out fracture of the floor of the orbit. A tennis ball aimed at the
globe of the eye forces it posteriorly, compressing the periorbital fat
and fracturing the thin orbital floor. Fractured fragments and
herniation of periorbital fat will be seen in the maxillary sinus

71. •The infraorbital rim remains intact. The fracture
may go unnoticed due to the presence of orbital,
periorbital oedema, haematoma and the clinically
intact infraorbital ridge.
•Enophthalmos with restriction of the extraocular
movements and at times diplopia may be present.
•Diagnosis can be confirmed by forced duction test
and by hanging drop appearance in PA view
Water’s position radiograph or by CT scan
71

72. 72

73. 73