midface fracture lefort fracture zygomatic fracture orbital floor fracture naso-orbital-ethmoid complex fracture

1. MAXILLOFACIAL TRAUMA
-CHAPTER THREE-
FRACTURE OF THE MIDDLE 3RD OF
FACIAL SKELETON
DR. HAYDAR MUNIR SALIH ALNAMER
BDS, PhD (BOARD CERTIFIED)

2. “
”
Define middle 3rd ?

3. Anatomical Review

4. Anatomical Review
The middle third of facial skeleton is formed by bones which
articulate with each other in immobile sutures. The bones are:
• Two maxillae
• Two nasal bones
• Two zygomatic bones
• Two palatine bones
• Two inferior conchae
• The ethmoid and its attached conchae
• Vomer bone
• Sphenoid bone

5. Vertical & horizontal buttresses
The bones of the midface constitute a series of
vertical and horizontal bony struts or
'buttresses', these buttresses of the face consist
of thicker bone that transmits the chewing
forces to the supporting regions of the skull.

7. Vertical & horizontal buttresses
• The vertical buttresses are the pterygomaxillary,
zygomaticomaxillary, and nasomaxillary buttresses.
These vertical pillars are further supported by the
horizontal buttresses;
• The horizontal buttresses are supraorbital or frontal
bar, infraorbital rims, and zygomatic arches. Joining
these buttresses together is lamellar thin bone.
This framework results in fairly predictable patterns of
fracture.

9. The Le Fort classification
In 1901, Rene Le Fort
described the classical
fracture patterns of the
midface and determined
three main levels of
fractures as interruption of
buttresses and lamellar bone
structures in the mid-facial
architecture
René Le Fort

12. Clinical features of lefort I (Guerin fracture)
• malocclusion
• mobility of whole of dentoalveolar segment.
• Hypoesthesia of the infraorbital nerve
• Palatal ecchymosis (Guerin sign)
• Ecchymosis and tenderness
of the zygomaticomaxillary buttress area.
• 'Cracked pot' percussion sound from upper teeth.
• Fractured cusps of teeth

13. Clinical examination of lefort I (Guerin fracture)

14. Clinical feature of lefort II
• Edema is often present overlying the fracture sites.
• Mobility of the upper jaw.
• Step deformity in the infraorbital rim.
• Bilateral cirumorbital edema
• Cerebrospinal fluid (CSF) rhinorrhea
• Tenderness over the nasal bridge area
• Hypoesthesia of the infraorbital nerve
• Malocclusion
• 'Cracked-pot' sound on tapping teeth.

15. Clinical examination of lefort II

16. Clinical features of Lefort III
• Classic dish face deformity and mobility of the
zygomaticomaxillary complex.
• Facial edema.
• Circumorbital ecchymosis
• CSF leakage
• 'Cracked-pot' sound on tapping teeth.
• There may be gagging of
the occlusion in the molar area.

17. Clinical examination of Lefort III

18. Detection of CSF Rhinorrhea
Clinical detection of CSF rhinorrhea may be
complicated by the presence of lacrimal fluid, blood
and nasal secretions. When the blood clots and dries
and the flow of CSF continues, it produces a classical
(tramline pattern). It also forms classical ring
around the clotted blood on the pillow

19. Detection of CSF Rhinorrhea

20. Imaging
•Plain radiographs have only limited role and
they are indicated when three-dimensional
imaging (CT scan) is not available
•These may include:

21. Occipitomental projection &
(Campbell-Trapnell lines)

22. CT scan

23. Surgical treatment: Reduction
Rowe's dis impaction forceps

24. Surgical treatment: Reduction

25. Surgical treatment: Reduction
Hayton-Williams forceps

26. Surgical treatment: fixation (Closed)

27. Surgical treatment: fixation (ORIF)
Lefort I Lefort II Lefort III

28. Palatal fracture

29. Palatal fracture: treatment

30. The zygomatic complex fractures
• The zygomatic complex
usually fractures in the region
of the frontozygomatic, the
zygomaticotemporal and the
zygomaticomaxillary sutures.
• The arch of the zygoma may
be fractured in isolation from
the rest of the bone.

31. Fractures of the zygomatic body involving
the orbit
1. Minimal or no displacement.
2. Inward and downward displacement.
3. Inward and posterior displacement.
4. Outward displacement.
5. Comminution of the
complex as a whole.

32. Fractures of the zygomatic arch alone not
involving the orbit
1. Minimal or no
displacement.
2. V-type in-fracture
3. comminuted

33. Clinical features of zygomatic complex
fractures
• Flattening of cheek
• Limitation of mouth opening
• Tenderness and palpable separation at
frontozygomatic suture
• Step deformity and tenderness of
infraorbital margin
• Periorbital (circumorbital) ecchymosis
and edema

34. Lockwood's suspensory ligament

35. Whitnall's tubercle
• Displacement of the
palpebral fissure and
unequal pupillary levels; due
to inferior displacement of
Whitnall's tubercle with the
attached Lockwood's
suspensory ligament that
leads to alteration in the
level of the globe.

36. Imaging of zygomatic complex fracture
Occiptomental
view

37. Imaging of zygomatic complex fracture
Submentovertex view

38. Imaging of zygomatic complex fracture

39. Treatment of fracture zygoma: Indications
• To restore the normal contour of the face both
for cosmetic reasons and to re-establish skeletal
protection for the globe of the eye.
• To correct diplopia.
• To remove any interference with the range of
movement of the mandible.
• When pressure on the infraorbital nerve results in
significant numbness or dysesthesia

40. Treatment of fracture zygoma
DR. Haydar Munir Salih DR. Haydar Munir Salih

41. Treatment of fracture zygoma: Reduction
• Many zygomatic complex fractures are stable after
reduction without any form of fixation, especially when:
• The displacement is a medial or lateral rotation round
the vertical axis without separation of the
frontozygomatic suture.
• Recent fractures are more stable than those that are
more than 2 weeks old.
• Fractures in which there is disruption of the
frontozygomatic suture and those that are extensively
comminuted are usually unstable after reduction.

42. Indirect reduction: Gillies approach

43. Indirect reduction: Keen approach 1909

44. Indirect reduction: The percutaneous approach

45. Open reduction and internal fixation:
Indications
•Displaced fractures that are not stable after
reduction.
•Comminuted fractures.
•Fractures that are more than 2 weeks old.
•When orbital exploration is required due to
the presence of diplopia or enophthalmos.

46. Open reduction and internal fixation

47. Approaches to the frontozygomatic suture
a)Lateral eyebrow
(also called
supraorbital
eyebrow).
b)Supratarsal fold
(upper eyelid)
approach

48. Approaches to the inferior orbital rim and
orbital floor
A. Subciliary (lower
blepharoplasty) incision is
placed lid 2-3 mm away from
the margin
B. Midtarsal incision is placed
half way between the lash
margin and the orbital rim.
D. Transconjunctival approach
through the lower fornix has
the obvious advantage of an
invisible scar.

49. Approaches to the lateral orbital rim, body and
arch of zygoma
Lateral canthal incision Extended preauricular approach

50. Approaches to the medial orbital wall
Transcaruncular approach

51. Orbital floor fractures
• The orbits are described
as conical or pyramidal in
shape that consists of 7
bones, the normal orbital
volume is about 30 mL, of
which the globe occupies
6.5 ml.

52. Orbital floor fractures
Isolated orbital wall fractures
are termed blow-out or blow-
in fractures. Blow-out
fractures are further described
as pure, for those that occur in
the presence of an intact
orbital rim, and impure, for
those with a concomitant
fracture of the orbital rim.

53. Diplopia

54. Diplopia
• Binocular diplopia that develops following trauma
can be the result of:
1. soft tissue (muscle or periorbital) entrapment,
2. neuromuscular injury,
3. intraorbital or intramuscular hematoma or
edema, or a change in orbital shape, with
displacement of the globe causing a muscle
imbalance.

55. Diplopia
• The presence of
entrapment of orbital
contents by the
fracture through the
orbital floor can be
determined with a
forced duction test.

56. Enophthalmos
• If a large enough
amount of orbital
fat is displaced
through the orbital
floor defect it may
result in
enophthalmos
Enophthalmos clinically obvious to most patients when
exceeds 2mm.

57. Hess chart
It is essential to measure
this interference with
orbital movement by
means of a Hess chart
and to monitor any
improvement, or lack of
it, by repeating the test
during the first 7-10 days
after injury.

58. Imaging
Plain radiographs may show
evidence of orbital floor or wall
fractures, but are unreliable in
excluding such an injury or
determining its extent.
Occipitomental view may
demonstrate the classical (hanging
drop) appearance of a large orbital
floor defect with herniation of
orbital contents.

59. Imaging
CT has the advantage of
better bone visualization.
Coronal, axial and
sagittal views may be
required to determine
the extent of the defect

60. Treatment
When orbital fractures occur with other
fractures of the midface, the latter must be
repaired first. This is because safe orbital
dissection and repair of orbital defects are
dependent on repositioned key landmarks
and a correctly positioned infraorbital rim to
support an implant.

61. Treatment: Indications
1.Significant restriction of eye movement
(diplopia) with CT confirmation of
entrapment.
2.Significant enophthalmos.
3.Large 'blowout' defect
4.Significant orbital dystopia

62. Treatment: Indications
Large 'blowout' defect Significant enophthalmos

63. Treatment: Relative Contraindications
1. Visual impairment
2. Anticoagulant medication
3. Patient unconcerned
4. Proptosis
5. An already 'at risk' globe

64. Treatment
• It is generally accepted that treatment of orbital floor
fractures should be delayed for 7-10 days allowing time
for edema to subside and the true ophthalmic situation
to be revealed.
• The exception to delayed treatment is in children and
young people with diplopia where exploration should be
performed as soon as possible to prevent persistent
problems.

65. Treatment

66. Treatment: treatment options

67. Treatment options: Autografts

68. Treatment options: Alloplastic materials

69. Treatment options: Alloplastic materials

70. Complications: Retrobulbar hemorrhage

71. Signs and symptoms
• Pain
• Decreasing visual acuity
• Diplopia with developing ophthalmoplegia
• Proptosis
• Tense globe
• Sub-conjunctival edema/chemosis
• Dilated pupil
• Loss of direct light reflex (Relative afferent
pupillary defect)

72. Treatment
Medical treatment:
involves administering
intravenous 20% mannitol
(1 gm/kg) and 500 mg
acetazolamide(diuretic) to
reduce intra-ocular
pressure, and 3-4 mg/kg
intravenous
dexamethasone to reduce
edema and vascular spasm
or

73. Complications: Dacryocystitis

74. Complications: Ectropion

75. Nasal bone fractures
• The nasal bone is one of the most commonly
fractured due to its prominent position and little
protection and support. The nasal bones are
relatively thick superiorly where they are attached
to the frontal bone, but are thinner inferiorly where
the upper lateral cartilages are attached. Hence
they are more susceptible to fractures lower down.

76. According to the force applied, nasal complex
fractures can be divided into three planes:
1. The first plane involves the
nasal tip only.
2. The second plane involves
the whole of the external
nose anterior to the orbital
rim.
3. The third plane is a much
more severe injury involving
the medial orbital wall and
sometimes the anterior
cranial fossa.

77. Nasal Fracture: Clinical Features
• Edema over the bridge of the nose.
• Bilateral circumorbital ecchymosis
• Deviation of the nose to one side
following a lateral injury
• Epistaxis due to injury to nasal
mucosa
• Septal hematoma
• Nasal obstruction

78. Nasal Fracture: imaging
(lateral nasal radiograph)

79. Nasal fracture: imaging (CT scan)

80. Septal hematoma

81. Septal hematoma
• If untreated it can
become infected leading
to a septal abscess, with a
risk of intracranial
extension, it may also
result in avascular
necrosis with loss of
cartilage and a septal
perforation

82. Treatment: Closed Reduction

83. Treatment: immobilization (Ribbon gauze
packing )

84. Treatment: immobilization
(P.O.P.)

85. Naso-orbito-ethmoidal complex fractures
The naso-orbital-ethmoid (NOE) fracture represents a
significant diagnostic and reconstructive challenge.
This region houses the lacrimal apparatus, medial
canthal ligament, and anterior ethmoidal artery.

86. Naso-orbito-ethmoidal complex fractures

87. Classification of NOE Fractures
Type I; the simplest
form of NOE fracture
involves single central
fragment bearing the
canthal ligament.

88. Classification of NOE Fractures
Type II; comminuted central
segment with medial canthal
ligament still attached to a
bone fragment.

89. Classification of NOE Fractures
Type III; comminuted
central segment with
detached medial canthal
ligament.

90. Clinical features
• Bilateral circumorbital ecchymosis and edema
• Subconjunctival hemorrhage.
• Epistaxis
• Deformity of nose and inter-orbital area
• Crepitus of bones of nasal complex
• Unilateral or bilateral telecanthus,
• rounding of the medial canthus of the eye.
• Airway obstruction
• Septal deviation
• Cerebrospinal rhinorrhea
• The damage to the cribriform plate of ethmoid results in damage to the
branches of the olfactory nerve and loss of smell sensation (anosmia).

91. Traumatic Telecanthus

92. NOE fracture: imaging

93. Treatment: Trans-nasal canthpexy

94. Treatment: Trans-nasal canthpexy

95. COMPLICATIONS: Early complication
• Epistaxis
• Ophthalmic complication:
Retrobulbar hemorrhage
• Inaccurate reduction
• Nerve damage

96. COMPLICATIONS: Late complication
1. Delay or non-union
2. Malunion
3. Residual ophthalmic complication:
• Deformity of the bony orbit.
• Neurological damage such as damage to the oculomotor and abducent
nerves.
• Damage to the globe itself and its surrounding soft tissue
4. Complications associated with paranasal sinuses
5. Complications associated with the lacrimal system
6. Loss of sensation
7. Late problems with internal fixation