MIDFACE FRACTURES. Midface fractures. Fractures of the middle third may be subdivided into: Dento-alveolar fractures. Fractures of the maxilla. Fractures of the zygomatic bone & arch. Blow out fractures. Nasal-orbital-ethmoidal fractures. Dento-alveolar fractures.
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Midface fractures Fractures of the middle third may be subdivided into: • Dento-alveolar fractures. • Fractures of the maxilla. • Fractures of the zygomatic bone & arch. • Blow out fractures. • Nasal-orbital-ethmoidal fractures.
Dento-alveolar fractures It consists of fracture, subluxation, or avulsion of the teeth with or without an associated fracture of the alveolus, and they may occur as a clinical entity or in conjunction with any other type of fracture.
Fractures of the maxillaClassification The Le Fort classification defines the weakest areas of the midface complex when it is assaulted from a frontal directions at a different levels into : Le Fort type I Le Fort type II Le Fort type III
Le Forte type I fracture Fracture lines
Le Fort type I It results from a force delivered above the level of the teeth. The fracture courses from the lateral border of the pyriform aperture
Le Fort type I above the canine eminence lateral antral wall behind the maxillary tuberosity across the lower third of the ptergoid plate. The nasal septum may be fractured
Le Fort type I fractures * It may be unilateral or bilateral * It may occur single or in conjunction of with Le Fort type II or III fractures. *The clinical findings may be largely masked by more severe fractures. * Caused by blow with a sharp object above the apices of the teeth.
Clinical findings in Le Forte I fractures low level or Guerin type
Le Fort type I fractures Clinical findings: Extra-orally • Swelling of the upper lip. • Soft tissue laceration. • Open mouth to accommodate the displaced dento-alveolar portion. • Epistaxis.
Le Fort type I fractures Clinical findings: Intra-orally • Malocclusion. • Mobility of tooth bearing portion. • Ecchymosis of the buccal sulcus. • Dull sound on percussion.
Le Forte type II fractures Fracture lines
Le Fort type II It results from a force delivered at a level of the nasal bones. The fracture line occurs along the nasofrontal suture lacrimal bone across the infra- orbital rim in the region of the zygomatico-maxillary suture
Le Fort type II above the canine eminence inferiorly and distally along the lateral antral wall, but at a higher level than Le Fort type I across the pterygoid plate at its middle.
Clinical findings in Le Forte II fractures Sub-zygomatic fracture Pyramidal fracture
Le Fort type II fractures Clinical Findings: Extraorally - Ballooning of the face. - Lenghtenening of the face - Circumorbital ecchymosis - Subconjunctival Hg. • Epistaxis • Dipobia (cont)
Le Fort type II fractures Clinical Findings: (cont) Extraorally - Enophthalmos • CSF rhinorrhoea • Step deformity in the lower border of the orbit • Intact zygomatic bone & arch
Le Fort type II fractures Clinical Findings: Intraorally • Malocclusion • Gagging of the posterior teeth and anterior open bite • Mobility of the maxilla • Ecchymosis of the sulucs
Le Forte type III fractures Fracture lines
Le Fort type III The fracture is caused by a force at the orbital level , the resultant fracture is craniofacial dysjunction. It is called :high level fracture or supra-zygomatic fracture
Le Fort type III The fracture line courses through the zygoma-ticotemporal and zygomaticofrontal sutures lateral orbital wallinferior orbital fissure medially to the naso-frontal suture fractures the pterygoid plate at its base.
Clinical findings in Le Forte III fractures Supra-zygomatic fracture High level
Le Fort type III fractures Clinical Findings Extraorally - Severe edema of the face “ballooning” - Lengthening of the face - Flattening of the cheek - Circumorbital ecchymosis - Subconjunctival Hg
Le Fort type III fractures Clinical Findings (cont) Extraorally • Epistaxis • Enophthalmos • CSF rhinorrhoea
Le Fort type III fractures Clinical Findings Intraorally • Gagging of the posterior teeth and anterior open bite • Ecchymosis and Hg of the buccal sulcus • Mobility of the maxilla • Mandibular interference
Radiology for maxillary fractures • Occipto-mental view • CT scan
Computerized tomography TYPES * Axial scan * Coronal scan * 3/D CT
imaging Axial scan
Computerized tomography Axial scan
Coronal scan Axial scan
Treatment of the maxillary fractures First aid treatment Preliminary treatment Definitive treatment
Treatment of the maxillary fractures REDUCTION IMMOBILIZATION
Treatment of the maxillary fractures REDUCTION * Digital pressure * The use of Rowe’s forceps , Hayton- Wiliams disimpac- tion forceps. * Surgical
Maxillary fracturesImmobilization Methods • MMF • Internal fixation • Skeletal suspension • Support • External fixation
Maxillary fracturesImmobilization Circumzygomatic suspension Obwegeser technique
Maxillary suspension 1- Frontal susp. 2- Pyriform fossa susp. 3- Infraorbital rim susp. 4- Circumzygomatic susp.
Treatment of unilateral Le Fort type I fractures • Closed reduction & fixation * Digital pressure. * Arch bar tightened in the unfractured side and loose in the fractured side. * Adjust occlusion, tighten the fractured side then secure MMF.
Treatment of unilateral Le Fort type I fractures B) Open reduction & fixation * Cases of unstable fractures. * Arch bars are prepared * Sulcus incision to expose the fracture site in canine & buttress regions * Transosseous wiring or miniplates are used for fixation.
Transosseous wiring • Sulcus incision • Fracture exposure • Reduction • Drilling wholes • 24-26 guage wire is used
Treatment of bilateral Le Fort type I fractures • Reduction closed or open • Immobilization suspension or internal fixation