“MID FACE

FRACTURES”
CLASS BY :

DR. PRATEEK TRIPATHY, MDS (OMFS)

SENIOR LECTURER, HDCH
BHUBANESWAR
 INDE
X
 INTRODUCTION
 BONES OF MIDFACE
 ANATOMIC CONSIDIRATION
 HISTORY
 ETIOLOGY
 CLASSIFICATION
 CLINICAL FEATURES:
 RADIOLOGICAL
EXAMINATION
 MANAGEMENT
 INTRODUCTION
 Face is intimately related to self image.
 Facial features depend upon underlying bony frame work.
• The maxillofacial region has special importance because of its
proximity to the all important brain-case as well as
respiratory passages.

 The maxilla represents the bridge between the cranial base superiorly
and the dentition inferiorly.

 Its intimate association with the oral cavity, nasal cavity, and orbits
and the important structures adjacent to it make the maxilla a
functionally and cosmetically important structure.

 It is a region responsible for senses like vision, smell, hearing and

taste and resonance of voice.
 Fracture of these bones is potentially life-threatening as well as
disfiguring.

 Hence we being maxillofacial surgeons need to do systematic and

timely repair of these fractures to correct deformity and prevent
unfavorable sequalae.

 To reconstruct the face following trauma is highly

demanding and requires uncompromising care.
WHAT IS MID
FACE??
Area between a superior plane drawn
through the zygomaticofrontal sutures
tangential to the base of the skull and an
inferior plane at the level of the maxillary
dental occlusal surfaces.

 These planes do not parallel each other but

converge posteriorly at a level
approximating that of the foramen magnum

 Triangular region with its widest

dimension facing anteriorly.
 BONES OF MIDFACE
(17 :
Paired Bones BONES)Unpaired Bones

Maxilla Vomer

Zygomatic bone Ethmoid

Zygomatic process of Sphenoid (Pterygoid

temporal bone plates)

Palatine bone

Nasal bone

Lacrimal bone

Inferior conchae
Anatomical specimen showing the disarticulated bones of the skull exploded
and mounted to demonstrate their complex interrelationship.
 MECHANISM OF MIDFACE
FRACTURE :
 These facial bones in isolation are comparatively fragile but gain
strength and support as they articulate with each other.
 It is this strength gained from each other that has been
described as thefacial buttress by Manson.

• Area of strength
• Vertical and horizontal pillars
• Muscular attachment
• Area of weakness
• Sutures
• Lining tissuesand air-filled cavities
Vertical buttress:
nasomaxillary
zygomaticomaxillary
pterygomaxillary

Horizontal buttress:
frontal bar(supra orbital
rims)
 infra orbital rims
 maxillary palate
 11

Vertical and horizontal pillars:

Midface is so designed that it can withstand
forces in inferior superior directions.
Poorly constructed to withstand lateral
and frontal forces.
 ANATOMICAL
CONSIDERATIONS:

∏ This structure is analogous to a matchbox sitting below andanterior to

hard shell containing brain

∏ Act as cushionfor trauma directed towards cranium from anterior or

antero- lateral direction
 HISTORY
:
 The first clinical examination of a maxillary fracture was recorded in 2500 BC.

 In 1822 Charles Fredrick William Reiche provided the first detailed description

of maxillary fractures.

 In 1823 Carl Ferdinand van Graefe described the use of a head frame for treating

a maxillary fracture.
 HISTOR
Y:

 In 1901 , Rene Le Fort published his landmark work, a three-part experiment using

32 cadavers.

 The heads of the cadavers were subjected to low velocity forces; the soft tissue

were then removed and the bones were examined.

 HISTOR
Y
 Le Fort noted that generally face was fractured and the skull was not. He then stated
that fractures occurred through three weak lines in the facial bony structure. From
these three lines the Le Fort classification system was developed.
 External Fixation
Craniomaxillary fixation- Wassmund’s(1927) maxillary splint
with side bars attached to a head cap
ETIOLOGY:

∏ Assault
∏ RTA
∏ Alcohol and Drug abuse
∏ Gunshot wounds
∏ Sports
∏ Falls
∏ Industrial accidents
Classification
1. ALPHONSO GUERIN(1886)

2. RENE LE FORT FRACTURE CLASSIFICATION (1901)

3. ROWE AND WILLIAM CLASSIFICATION (1985)

4. MODIFIED LE FORT CLASSIFICATION

(MARCIANI,1993)
5. ERICH’S CLASSIFICATION (1942)
 1) Rene Le Fort classification (1901):

Le Fort classification:
 •Le Fort I
 •Le Fort II
 •Le Fort III
 3. Rowe & william’s classification :

 A – FRACTURES NOT INVOLVING

DENTOALVEOLAR COMPONENTS
1. Central region
a- fracture of nasal bone &/or nasal septum
- lateral nasal injuries
- anterior nasal injuries
b. fractures of frontal process of maxilla
c. fractures of type a & b which extend into ethmoid
bone
d. fractures of type a ,b ,c which extends into
frontal bone

2.Lateral region-
Fractures involving zygomatic bone,arch & maxilla excluding
dentoalveolar component
 B –FRACTURES INVOLVING DENTOALVEOLAR
COMPONENT

1.Central region
a-dentoalveolar fractures
b-lefort I (subzygomatic fractures)

2.Combined central & lateral region

a-high level
b-LeFort III with midline split
c-LeFort III with midline split + fracture
of roof of orbit or frontal bone
 Limitations of the lefort classification

• The LeFort classification has proven to be less satisfactory

to describe more complex fracture patterns, comminuted,
incomplete, combination maxillary fractures or to
describe fractures of the part bearing the occlusal segment.
 3) Marciani modification of Le Fort:

 LE FORT I: LOW MAXILLARY FRACTURE

Le Fort I (a)Le fort
 I-
multiple segment
 LE FORT II:PYRAMIDAL
FRACTURE
 Le Fort II (a) : le fort II + nasal
 Le Fort II (b) : le fort II (a) + ethmoid
 LE FORT III: CRANIOFACIAL
DYSJUNSTION
 Le Fort III (a) : Le Fort III + nasal
fracture
 Le Fort III (b) : Le Fort III (a) +
ethmoid
 LE FORT IV: LE FORT II OR LE FORT III
WITH CRANIAL BASE
 Le Fort IV (a) : Le Fort IV with supraorbital
rim
PREVALENCE OF MID-
FRACTURE
FACE
S Fracture Type Prevalence
Zygomaticomaxillary complex (tripod fracture) 40 %

I 15 %
LeFort I 10 %
I
II 10 %
I
Zygomatic arch 10 %
Alveolar process of maxilla 5%
Smash fractures 5%
Other 5%
 Erich’s classification (1942)
 Horizontal, pyramidal, transverse

 Classification based on relationship of fracture line to zygomatic bone

 Subzygomatic, suprazygomatic

 Classification based on level of fracture line

 Low, mid, high level fractures
PALATAL
FRACTURE:
 Handrickson M, Clark n, TYPE Type 2: Type 3:
Manson P,Palatal fracture 1:
Anterior alveolus posterolateral sagittal

classification, patterns and

Treatment with rigid internal
fixation:. Plast recostr surg
101(2):319-332,1998
Type 4: Type 5: Type 6:
parasagittal ParaAlveolar Complex/comminuted

Type 7: transverse
Le Fort 1
A violent force applied over a more extensive are, above the
level of the teeth will result in a Le Fort I Fracture.
Which is not confined to smaller section of the alveolar
bone
Low-level fracture, a subzygomatic Fracture.
Guerin’s fracture
Horizontal fracture
Floating fracture
 LEFORT 1 : Fracture line:
 I st line : starts from the lateral border of the pyriform
aperture passes above the nasal floor, then it goes posteriorly
above the canine fossa going backward below the zygomatic
butress coming on the posterior wall of the maxilla, where it
rises abruptly crossing the pterygo-maxillary fissure &
breaks the pterygoid plates in lower1/3 & upper 2/3 parts.

 2nd line : starts from same starting point and also passes
along the lateral wall of nose and subsequently joins the
lateral line of # behind the tuberosity.

 3rd line : detaches the nasal septum from anterior nasal

spine upto vomer bone.
 A typical Lefort-I fracture is always bilateral with the fracture of lower third
of nasal septum.
 It can also occur as unilateral
fracture.
 Lefort-I may occur as a single entity or in association with Lefort-II & III
#.
LEFORT II
 LEFORT 2
 Pyramidal or
fracture subzygomatic
fracture
from an
 Violent direction,
anterior force, sustained by the
usually region of the middle third
central
of the facial skeleton over an area
extending from the glabella to the
alveolar margin results in a fracture
of a pyramid shape.
 The force may be delivered at
the level of the nasal bones.
 FRACTURE
LINE
 itstarts just below the
frontonasal suture bilaterally
 Runs from the thin middle area of
the nasal bones down either side.
 Crossing the frontal processes of
the maxillae into the medial wall
of each orbit.
 Within each orbit, the fracture
line crosses the lacrimal bone
behind the lacrimal sac.
 Before turning forwards to cross the infra-
orbital margin slightly medial to or through
the infra-orbital foramen.
 The fracture now extends downwards and
backwards across the lateral wall of the
antrum below the zygomatic-maxillary
suture.
 Dividesthe pterygoid lamina about
halfway up.
LE FORT 2: Fracture
Line
LEFORT III
 LEFORT III
 Suprazygomatic or transverse
fracture or high level
fracture.
 The line of fracture extends
above the zygomatic bones on
the both sides as a result of
trauma being inflicted over a
wider area, at the orbital level.
 Mechanism of LF3 #:
 Initial
impact is taken by the
zygomatic bone resulting in
depressed fracture.
 Then because of the severe
degree of the impact, the entire
middle third will then hinge
about the fragile ethmoid bone.
 The impact will then be transmitted
on the contralateral side resulting
laterally displaced zygomatic
fracture of the opposite side.
 THE FRACTURE LINE
 Runs from near the frontonasal suture transversely backwards, parallel
with the base of the skull and involves the full depth of the ethmoid
bone, including the cribriform plate.
 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:
 Backwards across the pterygo-maxillary fissure to fracture the roots of the
pterygoid laminae.
 Laterally across the lateral wall of the orbit separating the zygomatic bone
from the frontal bone by fronto-zygomatic suture.
 The entire mid-facial skeleton becomes detached from the cranial base.

FZ SUTUTE
#

Zygomatic arch#
 CLINICAL ASSESSMENT OF
MIDFACE FRACTURES
 Extra-oral & Intra-oral
examination.

 Inspection.

 Palpation.
 Extra-oral examination

Inspection of midface-
 Swelling & Facial Asymmetry.

 Bruising of upper lip and lower half of mid-face.

 Circum-orbitalEcchymosis ( bilateral =
Racoon’s eye).

 Subconjunctival Hemorrhage.

 Periorbital Oedema.
 Cerebrospinal fluid rhinorrhoea

 Lengthening of Midface

 Depressed midface (dish face)

 Saddle shaped depression of nose

 Enophthalmos

 Proptosis

 Diplopia
 Cerebrospinal Fluid
Rhinorrhoea

-Watery nasal or postnasal salty discharge.

CSF content assessment- most reliable.

ß2 Transferrin isoenzyme- most diagnostic.

“HALO”
sign
 Palpation -

1. Subcutaneous Emphysema – Crepitus

2. Tenderness

3. Step Deformity

4. Abnormal Mobility of bone

5. Impairment of sensation
Palpation of facial skeleton
 Intra-oral examination

Inspection

1. Disturbed occlusion (posterior occlusal gagging , open bite)

2. Haematoma intraorally over root of zygoma

3. Haematoma in palate (Guiren’s sign)

4. Fractured cusps of teeth

5. Midline diastema
Clinical features:
  Inspection :

 Slight swelling and edema of the lower part of the face

along with the upper lip swelling

 Ecchymosis in the labial and buccal vestibule, as well as

contusion of the skin of the upper lip may be seen

 Bilateral nasal epistaxis may be observed

 The patient may develop open bite if the

fractured segment is mobile , due to

posterior gagging of occlusion.

 Sometimes fracture of the palate can also

be associated with

Le Fort I fracture.
 Occlusion may be disturbed,
difficult mastication

 Pain while speaking and moving the

jaw

• GUERIN sign: ecchymosis of palate ,

bilateral greater palatine foramen.
PALPATION :
 In Le Fort I, the teeth and maxilla are
mobile (floating maxilla), but the nose and
upper face is fixed.

 Sometimes there willbe upward

displacement of theentire
fragment, locking it against
thesuperior intact structures,
such a fracture is
called as impacted or telescopic
fracture.
 Percussion of the maxillary teeth results
in distinctive 'cracked-pot sound',

 No tenderness and mobility of the

 Common features of LF2&3:

 Gross edema of soft  Limitation of ocular

tissue movement
 Bilateral  Possible diplopia and
circumorbital enophthalmous
ecchymosis  Retropostioning of the
 Bilateral subconjunctival maxilla with anterior open
hemorrahge bite
 Obvious deformity of the  Lengthening of the face
nose  Difficulty in mouth opening
 Nasal bleeding and
 Mobility of the upper jaw
obstruction
 Occasional hematoma of
 CSF leak rhinorrhea
the palate
 Dish-face deformity  Cracked-pot sound on
percussion
SPECIFIC FEATURE OF LF2#:
 Step deformity at infra-orbiatal margin
 Anasthesia of midface
 Nasal bone moves with mid-face as a whole

SPECIFIC FEATURE OF LF3#:

 Tenderness and sepration at FZ suture
 Tenderness and deformity of zygomatic arch
 Depression of occular level and pseudoptosis
Clinical features:
Clinical features -

 The resulting gross edema of the

middle third gives an appearance
of "moon face" to the patient.

• Depressed nasal bridge,

• Dish shape deformity.
 CSF rhinorrhoea is possible and should be

looked for.

 Bilateral circumorbital ecchymosis giving an

appearance of 'raccoon eyes' is invariably

seen in the fractures of both Le Fort II and Le

Fort III.

 Subconjunctival hemorrhage develops rapidly

in the area adjacent to the site of injury.(mostly

in medial half )
 Diplopia may be seen in cases of
orbital floor injury.

 Pupils are at level unless there is

gross unilateral enophthalmos.

 Anaesthesia or paraesthesia of the

cheek as a result of injury to the
infraorbital nerve due to the fracture
of the inferior orbital rim.
 On intraoral examination, retropositioning of the whole maxilla
and gagging of the occlusion are seen.

 Hematoma formation is seen in the buccal sulcus opposite to the

maxillary first and second molar teeth as a result of fracture of the
zygomatic buttress.
 Extraoral palpation of LFII:

 Step deformity at the infraorbital rims

or frontonasal junction is noticed.

 Orbital wall fractures can cause

entrapment with limitation of ocular

movement.
 When maxillary teeth are
grasped, the mid-facial
skeleton moves as a pyramid
and the movement can be
detected at the infraorbital
margin and the nasal bridge.
Clinical features:
 LE FORT III
Clinical features - FRACTURE

 Gross oedema of the face.

 Bilateral circumorbital ecchymosis with subconjunctival

hemorrhage.

 Characteristic 'dish face' appearance with lengthening of the

face.
 'Hooding of eyes' may be seen due to separation of the

frontozygomatic suture.

 Deformity of the zygomatic arches.

 Difficulty in opening the mouth, inability to move

lower jaw.

 CSF rhinorrhoea.
 Depression of ocular levels.

 ‘Battle’s
Sign’
 Tenderness and often separation of the

bones at the frontozygomatic suture.

 Mobility of the whole of facial skeleton

as a single unit.

 When lateral displacement has taken

place tilting of the occlusal plane and

gagging of one side is seen.

Radiographic Examination
 Opg
 Lateral view
 15/30 degrees occipitomental view
 Submentovertex view
 Cranial postero anterior view.
 PA view (Water’s View)
30 DEGREE OCCIPITOMENTAL LATERAL
VIEW
WATER,S VIEW
NORMAL
CT -
SCAN

Coronal CT demonstrating a right Le Fort I fracture and a left Le Fort II fracture.

radiographic features:
LEFORT I – Waters view
 CT findings - axial section

Pterygoid Plate Fractures in lefort I

3D - CT
radiographic features:
CT findings - coronal section
 CT findings - axial section

The blue arrows show bilateral fracture of the pterygoid

processes, which is a common association in all three
types of Le Fort fractures.
Middle age man in motor vehicle accident.
Fracture lines are demonstrated in red arrows.
 3D - CT

Three-dimensional reconstruction of a
patient with right Le Fort I fracture
and a left Le Fort II fracture
radiographic features:
32-year-old man, driver in a motor vehicle
accident.

.
3D - CT
MANAGEMENT
1. Emergency care &
Stabilization - ( First aid and
resuscitation )
2. Initial Assessment and Early care-

3. Definitive Treatment-

4. Rehabilitation -
STAGE I - Emergency care & Stabilization

1. Maintenance of airway.
2. Control of hemorrhage.
3. Prevent or control shock.
4. C-Spine stabilization.
5. Control of life-threatening injuries.
Head injuries, chest injuries, compound limb fractures,
intra abdominal bleeding.
 Emergency Care
A) Airway Maintainance -
 Existence & identification of obstruction.
 Manually clear fractured teeth, blood clots,
dentures.
 Endotracheal intubation if needed.

NOTE:
 Altered
level of consciousness is the most
common cause of upper airway obstruction.
B) Breathing and ventilation
 Airway patency alone does not ensure adequate
ventilation
 Adequate gas exchange is required to maximize
oxygenation and carbon dioxide elimination
 Ventilation requires adequate function of the lungs,
chest wall, and diaphragm
 C) Circulation & hemorrhage control

 Hemorrhage is most common cause of

shock after injury.
 Multiple
injury patients have
hypovolemia.
 Monitor vital signs closely.
 Goal is to restore organ
perfusion.
 Treatment of Blood Loss & Shock

 Externalbleeding controlled by direct pressure

over bleeding site.
 Gain prompt access to vascular system with IV
catheters.
 Fluid replacement:
 Ringer’s Lactate
 Normal saline
 Transfusion.
 D) DISABILITY (NEUROLOGIC
EVALUATION)

 A rapid
neurologic evaluation is performed at the end of the
primary survey.
 TheGlasgow Comma Scale (GCS) is a quick, simple
method for determining the level of consciousness.
PATIENT SCORE
DETERMINES CATEGORY
OF NEUROLOGIC IMPAIR

SCORE

>15 = NORMAL
13-14= MILD INJURY
9-12 = MODERATE INJURY
3-8 = SEVERE INJURY
E) EXPOSURE AND ENVIRONMENTAL
CONTROL

 The patient should be completely undressed

 usuallyby cutting off his or her garments to facilitate a
thorough examination and assessment

The patient’s body temperature is more important than

the comfort of the healthcare providers.
 Stabilization of associated injuries

 C-spine injury is primary concern with all

maxillofacial trauma victims.

 Signs/symptoms of C-Spine injury

Neurologic deficit.

Neck pain.
 Stabilization of associated injuries

 C-spine injury suspected:

 Avoid any movement of
neck
 Establish & maintain
proper immobilization
until vertebral fractures or
spinal cord injuries ruled
out
Lateral C-spine
radiographs
CT of C-spine
Neurologic exam
 STAGE II. Initial Assessment and Early care

 Emergency care has stabilized patient.

 Initial stabilization of fractures.
 Debridement & dressing of soft tissues.
 Physical exam & history.
 Laboratory tests.
 Clinical & Radiographic Assessment of Patient.
Diagnosis of maxillofacial injuries.
 Pre-operative planning.
 STAGE II. Initial Assessment
 Pre-operative planning
1. Need for Tracheostomy
2. Surgical Approaches to Midface
3. Whether ‘Open’ or ‘Closed’ methods of reduction are to
be employed.
4. Necessity for & type of Maxillary fracture Fixation.
 STAGE II. Initial Assessment
 Pre-operative planning

 Surgical Approaches to Midface

Pre-operative planning

 Principle of treatment for Mid face #:

 CONSERVATIVE
 OPERATIVE/SURGICAL: REDUCTION and
FIXATION
 Indications for Closed Reduction:
 Non displaced fracture,
 Grossly comminuted fractures,
 Fractures exposed by significant loss of overlying soft tissues,
 Edentulous maxillary fractures,
 In children with developing dentition.

 Indications for open reduction:

 Displaced fractures,
 Multiple fractures of the facial bones,
 Fractures of the edentulous maxilla with severe displacement,
 Delay of treatment and interposition of soft tissues between non-contacting displaced
fracture segments, Specific systemic conditions contraindicating IMF.
principles

1. Accurate diagnosis
2. Determination of priority of treatment
3. Early reconstruction
4. Wide exposure of vertical and horizontal pillar of face
5. Use of bone graft to restore skeletal form
6. Use of rigid fixation to stabilize # segment
7. Restoration of bony support to over lying soft tissue
envelop
Incisions for exposure of LeFort fractures
1. Supraorbital eyebrow incision
(Lefort III)
2. Subciliary incision (LeFort II & III)
3. Median lower lid (LeFort II & III)
4. Infraorbital incision (LeFort II & III)
5. Transconjunctival (LeFort II )
6. Zygomatic arch
7. Transverse nasal (LeFort II & III)
8. Vertical nasal incision (LeFort II & III)
9. Medial orbital incision.
10. Intra-oral vestibular incision. (LeFort I)
Classification of methods of Maxillary Fracture Fixation

A ) Internal Fixation-
1. Suspension Wires
2. Direct Osteosynthesis

B) External Fixation-
1. Craniomandibular
2. Craniomaxillary
 Internal Fixation

Suspension Wires – non-rigid osteosynthesis -

i. Frontal-central or laterally placed

ii. Circumzygomatic
iii. Zygomatic
iv. Circumpalatal/palatal screw
v. Infraorbital
vi. Piriform Aperture
vii. Peralveolar
 Internal Fixation

Suspension Wires- Circumzygomatic wiring by Obwegeser.

 Internal Fixation
Suspension Wires-
Circumzygomatic wiring by Obwegeser
 Internal Fixation

Suspension Wires- Orbital rim wiring

Suspension Wires-
Piriform aperture wiring
 Summary of Suspension wiring according to fracture site

Type of Suspension Wire Type of Le Fort Fracture

1. Frontal

a. Central Le Fort III & II

b. Lateral Le Fort III & II

2. Le Fort I & II
Circumzygomatic

3. Zygomatic Le Fort I

4. Infraorbital Le Fort I

5. Piriform Aperture Le Fort I

 Disadvantages of Suspension Wiring

 Incomplete fixation of fractured fragments

 Insufficient visualization of fractures by closed
reduction
 Compression against the cranial base
 No 3-dimensional stability
 Patientsdislike intra-oral splints as it hinders
oral hygiene maintainence.
 Internal Fixation

Direct Osteosynthesis -

1. Interosseous Wires.

2. Plates and Screws.

 Direct osteosynthesis
Intraosseous Wires-

1. Maxillary (Lefort –I )
2. Zygomaticomaxillary (Lefort –II)
3. Frontonasal (LeFort –II &III)
4. Zygomaticofrontal (Lefort III)
5. Zygomatic bone (comminuted)
Disadvantages -
 Non rigid type of osteosynthesis
 No 3 dimensional stability, it provides only
monoplane traction.
 IMF is always needed
 Interfragmentary pressure can not be
controlled.
 Under functional stress, wire loses rigidity, direction
control and surface contact.
 Delayed healing because of micromovement at
 Direct osteosynthesis-

2. Plates & Screws for midface fractures -

 Stainless steel mini-plating

system
 Titanium mini-plating system

 Vitallium, Cobalt chromium, molybdenum alloy plates

 Bioresorbable plating system.

 Miniplates and screws
These are monocortical, semi-rigid fixation
device which provide 3D stability.
Designs: X, H, L, T, Y
Thickness:0.6-1 mm

Type of metals: Stainless steel, Titanium,

Vitallium
Advantages:Easily adaptable,
Monocortical, Functional stability,
Reduced surgical access
 Plating system depends on:
1. Rigidity of plate
2. Width and shape
3. Diameter and number of screws

 Increase in width provides more stability towards

rotational
forces.

 Type of metal:
a. Stainless steel
b. Titanium
c. Vitallium

 Advantages:
1) Easily adaptable
2) Monocortical
3) Functional stability
Factor affecting screw stability
 Minimum screws required in bone segment
prevent
2 rotation
eachin X and Y axis to

Farther the point of stabilization the more effective

the device is in preventing rotation.

 Large diameter screws are not used because of

constraint imposed by particular anatomic
location

 All screw require adequate intervening bone

between adjacent holes to preserve integrity of
screw bone interface
Location of fixation
 Le fort I: L plates at zygomatic buttress
Curved plate at pyriform aperture
3D plate sometimes to fix buttress
#
 Le fort II: Linear/Y plate/curved plate along intra orbital
rim L plate at buttress

 Le fort III: Linear/Y plate at FN and ZF

junction
Micro plates
Harle & duker(1975;Luhr(1979)
0.3 – 0.6 mm
Used for : FN region ,Frontal bone,Frontal process of
maxilla
Sites of application:Linear/T/Y plate at FN
region,Long curve plate for frontal process of maxilla
or frontal bone

Mesh fixation Used for retention and alignment of

small fragments or bone grafts.
Sites of application: Anterior and lateral wall of
maxilla and Anterior table of frontal bone
 Bone plate osteosynthesis
Advantages –
1. Simple & less intraoperative time
2. Intraoral approach is sufficient
3. Postoperative IMF is not needed or
period of IMF is reduced.
4. Three dimensional stability and early
return of function.
 STAGE III. DEFINITIVE TREATMENT

 LEFORT I FRACTURE
 LEFORT II FRACTURE
 LEFORT III FRACTURE
  STAGE III. DEFINITIVE TREATMENT
LEFORT I FRACTURE
SURGICAL APPROACH- MAXILLARY VESTIBULAR

1. 3.

4.
2.
REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
FIXATION- 4-point fixation with MINIPLATE.
IMMOBILISATION- MAXILLOMANDIBULAR FIXATION(MMF)
 LEFORT II FRACTURE
 SURGICAL APPROACH-
A – Subciliary

incision
B – Sub tarsal

incision C -

Infraorbital incision D -
Existing Laceration

Maxillary vestibular
approach can also be
taken for LeFort II
fracture
 GLABEL
CORONAL APPROAC
LA
APPROACH H
 FIXATION 3-POINT fixation
-
 IMMOBILISATION- MAXILLOMANDIBULAR FIXATION
 STAGE III. DEFINITIVE TREATMENT
LEFORT III FRACTURE-
 SURGICAL APPROACH-

Existing Laceration
A . Lateral eyebrow approach GLABEL
B. Upper-eyelid approach
APPROAC
LA
H
Coronal approach -
PREAURICULAR
APPROACH
REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
Zygoma hook
 FIXATION- 3-point
fixation
 IMMOBILISATION- MAXILLOMANDIBULAR FIXATION if
required
Principles of Maxillary Reconstruction

 Miniplates can bridge gaps of up to approximately 0.5cms

 Gaps >0.5cms – bone grafts
 Bone grafts bridging the gap should be wedged
underneath the plate & held in place with screws fixed
from plate directly into the graft.
 Immediate Bone Grafting

Buttress reinforcement retained by plates or screws can

assist in restoring maxillary height & preventing
Contour deficiencies.
 Rib graft
 Iliac crest
 Calvaria
 Mandibular bone graft
 Alloplastic bone graft
Recent Advancements
1. Resorbable plates
2. Endoscopic management(Harold
Hopkins)
3. Distraction osteogenesis(Ilizarov)
 CONCLUSION:

Le fort fractures are common in the trauma patient.

They require accurate radiologic diagnosis and surgical
management to prevent severe functional debilities and
cosmetic deformity.
A thorough understanding of the anatomy, craniofacial
buttresses and treatment options will give the
maxillofacial surgeon the optimal tools for achieving a
successful result.

THANK
YOU
 REFERENCE
S:

1. Rowe NL, Williams JL. Maxillofacial

Injuries.
Edinburgh, Churchill Livingstone,1985.
2. Oral and maxillofacial trauma : Fonseca vol. 2.
3. Marciani RD. Management of Midface
Fractures: fifty years later. J Oral Maxillofac
Surg 1993;51:962
4. www2.aofoundation.org