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Maxillary fractureDeepak K Gupta

Applied Anatomy• Maxilla is composed of mainly 4 processes

– Frontal

– Zygomatic

– Alveolar

– Palatine

• Its largest part of middle third of the face and contributes in the formation orbit, nasal cavity and hard palate.

• Its mainly composed of cancellous bone enclosed in a thin layer of compact bone

• Force that are applied to the face are absorbed and transmitted by buttress system, mainly of two types• Vertical

• Horizontalhttps://www.facebook.com/notesdental

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Buttresses of Maxillofacial


Horizontal Buttresses

1. Frontal Bar2. orbital rims

3. Maxillary Alveolar4. Mandibular alveolar

5. Inferior border of mandible


Vertical buttress1. Nasomaxillary,

2. Zygomaticomaxillary, 3. Pterygomaxillary

1

2

3


Classification of Fracture of maxilla• Rene Le Fort classification (1901)

• Le Fort I• Le Fort II • Le Fort III

• Marciani modification of Le FortLe Fort I low maxillary fractureLe Fort I (a) Le fort I - multiple segmentLe Fort II Pyramidal fractureLe Fort II (a) le fort II + nasalLe Fort II (b) le fort II (a) + ethmoidLe Fort III Craniofacial dysjunstionLe Fort III (a) Le Fort III + nasal fractureLe Fort III (b) Le Fort III (a) + ethmoidLe Fort IV Le Fort II or Le Fort III with cranial baseLe Fort IV (a) Le Fort IV with supraorbital rimLe Fort IV (b) Le Fort IV + anterior cranial baseLe Fort IV (c) Le Fort IV (b) + le fort (a)


Le Fort Classification

• Based on low energy impact which is seldom found separately

• Today due to increased High energy impact -comminution and combinations of fracture type are usually found


Le Fort I

• nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillaryjunction, and traverses the pterygomaxillaryjunction to interrupt the pterygoid plates


Le Fort I : Guérin fractures OR Low Level

• Result from a force of injury directed low on the maxillary alveolar rim in a downward direction from opposite jaw.• Escapes diagnosis


Sign and symptom

• Sweeling of upper lip and cheek

• Ecchymosis – maxillary buccalsulcus

• Nasal block – oral breathing

• Eye or ocular sign are usually absent

• Guerin sign– Echymosis in palate – greater

palatine foramen bilaterally


Sign and symptom

• Occlusion

– Undisplaced incomplete fracture – no disturbance to occlussion

– Displaced occlusion

• Anterior open bite : backward and downward distraction of posterior maxilla – traction from medial pterygoid muscle

• Posterior gagging of occlusion – threat to airway


• Teeth fracture– Damage to the cusp of

individual teeth due to impact from opposite teeth

• Palatal fracture• 8–15% of Le Fort fractures

• follow a sagittal or parasagittaldirection, splitting the maxilla longitudinally close to the midline

• exit anteriorly between the central incisors, or between the lateral incisor and the canine tooth


• Bilateral epistaxis or nasal bleeding may be observed

• Pain while speaking and moving the jaw upper dentoalveolar portion of the jaw, which is frequently mobile to digital pressure

• Cracked pot sound

• Floating maxilla

• Palpation– Step deformity along the piriform aperture,

buccal sulcus and tuberosity region


Le Fort I


Le Fort II/Pyramidal fracture• Starts from nasal bridge at or below the nasofrontal suture through the

frontal processes of the maxilla, • Inferolaterally through the lacrimal bones and inferior orbital floor and

rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus;

• It then travels under the zygoma, across the pterygomaxillary fissure, and through the pterygoid plates


Clinical feature

• gross edema of the middle third of the face known as ballooning or moon face

• bilateral circumorbital edema and ecchymosis (Black eye)

• Bilateral subconjunctival hemorrhage - medial half

• Bridge of the nose will be depressed (flat face)

• Anterior open bite - impaction of the fragment

• Gross downward and backward displacement of the fragment Posterior gagging of the occlusion with -anterior open bite (Dishshaped face)


Clinical Feature

• Pseudotelecanthus: swelling over the nasal bridge illusion of telecanthus, true telecanthus on the involvement of NOE complex

• Bilateral epistaxis• Difficulty in mastication, and speech• Loss of occlusion may be seen• CSF leak may be present • Step deformity at the infraorbital margins• Anesthesia and/or paresthesia of the cheek is

noted


Le Fort III fractures (transverse)• craniofacial dysjunctions• Anteriorly: nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of

the orbit through the nasolacrimal groove and ethmoid bones. • The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic

canal.• Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and

continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch.

• Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer, and through the interface of the pterygoid plates to the base of the sphenoid.


Clinical feature

• high level fracture• Lateral direction with a severe impact• Clinically this fracture appears similar to the

LeFort II fracture, but close examination will demonstrate a more serious condition.

• After stabilizing the head and then gripping of the maxillary teeth with one hand and simple manipulation, will confirm complete movement of the middle third of the face.

• Mobility of whole skeleton as a single block can be felt


Signs and symptom

• Gross edema of the face, ballooning. “Panda facies” within 24 to 48 hours

• Bilateral circumorbital/periorbital ecchymosisand gross edema ’Racoon eye

• Gross circumorbital edema will prevent eyes from opening

• Bilateral subconjunctival hemorrhage

• tenderness and separation at the frontozygomatic sutures.


Signs and symptom

• Characteristic ‘dish face’ deformity

• enophthalmos,

• diplopia or

• impairment of vision, temporary blindness,

• Flattening and widening, deviation of the nasal bridge.

• Epistaxis, CSF rhinorrhea


Investigation

• CT-scan is best option for studying mid-facial fracture but plain radiograph may be helfulltoo.

• Radiographic examination

– Water’s view: PA view with cephaled angulation

– Caldwell view : PA view

– Lateral view

– Submentovertex view:


Waters’ view: Le Fort I fracture


CT scan (coronal view) documenting a Le Fort I fracture in more detail


CT scan, axial view of a Le Fort II fracture, shows the fracture line through anterior and posterior maxillary sinus walls


CT scan, axial view of a Le Fort II fracture, shows the fracture line through both infraorbital rims and zygomatic arch on the right


CT scan, coronal view, shows the fracture at Le Fort III level on the right and Le Fort II level bilaterally


CT scan; 3-D reconstruction of a panfacial fracture


Management of Le Fort Fractures

• Timings of surgery

– Controversial issue

– Delayed repair (7-14 days)

• manipulation of bones and soft tissue easier –suppression of edema.

• risk of fibrosis and healing is there

• Unstable patient – Haemodynamically unstable and increased intracranial pressure ICP

– Immediate: only in stable patient


Surgical approaches: Le Fort I

• Transoral vestibular incision

– mobile mucosa 5–10 mm above the attached gingivaaround the maxillary arch, leaving a “flange” for easier suturing

– crestal incision in edentulous patients

• facial degloving : irregular fracture


Alar-cinch technique

Identify and reposition the

alar base with a suture to avoid lateral position of the alae bases


Reduction

• Loosely mobile : Finger manipulation

• Impacted : Rowe’s William forceps– Padded blade is inserted inside the

mouth and unpadded in nostril– Standing from behind, grasping the

two forceps, fracture segment is manipulated

• Firmly impacted : fracture line should be exposed and mobilisedusing osteotome and disimpactedforceps

• Split Palate: firstly two palatal halves are approximated by traction applied by HAYTON-WILLIAM forceps and then with Rowe’s William forceps


Fixation

• Indirect– Suspension wire– MMF for 4-6 weeks

• Direct– Miniplate : Stabilization

with L-shaped miniplates(1.5 or 2.0), Fixation with at least two screws on either side of the fracture line in order to avoid rotational instability

– Transosseous wire fixation –buttress bone (lateral piriform rim and zygomaticomaxillary)


Fixation for palatal split

• Stabilization of Le Fort fracture as described earlier

• The additional sagittalfracture is stabilized subnasally with a miniplate 1.5 or 2.0

• Fixation of the palatal fracture with a miniplate


Le Fort I fracture with comminution on both sides


Stabilization with longer miniplates bridging the areas of comminution. Reconstruction and stabilization of the right

anterior maxillary sinus wall with a titanium mesh


In situations with bone loss in buttress areas, bone grafts, often in combination with miniplate fixation, should be used to

bridge the defect.


Surgical approaches: Le Fort II and III

• choice of approach depends– fracture pattern– amount of displacement,– other accompanying

fractures– surgeon’s preference

• Coronal approach– cutaneous incision is

made from the helix root on one side to the vertex of the skull and then to the contralateral helical root


• Modifications

– the sinusoidal or saw-tooth stealth incision,

– extension of the incision behind the pinna in the postauricular area instead of the preauricular region

– hemicoronal


• frontal branch of the facial nerve by transection of the superficial layer

• surgical dissection and release of the supraorbital nerve is required https://www.facebook.com/notesdental

Upper blepharoplasty

• zygomaticofrontalsuture areas are exposed through the lateral portion

• disadvantage of limited exposure, making a symmetrical control of reduction impossible

• hemicoronalapproaches should be avoided.


Subciliary and mid-eyelid incision (lateral view).

Reduction and fixation of infraorbitalrimOrbital floor reconstructionLess risk to cornea and relatively quickRisk of ectropian and visible scar


Transconjunctival incision (lateral view).

• Scarless and doesn’t create ectropion(lower eyelid turns outwards)

• With lateral canthotomy it can be used to approach frontozygomaticsuture too


Mid-eyelid incision (frontal view)

Exposure of the infraorbital rim through

mid-eyelid incision


Reduction

• Done in a similar as in Le Fort I using ROWE’S Williams forceps but care should be taken as it involves base of skull

• Ash’s or Walshman’s forceps for nasal septum may be used


FixationIt may be direct or indirect means.Direct: miniplate, Transosseous wiring at ZM buttress, infraorbital rim and frontonasal junctionIndirect: MMF for 4-6 weeks

The infraorbital and NOE area are stabilized with miniplates 1.3. Zygomaticomaxillary buttresses are stabilized with miniplates 2.0.

Reconstruction and fixation of outer facial frame as the first step during repair of a Le Fort III fracture.


• Le Fort III fracture in combination with zygomatico-orbital fracture on the left and typical occlusaldisturbance

• Fixation of Le Fort III and zygomatico-orbital fracture with miniplates2.0 and 1.3. The patient is in MMF during surgery only


• Fixation of Le Fort I, II, and III fractures with miniplates 2.0 and 1.3.

• On the left, a bone graft is covering a bony defect at the zygomaticomaxillary buttress area.


Aftercare

• Evaluation of vision– as soon as they are awakened from anesthesia– regular intervals until they are discharged from the

hospital

• Postoperative positioning : upright position - improve periorbital edema and pain

• Nose-blowing: avoided for 10 days - orbital emphysema

• Medication : Nasal decongestant, Antibiotics, Analgesia, Steroids, Ophthalmic ointment excluding NSAID’S and aspirin

• Ophthalmological examination• Postoperative imaging: 3-D imaging (CT, cone beam)


Afercare• Wound care: suture removal within 5 days, ice packs, avoid sun

exposure• Diet

• Soft diet: after healing of the maxillary vestibular incision.• Intranasal feeding: oral bone exposure and soft-tissue defects.• liquid diet : Patients in MMF

• Clinical follow-up: complexity of the surgery• Eye movement exercises• Oral hygiene : use of soft tooth brush and oral rinse tds• MMF: duration of MMF is controversial and is dependent on

– Fracture morphology– Type and stability of fixation (including palatal splints)– Dentition– Coexistence of mandibular fractures– Premorbid occlusion


Complication of Mid-face fracture

• Early– Extensive Hemorrhage– Airway Obstruction– Infection– CSF Leak – Blindness

• Late– Palpable Hadware– Non-Union / Malunion– Plate Exposure– Lacrimal System obstruction– V2 Anesthesia– Devitalized Teeth– Extra-Occular Muscle

Imbalance– Diplopia– Enophthalmos– Orbital Dystopia– Change In Facial Appearance– Nasal Obstruction– Malocclusion


Refrences

• Principles of Internal Fixation of the CraniomaxillofacialSkeleton - Trauma and Orthognathic Surgery by AO foundation

• Textbook of oral and maxillofacial surgery 2nd edition: S M Balaji

• Text book of oral and maxillofacial surgery 3rd edition_neelima Mallik

• Contemporary oral and maxillofacial surgery _hupp_ellis_tucker

• clinical handbook of oral and maxillofacial surgery_lashkins

• Netter’s Atlas version 5.1


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