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1fractures of Maxilla
1fractures of Maxilla
MAXILLA
BY
DR JAHANGIR HAMMAD
BDS ,FCPS
Classifications
Le Fort’s classification (1901)
Le Fort I, II, III
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
LeFort fractures
Rene LeFort 1901 in cadaver skulls
Frequently different levels on either side
LeFort I
LeFort II
LeFort III
LeFort Fractures
From: Dolan KD, Jacoby CG, Smoker WR. Radiology of Facial Injury. New York, MacMillian Publishing
Company 1988, pg76.
Marciani’s classification (1993 )
Le fort I – low maxillary #s
Ia – low maxillary #s/multiple segments
Le fort II – pyramidal #s
IIa - Pyramidal and nasal #s
IIb – pyramidal and naso-orbito-ethmoidal complex #s
Le fort III – craniofacial dysjunction
IIIa – craniofacial dysjunction and nasal #
IIIb – craniofacial dysjunction and NOE #
Le fort IV – le fort II or III with cranial base #
IV a - +supraorbital rim #
IVb - +anterior cranial fossa and supra orbital rim #
IVc - +anterior cranial fossa and orbital wall #
Modified LeFort
Classification
From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg
1993;51:962.
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Dento alveolar
Subzygomatic
Le fort I
Le fort II
Suprazygomatic
Le fort III
Lé Fort I Line
Aka horizontal/guerin’s/ floating/ low level/
subzygomatic fracture
# line – commences at a point on the lateral margin of
the nasal aperture, passes above the nasal floor,
laterally above the canine fossa and traverses the
lateral antral wall, dipping down below the zygomatic
buttress and then inclines upward and posteriorly
across the pterygomaxillary fissure to fracture the
lower 1/3rd of the pterygoid laminae.
Lefort 1
Typically bilateral, with fracture of lower third of nasal
septum, but may be unilateral
May occur as a single entity or in association with Le
Fort II & III #s
Usually caused by violent force applied over a more
extensive area above the level of the teeth
May also be caused by a blow to the lower jaw
Clinical signs and symptoms
OMVIEW 30 DEGREES
TRUE LAT. VIEW OF SKULL
LEFORT II FRACTURE
Lé Fort II
Aka pyramidal/ subzygomatic fractures
# line runs below frontonasal suture from the thin
middle area of the nasal bones down on either side,
crossing the frontal process of the maxillae into the
medial wall of each orbit, and passing across lacrimal
bones immediately behind the lacrimal sac. From this
point, it passes downward, forward and laterally
crossing the inferior orbital margin slightly medial or
through the infraorbital foramen.
Lé Fort II
It then runs downwards and backwards across the
lateral wall of the antrum below the ZM suture, and
divides the pterygoid lamina at its middle third
Seperation of the block of the midface from the base
of the skull is completed via the nasal septum and may
involve the floor of the anterior cranial fossa
Lé Fort II
Usually caused by a violent force in an anterior
direction sustained by the central region of the middle
1/3rd of the facial skeleton over an area extending from
the glabella to the alveolar margin
Force may be delivered at the level of the nasal bones
Clinical signs and symptoms
60
Indications for treatment
61
Aims of treatment
Relieve pain
Restore function.
Prevent infection
64
Factors affecting the risk
65
TREATMENT
TREATMENT
CLOSED REDUCTION
OPEN REDUCTION
Principles of treatment
68
Open reduction may be appropriate where
69
Definitive treatment
Reduction
Manual manipulation
70
TREATMENT MODALITIES
Fixation and immobilization
Extraoral fixation
Craniomandibular fixation
Box-frame (pin fixation)
Halo-frame
Plaster of paries headcap
Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame
72
Immobilization within the tissue
Direct fixation
Transosseous wiring at
fracture sites
Frontozygomatic sutures
Infrorbital margin
Midline of the palate
73
74
Immobilization within the tissue
Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular
75
Immobilization within the tissue
76
Length of the hospital stay will depend on a
number of factors including:
Presence of other injuries
77
FRACTURES OF THE
ZYGOMATIC BONE
ZYGOMATIC BONE FRACTURES
Zygomatic or malar fracture are the terms commonly used to
described fractures that involve the lateral one third of the
middle face.
Other names for this fracture are:
1. Zygomatico-maxillary complex.
2. Zygomatico-maxillary compound
3. . Zygomatico orbital.
4. Zygomatic complex.
5. Malar.
6. Trimalar.
7. Tripod.
introduction
Masseter muscle
82
Four sutures involved in
Zygomaticomaxillary Complex
Fractures
1. Zygomaticonfrontal Suture
2. Zygomaticomaxillary Suture
3. Zygomaticotemporal Suture
4. Zygomaticosphenoid Suture
Zygomatic complex and arch fracture
91
ENOPTHALMOS
Clinical examination
Inspection
Palpation
Visual examination
Eye movement
Diplopia
Pupil reaction
93
Radiographical evaluation
96
Occipitomental view
(Posterioanterior oblique)
(water’s view)
97
submentovertex
99
Treatment
Timing:
As early as possible unless there are ophthalmic,
cranial or medical complications
Indications:
• Diplopia
• Restriction of mandibular movement
• Restoration of normal contour
• Restoration of normal skeletal protection for the eye
101
Methods of reduction
Temporal approach (Gillies et al
1927)
Buccal sulcus
approach (Keen
1909)
Elevation from
eyebrow approach
(the same principle of Gillies
approach)
104
Open reduction and fixation
Transosseous wiring at
Frontozygomatic suture
Infraorbial rim
Surgery:
•Infraorbital approach
105
Open reduction and fixation
Rigid fixation using plate and screws at
Frontozygomatic suture
Infraorbial rim
Inferior buttress of the zygoma
Surgery:
Kirschener wire
Pin fixation
Antral pack
108
QUESTIONS
THANK YOU