1. Dr V.RAMKUMAR
CONSULTANT DENTAL &FACIOMAXILLARY SURGEON
REG NO: 4118 –TAMILNADU- INDIA (ASIA)

2. LeFort fracture
Fracture of middle third
CLASSIFICATION:
A.Fractures not involving occlusion
1.Centralregion:
a. Fractures of the nasal bones and / or
nasalseptum
b. Fractures of the frontal process of the
maxilla.
c.Fractures of type ‘a’ and ‘b’ which extent
into the ethmoid bone (nasoethmoid).

3. d. Fractures of types ‘a’, ‘b’ and ‘c’ which
extent into the frontal bone (fronto-orbito-nasaldislocation).
2. Lateral regions : Fractures involving
the
zygomatic bone, arch and maxilla (zygomatic
complex) excluding the dentoalveolar
component.

4. B. Fractures involving the occlusion
1.Dentoalveolar
2.Subzygomatic
a)LefortI(low–level)
.Unilateral
.Bilateral
b)LeFortII(pyramidal)
.Unilateral
.Bilateral

5. 3.Suprazygomatic:
LeFort III (high level or
cranio facial dysfunction):
.Unilateral
.Bilateral

6. Signs and symptoms of LeFort I
fracture
1. Floating maxilla
2. Swelling of upper lip
3. Posterior gagging of occlusion

7. 4. Bleeding from nose
5. Echymosis of palatal region (molar area)
6. Derangement of occlusion

8. TThhiiss iiss ootthheerrwwiissee ccaalllleedd aa ppyyrraammiiddaall ffrraaccttuurree
bbeeccaauussee ooff tthhee nnaattuurree ooff tthhee ffrraaccttuurreelliinneess..
TThhee ttoopp ppoorrttiioonn ooff tthhee ppyyrraammiidd iiss aatt tthhee nnaassaall
bboonneess aanndd tthhee ffrraaccttuurree lliinnee rruunnss llaatteerraallllyy iinnvvoollvviinngg
tthhee llaasscciimmaall bboonneess, tthhee mmeeddiiaall wwaallll ooff tthhee oorrbbiitt
aanndd tthhee iinnffrraaoorrbbiittaall bboorrddeerr, ffrraaccttuurriinngg tthhrroouugghh oorr
mmeeddiiaall ttoo tthhee iinnffrraaoorrbbiittaall ffoorraammeenn aanndd rruunnss
bbaacckkwwaarrdd bbeenneeaatthh tthhee zzyyggoommaattiiccoommaaxxiillllaarryy
bbuuttttrreessss tthhrroouugghh tthhee llaatteerraall wwaallll ooff tthhee mmaaxxiillllaarryy
ssiinnuuss..
IItt aallssoo ffrraaccttuurreess tthhee pptteerryyggooiidd ppllaatteess.. TThhee zzyyggoommaa
ffeemmaaiinnss iinnttaacctt wwiitthh tthhee bbaassee ooff tthhee sskkuullll..

9. Signs and symptoms of LeFort II fracture
1.Gross oedema of soft tissue of middle 3rd of
face
2.Bilateral circumorbital echymosis
3.Bilateral subconjunctival echymosis
4.Deformity of nose

10. obstruction
6.Dish face deformity of face
7.Retro positioning of maxilla with posterior
gagging
8.mobility of upper jaw at LeFort II level

11. 9.Limitation of ocular movements
10.CSF rhinorrhoea, appreciated by salty taste
11.Tenderness and sepration of infraorbital
margin and zygomatic buttress.

12. LeFortIIIFracture
These fractures are often called
craniofacial disjunction and the fracture
actually separates the entire facial
bones from the cranial base.
The fracture runs parallel to the
base of the skull.
This is sometimes termed ‘high level’
fracture or transverse fracture

13. The fracture line runs through the nasal
bone and continues posteriorly involving the
lacrimal bones and the full depth of the
ethmoid bone, and runs around the optic
foramen, involves the inferior orbital fissure,
the pterygomaxillary fissure and later orbital
wall involving the frontozygomatic suture,
LeFort III fractureszygomatic arch also.

14. Sings and symptoms of LeFort III fracture
1. Tenderness and separation at
frontozygomatic suture and zygomatic arc.
2. Lengthening of face
3. Enophthalmos
4. Hooding of eyes

15. 5.CSF rhinorrhoea
6.Tilting of occlusal plane
7.Mobility of whole facial skeleton as a single block

16. Management of middle third fracture
DIRECT /INTERNAL FIXATION OF MAXILLA
A. Direct osteosynthesis :
a) Transosseous wiring at fracture :
i. LeFort I (Alveolar /midpalatal)
ii. LeFort II (orbital rim /zygomatic buttress)
iii.LeFort III (dentozygomatic and pentonasal)

17. b) Miniplates:
i. Stainless steel plate /titanium plate
ii. Microplating
iii. Compression plates
. Dynamic
. Eccentric
iv. Polyglycolic acid resorbable plates

18. c) Transfixators with kinschnes wire or
steinman pin
i. Transfacial
ii. Zygomatic septal

19. a. Frontal
1. Central
2. Lateral
b. Circumzygomatic
c. Zygomatic
d. Intraorbital
C. Support
a) Antral pack
b) Antral ballon

20. External Fixation of maxilla
1. Craniomandibular
a. Box frame
b. Halo frame
c. Plaster of paris head layer

21. 2.Craniomaxillary
a.Supraorbital pins
b.Zygomatic pins
c. Haloframe

23. INTERNAL SUSPENSION
Internal suspension for stabilization of middle third
fracture is of following types :
a. Circumzygomatic suspension
b. Zygomatic suspension
c. Intraorbital suspension
d. Pyriform aperture suspension
e. Frontal
1. Central
2. Lateral

24. (A) Circumzygomatic suspension
This technique is used in subzygomatic
fractures where the zygoma is intact. The
wire is passed around the zygomatic arch.

25. Technique
An obwegeser bone awl is pierced extraorally at the
point of the junction of the temporal and frontal processes
of the zygomatic bone.
It is directed beneath the zygoma intraorally in such a
way as to enter the oral cavity in the buccal sulcus at the
first molar region.

26. The wire is attached and the bone awl is
withdrawn to a level where is tip lies just above
the arch without emerging from the skin.
The awl is then passed over the lateral aspect
and directed downwards to enter the oral cavity
at the original point in the buccal sulcus.

27. Instead of a bone awl a wide born spinal needle can
also be used for the purpose.
The wire is sawed so as to cut through the soft
tissue and come in contact with the zygomatic bone.
The wire is then fixed to the arch bar or splint,
either to the maxilla or mandible in the premolar area.

28. (b) Zygomatic suspension:
The inferior ridge of the zygomatic buttress is
used for suspension.
The area is approached through the buccal
sulcus.

29. (c)Infraorbitalsuspension
A small hole is drilled through the lower border
of the orbit and the wire is suspended from the
border.
The area is approached through a 2.5 cm,
semilunar incision beneath the orbit.

30. intraoral approach through the buccal sulcus
above can also be used for this purpose.
A 3 cm incision is placed above the canine
fossa.
During drilling of the hole and threading the wire
the eyeball should be well protected by malleable
retractors.

31. (d) Pyriform aperture suspension
A 2 cm incision is placed transverse above the
lateral incisor and the bony pyriform aperture is
exposed.
A drill hole is made 1 cm from the free border to
the lateral side.
The wires are then fixed to the appropriate loop
or splint on the arch.
This method is useful in cases of LeFort I type
of fractures.

32. Frontal suspension
(i)Lateral
An incision is made in the lateral border of the
eyebrow to expose the zygomatic process of the
frontal bone just above the frontozygomatic
suture.

33. A bur hole is drilled about 5 mm above the suture
line.
The wire is passed and the both ends together
are passed downward and forward behind the
zygomatic bone using a Rowe's zygomatic bone
awl to emerge in the buccal sulcus near the first
molar tooth.

34. where the wire passes through the bone hole.
This facilitates easy removal of the wire after the
completion of the treatment.
This type of suspension is used in cases where
the fracture is supra zygomatic .

35. (ii)Central
This method was introduced by Kufner (1970). A
2 cm incision is made horizontally on the
forehead just above the frontal sinus.
A Roger Anderson pin is introduced in an oblique
downward direction engaging the inner table of
theskull.

36. A 2 cm subcutaneous tunnel is created below the
pin.
An level is passed through the vestibule of the
cavity in the upper canine region and passing
lateral to the pyriform margin of the nose in front
of the lacrimal gland and emerges through the
subcutaneous tissue tunnel.

37. The two ends of the wire (looped around the pin)
is engaged in the awl and withdrawn.
The same procedure is repeated on the opposite
side and wires are pulled to remove any
slackness.
After reduction of the fracture the wires are fixed
to the maxillary or mandibular splints or loops for
fixation.

38. Duration of treatment:
The duration of treatment varies depending on
the site of fracture, condition of each case
and the treatment modality.
As a general rule the intermaxillary fixation
has to be kept in position for a period of three
to four weeks in children and adolescents.
In adults the period of IMF is 5 to 6 weeks.
In old patients and in infected cases the
period of fixation has to be increased from 7
to 10 days more.

39. .
COMPLICATIONS
In properly treated maxillofacial injuries
complications are comparatively rare.
The complications seen are :
1 Anaesthesia:
Anaesthesia of the lower lip occurs in cases of
neuropraxia, axonotmesis or neurotmesis of the
mandibular nerve.

40. This may occur in fracture of the body of the
mandible.
Neuropraxis will usually recover in a period of
few weeks.
But if the nerve is severed it may take about 1
to 2 years for recovery.
If the infraorbital nerve is involved
anaesthesia occurs in the region of lower
eyelid, lateral part of the nostril, upper lip
on the affected side and the anterior teeth.

41. 2. Malunion and deformities
Deformities of the face occur if the reduction is not
satisfactory or malunion occurs.
In the case of mandible, functional remodelling takes
place very rapidly in a matter of months.
Proper remodelling does not take place in the instance
when the fracture at one side of the genial tubercle is
malpositioned.
This results in a marked asymmetry.

42. In the middle third injuries, improper reduction
can result in flattening of the face, dish face
deformity and anterior open bite with gagging of
the molar teeth.
Anterior open bite with gagging of the molar
teeth occurs in bilateral condylar fractures also.

43. 3.INFECTIO
N
Infection is a very rare complication.
It occurs if the root stumps are left in the
fracture line or in cases where the general
resistance of the patient is poor.
Infection can also occur when there is improper
fixation causing mobility at the fracture site.

44. 4. Superior orbital fissure syndrome
Trauma to the zygomatic complex sometimes
may damage the contents of the superior orbital
fissure.
Haematoma or aneurysm within the fissure
affects the 3rd, 4th and 6th cranial nerves,
resulting ophthalmoplegia, ptosis, proptosis and
a fixed dilated pupil.
Unless the nerve is traumatized there is
complete or partial recovery.

45. Nonunion is comparatively rare in the
maxillofacial region. However, non-union or
delayed union occurs in the following conditions :
(a)If a tooth has been left in the fracture line.
(b)The fracture is infected due to some other
reasons.
(c)Inadequateimmobilization.
(d) Patients debilitated by systemic diseases and
deficiencies.

46. 6. Derangement ooff tthhee oocccclluussiioonn
IInn aa ssaattiissffaaccttoorriillyy ppeerrffoorrmmeedd ttrreeaattmmeenntt,, oocccclluussaall
ddeerraannggeemmeenntt iiss mmiinniimmaall aanndd tthhiiss ggeettss ccoorrrreecctteedd
bbyy iittsseellff aass tthhee ppaattiieenntt ssttaarrttss uussiinngg tthhee tteeeetthh..
IIff tthheerree iiss aa ppeerrssiisstteennccee ooff ttrraauummaattiicc oocccclluussiioonn
sseelleeccttiivvee ggrriinnddiinngg iiss ddoonnee..
IIff oocccclluussaall ddeerraannggeemmeenntt iiss sseevveerree iinn nneegglleecctteedd
ffrraaccttuurreess rreeffrraaccuuttuurraall ooff tthhee ffrraaggmmeenntt aanndd
ccoorrrreeccttiioonn iiss ppeerrffoorrmmeedd..

47. 7. Ankylosis of the temporomandibular joint
This is comparatively higher in young
children.
The chances are more if there is an
intracapsular fracture.
Prolonged immobilization also may result in
ankylosis of the temporomandibular joint.

48. 8. Other complications
Diplopia, enophthalmos, strabismus,
etc. are certain other
complications associated with injuries
of the orbit.
Deviated nasal septum my result in
blockade of the nares.
Damage to the nasolacrimal duct result
in epiphora.
Anosmia occurs if the olfactory nerve is
affected due to the communication of the
cribriform plate of ethmoid.