Fractures of the Middle Third
of the Face
Maxillary Fracture
Can compromise the airway
Commonly transverse
Direct trauma to the face
4/9/2015
Professor Sameer Bafaqeeh
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Le Fort Fractures
System
• Le Fort 1: The upper
alveolus is detached
• Le Fort 2: the entire
upper jaw is detached
• Le Fort 3: the F.S. is
separated from the S.B.
4/9/2015
Professor Sameer Bafaqeeh
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Fractures of the Middle
Third
of the Face
• High-speed injuries
(Motor vehicle accidents)
• Seatbelt Laws
4/9/2015
Professor Sameer Bafaqeeh
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Fractures of the Middle
Third
of the Face
• Careful history &examination
• Palpation around the facial
structures
• Jaw movements &mobility
• Eye & eye movements
4/9/2015
Professor Sameer Bafaqeeh
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Types of Central Middle Third Fracture
(Le Fort Classes I )
Maxillary Fracture
Clinical presentation
*Le Fort Class I
– Low max. horizontal fractures
– # the upper alveolus
– Abnormal occlusion
– Hematoma or fracture of the
antral wall
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Professor Sameer Bafaqeeh
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Types of Central Middle Third Fracture
(Le Fort Classes II )
Maxillary Fracture
Clinical presentation
*Le Fort Class II
– Pyramid fractures
– # the upper jaw
– The fracture passes
– Dislocation and depression
– Ethmoids, orbital, lacrimal involvement
– Hypertelorism
4/9/2015
Professor Sameer Bafaqeeh
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Types of Central Middle Third Fracture
(Le Fort Classes III )
*Le Fort Class III
– F. Sk. and SB are separated
– The fracture line: zygomaticofrontal,
maxillofrontal, and nasofrontal sutures
– All the structures of the central part
of the facial skeleton are involved
– Massive depression of the middle third
of the face
– Multiple fractures of the bones (dish face)
– Typical symptoms (shock, concussion,
cerebral contusion)
4/9/2015
Professor Sameer Bafaqeeh
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Pathogenesis
Central Middle-third Fractures
# High-speed injuries
• Traffic accidents
• Occupational injuries
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Professor Sameer Bafaqeeh
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Trauma of the Middle Third of the Face
Diagnosis
* History: Type, direction and force
* Inspection:
– Skeletal (fracture, dislocations,depression)
– Symmetry of middle and frontal areas
– The nose
– The orbit (hematoma, movement, & vision)
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Professor Sameer Bafaqeeh
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Trauma of the Middle Third of the Face
Diagnosis (cont.)
* Palpation: Tenderness, upper jaw,
facial contour, bony skeleton,
orbital rim, trismus, nose root,
mandible, occlusion, teeth.
* Sensory or motor innervation
* CSF Rhinorrhea
* Brain tissue
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Professor Sameer Bafaqeeh
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Trauma of the Middle Third of the Face
Diagnosis (cont.)
* Radiography: – Skull radiography
(Radiopaque F.B.)
– Angiography
– C.T. scan
– Olfactometry
* Maxillofacial surgeon, an ophthalmologist
a neurologist, a neurosurgeon, general
and orthopedic surgeon are consulted.
4/9/2015
Professor Sameer Bafaqeeh
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NOTE:
Rapid soft tissue
swelling.
Bloody effusion.
Soft tissue injuries.
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}
concealed
concealed
Skeletal
assymetry
or deformity
Life-threatening
skeletal injuries
Professor Sameer Bafaqeeh
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Treatment of
Middle Third Injuries
Traumatologic ABC
A = Airway (the airway is secured and
aspiration is prevented)
B = Bleeding (must be controlled)
C = Circulation (shock must be treated)
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Professor Sameer Bafaqeeh
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Fracture Middle 1/3 Face
• Hospitalization: Traumatologic center
• Admission: Extent and type of the skull,
thorax, abdomen & extremities
• Patient head injury: Special traumatologic
teams
(A neurosurgeon, a rhinosurgeon, a maxillofacial surgeon and an ophthalmic surgeon)
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Professor Sameer Bafaqeeh
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Definitive Surgery of
Middle Third Fractures
• Reconstitution (anatomy and function)
- Debridement
- Ventilation
- Drainage
• Rhinologic surgeon:
I - Soft tissue injury, nose and sinuses
II - Assessment of the base skull
III- Correction of the F.Sk. and the B.O.
• D.S. should be carried out quickly
Fracture
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Formation
of callus
Rapidly heal in wrong
position
Professor Sameer Bafaqeeh
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Fractures of the
Mandible
•
•
•
•
•
•
Maintain the airway
Stop hemorrhage
Intracranial or other injury
Mouth deformity& malocclusion
Inferior dental nerve
Orthopantamogram [OPG]
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Professor Sameer Bafaqeeh
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Mandible Fractures
Treatment
• Undisplaced fractures:
Analgesia & antibiotics
.A simple fracture: Intermaxillary
fixation [eyelet wiring]
.An irreducible fracture:
Open reduction&fixation
Wires or an AO Plate.
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Professor Sameer Bafaqeeh
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Key Points:
• 1.In orbital trauma, check the eye
movements, palpate the bony orbital
rim, and record visual acuity.
• 2.In patients with facial injury, always
check the full range of jaw mov.
&determine whether or not the upper
jaw is mobile. fractures of the cheek
bone [ zygoma ] are often overlooked.
• 3.Wear eye protection while playing
racquet sports.
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Professor Sameer Bafaqeeh
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Isolated Blowout Fracture
– Localized violence -->
Orbital contents
– A blow (a fist, a tennis ball, a sq. ball,
a champagn bottle cork, etc )
– Fractures of the orbital bony floor
– Trapping of the orbital contents
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Professor Sameer Bafaqeeh
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Blowout Fracture
Symptoms
– Enophthalmos
– Double vision
– Limitation of eye movement
– Infraorbital nerve sensation
disorders
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Professor Sameer Bafaqeeh
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Blowout Fracture
Diagnosis
• Radiographs “tear drop”
• Tomograms
• Ophthalmologic examination
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Professor Sameer Bafaqeeh
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Blowout Fracture
Treatment
• The antral cavity must be explored:
- The bony fragments are exposed
- The prolapsed part is replaced
- Bridging or stabilization
(Lyophilized dura, cartilage or plastic prop)
• Alternative or supplementary measures:
- Orbital access
- Lyophilized dura, silicone sheet, or teflon
- Autologous implant to correct enophthalmos
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Professor Sameer Bafaqeeh
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Professor Sameer Bafaqeeh
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Nasal trauma
in Childhood
• Child’s nose - less promineent
-more cartilaginous
.Nonaccidental injury -[grotesque]
.# growth centers N.deformity
.Surgical correction :conservative
delay
.Cart. : repositioned not resected
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Professor Sameer Bafaqeeh
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Mucosal injuries of the
MOUTH & Pharynx
[ F.B. & Trauma ]
• Good healing
properties
• Mucosal
suture in
extensive
injuries
• Antibiotic
cover
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Professor Sameer Bafaqeeh
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Penetrating soft tissue injuries of the
Mouth and Pharynx
• Bullet, stab, and
traffic accidents
wounds.
• Mouth and Pharynx
must be assessed
with related soft
and bony tissues
• Structures shoud
be debrided,
repositioned, fixed,
and sutured in
layers
• Antibiotic
• Surgical
emphysema
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Professor Sameer Bafaqeeh
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Impalement injuries of the
Palate and posterior
Pharyngeal wall
• Children falling on pointed
objects.
• Expert examination
• Suture of the wound
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Professor Sameer Bafaqeeh
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Tongue Bites
 Heal spontaneously
 Penetrating bite
require suture
 Completely divided
tongue
reimplanted :
 -the time of
reconstruction
 -the condition of
the wound
 -the blood
supply
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Professor Sameer Bafaqeeh
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Insect Bites
• Swallowing a living
insect
[bees, etc.] .
• Edema of the
pharynx
respiratory
obstruction
• I.V. high-dose
steroids
• Ice packs
• Calcium &
tracheotomy
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Professor Sameer Bafaqeeh
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