MIDDLE THIRD MIDDLE THIRD FRACTURESFRACTURES

Dr V.RAMKUMAR Dr V.RAMKUMAR

CONSULTANT DENTAL&FACIOMAXILLARY CONSULTANT DENTAL&FACIOMAXILLARY SURGEONSURGEON

REG:NO:4118-TAMILNADU-INDIA(ASIA)REG:NO:4118-TAMILNADU-INDIA(ASIA)

THE FACIAL SKELETONTHE FACIAL SKELETON

Facial skeleton: a) Lower third/ MandibleFacial skeleton: a) Lower third/ Mandible b) Upper third/ Frontal b) Upper third/ Frontal

bonebone c) Middle third ( Frontal/ c) Middle third ( Frontal/

Upper alveolus)Upper alveolus)

Fractures of the middle third are called Fractures of the middle third are called maxillofacial injuriesmaxillofacial injuries

AETIOLOGYAETIOLOGY

a) a) Chief cause – RTAChief cause – RTA b) Urban violence b) Urban violence c) Sports injuriesc) Sports injuries d) Falls (Zygomatic)d) Falls (Zygomatic)

STRUCTURES INVOLVEDSTRUCTURES INVOLVED Overlying soft tissue injuries & Overlying soft tissue injuries &

neighboring structuresneighboring structures- Eyes- Eyes- Nasal airways- Nasal airways- Paranasal sinuses- Paranasal sinuses - Tongue- Tongue

Bones that are not usually involved in Bones that are not usually involved in middle third fractures are : middle third fractures are :

- Frontal bone- Frontal bone - Greater & lesser wings of sphenoid - Greater & lesser wings of sphenoid

bonebone

BONES OF THE MIDDLE THIRD BONES OF THE MIDDLE THIRD FACIAL SKELETONFACIAL SKELETON

Two maxillaeTwo maxillae Two zygomatic bonesTwo zygomatic bones Two zygomatic processes of temporal Two zygomatic processes of temporal

bonesbones Two palatine bonesTwo palatine bones Two lacrimal bonesTwo lacrimal bones The vomerThe vomer The ethmoid and its attached conchaeThe ethmoid and its attached conchae The inferior conchaeThe inferior conchae The pterygoid plates of the sphenoidThe pterygoid plates of the sphenoid

INVOLVEMENT OF BRAIN & CRANIAL INVOLVEMENT OF BRAIN & CRANIAL NERVES IN CRANIOFACIAL INJURIESNERVES IN CRANIOFACIAL INJURIES

CSF RhinorrhoeaCSF Rhinorrhoea

- - severe fractures of the nasal complex severe fractures of the nasal complex causing a dural causing a dural

tear in the cribiform plate of ethmoidtear in the cribiform plate of ethmoid

- # involving posterior wall of frontal sinus- # involving posterior wall of frontal sinus

- Coincident # of orbital roof- Coincident # of orbital roof

- Rarely fracture involving the sphenoid - Rarely fracture involving the sphenoid bonebone

NERVES DAMAGEDNERVES DAMAGED

Anterior, middle and superior Anterior, middle and superior alveolar nervesalveolar nerves

Cranial nerves within the orbitCranial nerves within the orbit More commonly the 6More commonly the 6thth cranial nerve cranial nerve

INVOLVEMENT OF THE ORBITINVOLVEMENT OF THE ORBIT

Hooding of the eyeHooding of the eye Temporary or permanent diplopiaTemporary or permanent diplopia EnophthalmusEnophthalmus EpiphoraEpiphora TelecanthusTelecanthus Haemorrhage (Retrobulbar)Haemorrhage (Retrobulbar)

BLOOD VESSELSBLOOD VESSELS

Third part of the maxillary arteryThird part of the maxillary artery When the artery or its greater palatine When the artery or its greater palatine

branch torn in region of the branch torn in region of the pterygomaxillary fissure or pterygopalatine pterygomaxillary fissure or pterygopalatine canal it is life-threatening as it causes canal it is life-threatening as it causes hemorrhage in to nasopharynx.hemorrhage in to nasopharynx.

CLINICAL CLASSIFICATION OF CLINICAL CLASSIFICATION OF MIDDLE THIRD FRACTURESMIDDLE THIRD FRACTURES

Le Fort I fracture (Low level or Le Fort I fracture (Low level or Guerian fracture)Guerian fracture)

Le Fort II fracture (Pyrimidal or Le Fort II fracture (Pyrimidal or subzygomatic fracture)subzygomatic fracture)

Le Forte III fracture (High Le Forte III fracture (High transverse or suprazygomatic #)transverse or suprazygomatic #)

Le Fort I Le Fort I

Le-Fort Fracture LinesLe-Fort Fracture Lines

Naso-Orbital AnatomyNaso-Orbital Anatomy

CLASSIFICATION CLASSIFICATION A. # not involving the occlusionA. # not involving the occlusion

1) Central region:1) Central region:

a) # of the nasal bones and or nasal septum a) # of the nasal bones and or nasal septum

i) Lateral nasali) Lateral nasal

ii) Anterior nasalii) Anterior nasal

b) # of the frontal process of maxillab) # of the frontal process of maxilla

c) # of a & b which extend in to ethmoid bone c) # of a & b which extend in to ethmoid bone (naso (naso

ethmoid)ethmoid)

d) # of a, b, & c which extend in to frontal bone d) # of a, b, & c which extend in to frontal bone

(fronto-orbito-nasal dislocation)(fronto-orbito-nasal dislocation)

Contd...Contd...

22) Lateral region) Lateral regionFractures involving the zygomatic bone, Fractures involving the zygomatic bone, arch, and maxilla (zygomatic complex) arch, and maxilla (zygomatic complex) excluding the dento-alveolar compartmentexcluding the dento-alveolar compartment

B. Fractures involving the occlusionB. Fractures involving the occlusion1)1) DentoalveorDentoalveor2)2) SubzygomaticSubzygomatic

Le fort I & II #Le fort I & II #3)3) SuprazygomaticSuprazygomatic

Le forte IIILe forte III

IMMEDIATE TREATMENTIMMEDIATE TREATMENT

THE AIRWAY:THE AIRWAY:

- Nasopharyngeal tube (latex)- Nasopharyngeal tube (latex)

- Endotracheal intubation- Endotracheal intubation

- Tracheostomy- Tracheostomy

- Haemorrhage- Haemorrhage

nasal & post nasal packnasal & post nasal pack

SHOCK:SHOCK:

PRELIMINARY EXAMINATIONPRELIMINARY EXAMINATION

Head injuryHead injury EyesEyes SpineSpine LimbsLimbs Abdomen & chestAbdomen & chest Soft tissue lacerationsSoft tissue lacerations

STEPS IN DIAGNOSIS & STEPS IN DIAGNOSIS & MANAGEMENTMANAGEMENT

History and local examinationHistory and local examination Control of pain – Diazepam IV 10 mgControl of pain – Diazepam IV 10 mg Control of infection Control of infection

- Benzyl penicillin IM/later orally- Benzyl penicillin IM/later orally - Sulphadiazine 2 mg for 5 days (in - Sulphadiazine 2 mg for 5 days (in CSF leaks)CSF leaks)

Management of CSF RhinorrhoeaManagement of CSF Rhinorrhoea

RADIOGRAPHIC EXAMINATIONRADIOGRAPHIC EXAMINATION A) For the midface:A) For the midface:

- Occipiotmental at 10- Occipiotmental at 10˚̊& 30& 30˚̊- True lateral at 6 feet- True lateral at 6 feet

- Soft tissue lateral at 6 feet- Soft tissue lateral at 6 feet

- Soft tissue lateral at 6 feet- Soft tissue lateral at 6 feet

- occlusal view of maxilla- occlusal view of maxilla

- Intra oral- Intra oral B) For the skull vault:B) For the skull vault:

- lateral view to include cervical spine- lateral view to include cervical spine

- occipitofrontal with tube angled at 28- occipitofrontal with tube angled at 28˚̊- fronto occipital (Towne’s projection)- fronto occipital (Towne’s projection)

Contd…Contd…

Others:Others:

- Xeroradiograph- Xeroradiograph

- Computed tomography- Computed tomography

- Hypocycloid tomography- Hypocycloid tomography