DIAGNOSIS &

MANAGEMENT OF
MIDFACE FRACTURES

DR SOBIA NASEEM
 MIDFACE

• Spans from the cranial base to maxillary occlusal

plane
• Important both functionally and cosmetically
• Provides support to the globes, sinuses, muscles of
mastications, muscles of facial expressions and
upper dentition
 INCIDENCE AND ETIOLOGY

• Account for approximately 33% of all facial

fractures
• Result from high-energy (>1200 m/sec), blunt force
injury to the facial skeleton
• Motor vehicle accidents, assaults, and falls
• Male to female ratio – 4:1

Author
Kris S Moe, MD, FACS Chief, Division of Facial Plastic and Reconstructive Surgery,
Department of Otolaryngology-Head and Neck Surgery, University of Washington School of
Medicine
Jun 17, 2018
 ANATOMY

• Centred by maxilla
• Articulations
• Palatine
• Zygomatic
• Nasal
• Sphenoid
• Ethmoid
• Vomer
 BLOOD SUPPLY
• Internal maxillary artery
• Descending palatine
• Sphenopalatine
• Infraorbital
• Superior alveolar artery
• Opthalmic artery
• Anterior and
• posterior ethmoidal
 NEUROSENSORY SUPPLY

• Maxillary Nerve
• V2 – Second division of trigeminal nerve
• Exits the infraorbital foramen and supplies the
• Lateral nasal
• Superior labial
• Inferior palpebral
• Labial mucosa
• Maxillary anterior teeth
 SKELETAL BUTTRESSES

• Provide support and protect vital structures from

external forces
• Vertical pillars
• Nasomaxillary (medial) Resistant to vertically
directed forces
• Zygomaticomaxillary (lateral)
• Pterygomaxillary (posterior)
• Horizontal pillars
• Supraorbital/frontal bars Weaker but provide
• Infraorbital rims some resistant
• Zygomas/Maxillary alveolus
• Weakest protection is available from thin sagittal
butresses provided by the maxillary walls, palate,
lateral nasal walls, and the nasal septum
• Thin bone between this framework creates
anatomic sites of weakness – results in predictable
fracture patterns
 CLINICAL SIGNIFICANCE

• Allows improved appreciation of facial structure

• Provide sufficient bone thickness to accommodate
metal screw fixation
• Linked directly or indirectly to the cranial base as a
stable reference point
• Reduction of transverse / horizontal buttresses
restores facial profile and width
• Reduction of vertical buttresses restores facial
height
• Reduction of the buttresses restores functional
support to the teeth and globes
 CLASSIFICATION

• Includes
• Nasal fractures
• Orbital fractures
• Naso-orbital-ethmoid fractures
• Zygomatic and zygomaticomaxillary complex fractures
• Le fort fractures
• Palatal fractures
• Maxillary dentoalveolar fractures
• Alphonso Geurin (1886)
• Rene` Le Fort Classification (1901)
• Rowe and William Classification (1985)
• Modified Le Fort Classification (Marciani, 1993)
• Donag, Endress, Mathog Classification (1998)
LE FORT CLASSIFICATION SYSTEM- 1901

• Rene` Le Fort identified the lines of weakness of

maxilla
• 3 patterns of separation
• Le Fort I – low level fracture
• Le Fort II – pyramidal or subzygomatic fracture
• Le Fort III - high transverse or suprazygomatic, craniofacial
dysjunction
• Less satisfactory – to describe more complex
fracture patterns,
communited, incomplete,
combination or fractures
bearing occlusal segment
MODIFIED LE FORT CLASSIFICATION
Proposed by Marciani in 1993
Le Fort I Low maxillary fracture
Ia Low maxillary fracture/multiple segments
Lefort II Pyramidal fracture
IIa Pyramidal and nasal fracture
IIb Pyramidal and NOE fracture
Lefort III Craniofacial disjunction
IIIa Craniofacial disjunction and nasal fracture
IIIb Craniofacial disjunction and NOE fracture
Lefort IV Lefort II or III fracture and cranial base fracture
IVa + supraorbital rim fracture
IVb + anterior cranial fossa and supraorbital rim
IVc + anterior cranial fossa and orbital wall fracture
 ROWE AND WILLIAM FRACTURE
CLASSIFICATION
• Fracture not involving the occlusion
• Central region
• Nasal bone/septum(lateral, anterior injuries)
• Frontal process of the maxilla
• Nasoethmoid
• Fronto-orbito-nasal dislocation
• Lateral region
• Zygomatic complex
• Arch
• Fracture involving the occlusion
• Dentoalveolar
• Subzygomatic – Lefort I, II
• Suprazygomatic – Lefort III
DONAG, ENDRESS, MATHOG
CLASSIFICATION
 DIAGNOSIS

• Initial evaluation – ATLS

• Comprehensive facial examination
• Inspection
• Assymetry
• Edema
• Ecchymosis
• Abrasions
• Lacerations
• Haemorrhage
• Gross deformities
• Otorrhea
CSF leakage
• Rhinorrhea
• Intra-oral – fractured teeth, vestibular ecchymosis and edema,
palatal ecchymosis, mucosal lacerations and bleeding,
• Palpation
• Assess for step-offs, mobility, crepitus or irregular segments
• Begin at the frontal bone and supraorbital rims progress
downward to evaluate zygomas, maxilla and mandible
• Full ocular examination
• Ocular injury is present in 90% of midface trauma
• In 30 % of NOE fractures there is a significant risk of ocular injury
and subsequent loss of vision
• Signs of orbital trauma – periorbital edema, ecchymosis
• Proptosis
• Diplopia
• Extraocular muscle movement
• Pupillary size
• Reactivity to light
• Visual acuity – snellen chart
• Fundoscopic examination
• Examination of cranial nerves
• Focus on facial and trigeminal nerve functions
• Most midface fractures are accompanied by disturbance
of sensation- hypothesia or anesthesia, in the distribution of
infraorbital nerve supply
• Nasal examination
• Endonasal inspection
• Mobility or assymetry of nasal bone
• Septum hematoma and lacerations
• nose speculum
• Evaluation of maxilla
• Firmly grasping the pre-maxilla and attempting to displace it
in 3 dimensions
• Ecchymosis and laceration of the vestibule or palate
• Malocclusion, widening of maxilla – palatal fracture
Head is stabilized and the
dentoalveolar process is
manipulated so that gross movements
of fractured segments
can be detected. Checking for Le Fort
II or III fractures requires
that one hand holds the bridge of the
nose while the other
manipulates the maxilla. Movement at
the nasofrontal suture
suggests a Le Fort II or III fracture.
 IMAGING
• Plain radiographs
• Water’s view Caldwell antero-posterior view
• Lateral facial radiographs Submentovertex view
• CT
• Modality of choice
• Axial and coronal scans
• Thin cuts of 1.0-2.0mm show adequate anatomic detail
• 2D CT
• 3D CT
• Decreased ability to detect non displaced fractures; inadequate
soft tissue evaluation; difficulty detecting deeper fractures
• MRI
• When intracranial injury or unusual soft tissue injury is suspected
• Helpful in evaluation of cranial nerve deficits
 LE FORT I

• Traverse the lateral antral wall, the lateral nasal wall,

and the lower third of the septum, and they
separate at the pterygoid plates
• Consists of the maxillary alveolar bone, the palatine
bone, the lower third of the nasal septum, and the
lower third of the pterygoid plates
• Caused by force delivered above the apices of
maxillary teeth
• Clinical findings
• Maloccluson - Anterior open bite – due to pull of lateral and
medial pterygoid maxilla is displaced backward and
downward
• Maxillary mobility - Examination
• Manual assessment – placing index finger and thumb posterior
on the bony segment of maxillary arch and attempt movement
3 dimensionally
• Pain on palpation and on occlusion
• Palatal fracture – manually to transversely widen or collapse of
maxillary arch and palatal ecchymosis
 LE FORT II

• Also called pyramidal fracture

• extends from below the nasofrontal suture through the
nasal bones along the maxilla to the
zygomaticomaxillary suture and includes the medial
inferior third of the orbit. The fracture then continues
along the zygomaticomaxillary suture to and through
the pterygoid plates
• involve the nasal bones, the maxillary bones, the
palatine bones, the lower two thirds of the nasal septum,
the dentoalveolus, and the pterygoid plates
• Associated with intracranial injury and increased
mortality
• Clinical Findings
• Extensive soft tissue edema
• Mobility and step offs at infraorbital rims and nasal bridge
with overlying edema and ecchymosis
• Racoon eye sign – in orbital fracture - bilateral periorbital
edema and ecchymosis
• Manipulation of maxilla
• Mobility at nasofrontal junction and infra-orbital rims
• Epistaxis
• CSF rhinorrhea, or otorrhea – in dural tear
• Disturbed sensation – infraorbital nerve
 LE FORT III

• Extends from the nasofrontal suture along the medial

wall of the orbit through the superior orbital fissure. It then
extends along the inferior orbital fissure and the lateral
orbital wall to the zygomaticofrontal suture. The
zygomaticotemporal suture is also separated. The
fracture then extends along the sphenoid bone,
separating the pterygoid plates.
• Involve the nasal bones, the zygomas, the maxillae, the
palatine bones, and the pterygoid plates
• Majority are combination of Le Fort I, II, ZMC and NOE
• Associated with serious intracranial injuries, orbital and
fascial
• Clinical Findings
• Le Fort II findings
• Mobility at zygomaticofrontal and nasofrontal sutures
• CSF rhinorrhea or otorrhea
• Battle sign – ecchymosis overlying the mastoid process due
to skull base fractures
 MANAGEMENT

• General considerations
• Ideal management is best performed within 10-14
days
• After this it is difficult to disimpact the maxilla and
achieve optimal soft tissue drape
• Steps
• Reduction
• Fixation
 LE FORT I

• Closed reduction - IMF

• Open reduction
• Exposure – maxillary vestibular incision
• Mobilization of maxilla may be necessary in delayed cases
• Mobilization and Reduction
• Rowe maxillary disimpaction forcep
• Tessier maxillary mobilizers
• Towel clamp in the anterior nasal spine region
• Establish occlusion – IMF
• 4 point Rigid internal fixation
• Miniplates placed onto zygomaticomaxillary buttress and along
the pyriform rim bilaterally
• IMF can be released
• The paired forceps are placed with the fat end in
the nose and the bowed end on the palate.
• The surgeon stands over the patient’s head and
disimpacts the maxilla with an inferior-anterior
movement.
• Further assistance may be provided by Hayton-
Williams forceps used in conjunction with the Rowe
disimpaction forceps.
 LE FORT II

• Open reduction and internal fixation

• Intraoral vestibular lesion
• Achieve 4 point fixation and stability
• Coronal incision
• In cases where multiple sites of fixation are required
• Additional advantage of the exposure of cranial vault for
graft harvest
• Transconjunctival
• Subciliary To gain access through the infraorbital rim
• Subtarsal or “mid lid”
• Infraorbital incision
• Mobilization of maxilla
• Fixation
• IMF
• Pure Le Fort II – rigid internal fixation is achieved at
zygomaticomaxillary buttresses and the infraorbital rims
• Additional points of fixation- based on fracture pattern and
communition
• If vertical facial height can not be re-establish due to
communition-maxilla can be fixated at a position that
allows allows approximately 2mm of incisor show at repose
 LE FORT III

• Often found to co-exist with other facial fractures

with varying patterns of complexity and
communition
• It can be a combination of bilateral Le Fort I/II,
zygomatic and NOE fractures
• Marciani and Gonty
• 4 factors contributing to successful management of
complex cranimaxillofacial fractures
• Early definitive treatment
• Anatomic and functional repair of NOE
• Wide exposure of fractured segments
• Stable fixation in all planes
• 2 school of thoughts
• Gruss et al
• Reconstruction proceeds from stable to unstable segments
• From outer to inner facial frame
• Mandibular fractures are fixated last
• Fixation of the outer facial frame then proceeds from lateral
to medial
• Frontozygomatic – frontotemporal – nasofrontal – maxilla is
secured to mandible (IMF) – reconstruction of nasal frame –
NOE segments – anterior maxillary buttresses
• Markowitz
• Width of the midface is first established at the NOE
region
• Followed by outward sequence of fixation (inside –
out)
• Mandible was fixated before final reduction of
midface is completed (bottom-up)
• Goals – facial width, height and projection and pre-
injury occlusion
• Increased communition
• Use bone grafting procedures to re-establish skeletal
buttress. Bone can be harvested from
• Calvarium – best option
• Ribs
• Ilium
• Intraorally from the mandible
• Titanium mesh
• Malleable
• Can be quickly fixated
• Resists pressure of the soft tissues of the face
• Becomes osseointegrated
• Allows regrowth of the native tissue (i.e., ciliated respiratory
epithelium, goblet cells, squamous epithelium)
 PALATAL FRACTURES

• 8-13% of Le Fort fractures are complicated with palatal

fractures
• Classification
• Hendrickson et al – 6 types based on fracture pattern
• Type I – alveolar
• Type II – sagittal
• Type III – parasagittal – most common (thin)
• Type IV – para alveolar
• Type V – Communited/complex
• Type VI - transverse
• Park and Ock – 4 class based on required treatment plan
• Class I – Closed reduction
• Class II – Anterior treatment
• Class III- Anterior and palatal treatment
• Class IV - Combined
• Rigid internal fixation is not indicated in routine use
• Arguments
• Significant compromise in blood supply effected with
mucosal stripping leading to bony necrosis
• Increase in the likelihood of oral nasal fistula
• Inability to simultaneously fixate the palate while
maintaining IMF – error in reduction of correct occlusion
• Pollock
• Palatal vault fixation transmucosally, decreasing the risk of
vascular compromise
• Reduction
• Digital pressure
• Specially designed forceps
• Occlusal splints
• pre-operative impressions – study models – splint fabricated
• When no mandibular fracture exist
• Cannot be used in edentulous maxilla – rigid internal fixation
• Fixation
• Arch bars
• K wires
• Transpalatal wire
• Palatal bar
• Mini plates
• Others
• Figure of eight wiring
• Pyriform wiring
NASO-ORBITO- ETHMOID FRACTURES

• Significant challenge in diagnosis and management

• Often involves communited segments and associated
with medial canthal tendon and the lacrimal appratus
• Other traumatic injuries – CNS injuries and CSF leakage
• Occurs with other midface fractures
• Ellis – 65% of patients with NOE injuries had concomitant
Le Fort or frontal sinus fractures
• Early repair is indicated – midface retrusion, blunted
palpebral fissures, telecanthus, ocular dystopia,
epiphora, nasal deformities, cerebrospinal fistula
formation
 ANATOMY

• Complex intersection of the cranium, nose, orbit

and maxilla
• Primary vertical support
• Frontomaxillary buttress – made up of the internal angular
process of the frontal bone, the frontal process of the
maxilla, the lacrimal bone, ethmoid lamina papyracea
bilaterally
• Fragile and prone to communition and displacement
• Horizontal support
• 2 buttresses – superior frontal bar along with the supraorbital
rims; inferiorly infraorbital rims and zygomas
• Close proximity to cribriform plate of ethmoid –
associated injury can result in
• CSF leakage
• Pneumocephalus
• Olfactory dysfunction
• Medial canthal ligament
• Complex fibrous extension of the tarsal plates and
orbicularis oculi muscles
• Divides into anterior and posterior limbs, which
each supply fibres to superior limbs (surrounds
lacrimal sac)
• Anterior limb attaches to the anterior lacrimal
crest of the frontal process of the maxilla; fan
shaped, pull the medial commissure of the eyelid
forward and downward.
• Posterior limb attaches to the posterior lacrimal
crest of the lacrimal bone; maintains the eyelid
position tangent to the globe
• Superior limb attaches to the junction of the frontal
process of the maxilla and the internal angular
process of the frontal bone; pulls the eyelid in a
posterior and superior direction
• Tensor tarsi (horner) muscle is intimately associated
with posterior limb , functions to support the lacrimal
apparatus, and plays an important role in tear flow.
• Intercanthal distance – 28-35 mm
• Telecanthus – disruption of medial
canthal tendon results in unopposed
muscle pull of orbicularis oculi muscle,
which results in narrowing of palpebral fissure and
widening of intercanthal distance
• Adequate reattachment or stabilization of medial
canthal tendon is necessary to prevent:
• Telecanthus
• Enophthalmus
• Lacrimal system dysfunction
• Delayed reconstruction is extremely difficult
• Lacrimal apparatus
• Composed of lacrimal gland (superolateral aspect of
the orbit) and the drainage system (medial)
• Lacrimal drainage
• Upper and lower lacrimal canaliculus
• Lacrimal sac
• Nasolacrimal duct
• Tears drain into the lacrimal sac with the help of
orbicularis oculi and Horner muscle, and the
nasolacrimal duct carries this flow from sac to inferior
meatus of the nasal cavity
• Dysfunction of the drainage system – epiphora
• Must be evaluated perioperatively
 CLASSIFICATION

• Can be unilateral or bilateral

• Markowitz et al 1991- based on the description of central
fragment to which the medial canthal tendon attaches
superiorly
• Type I – central fragment as a single fragment, with the
medial canthal attached
• Type II – communition of the central fragment with the
medial canthal tendon attached to a single osseous
segment
• Type III – severe communition of the central fragment
with the medial canthal tendon being avulsed or
remaining attached to a small osseous segment that
cannot be fixated
 DIAGNOSIS

• Clinical
• Flattening of the nasal dorsum, retrusion and gross
mobility
• Intercanthal and interpupillary distance - < 35mm should
raise suspicion and < 40mm is diagnostic
• Epiphora
• Bowstring or traction test – applying lateral traction to
the eyelids while palpating the medial canthal tendon
attachment – positive if palpable bowing of the
fractured segment
• Bimanual exam – using a Kelly clamp intranasally and a
finger placed externally at the region of the medial
canthal tendon. Lateral displacement of the fractured
segment
• Radiographic
• Plain radiographs
• Occipitomental views (10 and 45 degrees)
• CT scans
• Axial and coronal CT scans – best evaluated with 1.0 - 2.0
mm cuts
• 3D CT with reconstruction – additional tool for assessment
of communition and fracture segmentsof
 TREATMENT

• Series of 8 steps presented by Ellis

1. Exposure
2. Identifying the medial canthal tendon / tendon bearing
bone
3. Reconstruction of the medial orbital rim
4. Reconstruction of the medial orbital wall
5. Transnasal canthopexy
6. Reduction of septal fractures
7. Nasal dorsum reconstruction / augmentation
8. Soft tissue re-adaptation
• Not all these steps are required for every fracture
• Exposure
• Coronal incision – good cosmesis, wide exposure of the
superior aspects of the fractures, provide access to
harvest outer calvarial bone for primary reconstruction
• Gull – wing
• Open sky Avoided because of visible
location of their scars
• Frontoethmoid (Lynch)
• Lower eyelid incision – exposure of the central fragment
• Maxillary vestibular incision – expose the lower part of
the nasomaxillary buttress for fixation
• Maxillary degloving approach – combination of coronal,
lower eyelid, and vestibular incision
• Identifying the medial canthal tendon
• Can be performed through the coronal flap exposure
• Or a skin stab incision placed 3mm medial to the canthus
• The tendon is evaluated for complete avulsion or
attachment to a bony segment
• Tagged with a suture or wire for later use in canthopexy
• Reduction / reconstruction of the medial orbital rim
• To avoid postoperative telecanthus
• Reduction – transnasal wiring – pass a 26/28 gauge wire
through 2 holes drilled in the medial orbital wall in a
horizontal mattress fashion
• Rigid fixation with miniplates is used when the level of
communition allows for it
• Reduction of medial orbital wall
• Assessed preoperatively using CT images
• Reconstructed to prevent – enophthalmus, diplopia, &
vertical dystopia
• Decision made if there is a significant increase in orbital
volume
• Choice of reconstruction
• Titanium mesh
• Alloplasts (porous polyethylene)
• Bone grafts – calvarium or ribs
• Mesh or graft is secured to the orbital rim with rigid fixation
• Transnasal canthopexy
• Indication – medial canthal tendon is felt to be
disrupted, or the comminution is too severe to reduce
the tendon bearing segment
• Place a 2 to 4 mm hole superior and posterior to the
lacrimal crest along the medial orbital wall
• Wire is passed transnasally with an awl and secured to
supraorbital rim on the contralateral side
• If bilateral canthopexy is required, separate transnasal
wires should be used, and the two should not be
secured to each other. This avoids total loss of anatomic
position if one side becomes loose postoperatively
• Reduction of the nasal septum
• Goal is to place the septum back into a midline position
to prevent nasal airway compromise
• Simple manipulation with an Asch forceps applies
anterior and posterior force and brings the septum back
into midline alignment
• Reconstruction / augmentation of the nasal dorsum
• Reconstruct with the use of a cantilever dorsal bone
graft
• Bone graft is shaped to taper the two ends- “surfboard
shape”
• Width is according to the gender, race and facial
proportions
• Graft is secured to the frontal bone with rigid fixation
• Columellar strut graft – to improve nasal tip projection
• Readaptation of soft tissues
• Poor adaption – due to soft tissue thickening – gives
the appearance of increased intercanthal distance
and widening of nasal bridge
• Dorsal nasal splint – Denver splint
• Thermoplastic splint – aquaplast
• External bolsters secured to each other with a
transnasal wire – severe communition
• Doyle splints
 COMPLICATIONS

• Malunion
• Enophthalmus
• Telecanthus
• Epiphora
• Ocular and extraocular muscle complications
• Entrapment of extraocular muscles
• Iatrogenic injuries to the globe
• CSF leakage – rhinorrhea or otorrhea
 MORE TO FOLLOW

• Communited midface fractures

• Nasal fractures
• Special considerations
• Endoscopic repair
• Future Advancements
THANK YOU