Lecture 3

Maxillofacial fractures Part 3
Lecture Outline
MIDDLE
MANDIBULAR Surgical
THIRD OF THE
CONDYLE Approaches
FACE
FRACTURE OF
MANDIBULAR CONDYLE
Importance of condylar fracture
• It contains the condylar growth centres which may be destroyed

by the effect of the trauma with subsequent failure of mandibular
growth if the condition occurs in children
• Misdiagnosis or improper management may lead to ankylosis
• The condylar process is rarely fractured by direct force but

usually by indirect force that is why it may be misdiagnosed
Condylar
fracture
patterns
Applied
anatomy
Classification of fracture of condylar process
1- Intracapsular fracture
• Above the level of insertion of the lateral

pterygoid muscle
• Usually there is no displacement of this fracture
• Fracture in this region may lead to ankylosis if

not properly managed
Classification of fracture of condylar process
2- Extracapsular fracture
• Below the insertion of the lateral pterygoid

muscle
• Usually there is mesial & forward displacement

of the condylar head
• This fracture may lead to mandibular deviation

but not ankylosis
Condylar neck fracture
Condylar head fracture
Subcondylar fracture
The relationship of the condylar
head to the glenoid fossa
• Nondisplaced: the condylar head is in

normal relation to the glenoid fossa.
• Displacement: the condylar head remains
within the fossa but there is alteration in
the joint space.
• Dislocation: the condylar head lies
completely outside the confines of fossa.
usually antromedial because of the
lateral ptrygoid pull.
Clinical features of condylar fracture
• Asymmetry of the face caused by shifting of the mandible to
the affected side
• Edema and ecchymosis over the joint
• Haemorrhage from the external auditory meatus may be seen

• Tenderness on palpation over the
area of the TMJ
• Inability to open the mandible in

bilateral cases
• In the unilateral cases the chin

shifted to the affected side
• Malocclusion:
• Unilateral condylar fracture usually results in ipsilateral
premature contact of the posterior dentition
• Bilateral condylar fractures may result in marked
anterior open bite and retrognathia

Subcondylar fracture
Treatment
Intracapsular fractures are treated by intermaxillary
fixation for a period of 7-10 days then it is
followed by active jaw movement ( Jaw exercise )

Treatment
Subcondylar fractures are treated by closed reduction and IMF

or Open reduction and fixation with plates or intraosseous wires
The choice of the technique depends on
Degree of displacement
Age of the patient
Degree of the condition ( unilateral or bilateral )
Factors to consider when deciding on open vs
closed treatment include:
• displacement/dislocation of the fracture – the more displaced, the more
difficult to treat closed
• bilateral condylar fractures – more difficult to treat closed
• non-compliant patient – closed treatment requires more frequent checking
of the occlusion, visits to the clinician, and wearing of elastics
• Other fractures – associated maxillary fractures (may need intact mandible
to position midface), bilateral condylar fractures (more difficult to treat
closed), multiple mandibular fractures
• Edentulism or poor dentition – dentition required to apply elastics/MMF to
control occlusion.
• Age of patient – the younger the patient, the better the outcome from
closed treatment. Open treatment is less indicated in the young.
Treatment options
• Observation
• Closed treatment
1. (MMF)
2. functional therapy
• ORIF, one single plate
• ORIF, two plates This Photo by Unknown Author is licensed under CC BY-SA
FRACTURE OF THE MIDDLE
THIRD OF THE FACE
Applied Anatomy
ANTERIOR ASPECT
(NORMA FRONTALIS)
LATERAL ASPECT
(NORMA LATERALIS)
Buttresses of the face
Maxillary fracture
CLASSIFICATION OF
MAXILLARY FRACTURE
RENÉ LE FORT
1901
Classification of maxillary fracture
Le Fort I ( Transverse fracture )
o Occurs transversally across the maxilla above the

level of the teeth
o The fracture segment contains the alveolar process ,
portions of the wall of the maxillary sinus , the palate
and lower portion of the pterygoid plates
Le-Fort I
Le Fort II ( Pyramidal fracture )
o It involves the nasal bones and the frontal process

of the maxilla and pass laterally through the lacrimal
bones , the inferior rim of the orbit and through the
zygomaticomaxillary sutures
o Then continue backward along the lateral wall of the
maxilla through the pterygoid plates
Le-Fort II
Le Fort III ( Craniofacial dysjunction )
o Complete separation of the facial bones from their

cranial attachment
o The fracture occurs through the zygomatico-frontal ,
maxillo-frontal and naso-frontal sutures through the
orbital floor
o The entire middle third of the face is detached
completely from the skull and only suspended by the
soft tissue
Le-Fort III
Le Fort Fractures
Le Fort Fractures
Le Fort Fractures
Diagnosis of maxillary fracture
It is made through
history of trauma ,
Clinical examination
radiographic examination
o Evidence of severe soft tissue injury in the facial

region
o Bleeding from the nose , periorbital , edema and
subcutaneous hematoma are signs of underlying bony
involvement
o Dish face deformity is a result of fractured and

displaced middle third
o Malocclusion and open bite
o Malocclusion is absent in Lefort III fracture
o Bimanual palpation of the orbital floor , the zygoma

, the nasal bones intraoral prominence of the maxilla
may indicate irregularities from the fracture
o Palpation of the maxillary sutures , ( Frontonasal ,

Maxillofrontal , Zygomaticofrontal )
o Diplopia in case of orbital muscle entrapment
o Maxillary fracture with fracture of the base of the

skull is associated with CSF Rhinorrhea or Ottorrhea
Diagnosis of Midface Fracture
Diagnosis of Midface Fracture
Radiographic examination
Water`s view ( Occipitomental )

Submentovertex view
Panoramic view
Occlusal
Posteroanterior
C.T scan
Radiographic Examination
- Water’s view (Occipitomental)
- Submentovertix
Water`s view Submentovertex view
( Occipitomental )
- Posteroanterior
- CT scan with 3D reconstruction
Treatment of Midface Fracture
- Same principles of mandibular fracture should be
considered
- Treatment should be directed towards placement
of the bone segments and dentition into the
proper relationship
- IMF is obtained to preserve normal occlusion
- More active fixation is obtained by suspending
the maxilla to the first solid structure above the
fracture site by means of suspension wires onto
the nasal spine, zygomatic arch and zygomatic
process of the frontal bone
- Fixation using miniplates
Suspension wires
Le Fort I fixation points
Le Fort II fixation points
Le Fort III fixation points
ZYGOMATIC
FRACTURES
Anatomy
Tripod malar fracture
ZYGOMATIC FRACTURES
 The position and contour of the zygoma
makes it more susceptible to injury
 The zygomatic bone articulates with the

Frontal , Maxillary , Temporal bones and The
great wing of sphenoid in four processes
 The zygomatic fracture rarely involves the

zygomatic bone alone usually the articulating
bones are included in the trauma
Classification of zygomatic fractures
Group I
No significant displacement although there is

radiographic evidence of fracture line
Treatment is unnecessary
Group II
Zygomatic arch fracture

Group III
Unrotated body fracture

Group IV
Medially rotated body fracture

Group V
Laterally rotated body fracture

Group VI
Complex fracture
Diagnosis of zygomatic fractures
 Pain and trismus during mandibular movements

 Anaesthesia in the distribution of the infraorbital
nerve
 Diplopia
 Bimanual palpation of the zygoma indicates
tenderness and irregularities
Diagnosis of zygomatic fractures
Radiographic examination
 Submentovertex
 C.T scan
Submentovertex
Treatment of zygomatic fractures
Reduction of the zygomatic arch fracture
1) Gillies method ( temporal approach )
2) Intra oral method
3) Hook method
Hook method
Gillies method
( temporal approach )
Intra oral method
( Keen’s Approach )
protection
Treatment of zygomatic fractures
Fixation of the zygomatic arch fracture
1) Intraosseous wire
2) Bone plates
Reduction of the ZMC fracture
Bone Hook Carol Gerrad Screw

Fixation of the ZMC fracture
Surgical Approaches
Mandibular Fractures
Transoral approach
Extraoral -
use of
existing
lacerations
Extraoral -
Submental
approach
Extraoral -
Submandibular
approach
Extraoral -
Preauricular
approach
Extraoral -
Retromandibular
approaches
Midface Fractures
Maxillary
vestibular
approach
Use of
existing
lacerations
Glabellar
approach
Approaches to the
superolateral orbital
rim
Lateral eyebrow approach (A)
Upper-eyelid approach (B)
Transcutaneous
lower-eyelid
approaches
Subciliary (A) with extension (D)
Subtarsal (B)
Infraorbital (C)
Transconjunctival
lower-eyelid
approaches
Indirect approaches
to the zygomatic
arch
Temporal (Gillies) approach (1)
Transoral (Keen) approach (a
lateral maxillary vestibular
incision), (2)
Coronal approach
Remember
MIDDLE
MANDIBULAR Surgical
THIRD OF THE
CONDYLE Approaches
FACE
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Maxillofacial fractures Part 3

• It contains the condylar growth centres which may be destroyed

• Misdiagnosis or improper management may lead to ankylosis

• The condylar process is rarely fractured by direct force but

• Above the level of insertion of the lateral

• Usually there is no displacement of this fracture

• Fracture in this region may lead to ankylosis if

• Below the insertion of the lateral pterygoid

• Usually there is mesial & forward displacement

• This fracture may lead to mandibular deviation

Condylar head fracture

• Nondisplaced: the condylar head is in

• Asymmetry of the face caused by shifting of the mandible to

the affected side

• Edema and ecchymosis over the joint

• Haemorrhage from the external auditory meatus may be seen

• Inability to open the mandible in

• In the unilateral cases the chin

• Unilateral condylar fracture usually results in ipsilateral

premature contact of the posterior dentition

• Bilateral condylar fractures may result in marked

anterior open bite and retrognathia

Intracapsular fractures are treated by intermaxillary

fixation for a period of 7-10 days then it is

followed by active jaw movement ( Jaw exercise )

Subcondylar fractures are treated by closed reduction and IMF

• ORIF, one single plate

Le Fort I ( Transverse fracture )

o Occurs transversally across the maxilla above the

Le Fort II ( Pyramidal fracture )

o It involves the nasal bones and the frontal process

Le Fort III ( Craniofacial dysjunction )

o Complete separation of the facial bones from their

o Evidence of severe soft tissue injury in the facial

o Dish face deformity is a result of fractured and

o Malocclusion and open bite

o Malocclusion is absent in Lefort III fracture

o Bimanual palpation of the orbital floor , the zygoma

o Palpation of the maxillary sutures , ( Frontonasal ,

o Diplopia in case of orbital muscle entrapment

o Maxillary fracture with fracture of the base of the

Water`s view ( Occipitomental )

 The zygomatic bone articulates with the

 The zygomatic fracture rarely involves the

No significant displacement although there is

Zygomatic arch fracture

Unrotated body fracture

Medially rotated body fracture

Laterally rotated body fracture

 Pain and trismus during mandibular movements

Reduction of the zygomatic arch fracture

1) Gillies method ( temporal approach )

2) Intra oral method

Fixation of the zygomatic arch fracture

Bone Hook Carol Gerrad Screw

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