MAXILLARY FRACTURES

Specific learning objectives

• To understand the etiology , biomechanics and demographics of maxillary fractures

• Clinical and radiographic evaluation of maxillary fractures
• Primary management of maxillary fractures
• Definitive management of maxillary fractures
• Complications of the Maxillary fractures
• The way ahead in the management of maxillary fractures
Introduction
• Maxilla - a paired bone in the facial skeleton defines the mid face of a person forming the
bulk of it
• Any fracture involving the maxilla can result in both functional derangements and
physical deformities
• History of maxillary fractures dates back to ancient times , where evidence of facial
trauma can be found in Ancient Greek and Egyptian texts
• The Greek physician Hippocrates wrote about treatment of maxillary fractures by using
splints and bandages
• The advancements in the field of both local and general anaesthesia in the 19th and 20th
centuries has allowed for precise and less painful surgical fixation of maxillary fractures
under direct vision
• The advancement of imaging techniques in 20th and 21st centuries have aided the
surgeons in precise Pre op planning and the advancements in the fixation techniques has
made the surgery hassle free and the outcomes more predictable
Surgical anatomy of Maxilla
Overall anatomy and connections
The maxillary bone processes

Alveolar process
The palate
The maxillary sinus and the orbital floor
The nerves of maxilla
The arterial supply
 The vertical and horizontal buttress
[Sicher and Tandler’s structural pillars]
Etiology
• Road traffic accidents - motorcycle accidents >Motor vehicle accidents
• Interpersonal violence
• Gun shot injuries
• Most of the interpersonal violence cases were invariably associated with the use of alcohol
and illicit drugs

• Sporting injuries
• Pediatric and geriatric maxillary fractures were commonly associated with falls
Demographics
• Incidence in males was about 82%
• Mean age - 30.6 years
• The most susceptible age groups were 11-30 years
• The age group and male predominance is in line with the number of people in the age
group and gender profile taking part in hig risk adventures , contact sports and violence

• The male predominance was less prevalent in age group less than 18
• Maxillary fractures were rare in children under 5 years making up only 1.4% of cases
owing to the less brittle nature of the bone as well as increased craniofacial ratio
BIOMECHANICS
Facial bones and the impact resistance
The crumble zone - match box model - Huelke

The maxillary bone(mid face)

crumbles on direct impact dissipating

the forces and cushioning the impact

thus protecting the cranial cavity

Classification systems
Le Fort classification and features
• French surgeon Rene Le Fort published his classic paper on mid face facial patterns
• He studied the maxillary fracture patterns by inflicting blunt trauma to the cadavers and
studying the damage caused

• He considered the vector of force , inertia of face , the mass of the object, bone thickness ,
impact location and muscle pull to assess the fracture pattern

• He found that the skull was left intact whenever the mid face crumbled and stated that

fracture occurred along three weak lines of the facial skeleton thus giving birth to Le

Fort classification
Le Fort 1
Maxillary mobility at lefort 1 level
Dento alveolar fracture
Floating maxilla
Anterior open bite
Impacted maxilla
Gurien sign
Other features
• Palatine split
• Increased vertical height
• Ecchymosis in buccal sulcus
• Tearing of gingiva
• Dull cracked cup sound on tooth percussion
• Increased visibility of anterior nares
Le Fort II- sub zygomatic/ pyramidal #
Mobility at lefort 2 level
 Moon face
Raccoon eyes
Other features
• Sub conjunctival haemorrhage posterior limit can be appreciated
• Lengthening of face
• Parasthesia in the lateral nasal area and cheek
• Bilateral epistaxis
• Dish face deformity in cases where maxilla is crumbled
• CSF rhinorrhea
• Diplopia
Le Fort III - Supra zygomatic #
Mobility in lefort 3#
Battle sign
Sub conjunctival haemorrhage Dish face deformity
Other features
• Posterior impaction of maxilla can cause breathing difficulties
• Increased sclera show and hooding of the upper eye lid
• No infra orbital step defects
• Lengthening of face
• Anti mongoloid slant of the eyes
• CSF rhinorrhea
Marciani modification of Le Fort fractures - 1993
Hendrickson classification of palatal fractures
Rowe and William classification
Maxillary fracture - Primary survey
• The patient must be stabilised before going for definitive management
• Posterior displacement of maxilla can cause breathing difficulty and airway need to be secured
in such cases

• Bleeding can be managed by pressure packs and posterior nasal bleeds may require nasal ballon
, compression using foleys catheter , nasal packing

• Head injuries should be ruled out

• Injuries to other systems are ruled out in the secondary survey
• Once the patient is stabilised the patient can be taken up for definitive examination and

management of maxillary fractures

Examination
Clinical examination
Extra oral
• Inspect to document lacerations , abrasions , avulsions and tissue loss
• Check for periorbital edema and echymosis
• Check eye opening , inspect presence of sub conjunctival haemorrhage and any restrictions ineye
movements

• Check for diplopia and dystopia

• Palpate the frontal bone followed by supra orbital rim , lateral wall of orbit , infra orbital rim ,
the zygomatic arches , zygomatic , TMJ and the mandible for any step defects , tenderness or

mobility

• Check for crepitus in the infra orbital region and cheek

Intra oral

• Examine for lacerations, abrasions , contusions, avulsive soft tissue injuries

• Check for gurien sign , mucosal echymosis , Coleman sign
• Inspect for palatal splits
• Check the occlusion for open bite , cross bite
• Check maxillary mobility and it’s level
• Check for DA fractures
• Palpate to rule out step defects in zygomatic buttress and palate
Eye examination
Maxillary lefort 2 and 3 fractures have orbital components that can result in diplopia and other

complications and hence a thorough orbital examination is mandatory

• Visual acuity
• Pupillary examination
• Extra ocular motility and alignment - Diplopia , Dystopia , enophthalmos
• Intra ocular pressure
• Visual field
• Slit lamp test
• Fundoscopic examination
• Globe position
Clinical testing specific to lefort fractures
CSF LEAK (Associated with lefort 2 and 3)

Halo sign /Double ring sign/Handkerchief sugn

Reservoir sign

Performed in the morning as patient wakes

up

Place chin towards chest for 1 minute

Copious leakage indicates leak

Use ipratropium bromide to reduce nasal

secretions
Lab tests
• Glucose concentration
• Chloride concentration
• Beta transferrin test

Radiographic diagnosis
• High resolution CT
• MR - Cysternography
• Intra the cal fluroscein injection
• Radionucleotide cysternography
Lacrimal system injuries

For secretory system Schrimer test

TC99
For the drainage Dye disappearance test
Jones I and II
Dacrocystography
Jones test
JONES I
JONES II
Dacrocystorhinostomy

Bypassing the nasolacrimal duct by anastomosing lacrimalsac with nasal mucosa

Diplopia
Forced duction test
 Diplopia charting

Other tests
• Hess charting
• Goldman visual field
Traumatic enopthalmos

Hertel’s exophthalmomrter
Radiographic examination
PNS view - McGrigor and Campbell lines
Dolons line and elephant of roger

1. Orbital line

2. Zygomatic line

3. Maxillary line
PNS hotspots
Delbaso’s 4 “s”

• Symmetry
• Sharpness
• Sinus
• Soft tissues
Submentovertex view
CT- gold standard

3d reconstruction Pterygoid plate fractures

Lefort II fracture
 Palatal fractures
Lateral orbital wall #
Management
Once the patient is stable with secured airway , optimalGCS score and

circulation patient can be taken up for definitive management

Principles of management
• Reduction
• Fixation
• Immobilisation
Manual reduction of fractures
Conservative management

Barton bandage can be used for simple immobilisation

Closed reduction
Upper lower arch bar and IME can be used to immobilise

minimally displaced fractures of maxilla and mandible

IMF screws Hybrid archbar
The fractures are immobilised using the upper and lower arch bars+ IMF

and is maintained in position for a period of 4-6 weeks to achieve optimal

healing
Suspension wiring
The conservative management , closed reduction and suspension wiring have their

own set of disadvantages like long healing time , poor patient compliance among

others. These disadvantages can be overcome with rigid internal fixation which has

become the standard of care in recent times.

 Open reduction and internal fixation
Access Maxillary vestibular approach
Expose piriform fossa and buttress
Supra orbital approach for lateral wall of orbit
Upper eyelid approach for lateral wall of orbit
Coronal approach - zygoma+ lateral wall
Modifications of coronal incision
Infra orbital rim
GMS Curr Top Otorhinolaryngol Head Neck Surg. 2015; 14: Dec 22
Trauma of the midface ,Thomas S. Kühnel and Torsten E. Reichert
Incision summary
• The approach is dictated by multiple factors like
1. The degree of displacement

2. Exposure required

3. Extent of fracture

4. Need for reconstruction

5. Communities
Timing of surgery

• Emergencies involving panfacial fractures require immediate surgery

– E.g. airway obstruction, uncontrolled bleeding etc

• If no such medical emergencies exist surgery may be delayed for all preoperative

examinations

• There is no harm in delaying surgical intervention upto 5th – 7th post traumatic day
Fracture reduction
Hayton Williams forceps to reduce Palatal flaring
Lefort 1 fracture. Fixation
Titanium mesh reconstruction Bone grafting in bone defects
Lefort II and III
Infra orbital rim plating
Lateral wall of orbit fixation
Complications
COMPLICATIONS OF MID-FACE FRACTURES
Late
Early
Non-Union / Malunion
Extensive hemorrhage
Plate Exposure
Airway Obstruction
Lacrimal System obstruction
Infection
V2 Anesthesia
CSF Leak
Extra-OccularMuscle Imbalance
Blindness
Diplopia

Enophthalmos

Orbital Dystopia

Nasal Obstruction
 Superior orbital fissure syndrome
Tolosa Hunt syndrome

• Pupillary dilatation - CN 111

• Opthalmoplegia - CN 111, 1V, V1

• Upper eyelid ptosis - levator palpebrae

• Anasthesia forehaead -V 1

• Loss of corneal reflex -V 1

• Proptosis - opthalmic vein

Orbital apex syndrome
• Retrobulbar hemotoma

• Compression of optic canal

• Superior orbital fissure

• Change in vision
Pediatric Maxillary Fractures

• Dentition and dental development are more conical crowns, larger interdental spaces, and

presence of permanent tooth buds

• Circum-mandibular wires, drop wires, or Ivy loops

• Interfragmentary ligatures using absorbable sutures play a much greater role in these

patients.
Recent advances
Planning
sequence
Virtual surgical planning

Surgical splint fabrication to aid in repositioning of fragments

Patient specific implants
Navigation surgery
Precise manipulation of orbital floor with minimal damage to the vital structures
Components
 Take home message

• Any case of maxillofacial trauma - rule out head injury, cervical spine injury and other associated injuries.

• Emergency airway management if required in case of Lefort fractures that obstruct the airway,

• Emergency neurosurgery consultation in case of Lefort fractures involving frontal bone – posterior table,

• Identify CSF leak,

• Lacrimal patency,

• Assessment of diplopia, hypoglobus and ruling out traumatic optic neuropathy,

• Early management : primary repair and reconstruction.

Thank you