*3.1.1. Classification*

Le Fort fractures are classified as three types. Le Fort I injury is defined as separation of maxilla from the mid-face (**Figure 1**A). Nasal septum, lateral nasal walls, lateral maxillary sinus wall, and pterygoid plates are involved in these kinds of fractures (**Figure 2**). Le Fort II fracture is also called the pyramidal fracture pattern which is identified by the separation of nasomaxillary complex (**Figure 1**B). Nasal and lacrimal bones, nasofrontal suture, infraorbital rims, and pterygoid plates are involved in this fracture pattern. Le Fort III also known as craniofacial dissociation is detected by the separation of the whole mid-face from the skull (**Figure 1**C). This fracture occurs in nasofrontal and zygomaticomaxillary sutures, zygomatic arch, and pterygoid plates.

*3.1.2. Signs and symptoms*

head).

As an initial examination mobility of maxilla is evaluated. The maxillary arch is grasped by thumb and pointing fingers of one hand and the mobility is checked by the other hand on pyriform

**Figure 2.** A, a three-dimensional view of Le Fort I fracture and B, pterygoid plate involvement in Le Fort I fracture (arrow

Maxillofacial Fractures: From Diagnosis to Treatment http://dx.doi.org/10.5772/intechopen.76166 55

**Figure 1.** Le Fort I (A), II (B), III (C) fracture patterns on a three-dimensional model.

**Figure 1.** Le Fort I (A), II (B), III (C) fracture patterns on a three-dimensional model.

**Figure 2.** A, a three-dimensional view of Le Fort I fracture and B, pterygoid plate involvement in Le Fort I fracture (arrow head).

### *3.1.2. Signs and symptoms*

The treatment of mid-face fractures is complex due to the physiology and anatomy of midfacial subunits. Quality of life of the patients is influenced following unsuccessful management of mid-face fractures which lead to permanent functional problems. Esthetic disfiguring

This chapter aims to present a comprehensive review of mid-face fractures types' diagnosis

Advanced trauma life support (ATLS) is the first step that should be applied in emergency cases. Airway obstruction should be evaluated as soon as possible since the mid-face is the beginning of the respiratory pathway. Hemorrhage and secretions may obstruct the oropharynx and nasopharynx. Removal of fractured teeth, clots, and loose dental crowns or dentures is important to open the oral airway. Packing should be used to control acute bleeding. Intubation to secure the airway in instable mid-face fractures is the next step that should be considered in emergency patients [7, 8]. It is important to keep the airway open in mid-face fractures because there is always the potential of airway obstruction due to displacement of

Cervical spine injuries are common in facial fractures. The incidence rate of cervical spine trauma in pediatric facial fracture cases is almost 3.5% [9] whilst this number is much higher in adult trauma patients [10]. According to the possibility of spinal injuries in facial trauma patients stabilizing the cervical spine by a rigid collar is necessary until the spinal injury is

After providing a secure airway, ATLS protocol can continued. When the patient is stable,

Le Fort fractures are classified as three types. Le Fort I injury is defined as separation of maxilla from the mid-face (**Figure 1**A). Nasal septum, lateral nasal walls, lateral maxillary sinus wall, and pterygoid plates are involved in these kinds of fractures (**Figure 2**). Le Fort II fracture is also called the pyramidal fracture pattern which is identified by the separation of nasomaxillary complex (**Figure 1**B). Nasal and lacrimal bones, nasofrontal suture, infraorbital rims, and pterygoid plates are involved in this fracture pattern. Le Fort III also known as craniofacial dissociation is detected by the separation of the whole mid-face from the skull (**Figure 1**C). This fracture occurs in nasofrontal and zygomaticomaxillary sutures, zygomatic

facial examination to detect the mid-face fractures is executed as follow.

trauma changes the whole mid-facial compartments.

**2. Examination of trauma patients**

bones or severe bleeding in such cases.

**3. Maxillofacial fractures**

**3.1. Le Fort fractures**

arch, and pterygoid plates.

*3.1.1. Classification*

and management.

54 Trauma Surgery

ruled out.

As an initial examination mobility of maxilla is evaluated. The maxillary arch is grasped by thumb and pointing fingers of one hand and the mobility is checked by the other hand on pyriform

**Figure 3.** A classic raccoon eye is a sign of Le Fort II fracture.

aperture, nasofrontal suture, and zygomaticofrontal suture. In Le Fort fractures, lateral and medial pterygoid muscles pull the fracture segment posteriorly and inferiorly lead to an anterior open bite deformity. So malocclusion is an important sign in diagnosing the Le Fort fractures. Epistaxis is a common sign in all three patterns of Le Fort fractures. Hypoesthesia of the infraorbital nerve is seen in types I and II of Le Fort fractures. Bilateral periorbital ecchymosis which is called raccoon eyes is a classic sign of Le Fort II and III fractures (**Figure 3**). The clinician should be aware of the possibility of cerebrospinal fluid (CSF) leak in Le Fort II and III fractures.

### *3.1.3. Management*

The decision to choose whether the open or closed technique in Le Fort fractures is dependent on the mobility of the maxilla and severity of maxillary displacement results in malocclusion. Minor maxillary displacement and malocclusion and low mobility of fractured segment are the indications of closed treatment. Closed technique could be performed by either maxillomandibular fixation (MMF) or skeletal suspension (**Figure 4**). The method of choice in the treatment of mobile maxilla with severe malocclusion is open reduction and internal fixation (ORIF). In the Le Fort I pattern lateral nasal walls and zygomatic buttresses are used to provide stability by four plates. Displaced Le Fort II fracture is treated by ORIF of bilateral infraorbital rims and zygomatic buttresses simultaneously using a miniplate to fix the nasofrontal suture. Mobile mid-face and esthetic problems following Le Fort III fracture (dish-face deformity) are the main indications of ORIF treatment. The number of fixations is dependent on

the extent of comminution and dislocation. Bilateral zygomatic arches and zygomaticofrontal

Maxillofacial Fractures: From Diagnosis to Treatment http://dx.doi.org/10.5772/intechopen.76166 57

Hendrickson et al. [11] classified the palatal fracture into six patterns anatomically (**Figure 5**). Computed tomographies (CTs) in coronal and axial views are helpful in detecting the palatal fractures. Alveolar fracture is classified as type I palatal fracture in which it is categorized

sutures and nasofrontal sutures should be fixed in severely displaced cases.

**Figure 4.** Suspension and closed treatment of comminuted Le Fort fractures.

**3.2. Palatal fractures**

*3.2.1. Classification*

**Figure 4.** Suspension and closed treatment of comminuted Le Fort fractures.

the extent of comminution and dislocation. Bilateral zygomatic arches and zygomaticofrontal sutures and nasofrontal sutures should be fixed in severely displaced cases.

### **3.2. Palatal fractures**

### *3.2.1. Classification*

aperture, nasofrontal suture, and zygomaticofrontal suture. In Le Fort fractures, lateral and medial pterygoid muscles pull the fracture segment posteriorly and inferiorly lead to an anterior open bite deformity. So malocclusion is an important sign in diagnosing the Le Fort fractures. Epistaxis is a common sign in all three patterns of Le Fort fractures. Hypoesthesia of the infraorbital nerve is seen in types I and II of Le Fort fractures. Bilateral periorbital ecchymosis which is called raccoon eyes is a classic sign of Le Fort II and III fractures (**Figure 3**). The clinician should be aware of the possibility of cerebrospinal fluid (CSF) leak in Le Fort II and III

The decision to choose whether the open or closed technique in Le Fort fractures is dependent on the mobility of the maxilla and severity of maxillary displacement results in malocclusion. Minor maxillary displacement and malocclusion and low mobility of fractured segment are the indications of closed treatment. Closed technique could be performed by either maxillomandibular fixation (MMF) or skeletal suspension (**Figure 4**). The method of choice in the treatment of mobile maxilla with severe malocclusion is open reduction and internal fixation (ORIF). In the Le Fort I pattern lateral nasal walls and zygomatic buttresses are used to provide stability by four plates. Displaced Le Fort II fracture is treated by ORIF of bilateral infraorbital rims and zygomatic buttresses simultaneously using a miniplate to fix the nasofrontal suture. Mobile mid-face and esthetic problems following Le Fort III fracture (dish-face deformity) are the main indications of ORIF treatment. The number of fixations is dependent on

fractures.

56 Trauma Surgery

*3.1.3. Management*

**Figure 3.** A classic raccoon eye is a sign of Le Fort II fracture.

Hendrickson et al. [11] classified the palatal fracture into six patterns anatomically (**Figure 5**). Computed tomographies (CTs) in coronal and axial views are helpful in detecting the palatal fractures. Alveolar fracture is classified as type I palatal fracture in which it is categorized

called para-sagittal fracture which occurs in the thin part of the palate lateral to the attachment of vomer bone to the maxilla. The anterior limit of the fracture is between canine teeth which extend to the pyriform aperture. Type III fracture pattern extends posteriorly to the tuberosity or track approximate to the midline. Type IV fracture also known as para-alveolar fracture is a variant of the type III pattern. The fracture line in this pattern tracks medial to the alveolar bone of maxilla. The type V pattern is a complex fracture with comminution fragments. The transverse palatal fracture is classified as the type VI pattern which is the least

Maxillofacial Fractures: From Diagnosis to Treatment http://dx.doi.org/10.5772/intechopen.76166 59

Mobility of alveolar segments should be checked for the entire maxillary arch. Displacement of fractured segments results in malocclusion which is an important sign to the clinician in diagnosing the palatal fracture. Ecchymosis of the palate may also indicate the line of fracture.

When the occlusion is good enough and the fractured segment is either minimally displaced or not displaced at all the surgeon may decide to follow the patient and choose no intervention. MMF is the treatment of choice in minimally displaced palatal fractures unless there is a contraindication for MMF. Gunning and palatal splints are other amenable methods for closed treatment of palatal fracture (**Figure 6**). ORIF of palatal fracture is indicated in severely

According to the involved orbital walls there are five fracture patterns. The most common fracture of the orbit is the orbital floor fracture mostly detected as a blow-out fracture [6] (**Figure 7**).

**Figure 6.** (A) Gunning for closed treatment of simultaneous mandibular and palatal fractures in an edentulous patient

and (B) Maxillomandibular fixation for closed treatment of the patient.

mobile and displaced patterns to prevent splaying of the fragments.

common palatal fracture type.

*3.2.2. Signs and symptoms*

*3.2.3. Management*

**3.3. Orbital fractures**

*3.3.1. Classification*

**Figure 5.** Classification of palatal fractures.

into two subcategories of anterior and posterolateral fractures. Anterior type I palatal fracture involves the incisor teeth and involving the posterior teeth it is defined as type 1b palatal fracture. Type II palatal fracture is defined as sagittal fracture which is less common in adults. Type III and IV fractures are the most common palatal fractures in adults [11]. Type III is also called para-sagittal fracture which occurs in the thin part of the palate lateral to the attachment of vomer bone to the maxilla. The anterior limit of the fracture is between canine teeth which extend to the pyriform aperture. Type III fracture pattern extends posteriorly to the tuberosity or track approximate to the midline. Type IV fracture also known as para-alveolar fracture is a variant of the type III pattern. The fracture line in this pattern tracks medial to the alveolar bone of maxilla. The type V pattern is a complex fracture with comminution fragments. The transverse palatal fracture is classified as the type VI pattern which is the least common palatal fracture type.
