128 1.
Smith
of the blow, when the posterior teeth are missing
and also when the m a n d i b l e is not fractured.
Clinically the bleeding is rather limited because
there are no m a j o r vessels in this area.
A high incidence of external auditory meatus
laceration associated neither with basal skull
fracture nor with condylar fracture was demon-
References
Killey, H. C.: Fractures of the Mandible (2nd ed.).
Wright & Sons Ltd, Bristol 1971
Kristiansen, K.: Open or Compound Wounds of the
Head. In: G. F. Rowbotham: Acute Injuries of the
Head (4th ed.). Livingstone Ltd. Edinburgh 1964
Rowe, N. L., H. C. Killey: Fractures of the Facial
Skeleton (2nd ed.). Livingstone Ltd. Edinburgh
1968
Fractures of the Middle Third of the Facial Skeleton -
A New Method of Treatment
Ian Smith
Head of the Department of Maxillo-Facial and Oral Surgery
Johannesburg General Hospital and University of the Witwatersrand, South-Africa
Summary
A new method of immobilization for fractures of the
middle third of the facial skeleton has been devised.
The intention of the described facial framc is to pro-
vide an immobilization for these fractures which is
totally independent of the mandibular segment, eli-
minates maxillo-faclal technical laboratory assistance,
and permits early or immediate freedom of movement
of the intact mandible. The procedure is described in
detail and pertinent observations have been noted. An
analysis of the first 17 cases which have been treated
by this method is included. The procedure has also
been used as a means of immobilizing the maxillary
segment when a Le Fort I maxillary osteotomy is
untertaken to correct a facial deformity.
Key-Words: Fractures of middle third of face; Facial
frame.
Introduction
Various methods of treatment have been ad-
vocated to restore the fractured facial skeleton
strated in this series. It should be mentioned that
the reported incidence, derived from patients re-
porting to a casualty department, is more objec-
tive than the incidence of the symptom in neuro-
surgical or m a x i l l o - f a c i a l clinics where the inci-
dence of basal skull fractures or condylar head
fractures is increased accordingly.
Prof. Christos Martis, D.D.S., M.D.,
Ass. Prof. Demetrius Karakasis, D.D.S., M.D.,
Department of Maxillo-Facial Surgery,
School of Dentistry,
University of Thesaloniki,
Thesalouiki, Greece
J, max,-fac. Surg. 2 (1974) 128-134
@ Georg Thieme Verlag, Stuttgart
and most of them yield successful results. W h e r e a s
the simpler types of fractures are easily managed,
the more complicated varieties provoke a greater
challenge in their treatment. Some of the methods
of treatment that promote a more rigid immobi-
lization of fragments are; the Mount-Vernon "box
frame" type of fixation, "Halo" frames (Mackenzi
1971) and cast metal cap splints with anterior
connecting rods, and the Levant (1973) cranio
m a x i l l a r y fixation technique. This new method is
presented as a further contribution to the manage-
ment of these facial injuries.
W i t h this method, a facial frame which acts as a
scaffold is suspended in front of the i n j u r e d face.
From this rigid apparatus an accurate reduction
and firm immobilization of the numerous bony
fragments is achieved without depending on the
m a n d i b u l a r component.
W h e n dealing with fractures of the facial skeleton
it is essential to make a thorough assessment of
 Fractures of the Middle Third of the Facial Skeleton
the nature of the injury. Le Fort's classification of
the middle third facial fractures is generally con-
sidered to be the most suitable, but greater
emphasis must be placed on the effect of the
injury. It is necessary to determine whether the
fractured segments are impacted or mobile, and
to assess the degree and direction of the displace-
ment. When a complex fracture is sustained some
of the fragments may be freely mobile and badly
displaced, whereas others are more or less stable
and undisplaced. The most severe injury presents
with all fragments being mobile and grossly dis-
placed. These variable features must be ascer-
tained, but exceptional difficulty may be ex-
perienced with the diagnosis of the impacted
fracture. This is particularly so with an impacted
Le Fort I type of fracture. Obviously an assessment
of the ocelusal relationship is an important facet
in the examination of these cases.
Prior to treatment the method of reduction and
the form of immobilization must be considered.
Simple fractures are often merely reduced and
remain stable, while the more complicated frac-
tures require reduction and some form of immo-
bilization.
It is noteworthy that the reduction of a selected
fragment may effect a concurrent reduction of
adjacent fragments. Often the reduction of the
maxillary segment effects the reduction of an
associated fracture of the nasal and zygomatic
component. In cases where this is not achieved, all
the components will have to be dealt with indi-
vidually.
Similarly, through an adequate immobilization of
one fragment, adjacent fragments may be satis-
factorily supported.
In essence these numerous factors will influence
the method of treatment and determine whether
the reconstruction should be effected from above
or from below.
Material and Technique
The aim of this new method of treatment is to
provide a more rigid form of immobilization
whereby the numerous facial segments will be
securely held in their corrected position.
The facial frame used in this technique is made up
of two sections. Each section is fashioned to a spe-
129
Fig. 1 A view of the assembled face frame. The
segments of the frame have been tailored to a de-
finite size and shape to accommodate any sized face.
cific pattern from l/s" (3.0 ram) stainless steel rods
(Fig. 1).
The upper section of the frame acts as the stable
element and is fixed with universal clamps to two
titanium pins which have been inserted into the
frontal bone immediately above the supraorbital
ridges. Moule's Vs" (8.0 ram) titanium pins, with
a coarse thread of the type used for insertion into
wood, are most suitable.
The lower section of the frame is fixed with
Tower Clamps (Tower Manufacturing Co. Inc.
Seattle, Washington, U.S.A.) to two Kirschner
wires which have been inserted into the bone of
the maxilla at two selected points directly under
the floor of the nose. Following the reduction of
the numerous facial fractures, the lower section
of the frame is locked to the stable upper' section
by means of universal clamps. For this technique
.062" (1.6 ram) gauge Vitallium Kirschner wire is
preferred and has been purposely selected because
of its slight flexibility and the whip action that
can be produced.
The apparatus is always set up in this fashion
having a basic four point bony fixation. Addi-
tional Kirschner wires are inserted into other
individual fragments for their specific immobi-
lization when this is required. These additional
Kirschner wires are locked by means of Tower
Clamps to the assembled facial frame. Alternately
direct bony wiring of individual fragments is used
in conjunction with the method.
Prior to the reduction of the fractures of the
middle third of the face it is necessary to re-
130 1. Smith
establish the occlusion of the teeth, if teeth are
present, eyelet wiring with intermaxillary fixa-
tion is generally used. Occasionally cap splints
may be required to restore the occlusal relation-
ship of the teeth. In the edentulous jaw Gunn-
ing Splints, or the patient's own dentures, are
inserted to guide the reduction and establish the
correct relationship of the upper and lower jaws.
The impacted fracture of the maxilla will require
special attention. Whereas cap splinting and elas-
tic traction assists in the reduction of the impacted
fracture. With this new method of treatment there
is no leeway and the impacted maxilla must be
completely reduced before the facial frame is
locked. If difficulty is expeiqenced in maintaining
the occlusion then cap splinting with elastic trac-
tion should be used in conjunction with this
method.
Insertion of the Supraorbital pins
A small incision is made in the eyebrow, gener-
ally in the outer third, and the supraorbital ridge
is exposed. Using a dental handpiece with a num-
ber 6 flat-fissure burr, a drill hole is made into
the bone. The hole must be correctly sited and
angled at 45 ° to the coronal and sagittal planes
and should not be placed further than half an
inch (1.25 cm) from the orbital margin. Using a
hand drill, the titanium pin is carefully turned
into the hole. Through the eyebrow incision which
may have to be extended, nearby fracture lines
can be visualized and dealt with by direct bone
wiring when necessary. The incision is sutured
and dressed.
Insertion of the two Kirsehner wires into the
maxilla
Each Kirschner wire passes through the skin of the
face in the upper end of the nasolabial skin fold
lateral to the ala of the nose and is driven into
the bone of the maxilla in the direction of the
centre of the palate. The point of the Kirschner
wire should come to rest under the palatal mucosa.
If it penetrates the mucosa it must be withdrawn
until it is no longer seen or felt. The point of entry
of the wire into the bone can be visualized, if two
vertical stab incisions are made in the mouth at
the gingiva-mucosal reflection, over the roots of
the canine teeth, before it is pushed through the
skin. One must be aware of the variable anatomi-
cal design of the bone of the inferior margin of
the anterior nasal aperture. If teeth are present it
is advisable that the Kirschner wire pass between
the roots of the canine and lateral teeth at a point
a third of the way down the root of the canine
from its apex.
The Kirschner wire is generally directed at an
angle of 45 ° to the horizontal and sagittal planes
of the maxilla.
In the edentulous case the Kirschner wire is
inserted in a similar manner.
Additional Kirschner Wires
When required, additional Kirschner wires are
inserted into mobile fragments for their specific
immobilization. This additional fixation is gener-
ally required when a very unstable zygomatic
component is present. To obtain the best purchase
and control, this Kirschner wire should be driven
into the bone from the front of the face.
Re-establishment of the Occlusion or the
intermaxillary relationship
Prior to the final reduction of the facial fractures
the mandible must be immobilized to the maxilla.
This is carried out by using any of the recognised
methods of immobilization but, if teeth are pre-
sent, simple eyelet wiring is preferred. In the
edentulous mouth, if the mandible is intact, the
patient's own dentures are inserted to control the
reduction.
The reduction and immobilization o] the facial
fractures
The upper section of the frame is locked to the two
titanium pins and the lower section to the two
Kirschner wires. The ends of the lower section of
the frame are placed in close relationship to the
vertical arms of the upper section. This design
allows for an upward as well as antero-posterior
movement of fragments during the manipulation.
When the reduction of fragments is completed the
two segments of the frame are lo&ed tightly
together by means of universal clamps, which have
been previously set in position.
Experiences
Within the last 18 months this new fixation appli-
ance for immobilisation of mobile parts of the
 Fractures of the Middle T h i r d of the Facial Skeleton
T a b l e 1 A n a l y s i s of Salient Features of First 17 Cases Treated.
Case rl'ype of injury or procedure
1. Le Fort II[ fracture with very unstable
(Fig. 2) left zygomatic component. Split palate.
Fracture of both condylar ne&s and
comminuted fracture of left body of
mandible
2. Le Fort Ill fracture with severely dis-
(Figs. 3-4) placed left zygomatic fragment. Gra&
fracture left canine region of mandible
3. Le Fort I osteotomy for "dish-faced"
(Fig. 5) deformity and pseudo-prognathism
in cleft pala|e case
4. Le Fort III fracture with left zygoma
grossly displaced and left eye dis-
organised. Fractured symphysis of the
mandible
5. Le Fort III fracture. Fractured sym-
physis of the mandible
6. Le Fort III fracture with left zygoma
comminuted and comminution of outer
half of left supraorbltal ridge. Left eye
disorganised. Crack fracture left body
of mandible
7. Le Fort III fracture with very unstable
right zygomatic component. Mandible
intact
8. Lc Fort I fracture with impaction.
Mandible intact
9. Le Fort Ill fracture. Impacted maxilla,
nasal complex and right zygoma,
Fracture right eoronoid process of
mandible
10. Le Fort II fracture, impacted maxilla
and nasal component. Mandible intact
1I. Le Fort II fracture with split palate.
Impacted maxilla. Mandible intact
12. Le Fort III fracture. MandibIe intact
13. Le Fort II fracture. Fracture left angle
and right condyle
14. Le Fort I osteotomy for malunited
fracture maxilla
15. Lc Fort I fracture. Fracture of necks of
both condyles of mandible with minimal
displacement
16. Le Fort III fracture. Mandible intact
17. Le Fort iII fracture. Mandible intact
131
Methods of immobilization Period of intermaxillary
immobilization
Face frame for middle third fracture. 7 weeks
Additional Kirschner wire to support
left zygmnatic component. Eyelet wiring
and intermaxillary immobilization
Face frame and direct interosseous wir- Post-operative mobilization
ing of left zygomatic fragment in of mandible for 24 hours
fronto-zygomatic suture region. Eyelet and then immobilization for
wiring with intermaxillary immobili- 3 weeks
zation
Face frame. Cap splinting for inter- Post-operative mobilization
maxillary immobilization for 24 hours and then immo-
bilization for 2 weeks
Face frame for middle third fracture. NIL
Lower Gunning Splint with circum-
ferential wiring for mandible
Face frame for middle third fracture. 5 weeks
Eyelet wiring with intermaxillary
immobilization
Face frame for middle third fracture. 2 weeks
On left side Moule's pin inserted in
frontal sinus region along supra-
orbital ridge. Eyelet wiring with inter-
maxillary immobilization
Face frame for middle third fracture. NIL
Additional Kirschner wire to support
right zygomatic component
Face frame. Eyelet wiring with inter- NIL
maxillary immobilization for reduction
Face frame. Eyelet wiring and inter- Post-operative mobilization
maxillary ilnmobilizatio n of mandible for 24 hours
and then immobilization for
3 days
Face frame. Eyelet wiring and inter- NIL
maxillary immobilization for reduction
Face frame. Eyelet wiring and inter- 7 days
maxillary immobilization
Face frame. Eyelet wiring and inter- Post-operative mobilization
maxillary immobilization of mandible for 24 hours
and then immobilization for
48 hours
Face frame. Upper border wiring left 5 weeks
angle fracture of mandible and eyelet
wiring and intermaxillary immobilization
Face frame. Eyelet wiring for inter- Post-operative mobilization
maxillary immobilization for 24 hours and then
immobilization 3 weeks
Face frame. Upper Gunning Splint, NIL
lower cap splint for reduction
Face frame only. Reduction achieved NIL
without any intermaxillary immo-
bilization
Face frame. Patient's own dentures used NIL
to guide reduction of fractures
132 I. Smith
Fig. 2 This full face photograph illustrates the new
method of immobilization. The photograph is of
case 1, and was taken on the 5th post-operative day.
Fig. 3a A full face photograph of case 2 referred
to in table 1. The photograph was taken on the 7th
postoperative day.
Fig. 3b The profile photograph of case 2.
Fig. 4 The post-operative radiograph of case 2. The
fracture at the left fronto-malar region has also been
directly wired.
middle third of the facial skeleton was used. The
method proved to be very satisfactory in our
hands. In T a b l e i our first 17 cases are briefly
reported.
Discussion
This procedure provides a rigid immobilization
of the maxillary segment and, should the man-
dible be intact, it is possible at the conclusion of
the operative procedure to release the inter-
maxillary linkage without jeopardizing the oc-
clusal relationship.
This is of immense value if an obstruction to the
cipated or does occur. If the links have been
released they can be re-applied when the patient
is fully concious or has made a reasonable post-
operative recovery.
Where the intermaxillary immobilization is
retained, early mobilization of the intact mandible
is possible, usually at the end of the second or
third post-operative week.
When the patient is edentulous and the mandible
is intact, intermaxillary immobilization is avoided
in the first instance.
If intermaxillary immobilization is removed in
the first instance or early during treatment, it is
essential that the articulation of the teeth or the
relationship of the edentulous jawsbeperiodically
che&ed.
Obviously when a severe mandibular fracture is
associated with the middle third injury, inter-
maxillary immobilization cannot be dispensed
with.
 Fractures of the Middle Third of the Facial Skeleton 133

Fig. 5 a Fig. 5 b Fig.5 c

Fig. 5 a-c A full faced pre-operative photograph of a patient with a "dish-face deformity" associated with
a cleft lip and palate (case 3 in table 1). b) The full faced post-operative photograph of case 3 showing the
face frame in position after Le Fort I osteotomy for advancement of maxilla, c) The profile photograph
of case 3.

To date this method of treatment has proved most
satisfactory. It has allowed for one-stage defini-
tive treatment, and 23 patients who had sus-
tained Le Fort I, II or I I I fractures of the middle
third of the facial skeleton have been treated by
this method. This method of immobilization was
also used for 4 patients who were treated for
facial deformities which required Le Fort I
maxillary osteotomies for their correction.
Within 24 hours of surgery all the patients were
free of pain. None experienced more than slight
discomfort while the apparatus was in position.
W h e n the apparatus was removed all the Kirsch-
ner wires and titanium screws were still so firmly
embedded in the bone that a hand drill was re-
quired to remove them.
In all but two cases the apparatus was removed
without subjecting the patient to an anaesthetic.
Neither electrical reactions nor bone infections
were noted at any site where the Kirschner wires
or screws were embedded in the bone.
In every case treated by this method the fractures
were firmly united when the frame was removed
on the 4th post-operative week.
Conclusion
This method of immobilization of fractures of tile
middle third of the facial skeleton has proved to
be of great value, and I and my associates have
used the technique almost exclusively during the
past 18 months.
However, as with any method of treatment, diffi-
culties do arise when additional or alternative
means of treatment have to be sought.
If the pins and wires are firmly inserted into the
bone and the fragments are correctly reduced, a
foreward position of the fragments is maintained
when the frame is locked in position. However it
is essential at the conclusion of the operative
procedure, when the anaesthetist's throat pack is
removed, to closely inspect the occlusal relation-
ship of the teeth. If there appears to be a slight
shift the intermaxillary links must be reapplied
and retained for a period of a few days, when the
intact mandible is again mobilized for inspection.
W h e n fragments are firmly impacted and treat-
ment has been delayed, it is preferable to use cast
metal cap splints in conjunction with this tech-
nique especially if difficulty is experienced in dis-
impacting the fractured segments.
If a split palate is encountered and it is obvious
that eyelet wiring with intermaxillary linkage
will be incapable of closing the midline gap and
holding the fragments, cast metal cap splints are
used to provide the added stability.
It has been my impression that the whip action of
the Kirschner wires on the maxilla produced a
foreward leverage on the reduced nasal complex
and thus provides it with added support.
134 S. R. Mektubjian
If the supraorbital ridge is fractured in its outer
aspect, the Moule pin can be inserted into the
stable side of the rim in the region of the frontal
sinus. P r o v i d e d that the pin is correctly sited and
angulated there is no danger of entry into the
anterior fossa of the skull. E n t r y into the frontal
sinus is without consequence. To insert the Moule
pins into the tapped hole in the bone of the supra-
orbital ridge it only requires a few slow turns of
the h a n d drill to obtain a firm hold of the pin.
W h e n the frame is being assembled the upper sec-
tion should be kept as close as possible to the skin
References
Lewmt, B. A., R. M. Cook, MacFarlane: Experience
with the Levant Frame for Cranio Maxillary Fixa-
tion. Brit. J. Oral Surg. 11 (1973) 30
Mackenzi, D. L.: The Royal Berkshire Hospital "Halo".
Brit. J. Oral Surg. 8 (1971) 27
A Method of Internal Suspension Fixation in Jaw Fractures -
General Considerations
Sarkis Rupen Mektubjian
Institute of Emergency Care "N. I. Pirogov" (Direclor: P. Ko:ndova)
Emergency Clinic of Neurosurgery (Head: Assist. Prof. M. Vanev) Sofia, Bulgaria
Summary
In multiple trauma cases which are characteristic of
modern living, definitive fixation of the jaw fractures
is often postponed under the pretext that it is not a
life-saving procedure. The main reasons that such an
attitude has been adopted are the rather prolonged
and relatively traumatic methods of reduction and
fixation hitherto used. A procedure for internal suspen-
sion fixation is described providing firm fixation of
the reduced jaw fragments by means of an operation
of short duration and minimum trauma.
Key-Words: Facial injuries; Fracture fixation.
Introduction
The earliest possible definitive bone fixation is
the ideal basic requirement in the treatment of
facial fractures. Due to the extensive multiple
of the face a n d should be placed beneath the
anaesthetist's cathether mouth.
Acknowledgement
My thanks are due to Dr. M. Salmon, Superintendent
of the Johannesburg General Hospital and to Dr. J. de
W. Becket, Superintendent of W.E.N.E.L.A. Hospital
for permission to publish, to my registrars, Dr. R. Lurie
and Dr. P. Uys for their unfailing assistance and to the
photographic department of the Department of Sur-
gery, Medical School, for providing the photographic
prints.
Further information concerning the components of the
face frame can be obtained frmn the author.
Dr. lan Smith,
103, Lancet Hall,
]eppe Street,
Johannesburg, 2001,
Transvaal,
Republic of South A#ica
j. max.-fac. Surg. 2 (1974) 134-141
@ Georg Thierne Verlag, Stuttgart
injuries which is characteristic of modern living,
definitive fixation of the facial bones is often
deferred on the ground that it is b y no means
urgent as a life-saving procedure. Not infrequent-
ly, it is postponed well beyond the 15th-20th post-
injury day. Such a policy is justified by the
rather prolonged and relatively traumatic me-
thods of reduction and fixation employed.
E v e r y d a y routine practice g r a d u a l l y necessitated
the development of a method which would enable
the institution of prompt and atraumatic defini-
tive fixation of the j a w fractures at the earliest
moment in cases of m a x i l l o - f a c i a l t r a u m a often
associated with life-threatening traumatic lesions
of other organs and systems. The method sug-
gested, owing to its short duration and la& of