Fig. 1.9  Diagram of the transversal buttresses of the midface, represented by the horizontal supraorbital frontal bar, the infraorbital rims and the maxillary alveolar process. The superior orbital-interorbital complex (upper midface) is like a framework, stabilized by two horizontal and four vertical buttresses to which the more delicate facial bones are attached (mod. a. Mathog et al. 1995). 1 Frontal process of maxilla, 2 inferior orbital rim, 3 superior orbital rim, 4 frontal bone; orange lines transverse supraorbital-frontal, infraorbita, and alveolar buttresses, green lines vertical lateral zygomatico-maxillary and anterior medial naso-maxillary buttresses

1.4  Subcranial and Midface Skeleton

The midface and the anterior base of the skull form a structural and biomechanical entity. Whilst anatomically the midface ends subbasally, on the basis of the close topographical-anatomical, functional, and biomechanical complexity of both structures, the frontofacial and frontobasal regions are still considered as belonging to the midface (Ewers et al. 1995; Hausamen et al. 1995).

•The high incidence of combined midfacial-fronto- basal fractures is based on the close topographical and biomechanical relationship of the osseous structures in the viscerocranium and skull base.

The anatomical connection between the midface and neurocranium is formed by the maxilla, the naso-­ ethmoidal complex, the palatal and vomerine bone, and the pterygoid process of the sphenoid.

•Through the pterygopalatal column of the sphenoid, the lower surface of the skull base is directly involved in constituting the posterior midface. Whereas through the frontal maxillary process, the naso-­ ethmoidal complex is indirectly involved in the anterior midfacial composition.

Biomechanically, both compartments – midface and neurocranium – are intimately connected through the intersection of the external as well as internal vertical and transversal facial trajectories. The horizontal as well as sagittal trajectories of the fronto-facial region are connected with the anterior skull base. Hence, in the case of craniofacial fractures, the frontobasal and frontofacial regions may be involved in complex severe facial injuries (Hardt et al. 1990; Ewers et al. 1995). This explains the high incidence of skull base fractures in midface fractures (Fig. 1.10).

Vertical forces along the naso-maxillary and zygomatic-maxillary pillars are indirectly absorbed by the frontal bone, whilst the posterior vertical forces along the pterygo-maxillary column may be directly transferred to the skull base. Sagittal forces are conveyed to the temporal bone via the zygomatictemporal column.

Forces applied to the central maxillofacial region may cause fractures on the subbasal level, which in turn may traumatize neighboring vital structures. The frontal skullbase and dura are in immanent danger. Acute and chronic ascending intracranial infection may result (Helms and Geyer 1983).

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