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Examination of Jaw
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Investigations for Jaw Disease
1. Orthopantomogram (OPG): It is a plain X-ray
of the jaw and mandible which shows the entire
mandible and partly maxilla in a single plane. It
is better than X-ray mandible lateral view as it
highlights proper dentition, inner and outer plates
of mandible (Figs 11.12A and B). It is a rotational
tomogram.
Indications: Jaw tumours—adamantinoma, dental
cyst, dentigerous cyst, osteoclastoma; osteomyelitis of the mandible; fracture mandible; to see
infiltration in carcinoma of oral cavity.
2. CT scan of jaw including neck and base of skull
in maxillary diseases, tumours, trauma to assess
extent. Sinus endoscopy.
3. Biopsy, discharge study, culture of discharge,
FNAC of lymph node.
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sphenoids are next in order. It is common in people
working in furniture industries, mustard gas industries,
and leather industries. It is common in Bantus in South
Africa where snuff with nickel and chromium is
commonly used. Squamous cell carcinoma is the
commonest type – 80%. Adenocarcinoma, transitional
cell carcinoma, salivary tumours, sarcomas, melanoma
and Burkitt’s lymphoma also can occur (Fig. 11.13).
Maxillary Tumours
They are rare. Maxillary sinus is the commonest site
of malignancy in paranasal sinuses. Ethmoids, and
A
B
Figs 11.12A and B: Orthopantomogram being taken
and X-ray OPG look.
Fig. 11.13: Extensions of tumour from maxillary
antrum.
Behaviour and Presentation
Initially may be asymptomatic or may present with
epistaxis or features of chronic sinusitis. When it
spreads to the floor, loosening of the teeth, necrosis,
antro-oral fistula can occur. Extension medially causes
nasal block, fungation, nasal discharge, blockage of
nasolacrimal duct (epiphora). Extension anteriorly
causes pain, anaesthesia and swelling in the cheek,
ulceration and fungation in the skin of cheek. Spread
above into the orbit causes epiphora, diplopia,
proptosis. Posterior spread is most dangerous as it
is not revealed easily. It causes postnasal discharge,
pain, trismus, limitation of movement of temporomandibular joint. Involvement of upper deep cervical
lymph nodes in later stage is common.
Differential diagnosis: Chronic sinusitis.
Classification
Ohngren’ s classification: An imaginary plane is drawn
extending between medial canthus of eye and the angle
of mandible. Growth situated above this plane is called
as suprastructural which has got poor prognosis.
Growth below this plane is called as infrastructural
and has got better prognosis (Fig. 11.14).
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Fig. 11.14: An imaginary plane is drawn extending between
medial canthus of eye and the angle of mandible and line
in this plane is called as Ohngren’s line.
SRB’s Clinical Surgery
Lederman’s classification: Two horizontal lines are
used, one passes through the floor of the orbit, another
passes through the floor of the antra. These lines are
called as line of Sebileau. (1) Suprastructure type:
In this type olfactory area of nose, ethmoidal, sphenoid,
and frontal sinuses are involved. (2) Mesostructural
type: This involves maxillary sinus and nasal
respiratory part. (3) Infrastructural type: This type
involves alveolar process. Lederman’s classification
is further divided by two vertical lines over medial
walls of the orbit to separate ethmoid sinuses and nasal
fossa from maxillary sinuses (Fig. 11.15).
Diagnosis: X-ray of the part-opacity of the involved
sinus with destruction of bony walls is seen. CT scan
is ideal method (Figs 11.16A and B). Biopsy is done
through nasal/oral route or on early stage through
TNM staging Staging
T1 Tumour limited to antral mucosa Stage I T1 N0 M
T2 Tumour causing bone erosion/destruction including extension into Stage II T2 N0 M
hard palate or middle meatus of nose. Stage III T3 N0 M0,
T
Tumour invading bone of posterior wall of maxillary sinus/skin of T1/T2/T3 N1 M
3
cheek/medial wall of orbit/infratemporal fossa/pterygoid plates/ Stage IVA T4 N0 M0, T4 N1 M
ethmoid sinuses. Stage IVB Any T N2 M0,
Tumour invading orbital contents beyond the floor or medial wall Any T N3 M
T
4
including orbital apex/cribriform plate/base of skull/nasopharynx/ Stage IVC Any T Any N M
sphenoid or ethmoidal sinuses.
Fig. 11.15: Diagrammatic representation of Lederman classification.
0
0
0
0
0
1
A
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B
Figs 11.16A and B: Carcinoma maxillary antrum
and CT picture.
Examination of Jaw
swelling from the gum which is firm and bleeds on
touch.
Fibrous epulis: It is a benign condition, can occur
in any individual. It is the commonest type of epulis;
it is firm or hard, commonly sessile rarely pedunculated
slow growing benign fibroma arising from periodontal
membrane. It is painless, well localised, hard/elastic,
non-tender gray-pink swelling in the gum which bleeds
on touch. It mimics squamous cell carcinoma. OPG;
biopsy from the lesion is essential. Recurrence can
occur if root is not removed properly.
Pregnancy epulis: It occurs in pregnant women due
to inflammatory gingivitis usually during 3rd month
of pregnancy. Clinically it resembles fibrous epulis
or pyogenic granuloma. It usually resolves after
delivery; otherwise it should be excised.
Granulomatous epulis: It is a mass of granulation tissue
in the gum around a carious tooth. It is soft, bright
red swelling which bleeds while brushing.
Myelomatous epulis: It is seen in leukaemic patients.
Investigated for leukaemia by peripheral smear, bone
marrow aspiration and biopsy.
Giant cell epulis: It is osteoclastoma causing ulceration
and haemorrhage of gum. It is painless expanding
swelling in mandibular part.
Carcinomatous epulis: It is squamous cell carcinoma
of the alveolus and gum presenting as localised, hard,
indurated swelling with ulceration.
Fibrosarcomatous epulis : It is fibrosarcoma arising
from fibrous tissue of the gum. It is with variable
consistency often softer, bluish red, progressive
swelling which bleeds on touch.
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Caldwell-Luc operation. Sinus endoscopy is done for
detailed examination of sinus and for biopsy.
Epulis
Swelling arising from the gums is called as Epulis
(gumboil, upon gum—Greek).
Congenital epulis: It is a benign condition seen in
a newborn arising from gum pads. It is a variant of
granular cell myoblastoma originating from gums. It
is more common in girls. It is more common in upper
jaw. It is not a malignant condition. It is well localised
Jaw Tumours
Classification
Swelling arising from the gums (Epulis): Congenital
epulis; Fibrous epulis; Pregnancy epulis; Giant cell
epulis; Myelomatous epulis; Sarcomatous epulis.
Swelling arising from the dental epithelium (Odon-
tomes): Benign odontogenic tumours: Epithelial—
Ameloblastoma; Calcifying odontogenic tumour;
Odontogenic adenomatoid tumour; Enameloma;
Composite odontoma, which may be either complex or
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SRB’s Clinical Surgery
compound. It is odontogenic hamartoma containing
all 4 layers—dentin, enamel, cementum and pulp.
Mesodermal tumour: Odontogenic fibroma, myxoma;
Cementoma, dentinoma. Malignant odontogenic
tumours: Malignant ameloblastoma; Fibrosarcoma.
Cysts arising in relation to dental epithelium: Dental
cyst; Dentigerous cyst.
Swelling arising from the mandible or maxilla:
Osteoma and osteoblastoma; Torus palatinus and
mandibularis; Fibrous dysplasia; Osteoclastoma;
Osteosarcoma; Secondaries.
Surface tumours: Tumours from the surface which
extend into the jaw (Fig. 11.17) .
Clinical features: Swelling in the jaw usually in the
mandible near the angle extending to vertical ramus
which attains a large size. It is gradually progressive,
painless, smooth and hard with intact inner table. Outer
table expansion is typical. Lymph nodes are not
enlarged. It is common in males; common in 5th decade.
It should be differentiated from osteoclastoma of
mandible (here inner table is not intact); dentigerous
cyst; dental abscess. Condition is curable by proper
surgery . Recurrent adamantinoma can spread through
blood. OPG shows eccentric expansion of the angle
and vertical ramus of the mandible with trabeculations
– honeycomb look (Fig. 11.18).
Fig. 11.17: Large jaw tumour – could be
adamantinoma or osteoclastoma.
Ameloblastoma (Adamantinoma [Greek
Adamas – strong/unconquerable], Eve’s
disease, Multilocular cystic disease of the jaw)
It arises from the dental epithelium probably from the
enamel/dental lamina. It occurs commonly in mandible
or maxilla. Occasionally it is seen in the base of the
skull in relation to Rathke’s pouch or in tibia.
Histologically it is a variant of basal cell carcinoma.
It is a locally malignant tumour. It neither spreads
through lymph node nor through blood. Hence it is
curable. It is usually unilateral. It can occur in a preexisting dentigerous cyst. It is multilocular but can
be unilocular.
Fig. 11.18: X-ray showing adamantinoma
with honeycomb look.
Curable malignancies
Adamantinoma
Basal cell carcinoma
Verrucous carcinoma
Papillary carcinoma thyroid
Marjolin’s ulcer
Carcinoma colon
Dentigerous Cyst (Follicular Odontome)
It is a unilocular cystic swelling arising in relation
to the dental epithelium from an unerupted tooth. It
is common in lower jaw (in relation to premolar or
canine), but can also occur in upper jaw; It occurs
over the crown of unerupted tooth; commonly seen
in relation to premolars or molars (Fig. 11.19). It causes
expansion of outer table of the mandible; it is solitary
and unilocular containing glairy fluid; histologically
contains enamel derived squamous cells; common in
younger age group; presents as painless swelling in
the jaw which is smooth and hard; egg shell crackling
Examination of Jaw
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Fig. 11.19: Dentigerous cyst.
often may be present. It mimics dental cyst, adamantinoma, osteoclastoma. It can turn into adamantinoma.
OPG shows well circumscribed translucent area in
the jaw with permanent unerupted tooth within it (Fig.
11.20).
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derived by epithelial debris of Mallassez. It is an
infective granuloma with epithelial proliferation which
later gets degenerated to cause cystic fluid in the cavity.
It is unilocular; contains mucoid material and
cholesterol crystals; presets as a smooth, tender
localized swelling in the jaw with exapansion in relation
to caries tooth; common in adult; common in maxilla
adjacent to upper incisor or canine. OPG shows circular
radiolucent area with clear often sclerosed margin in
relation to the tooth of the maxilla. It can cause
osteomyelitis of the mandible (Fig. 11.21).
Dental Cyst (Radicular Cyst, Periapical Cyst)
It occurs under the root of a chronically infected dead
erupted tooth. It is lined by squamous epithelium
Fig. 11.20: Orthopantomogram showing dentigerous cyst.
Differences between Dental cyst and Dentigerous cyst:
Dental cyst Dentigerous cyst
Site Maxilla – incisor / canine Mandible – premolar / molar
Type of tooth Erupted infected tooth often dead tooth Unerupted permanent tooth
Location Under the root of tooth Over the crown of the tooth
Age Adult Younger age group
Complication Osteomyelitis Adamantinoma
Fig. 11.21: Dental cyst.
Solitary Bone Cyst
It occurs in premolar or molar region of the mandible.
Rounded cyst bulges outwards. Bone resorption with
bone deposition in the margin is common. Fluid is
yellowish with high bilirubin content. Haemorrhage
with clot formation is known to occur.
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Ossifying Fibroma
SRB’s Clinical Surgery
It occurs exclusively in jaw bones. It is common in
young girls. In upper jaw it fills the maxillary antrum
and later presents as well localised external swelling.
Initial rapid growth ceases eventually and becomes
stationary. Alignment of teeth is known to occur.
X-ray shows soft tissue shadow with scattered bone
deposition.
Fibrous Dysplasia
It is a self limiting disease where the medullary/spongy
bone is replaced with fibroosseous tissue. It can be
monoostotic or polyostotic. Monoostotic is common
in long bones. In polyostotic type mandible also is
commonly involved. Maxilla can be involved occasionally. It is crab flesh white in colour; containing
islands of cartilages and cystic spaces. It can be bilateral
in mandible (Fig. 11.22A). It presents as painless
swelling in the mandible of growing children; common
in females; showing expansion of outer cortex but teeth
are normal. Treatment is done only after cessation
of skeletal growth. X-ray shows typical area of ‘smoke
screen translucency’ (Fig. 11.22B). Polyostotic fibrous
dysplasia; pigmentation of the skin; precocious puberty
in females is – Albright’s syndrome.
Osteoclastoma (Giant Cell Tumour)
of Mandible
It is giant cell tumour arising from epiphysis in
young adults; common in long bones; can occur in
mandible. It can be benign/intermediate or malignant
(10%). Expanding swelling towards inner table of the
mandible with cystic spaces; egg shell crackling;
discontinuity in inner table are typical. Central part
of the jaw either mandible (common) or maxilla is
involved (in mandible body is commonly involved).
When it is malignant spread can occur to lungs.
Pathological fracture is known to occur. Displaced
roots of adjacent teeth, loose teeth are common. Giant
cells are due to fused spindle cells (not due to
osteoclasts-misnomer). Giant cell epulis, brown
tumour of hyperparathyroidism, dentigerous cyst and
adamantinoma are differential diagnosis. X-ray and
biopsy confirms the diagnosis.
A
B
Figs 11.22A and B: Fibrous dysplasia of mandible (A)
and X-ray picture (B).
Giant Cell Reparative Granuloma
(Jaffe Tumour)
It is a swelling which occurs due to haemorrhage within
the bone marrow . It contains vascular stroma, collagen
and connective tissue cells. It is common in women.
It causes painless enlargement of jaw . It can be treated
by calcitonin (100 units/0.5 mg subcutaneously daily
for 12 months) or surgical curettage.
Upper Jaw Tumours
Ivory osteoma, osteoclastoma, osteosarcoma, squamous cell carcinoma of maxillary antrum, carcinoma
of hard palate are the examples (Fig. 11.23).
Lower Jaw Tumours
Fibrous dysplasia is common in mandible as it develops
partly from membrane. Paget’s disease of jaw,
osteoclastoma, oral malignancy infiltrating the mandible are common types (Fig. 11.24).
Fig. 11.23: Upper jaw tumour—from maxilla causing proptosis.
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Fig. 11.24: Lower jaw tumour—could be
adamantinoma mandible.
Examination of Jaw
Alveolar Abscess (Dental Abscess)
It is due to spread of infection from root of the tooth
into the periapical tissue. Initially it forms periapical
abscess which later spreads through the cortical part
of the bone into the soft tissues around forming an
alveolar abscess. Disease begins in the pulp of tooth
→ pulpitis → spread to root → localised osteitis →
abscess formation → spread into soft tissues outside
in cheek →initially diffused later localised swelling
in the jaw with redness and oedema of gum. Initial
dull continuous pain later becomes severe excruciating
pain. Fever, trismus, often dysphagia, palpable tender
neck lymph nodes occur eventually . Oedema, pain in
the floor of the mouth may occur (Fig. 11.25). Swelling
may burst spontaneously to form a sinus outside.
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Burkitt’s Lymphoma
It is multifocal childhood lymphoma common in Africa
probably due to Epstein-Barr virus. It can occur in
upper or lower jaw . It is common in premolar or molar
area. When many areas are involved it occurs on same
side of both maxilla and mandible. Disease expands
outwards involving cheek and soft tissues outside.
Lamina dura of teeth disappears. Neck nodes may get
enlarged; retroperitoneal mass; hepatomegaly; ovarian
tumour; renal, adrenal, pancreatic and mesenteric
nodal involvement are common. Involvement of
spinal nerves, salivary gland, breast, thyroid, bones,
intracranial spread, and cranial nerve palsies are known
to occur. Typical starry sky pattern in histology is
obvious.
Fig. 11.25: Typical dental abscess.
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SRB’s Clinical Surgery
Bacteria: Staphylococci, streptococci, anaerobic
bacteria and gram-negative organisms. Alveolar
abscess occurring in relation to upper lateral incisor
will not present outside but produces swelling on the
palate medially. Abscess in relation to wisdom tooth
also opens medially (not outside) and may cause
Ludwig’s angina. X-ray will reveal rarefaction of the
root of the tooth only after 10 days.
Complications: Septicaemia; spread of infection into
other spaces like parapharyngeal spaces; sublingual
and submandibular spaces causing Ludwig’s angina;
oedema of epiglottis and respiratory distress; spread
to pterygoid space and along pterygoid muscles
through emissary vein → cavernous sinus thrombosis;
upper canine tooth abscess → medial corner of eye
→ angular vein thrombophlebitis → cavernous sinus
thrombosis; submasseteric abscess; lower incisor
abscess can cause abscess in the chin and later median
mental sinus; chronic osteomyelitis of the jaw with
discharging sinuses.
Osteomyelitis of Jaw
It can be in the maxilla or mandible.
Causes: Alveolar abscess leading into osteomyelitis;
recurrent dental infection; trauma; after dental
extraction; surgeries of the jaw; postradiotherapy
osteomyelitis (osteoradionecrosis).
Types: Acute: Common in children; maxilla or
mandible may get involved (Fig. 11.26); swelling,
redness, fullness is the features; pus may trickle through
nostril if it is in maxilla. Subacute: It is the commonest
type; common in adult; apical sepsis, endarteritis, bone
necrosis is the pathology; common in mandible; rare
in maxilla due to existing network vasculature which
prevents endarteritis. Compression over inferior dental
nerve causes numbness in chin in distribution area
of mental nerve. Pain, swelling, tenderness, irregularity,
thickening are typical. Chronic: It is also common
in mandible; apical abscess, alveolar abscess, trauma,
radiation, chemical like phosphorus, tuberculosis,
syphilis, actinomycosis are the causes. Pain, thickening,
irregularity, discharging sinus, sequestrum in the
discharge, discomfort are the features. Infection from
lower incisor causes median mental sinus. X-ray shows
features of osteomyelitis with new bone formation and
sequestrum.
Fig. 11.26: Osteomyelitis of mandible.
Actinomycosis: Faciocervical is the commonest type;
lower jaw is commonly involved; infection begins at
carious tooth; indurated gums → nodules → abscess
→multiple sinuses → discharging sulphur granules
with normal X-ray (Ray fungus) → Actinomycosis
israelii is the causative agent.
Cherubism (Cherub–Angelic Being)
It is an autosomal dominant familial condition occurring in first year of life. It shows giant cell granuloma
with fibrous tissues in the jaw. It is commonly bilateral;
commonly seen in angles of the mandible and also
in maxilla. It presents as diffuse enlargement of maxilla
and both sides of the mandible; bulging of the cheek
causes pull of the lower eyelid. Hence child appears
like, as if looking upwards (winged face of angelic
babies); interference of the development and eruption
of the teeth. It is a self limiting disease. Often requires
dental care and treatment for proper dentition.
Treacher-Collins Syndrome
It consists of mandibulofacial dystosis; hypoplasia of
the zygomatic bone and mandible; antimongoloid slant
to the palpebral fissure; coloboma of lower eyelid;
Low ear lobule with deficient middle ears. It is familial.
Pierre-Robin Syndrome
It is a congenital entity consisting of – cleft palate
alone; mandibular hypoplasia; cyanotic episodes,
deficiency in transforming growth factor; defective
Examination of Jaw
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sucking and tongue falling backwards in infants,
cryptorchidism.
Micrognathism and Prognathism
Excessively small mandible is called as micrognathism.
Backward displacement of tongue in neonates with
micrognathism can cause respiratory distress. Here
oral cavity is small. Prognathism is where mandible
is larger than average with protrusion. Occasionally
maxilla is hypoplastic.
269
Soft-tissue injuries: Lacerations, contusions, cut
wounds, etc; Eyelid injuries with black eyes; Facial
nerve injury; parotid duct injury; lacrimal apparatus
injury.
Injuries to the facial bones: Fracture nose—Patient
presents with pain and swelling in the nose with
deviation and displacement. Injuries to the maxilla;
zygomatic bone injuries; mandibular bone fracture
and mandibular dislocation; orbital bone fracture:
presents with diplopia, enophthalmos, infraorbital
nerve sensory loss.
Diseases of the Palate
Cleft palate; Torus palatinus—a bony hard swelling
in the centre of the hard palate; nasopalatine cysts;
Epstein’ s pearls at the junction of soft and hard palates
in the midline in infants due to retained developmental
cell rests; apical cyst or abscess; minor salivary gland
tumour—commonest site is palate; Maxillary tumour
extending into the palate; Squamous cell carcinoma
of the palate; gummatous perforation in the middle
of the palate seen in congenital syphilis; perforation
of the palate anywhere in carcinoma palate.
Nasopalatine Cyst
It develops in incisive canal; causes spherical bone
cavity behind upper incisors; composed of epithelial
lining with fibrous capsule with mucous secreting cells.
It occurs in the midline of palate.
Maxillofacial Injuries
It may be due to road traffic accidents, assaults, bullet
injuries or sport injuries.
Classification
Fracture in maxillofacial region can be grouped as:
Fracture lower third that comprises mandible; Fracture
middle third that comprises maxilla, zygoma and nose;
Fracture upper third of the face involving part of the
orbit, frontal bones.
Maxillofacial fracture also can be grouped as:
Fracture of the face which do not involve the dental
occlusion; fractures of zygoma and nose; fracture
which involves the dental occlusion; fracture mandible
and maxilla.
Respiratory Obstruction
Causes: Oronasal airway block can occur by blood,
clot, vomitus, foreign body, dentures, teeth, saliva,
bone pieces, etc; Backward falling of tongue can cause
obstruction of the nasopharynx and oropharynx. It is
common in bilateral mandibular fracture; occlusion
of the nasopharynx and oropharynx can occur in
fracture maxilla with posterior and inferior displacement; haematoma in floor of the mouth or posterior
oral cavity can cause airway block; other features
include oedema of larynx/tongue/posterior third of
oral cavity/pharynx; surgical emphysema.
Haemorrhage in Maxillofacial Injuries
Haemorrhage in maxillofacial injuries is usually not
life threatening. But it should be identified and
controlled properly . In association with other internal
injury , such haemorrhage may be important to cause
the circulatory failure. Haemorrhage may be due to—
Soft tissue bleeding; bleeding from inferior alveolar
artery, palatine vessels; nasal bleeding.
Clinical Features
Localised swelling due to haematoma; facial oedema;
bleeding with open wounds; asymmetry which is
clinically confirmed by observing supraorbital ridges,
nasal bridge; localised tenderness; step deformity;
trismus; diplopia; features of associated injuries like
intracranial, abdominal or thoracic injuries.
Investigations: X-ray face; CT scan of head/jaw.
General treatment for faciomaxillary injuries:
Suturing of soft tissues; Airway maintenance; Control
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of bleeding; Pain relief; Control of infection; Treating
the individual fractures (Fig. 11.27).
Fracture Middle Third Area
It includes—maxillae, zygomatic bones, palatine
bones, nasal bones, lacrimal bones, inferior conchae
(one on each side), the vomer, ethmoid and its attached
conchae, pterygoid plates of sphenoid.
Fracture middle third includes fracture maxilla, zygoma and nasal bones.
Fractures not involving occlusion Fractures involving occlusion
Central Dentoalveolar
• Fracture nasal bones and or nasal septum
• Fracture of frontal process of maxilla Subzygomatic
• Fractures of above two extending into • Le Fort I-low level either unilateral or bilateral
ethmoid- nasoethmoid • Le Fort II-pyramidal either unilateral or bilateral
• Fractures above three which extends into
frontal bone – fronto-orbito-nasal dislocation Suprazygomatic Le Fort III –high level
Lateral
• Fractures involving zygomatic bone, arch and
maxilla excluding the dentoalveolar component
SRB’s Clinical Surgery
Zygomatic Complex Fracture
Classification
Simple fracture which is stable and undisplaced—
Here fracture line passes across the infraorbital
foramen downwards over anterior wall of the antrum.
Simple fracture which is displaced medially. It may
be associated with rotation/tilt in vertical axis, either
• Craniofacial disjunction—unilateral or bilateral
Le Fort classification (Fig. 11.28)
(Rene Le Fort – French surgeon classified these fractures by dropping rocks on the face of the cadavers and later
dissecting the area for study and research and published paper in 1911)
Types Features
Le Fort I (Guerin’s fracture-low level) • Bleeding from nose
(floating fracture, horizontal fracture of maxilla) • Posterior gagging of occlusion
• It runs horizontally above the floor of the nasal • Upper lip swelling
cavity involving lower third septum, palate, alveolar • Palatal echymosis
process of maxilla and lower third of pterygoid • Occlusion derangement
plates of maxilla • Floating maxilla
Le Fort II (pyramidal fracture) • Oedema of middle third face
• From the nasal bones at topmost, fracture runs • Both sides circumorbital and subconjunctival
laterally towards lacrimal bones, medial wall of orbit, ecchymoses
infraorbital margin, through or medial to infraorbital • Nasal bleeding/obstruction/deformity
foramen and backwards below the zygomaticomaxillary • Deformity of face (dish face), diplopia
area through lateral wall of maxillary sinus and pterygoid • Retroposition of maxilla with posterior gagging
plates. Zygoma is intact with skull base • Limitation of ocular movements, CSF rhinorrhoea
Le Fort III (craniofacial disjunction, high level) • Lengthening of face
• Here fracture runs parallel to skull base. It passes • Enophthalmos, ocular level depression
through the nasal bone, lacrimal bone, ethmoid bone, • Hooding of eyes, occlusal plane tilting
optic foramen, inferior orbital fissure, pterygomaxillary • Entire facial skeleton moves as a single block
fissure and lateral orbital wall with frontozygomatic • Tenderness and separation of suture line
suture with zygomatic arch • Diplopia
• Tenderness and separation of infraorbital margin
• Trismus, teeth mal-alignment
Guerin sign: Haematoma at greater palatine foramen
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