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LE FORT FRACTURES

The document discusses Le Fort fractures, detailing their classification, etiology, anatomy, and management techniques. It outlines the types of fractures (Le Fort I, II, and III), their signs and symptoms, and the general principles of treatment including reduction and immobilization methods. Additionally, it emphasizes the importance of radiographic examination for accurate diagnosis and treatment planning.

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Vishma Sai
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0% found this document useful (0 votes)
16 views65 pages

LE FORT FRACTURES

The document discusses Le Fort fractures, detailing their classification, etiology, anatomy, and management techniques. It outlines the types of fractures (Le Fort I, II, and III), their signs and symptoms, and the general principles of treatment including reduction and immobilization methods. Additionally, it emphasizes the importance of radiographic examination for accurate diagnosis and treatment planning.

Uploaded by

Vishma Sai
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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LE FORT

FRACTURES
MODERATOR : DR RAJANIKANTH BR
PRESENTER : AMRUTA T ACHAR

1
CONTENTS
• INTRODUCTION.
• ETIOLOGY.
• ANATOMY OF MIDFACE.
• CLASSIFICATION.
• LEFORT-I FRACTURES.
• LEFORT-II FRACTURES.
• LEFORT-III FRACTURES.
• COMPLICATIONS AFTER TREATMENT OF MIDFACE FRACTURES.
• EMERGING TECHNIQUES FOR MANAGEMENT.

2
INTRODUCTION

• A fracture is defined as loss of bone integrity resulting from mechanical

injury and/or diminished bone strength.

• Facial skeleton can be roughly divided into 3 areas: lower

third/mandible, upper third – frontal bone and middle third which is

frontal bone to level of upper teeth (in edentulous arches, upto alveolar

ridge)

3
ETIOLOGY
• Any severe trauma can cause a fracture of the middle third of the facial
skeleton.

• This trauma can be caused by the following reasons:

 Road Traffic Accident

 Assault

 Sports Injuries

 Workplace Hazards

4
ANATOMY
• Midfacial complex is constructed of a series of vertical pillars that
primarily provide protection from vertically directed forces.

• These vertical pillars are further supported by horizontal buttresses.

• Behind this buttress system, sits the medial and lateral pterygoid plates
inferiorly and skull base superiorly.

• This framework results in few anatomic sites of weakness, resulting in


fairly predictable patterns of fracture.

5
ANATOMY

6
ANATOMY
• The middle third of facial skeleton is made up of the following bones:
Two maxillae
Two Zygomatic bones
Two Zygomatic process of Temporal bones
Two Palatine bones
Two Nasal bones
Two Lacrimal bones
Vomer
Ethmoid with attached Conchae
Two Inferior Conchae
Pterygoid plates of Sphenoid

7
ANATOMY

Image Reference: Netter’s Head and Neck Anatomy 8


ANATOMY
PHYSICAL CHARACTERISTICS OF MIDFACE SKELETON

• Complex of bones are arranged in such a manner so as to withstand the

forces of mastication. These forces are distributed around the fragile

area of the nose and paranasal sinuses to the base of the skull.

• Because of relative fragility of the midface skeleton, it acts as a cushion

for trauma directed towards cranium from an anterior/anterolateral

direction.

9
ANATOMY
PHYSICAL CHARACTERISTICS OF MIDFACE SKELETON

• It is analogous to a ‘matchbox’ sitting


below and in front of a hard shell
containing the brain and differs
markedly from the rigid protection of
mandible below.
• A force/impact applied to the
midfacial skeleton is cushioned
sufficiently so that it may not lead to
loss of consciousness (but causing
considerable damage to the bones).
10
CLASSIFICATION
CLASSIFICATION OF FRACTURES ON AN ANATOMICAL BASIS (ROWE AND
WILLIAMS 1985)

FRACTURES NOT INVOLVING THE OCCLUSION FRACTURES INVOLVING THE OCCLUSION


CENTRAL REGION DENTOALVEOLAR FRACTURES
1. Fractures of Nasal bones and/or Nasal septum – SUBZYGOMATIC
Lateral Nasal Injuries, Anterior Nasal Injuries. 1. LE FORT I (LOW LEVEL/GUERIN)
2. Fractures of the Frontal process of Maxilla. 2. LE FORT II (PYRAMIDAL)
3. Fractures of type (1) and (2) which extend into SUPRAZYGOMATIC – LEFORT III (HIGH-LEVEL OR
Ethmoid bone (Naso-ethmoid). CRANIO-FACIAL DYSFUNCTION)
4. Fractures of type (1), (2) and (3) which extend
into frontal bone (Fronto-orbito-nasal dislocation).
LATERAL REGION
Fractures involving Zygomatic bone, arch and
maxilla (Zygomatic complex) excluding the dento-
alveolar component.

11
CLASSIFICATION
ERICHS (1942) CLASSIFICATION OF LEFORT FRACTURES

12
CLASSIFICATION
LE FORT CLASSIFICATION

13
CLASSIFICATION
LE FORT CLASSIFICATION MODIFICATION BY MARCIANI
• LE FORT I : Low maxillary fracture
LE Fort I (a) : LE fort I + Multiple Segments

• LE FORT II: PYRAMIDAL FRACTURE


LE Fort II (a) : LE Fort II + Nasal
LE Fort II (b) : LE Fort II (a) + Ethmoid

• LE FORT III : CRANIOFACIAL DYSJUNCTION


LE Fort III (a) : LE Fort III + Nasal Fracture
LE Fort III (b) : LE Fort III (a) + Ethmoid

• LE FORT IV: LE FORT II or LE FORT III WITH CRANIAL BASE


LE Fort IV (a) : LE Fort IV with Supraorbital Rim
LE Fort IV (b) : LE Fort IV + Anterior Cranial base 14
GENERAL EXAMINATION
FACIAL EXAMINATION

• The face is systematically evaluated for the presence of any lacerations or

obvious deformities of the skull and asymmetries are noted.

• The frontal area and supraorbital rim is examined first, with progression

downward, including the lateral and infraorbital rims.

• Periorbital edema and ecchymosis are often initial signs of orbital trauma .

15
GENERAL EXAMINATION
FACIAL EXAMINATION

• Crepitation to palpation is indicative of orbital emphysema.

• The attachment of the medial canthal ligament is evaluated by palpating the


insertion of the medial canthal ligament for crepitus or instability and by lateral
traction on the lateral canthus.

• Physical findings of medial canthal ligament disruption include rounding of the


lacrimal lake, epiphora, and increased intercanthal distance.

16
GENERAL EXAMINATION
FACIAL EXAMINATION

• The zygomatic arches, nasal bones, maxilla, and mandible are


then sequentially evaluated.

• The mandibular opening is evaluated for fracture or


displacement of the zygoma, which may obstruct the forward
movement of the coronoid process.

• The occlusion and quality of the dentition are recorded.

17
GENERAL EXAMINATION
RADIOGRAPHIC EXAMINATION

• Once the patient is sufficiently stabilized, radiographic


examination can be done.

• The preferred radiologic modality for midfacial injuries is a


maxillofacial computed tomography scan (CT scan).

• The CT scan allows evaluation of bone, providing detailed


information about fracture patterns.

• CT scans also provide characterization of soft tissues, including


the extent of edema, presence of foreign bodies, formation of a
retrobulbar hematoma, or entrapment of the extraocular 18
GENERAL EXAMINATION
RADIOGRAPHIC EXAMINATION

• Plain films, although necessary in the absence of CT scanning,


provide little diagnostic information.

• The plain films obtained in the history include the Water’s,


Submento-vertex, Anteroposterior and Lateral skull views.

19
GENERAL EXAMINATION
RADIOGRAPHIC EXAMINATION

20
MCGREGOR-CAMPBELL LINES
These lines were described by McGregor and Campbell for ease of searching on an
occipitomental view 10-degree frontal projection.

1. First line = across the zygomaticofrontal, the superior margin of the orbit and the frontal
sinus.

2. Second line = across the zygomatic arch, zygomatic body, inferior orbital margin and nasal
bone

3. Third line = across the condyles, coronoid process and the maxillary sinus / Zygomatic
buttress region

4. Fourth line = across the mandibular ramus, occlusal plane

5. Fifth line (Trapnell’s line, added later) across the inferior border of the mandible from
angle to angle
21
MCGREGOR-CAMPBELL LINES

22
DOLAN’S LINES
• Three lines described by Dolan and Jacoby that aid in evaluating for maxillofacial
fractures on an occipitomental skull radiograph.

• They are usually used as an adjunct to McGregor-Campbell lines.

23
DOLAN’S LINES
Orbital line (line 1): traces the inner margins of the
lateral, inferior and medial orbital walls and the nasal
arch.

Zygomatic line (line 2): traces the superior margin of


the zygomatic arch and body extending along the
frontal process of the zygoma to the zygomaticofrontal
suture.

Maxillary line (line 3): traces the inferior margin of the


zygomatic arch, body, and buttress and the lateral wall
of the maxillary sinus.

Elephant of Rogers - Lee Rogers pointed out that the


second and third lines of Dolan give the outline of the
head of an elephant.
24
PNS VIEW

In PNS view, the following four features are to be verified/compared with the
unaffected side (4 S’s described by Delbalso, Hall and Margarone)

1. Symmetry

2. Sharpness

3. Sinus

4. Soft tissues

25
LE FORT I
FRACTURE LINES

• Fracture line extends backwards from the lateral margin of the anterior

nasal aperture below the zygomatic buttress to cross the lower third of

the pterygoid laminae.

• It also passes along the lateral wall of the nose and the lower third of

nasal septum to join the lateral fracture behind the tuberosity.

26
LE FORT I
SIGNS AND SYMPTOMS

• Mild swelling of the Upper lip.

• Ecchymosis in buccal sulcus beneath each zygomatic arch.

• Mobility of tooth bearing segments of maxilla.

• Extreme cases = downward fracture of the maxilla.

• Impacted type fractures = maxilla is immobile. Damage to cusps of

individual teeth seen. 27


LE FORT I
SIGNS AND SYMPTOMS

• Percussion of upper teeth results in characteristic ‘cracked pot’ sound.

• Complete Le Fort I = often associated with mid-palatine split.

• Bilateral Le Fort I – Floating Maxilla.

• Palatal Ecchymosis = Guerin’s Sign.

28
LE FORT II
FRACTURE LINES

• Fracture extends from the thin middle area of the nasal bones down

either side, crossing the frontal processes of the maxillae into the

medial wall of each orbit.

• Within each orbit, fracture line crosses lacrimal bone behind lacrimal

sac. It extends downwards and backwards across the lateral wall of

antrum below zygomaticomaxillary suture.


29
LE FORT III
FRACTURE LINES

• Fracture runs near Frontonasal suture transversely backwards, parallel

with base of skull and involves full depth of ethmoid bone including

cribriform plate.

• Within the orbit, the fracture passes below optic foramen, into posterior

limit of Inferior Orbital fissure. From here, it extends in two directions:

backwards across pterygomaxillary fissure and laterally across lateral


30
wall of orbit.
SIGNS AND SYMPTOMS
COMMON TO LEFORT II AND III
FRACTURES
• Gross edema of soft tissues over middle third of face.

• Bilateral circumorbital ecchymosis

• Bilateral subconjunctival hemorrhage

• CSF rhinorrhea

• ‘Dish face’ deformity and lengthening of the face.

• Limitation of ocular movement with possible diplopia and


enophthalmos.

• Anterior open bite.

• Hematoma in palate. 31
SIGNS AND SYMPTOMS
PECULIAR TO LEFORT II
FRACTURES
• Step deformity at infraorbital margins.
• Mobility of midface detectable at nasal bridge and infra-orbital margins.
• Anesthesia/Paresthesia of cheek.
• Possible diplopia.
• CSF rhinorrhoea may not be clinically detectable.

32
SIGNS AND SYMPTOMS
PECULIAR TO LEFORT III
FRACTURES
• Tenderness and separation at frontozygomatic suture.

• Tenderness and deformity of zygomatic arches.

• Lengthening of face.

• Enophthalmos.

• Hooding of eyes.

• Lateral displacement of midline of upper jaw.

• Mobility of whole facial skeleton as a single block.

• Battle’s sign
33
MANAGEMENT OF LE
FORT FRACTURES
GENERAL PRINCIPLES OF TREATMENT

To achieve reduction followed by an adequate period of fixation to ensure


stable union.

REDUCTION :

LEFORT I

• Loose fractures may be reduced by finger manipulation alone.

• Impacted fractures are manipulated by grasping with two pairs of


Rowe’s Dis-impaction forceps; Reduction of displaced maxilla.

• Hayton William’s forceps = Reducing a fractured maxilla.


34
MANAGEMENT OF LE
FORT FRACTURES

35
MANAGEMENT OF LE
FORT FRACTURES
LEFORT II

• Similar to Lefort I. Fracture line involving Anterior Cranial Fossa should


not be disturbed as much as possible.

• Asche’s or Walshman’s septal forceps can be used to mobilize remaining


fragments of fracture.

• After tooth bearing portion is adequately reduced and immobilized, any


associated NOE fracture is treated.

36
MANAGEMENT OF LE
FORT FRACTURES
LEFORT III

• Frequently associated with Lefort I and II fractures with separate


zygomatic and nasal complex fractures. Disimpaction should be carried
out in the following order:

 Frontal and Zygomatic fractures should be reduced and fixed under


direct vision employing a coronal scalp flap for access.

 Upper part of central midfacial fracture can be usually reduced via same
approach.

 Tooth bearing portion is manipulated into correct occlusal relationship


by means of Rowe’s disimpaction forceps. 37
MANAGEMENT OF LE
FORT FRACTURES
LEFORT III

 After main fragments of central block have been fixed, NOE fractures
are treated.

• Further moulding of contour of face may require packing of the


maxillary sinus.

• Dingman and Harding in 1951, suggested the use of dental compound


loaded into impression tray for mobilizing the fractured fragment of
maxilla. This can be used, where some amount of fibrosis has set in
because of delayed treatment.

38
MANAGEMENT OF LE
FORT FRACTURES
REDUCTION BY TRACTION

• This is mainly used in delayed cases, where the fracture is 10 to 14


days old and no longer sufficiently mobile.

> Intraoral elastic traction.

> Extraoral elastic traction with appropriate extension.

> Bars and side bars.

• Intraoral intermaxillary elastic traction may be used in an appropriate


direction to restore normal occlusion. Once the satisfactory occlusion is
achieved, it is replaced by IMF.
39
MANAGEMENT OF LE
FORT FRACTURES
IMMOBILIZATION OF LEFORT FRACTURES

Methods are broadly classified as Internal Fixation (Immobilization within the


tissues) and External Fixation (Extra-oral Immobilization). Internal fixation methods
are as follows:

1. DIRECT OSTEOSYNTHESIS

TRANSOSSEOUS WIRING
TRANSFIXATION WITH
A. HIGH LEVEL KIRSCHNER
MINIPLATES
B. MID LEVEL WIRE/STEINMANN PIN
C. LOW LEVEL A. TRANSFACIAL
B. ZYGOMATIC-SEPTAL

40
MANAGEMENT OF LE
FORT FRACTURES

41
MANAGEMENT OF LE
FORT FRACTURES
IMMOBILIZATION OF LEFORT FRACTURES

Internal Wire Suspension – Involves connecting the lower jaw by wires within the
tissue to areas of facial skeleton above fracture line so sandwiching the fractured
portion between mandible and that part of facial skeleton which is not inbolved in
fracture.
1. SUSPENSION WIRES
TO MANDIBLE

FRONTAL-CENTRAL/
INFRAORBITAL PYRIFORM APERTURE
LATERAL ZYGOMATIC
CIRCUMZYGOMATIC

42
MANAGEMENT OF LE
FORT FRACTURES

43
MANAGEMENT OF LE
FORT FRACTURES
IMMOBILIZATION OF LEFORT FRACTURES

External Fixation methods are as follows:

EXTERNAL FIXATION

1. CRANIOMANDIBULAR CRANIOMAXILLARY
A. BOX FRAME A. SUPRAORBITAL PINS SUSPENSION BY CHEEK WIRES
B. HALO FRAME B. ZYGOMATIC PINS FROM HALO-FRAME OR
C. PLASTER OF PARIS HEADCAP C. HALO FRAME HEADCAP

44
MANAGEMENT OF LE
FORT FRACTURES

45
MANAGEMENT OF LE
FORT FRACTURES
LEFORT I

• Early reduction of Le Fort type I injuries presents minimal difficulty but, beyond 7
to 10 days, increasing amounts of force are required because of the natural
healing process.

• The advent of plate and screw fixation has transformed craniomaxillofacial


fracture repair from obligatory long-term MMF and craniofacial suspension to rigid
stabilization.

• The patient is first placed in MMF to reestablish the pretraumatic occlusal


relationship.

46
MANAGEMENT OF LE
FORT FRACTURES
LEFORT I

• Four-point fixation along the pyriform and zygomaticomaxillary buttresses is


routinely provided for stability of this fracture pattern. Occlusion should be
immediately rechecked following release of MMF.

47
MANAGEMENT OF LE
FORT FRACTURES
LEFORT I

48
MANAGEMENT OF LE
FORT FRACTURES
LEFORT II

• ORIF is advantageous for treatment of these fractures. If the nasofrontal suture


area is intact and continuous with the maxillary segment, bilateral intraoral
exposure allows appropriate four-point fixation.

• However, the orbital floor, inferior orbital rim, or nasofrontal region often
requires exploration and repair. In these situations, additional access is required.

49
MANAGEMENT OF LE
FORT FRACTURES
LEFORT II

• Le Fort II fracture lines at


the infraorbital rim area
may have to be accessed
directly, if required,
especially with
associated
zygomatic/orbit
fractures.
• In this case the lateral
orbital rim
reconstruction is done
via combined access
from left sub ciliary
incision and left supra
tarsal incision

50
MANAGEMENT OF LE
FORT FRACTURES
LEFORT III

• The Le Fort III fracture pattern is a craniofacial


dysjunction.

• The Le Fort III fracture is essentially a complicated


combination of bilateral zygoma and NOE fractures,
and the same principles apply when treating this
fracture pattern.

• There are two general schools of thought regarding


the sequence of repair.

51
.
MANAGEMENT OF LE
FORT FRACTURES
LEFORT III

• Gruss et al have proposed a method of reconstruction whereby reconstruction


begins with the outer framework and progresses to the inward facial
structures, from stable to unstable areas.

• A stable outer framework of the midface is established with reduction and


fixation of the zygomaticofrontal, zygomaticotemporal, and nasofrontal
sutures and the appropriate reduction of the maxilla to the midface inferiorly.

• Once the outer framework has been established, one can proceed to
reconstruct, in order, the nasal skeleton and floors of the orbits, correct any
lacrimal system disorders, and reestablish the proper positioning of the medial
canthal ligaments.
52
MANAGEMENT OF LE
FORT FRACTURES
LEFORT III

• A second school of thought, popularized by Markowitz and Manson, focused


on reestablishing facial width at the NOE complex and proceeding in laterally.
A method described by Kelly and Manson outlines this approach.

• Marciani and Gonty have summarized the four factors contributing to positive
outcomes following reconstruction of craniomaxillofacial trauma.

• These are early definitive treatment, anatomic and functional repair of NOE
injuries, wide exposure of fractured segments, and anatomic repositioning
and stable fixation in all planes.

53
MANAGEMENT OF LE
FORT FRACTURES
LEFORT III – SURGICAL APPROACH

54
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES
MALUNION OF MIDFACE FRACTURES

• Malunion of the midface resulting from improper reduction or fixation,


postponement of treatment, or excessive comminution may result in suboptimal
post-repair function and aesthetics.

• This may require correction by appropriate osteotomies and bone grafting.

• If a functional deformity exists, a corrective osteotomy should be considered and


performed as early as possible.

• If the deformity is primarily cosmetic in nature, such as a flattened paranasal


prominence or malar prominence caused by deficient projection of the zygoma, an
onlay graft of autologous or alloplastic material may be acceptable.

55
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

56
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

BLEEDING OCULAR NEUROLOGIC


COMPLICATION CSF LEAK COMPLICATION COMPLICATION
S S S
• Control of • Rhinorrhoea • Traumatic • Infraorbital
Bleeding • Otorrhea Diplopia Nerve
• Ligation • Enophthalmos Paresthesia
Techniques • Blindness
• Traumatic
Optic
Neuropathy
• Superior
Orbital Fissure
Syndrome and
Orbital Apex
Syndrome

57
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

GENERAL LEFORT I LEFORT II LEFORT III


• Bleeding • Wound Dehiscence • CSF • CSF
• Enophthalmos • Necrotic Teeth Rhinnorhea/Otorrhea Rhinorrhea/Otorrhea
• Infection • Maxillary • Palatal Fistula • Facial Nerve Paralysis
• Altered Vision Hypoperfusion • Nasal Septum • Trigeminal Nerve
• Non Union Deviation Injury
• Mal Union • Infraorbital
• Epiphora Paresthesia
• Scarring

58
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

59
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

60
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

61
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

62
COMPLICATIONS AFTER
TREATMENT OF MIDFACIAL
FRACTURES

63
EMERGING TECHNIQUES

• Endoscopic Management of Midface Fractures

• Advances in CT Imaging - Advances in presurgical planning include the use of


stereolithographic models, which can help guide preoperative plate
contouring and precise positioning of plates and fractured segments.

64
TO SUMMARIZE

• One of the most common type of fractures a maxillofacial surgeon comes


across is Midface Fractures.

• The optimal way of management of these fractures is important for a


functionally and cosmetically adequate post operative outcome.

• A number of surgical approaches are present for fracture fixation and the
surgeon’s skill and experience will determine the best approach for the same.

65

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