Le fort 1

dental surgical

1. Le Fort 1

2. Le Fort 1 The fracture extend from : Lateral margin of anterior nasal aperture Canine fossa Below zygomatic buttress Along the lateral wall of anturm Posteriorly across the pterfgomaxillary fissure To fracture the lower 1/3 of pterygiod laminae

3. Lateral margin of anterior nasal aperture Canine fossa Below zygomatic buttress Along the lateral wall of anturm Posteriorly across the pterfgomaxillary fissure To fracture the lower 1/3 of pterygiod laminae 1 2 3 4 5 6

4. Types Le Fort I – linear fracture Le Fort I - with unilateral comminution (with or without defect) Le Fort I – with bilateral comminution (with or without defect) Le Fort I – edentulous patients

5. Line of treatment : Linear fracture Observation Closed treatment Open reduction internal fixation Unilateral comminution Closed treatment Open reduction internal fixation Bilateral comminution Open reduction internal fixation Edentulous patients Observation Open reduction internal fixation

6. Observation Observation indication : Le Fort I – linear fracture Le Fort I – edentulous patients Observation is reserved for non- or minimally mobile Le Fort I fractures with unaffected occlusion. The patient is advised to stay on a soft diet for several weeks. The maxilla should become firm at which point the diet can be advanced to as tolerated. Observation implies close follow-up. The majority of Le Fort I fractures in edentulous patients with atrophic maxilla are treated by observation and a soft diet

7. Closed treatment Closed treatment indication Le Fort I – linear fracture Le Fort I - with unilateral comminution Closed treatment of Le Fort I fractures with minor malocclusions can be performed with maxillary disimpaction and manipulation, and mandibulomaxillary fixation (MMF) Patients with malocclusion unable to have general anesthesia can be treated by application of arch bars and elastic traction. A closed reduction of the midface may be part of an emergency treatment to reduce bleeding.

8. Open reduction internal fixation Open reduction internal fixation indication : Le Fort I – linear fracture Le Fort I - with unilateral comminution (with or without defect) Le Fort I – with bilateral comminution (with or without defect) Le Fort I – edentulous patients

9. Open reduction internal fixation Principles Decision on whether to use bone graft Choice of implant Reduction Fixation (without bone graft) Fixation (with bone graft) Check of occlusion

10. Principle Reestablish the midfacial vertical buttresses. Reestablish the premorbid dental occlusion Class III tendency often occurs in the postoperative due to?? To overcome?? The goal is to achieve an anatomical correct repositioning by means of 3-D reconstruction. Le Fort I fractures with bilateral comminution display loss of the correct facial height

11. Bone Graft Bone graft is used to fill defects and the buttresses are restored using two plates. Indications (bone grafting): Loss of bone volume and loss of buttressing Contraindications (bone grafting): Inability to stabilize bone graft and maxilla Inability to obtain soft-tissue closure over graft Advantages (bone grafting): Support for facial soft tissues Restoration of bony buttresses Prevention of loss of facial height Disadvantages (bone grafting): Donor site required for bone graft harvesting

12. Choice of implant Principles A plate that is placed for the fixation of the fracture at the zygomaticomaxillary buttress is generally a larger plate because it is the point that will provide most stability to the Le Fort I fracture. The highest forces of mastication would be in this area. Another plate can also be applied at the piriform rim.

13. Reduction Arch bars Exposure of the fracture segments through a maxillary vestibular approach Mobilization the fracture has to be mobilized to enable reduction and fixation. Reduction instruments Rowe disimpaction forceps Bone hooks Placing the patient into MMF Reducing the maxilla

14. Fixation (without defect) linear fracture Lateral plating Apply one plate to each zygomaticomaxillary buttress first. Medial plating Fix an additional plate to the nasomaxillary buttresses bilaterally Unilateral commiuntion Apply plates to the linear fracture side Fix the noncomminuted side by applying two plates along the vertical buttresses. Apply plates to the comminuted fracture side Fix two plates to the comminuted side predrilling of comminuted fragments Reposition the bony fragment using a forceps B ilateral comminution Apply two L-plates to the lateral buttresses Fix two plates which have been bent to conform to the shape of the lateral buttresses Apply two plates to the medial buttresses Fix two plates to the medial buttresses

15. Fixation (with defect) Unilateral communition Apply plates to the linear fracture side Fix the noncomminuted side by applying two plates along the vertical buttresses. Buttressing of the defect side The lateral buttress is plated first, followed by the medial buttresses. The medial plate is applied second. Shaping the bone graft Bilateral communition Lateral buttress The lateral buttresses are plated first, followed by the medial buttresses . Insert the bone graft. Apply the second lateral buttress plate in the same manner. Medial buttresses

16. Check of occlusion After internal fixation has been completed, MMF is released and the occlusion checked. If an open bite and/or Class III tendency occurs when checking the occlusion , one or both mandibular condyles were malposed in posterior and/or inferior direction . In such cases, it is necessary to remove the bone plates, reapply MMF, and passively reposition the maxillomandibular complex again, assuring the condyles are properly seated. Bone plates are again applied and the occlusion verified.

17. Thank you