Le fort fracture(2)

1. LE FORT FRACTURES - Dr. Dona Bhattacharya

2. Contents Introduction Surgical anatomy Classification Etiology Clinical features Management Conclusion References

3. I ntroduction Area between a superior plane drawn through the FZ sutures tangential to the skull base and inferior plane at the level of maxillary occlusal surface Triangular region with widest dimension facing anterior

4. Surgical Anatomy Middle 3rd of face is composed of Paired Bones Unpaired Bones Maxilla Vomer Zygomatic bone Ethmoid Zygomatic process of temporal bone Sphenoid ( Pterygoid plates) Palatine bone Nasal bone Lacrimal bone Inferior conchae

5. Maxilla –central bone; prominent position where trauma hits face This structure is analogous to a matchbox sitting below and anterior to hard shell containing brain Act as cushion for trauma directed towards cranium from anterior or antero -lateral direction

6. Areas of weakness act as “crumple zone ”. Sutures Areas of strength: pillars of face

7. This arrangement with stands force of mastication from below and protects the vital structure Bones easily fractured from forces applied from other directions. Clinical implications

8. Soft tissue attachments

9. Alphonso Guerin(1886) Rene Le Fort Fracture classification (1901) Rowe and william classification (1985) Modified Le fort classification (Marciani,1993) Donag,Endress,Mathog classification(1998) Classification

10. Le fort fracture classification

11. Pitfalls: # caused by loc penetrating missile injuries & gun shot wounds not included. Only meant for bilateral # occuring at same level mid palatine split along palatal suture not described Inaccurate prediction of reduction techniques.

12. Fracture not involving the occlusion Central region Nasal bone/ septum (lateral, anterior injuries) Frontal process of the maxilla Nasoethmoid Fronto - orbito -nasal dislocation Lateral region ( zygomatic complex ,arch, dento -alveolar fracture Fracture involving the occlusion Dento alveolar Subzygomatic : Le Fort (I, II) Supra zygomatic : Le Fort III Rowe and William fracture classification

13. Marciani fracture classification

14. Donat , Endress , Mathog classification From: Donat TL et al. Facial Fracture Classification According to Skeletal Support Mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314 .

15. Aetiology Assault RTA Gunshot wounds Sports Falls Industrial accidents

16. Prevalence of mid-face fractures Fracture Type Prevalence Zygomaticomaxillary complex (tripod fracture) 40 % LeFort I 15 % II 10 % III 10 % Zygomatic arch 10 % Alveolar process of maxilla 5 % Smash fractures 5 % Other 5 %

17. A). Le fort I/ Floating fracture/ Guerin fracture/ Low level fracture/ Subzygomatic fracture Mobility of maxillary alveolar segment (floating fracture) Pain and tenderness while speaking or clenching Ecchymosis or laceration in labial or buccal vestibule Ecchymosis at GP foramen (Guerin sign) Swelling and oedema of upper lip Mal occlusion Bilateral epistaxis Brusing of palatal tissues (15-20% of cases) On palpation tenderness over buttress area Percussion of teeth – cracked pot sound Clinical Features

18. B ). Le fort II/ Pyramidal fracture/ Mid level fracture/ Subzygomatic fracture Oedema mid third of face (Moon face) Paresthesia of cheek Bilateral circumorbital ecchymosis Bilateral subconjunctival haemorrhage Dish face deformity Depressed nose Epistaxis CSF rhinorrhea Limited ocular movement ( Diplopia ) Mal occlusion Inability to open mouth Step deformity at IO margins Mobility of fractured fragment at nasal bridge and IO margins Percussion of teeth – cracked pot sound

19. C ). Le fort III/ Craniofacial dysfunction / High level fracture/ Suprazygomatic fracture Oedema of face (Panda facies ) Bilateral periorbital edema Bilateral circumorbital ecchymosis ( Racoon eyes) Bilateral subconjunctival haemorrhage Dish face deformity Depressed nose, flattening of nose Epistaxis CSF rhinorrhea Limited ocular movement ( Diplopia , Enophthalmos ) Dystopia, hooding of eyes with antimongloid slant Haemotympanum CSF otorrhoea Mal occlusion – posterior gagging of occlusion Inability to open mouth Mobility of fractured fragment at NF, FZ sutures Tenderness over zygomatic bone, arch and FZ suture Ecchymosis at mastoid process (Battle’s sign)

20. Management Emergency care and stabilization Initial assessment Definitive treatment Continuing care

21. Emergency Care Airway immediately evaluated for obstruction Control of oral or nasal bleeding Possibility of C – spine fracture – endotracheal incubation should not be attempted Cervical collar in case of suspected spine fractures Circulation

22. LeFort I fracture LeFort I fracture with Mandible fracture LeFort I fracture with Nasal injury LeFort II fracture Lefort III fracture Panfacial fractures Nasal Airway Edentulous Partially Dentate with space Fully Dentate Oral Airway through portal cut in Gunning splints or dentures Oral Airway with tube displaced through space Surgical Airway Guided Nasal Intubation fixate maxilla and mandible switch to Oral Airway for nasal/NOE reduction

23. Submental Intubation Premlatha Shetty et al;submental intubation in patients with panfacial fractures;Indian journal of anesthesia,vol 55,issue 3,may 2011

24. Initial assessment History Palpation of entire facial skeleton I/O Examination Ophthalmologic exam / consultation Radiographic examination

25. Facial Examination After stabilization of patients condition, complete facial examination is performed. Laceration, bruising , etc. Obvious depressions on nose, check, etc. Facial asymmetry, swelling Nasal discharge (Blood/ CSF)

26. Features CSF fluid Nasal secretion History Nasal or sinus surgery, head injury or intracranial tumour Sneezing, nasal stuffiness, itching in the nose or lacrimation Flow of discharge A few drops or a stream of fluid gushes down when bending forward or straining; can’t be sniffed back Continuous. No effect of bending forward or straining. Can be sniffed back Character of discharge Thin, watery and clear Slimy (mucus) or clear (tears) Taste Sweet Salty Sugar content More than 30 mg/dl (Compare with sugar in CSF after lumbar puncture as sugar is less in CSF in meningitis) Less than 10 mg/dl Presence of β 2 transferrin Always present. It is specific for CSF Always absent

27. Palpation of facial skeleton Bowstring test

28. Ophthalmologic evaluation Periorbital edema Periorbital ecchymosis Proptosis Diplopia Pupillary size and shape Sub- conjunctival haemorrhage Lid laceration Visual acuity Dystopia

29. Intra oral examination Inspection Palpation Percussion Laceration Ecchymosis Restricted mouth opening Occlusion Tenderness Mobility of teeth Crepitus Mobility of fractured fragment Cracked pot sound

30. Radiologic evaluation OPG OM Lateral skull view Occlusal view for split palate CT Scan 3D CT Scan MRI

31. Definitive treatment Aims of treatment Relieve pain Precise anatomical reduction of the # fragment Stable fixation of the reduced fragment Restore function Restore the dental occlusion

32. Preoperative planning: Need for surgical airway Open/closed method of reduction Necessity for and type if IMF to be employed in case for closed reduction Type of osteosynthesis in case of open method Need for internal suspension in case of communited # Timing of surgery

33. Timing of surgery Optimum time for reduction of mid face fracture is 5 th to 8 th post injury day After this with every succeeding day disimpaction become difficult and open reduction more essential

34. Operative Procedure Open reduction Closed reduction Displaced # Non displaced # Multiple # of facial bones Grossly communited # Edentulous maxillary # - with severe displacement Fractures associated with significant loss of soft tissues Edentulous maxillary # - opposite to Edentulous mandibular # Edentulous maxillary # Delay of treatment In children with developing dentition Inter position of soft tissues between non contacting displaced # segment Systemic condition contra indicating IMF

35. Accurate diagnosis Determination of priority of treatment Early reconstruction Wide exposure of vertical and horizontal pillar of face Use of bone graft to restore skeletal form Use of rigid fixation to stabilize # segment Restoration of bony support to over lying soft tissue envelop Le Fort fracture principles

36. Surgical access Intra oral Vestibular Extra oral Lower eye lid incision Sub cilliary Infra orbital Trans conjunctival Coronal approach Midface degloving approach

37. Vestibular

38. Subtarsal

39. Sub cilliary

40. Infra orbital

41. Transconjunctival Technique Advantages Disadvantage Indication

42. Coronal/bi-temporal approach Technique Advantages Indication

43. Degloving incision

44. Reduction of maxilla Manual reduction Reduction with wires Reduction using disimpaction forceps Reduction with bone hook Reduction with elastics

45. Manual reduction Simple manipulation by hand Use of dental compound loaded in impression tray ( Dingman and Harding, 1951) Use of rubber dam sheets, long ribbon/strip gauze or rubber catheter ( Propescu and Burlibasa , 1966)

46. Disimpaction and reduction of maxilla Rowe’s maxillary disimpaction forceps Hayton William’s disimpaction forceps

47. Movements: Downwards – to affect disimpaction of pterygoid plates down Anterior Combination of forward traction with rotational movement in both horizontal and vertical axis Universal rule Oculocardiac reflex

48. Reduction by elastic traction Used in delayed cases: Intra oral elastic traction Extra oral elastic traction

49. Direct Osteosynthesis

50. Intraosseous wires By Merville & Derome (1976)

51. Miniplates and screws These are monocortical , semi-rigid fixation device which provide 3D stability. Designs: X, H, L, T, Y Thickness:0.6-1 mm

52. Plating system depends on: Rigidity of plate Width and shape Diameter and number of screws Increase in width provides more stability towards rotational forces. Type of metal: Stainless steel Titanium Vitallium Advantages: Easily adaptable Monocortical Functional stability Reduced surgical access

53. Minimum 2 screws required in each bone segment to prevent rotation in X and Y axis Farther the point of stabilization the more effective the device is in preventing rotation Large diameter screws are not used because of constraint imposed by particular anatomic location All screw require adequate intervening bone between adjacent holes to preserve integrity of screw bone interface Factor affecting screw stability

54. Le fort I: L plates at zygomatic buttress Curved plate at pyriform aperture 3D plate sometimes to fix buttress # Le fort II: Linear/Y plate/curved plate along intra orbital rim L plate at buttress Le fort III: Linear/Y plate at FN and ZF junction Location of fixation

55. Harle & duker (1975;Luhr(1979) 0.3-0.6 mm Used for : FN region Frontal bone Frontal process of maxilla Sites of application: Linear/T/Y plate at FN region Long curve plate for frontal process of maxilla or frontal bone Micro plates

56. Used for retention and alignment of small fragments or bone grafts. Sites of application: Anterior and lateral wall of maxilla Anterior table of frontal bone Mesh fixation

57. Suspension Wires

58. Introduced by Kuffner , 1970 Two types Central Lateral Usually used for high midface fracture. Frontal wire

59. Indication: le fort II and III fracture Infraorbital rim wire

60. Also known as buttress wire Zygomatic wire

61. Circum zygomatic wire Cubero Technique

62. Introduced by Bowerman and Conroy, 1981 Simple technique for fixing gunning splint to maxilla Superior retention, stability and decreased discomfort Nasal spine wire

63. Pyriform aperture wire

64. Peralveolar

65. Trend towards ORIF has changed External fixation is used in cases where there is depressed posterior displaced # Principle: External appliances relies on sandwiching the midface between base of skull and mandible to provide cantilever support to midface in 3D following disimpaction and closed reduction. Disadvantages: Extra cranial fixation forms

66. POP head cap with metal frame Disadvantage: Heavy Uncomfortable Unstable Method of application

67. Halo frame Described by Crawford;modified by Mackenzie & Ray,1970 Secure the frame work to the skull directly by screw pins Advantage: Light weight Adjustable Titanium Screw pin

68. Box frame More stable and rigid Other unstable fracture fragment can also be attached to vertical rod

69. Levant frame Developed at Royal Melbourne Hospital Provided simple rigid craniomaxillary fixation between supraorbital rims and maxilla connected by central rod attached at lower end by means of cast metal splint or acrylic splint

70. Bone grafts Provide dimensional stability Indications: Grossly communited # Extensive soft tissue loss Bone gap>5mm Sites: Calvarium Illium Rib

71. Recent Advancements Resorbable plates Endoscopic management(Harold Hopkins) Distraction osteogenesis ( Ilizarov )

72. Complications Immediate Airway Nasal hemorrhage Ophthalmic complications Inaccurate reduction Insecure fixation Late complications Non union mal occlusion Cranial nerve dysfunction Secondary nasal deformity Dacrocystitis Facial asymmetry

73. Conclusion Due to the complex 3D arrangement of the structures of middle third of face,management is complicated.Proper reduction of the # fragments remains the key component. A proper understanding of the anatomy,fracture patterns, its clinical presentation and the available treatment modalities is necessary to successfully treat Le Fort Fractures.

74. References Oral & maxillofacial trauma-Fonseca & walker vol 2 Oral & maxillofacial surgery-Fonseca vol 3 Oral & maxillofacial trauma-Rowe & Williams vol 2 Principles of Oral & maxillofacial surgery-Peterson Fractures of middle third of face- Killey & Kay Oral & maxillofacial surgery- Fragiskos Maxillofacial trauma & facial reconstruction-Peter Ward Booth Oral & maxillofacial surgery-Peter Ward Booth: vol 2 Chen Lee et al ;Applications of the Endoscope in Facial fracture Management, seminars in plastics surgery/volume 22, number 1 2008

75. Manual of internal fixation-J Prein Donat TL et al. Facial Fracture Classification According to Skeletal Support Mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314. Mirko S. Gilardino et al;Choice of Internal Rigid Fixation materials in the treatment of facial fractures; craniomaxillofacial trauma & reconstruction/volume 2, number 1 2009 Khaled M Emara et al ;Methods to shorten the duration of an external fixator in the management of fractures; World J Orthop 2011 September 18; 2(9): 85-92 Chan hum park et al;resorbable skeletal fixation systems for treating maxillofacial bone fractures; arch otolaryngol head neck surg / vol 137 (no. 2), feb 2011 Premlatha Shetty et al;submental intubation in patients with panfacial fractures;Indian journal of anesthesia,vol 55,issue 3,may 2011.