Le fort fracture by Dr. Amit Suryawanshi .Dentist in Kolhapur (MDS). Oral & Maxillofacial Surgeon in Kolhapur, India

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Hi. This is Dr. Amit T. Suryawanshi. Dentist in Kolhapur (MDS) Oral & Maxillofacial surgeon from Kolhapur, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best & your replies are welcomed!

1. LE FORT FRACTURES Dr. Amit T. Suryawanshi Oral and Maxillofacial Surgeon Pune , India Contact details : Email ID - [email protected] Mobile No - 9405622455

2. Introduction History Surgical Anatomy of Maxilla Etiology of Lefort fractures Epidemiology Classification & LeFort fracture lines Clinical examination Clinical features Diagnostic radiography CONTENTS

3. Management - Emergency care - Early care - Definitive care Complications Controversies Conclusion.

4. INTRODUCTION: The maxilla represents the bridge between the cranial base superiorly and the dentition inferiorly. Its intimate association with the oral cavity, nasal cavity, and orbits and the important structures adjacent to it make the maxilla a functionally and cosmetically important structure.

5. Fracture of these bones is potentially life-threatening as well as disfiguring. Hence we being maxillofacial surgeons need to do systematic and timely repair of these fractures to correct deformity and prevent unfavorable sequalae .

6. The first clinical examination of a maxillary fracture was recorded in 2500 BC. In 1822 Charles Fredrick William Reiche provided the first detailed description of maxillary fractures. In 1823 Carl Ferdinand van Graefe described the use of a head frame for treating a maxillary fracture. HISTORY

7. In 1901 , Rene Le Fort published his landmark work, a three-part experiment using 32 cadavers. The heads of the cadavers were subjected to low velocity forces; the soft tissue were then removed and the bones were examined. HISTORY

8. Le Fort noted that generally face was fractured and the skull was not. He then stated that fractures occurred through three weak lines in the facial bony structure. From these three lines the Le Fort classification system was developed. HISTORY

9. External Fixation Craniomaxillary fixation- Wassmund’s (1927) maxillary splint with side bars attached to a head cap

10. Surgical anatomy of Midface Lacrimal fossa is partially formed by maxilla .Hence fracture can cause injury to nasolacrimal duct. Damage to infraorbital nerve can occur unilaterally or bilaterally in fracture of maxilla. Fracture involving orbital walls may give rise the change in the ocular level due to separation above the attachment of suspensory ligament of lockwood . ( LeFort III) If orbital floor is fractured, there will be herniation of orbital content into maxillary sinus.

11. Etiology - Road traffic accidents (most common) -40% Industrial accidents- 10 % Assault -15% Sports.- 25 % Fall.- 10 %

12. Epidemiology Most maxillary fractures occur in young men aged between 16 to 40 years. Peak age- 21 - 25 years Male : Female - 4:1

13. Lefort fracture classification Rene LeFort (1901) discovered the complex fracture patterns of Maxilla which is broadly classified as Lefort I Lefort II Lefort III

14. IMPORTANT POINTS TO REMEMBER (i) These fractures may occur unilaterally or may be associated independently with a fracture of the zygomatic complex. (ii) There may be a midline separation of the maxillae or extension of the fracture pattern into the frontal or temporal bones.

15. Limitations of the lefort classification The LeFort classification has proven to be less satisfactory to describe more complex fracture patterns, comminuted, incomplete, combination maxillary fractures or to describe fractures of the part bearing the occlusal segment.

16. NEWER CLASSIFICATION SYSTEM Need for newer system: Midface fracture patterns now are far more complex than those produced in Le Fort's laboratory. Fractures involving the cranial base and other midface fracture configurations, including severely comminuted segments of the facial skeleton, are not accurately classifiable using the traditional Le Fort scheme. A more precise system of describing fracture patterns is necessary to establish an accurate diagnosis & determine potential surgical approaches.

17. MODIFIED LEFORT CLASSIFICATION: Proposed by Marciani (1993) Le Fort I Low maxillary fracture Ia Low maxillary fracture/multiple segments Le Fort II Pyramidal fracture IIa Pyramidal and nasal fracture IIb Pyramidal and NOE fracture Le Fort III Craniofacial disjunction IIIa Craniofacial disjunction and nasal fracture IIIb Craniofacial disjunction and NOE fracture. (From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962 .)

18. Le Fort IV LeFort II or III fracture and cranial base fracture IV a + Supraorbital rim fracture IV b + Anterior cranial fossa and supraorbital rim fracture IV c + Anterior cranial fossa and orbital wall fracture

19. There is separation of complete dentoalveolar part of maxilla ( Pterygomaxillary dysjunction ) and the fractured fragment is held only by means of soft tissues. Cause - A violent force applied over more extensive area of maxilla above the level of maxillary teeth results in Lefort I fracture. Lefort - I

20. Fracture line – The fracture line commences at the point on the lateral margin of the anterior nasal aperture, passes above the nasal floor, passes laterally above the canine fossa and traverses the lateral antral wall, dips down below the zygomatic buttress and then inclines upward and posteriorly across the pterygomaxillary fissure to fracture the pterygoid laminae at the junction of their lower third and upper 2/3 rd.

21. Le Fort II Cause – Violent force, usually from an anterior direction, sustained by the central region of the middle third of the facial skeleton over an area extending from glabella to the alveolar margins results in fracture of pyramidal shape .

22. The fracture line runs below frontonasal suture from the thin middle area of nasal bones down on either side crossing the frontal process of maxilla and passes anteriorly across the lacrimal bone, immediately anterior to nasolacrimal canal. Then fracture line passes downward, forward and laterally crossing the inferior orbital margin in the region of zygomaticomaxillary suture Fracture line -

23. . It may or may not involve infraorbital foramen. Then fracture line now extends downward, forward and laterally to traverse the lateral wall of antrum , just medial zygomaticomaxillary suture line.

24. As in Lefort I , this fracture line passes beneath the Zygomatic buttress, inclines abruptly traversing the pterygomaxillary fissure at a higher level and fracturing the pterygoid laminae approximately midway from its base. Seperation of entire pyramidal block from the base of the skull is completed via nasal Septum.

25. Le Fort III Cause - Due to force from the lateral direction with a severe impact. Here , the initial impact is taken by Zygomatic bone resulting in depressed fracture. Then entire middle third will then hinge about the fragile ethmoid bone and the impact will then be transmitted to the contralateral side resulting in laterally displaced zygomatic fracture of opposite side. (Craniofacial dysjunction )

26. Fracture line - Line commences near the frontonasal suture, causes dislocation of the nasal bones and disruption of cribriform plate of the ethmoid bone.Then line crosses both the nasal bones and frontal process of maxilla, near the frontonasal and frontomaxillary sutures and then traverses the upper limit of the lacrimal bones .

27. continuing posteriorly , the line crosses the thin orbital plate of the ethmoid bone constituting part of the medial wall of the orbit. As optic foramen is surrounded by a dense ring of bone, Then fracture line gets deflected downward and laterally to reach the medial aspect of the posterior limit of the inferior orbital fissure.

28. From this point , fracture descends across the upper posterior aspect of maxillae in the region of sphenopalatine fossa and upper limit of pterygomaxillary fissures and fractures the roots of pterygoid laminae at its base.

29. From anterior and lateral aspect of inferior orbital fissure, line passes across the lateral wall of orbit , adjacent to the junction of zygomatic bone with greater wing of sphenoid .The fracture line seperates zygomatic bone from frontal bone near suture and then inclines laterally , running abruptly downwards across the infratemporal surface, thus in effect joins the previous line of fracture seen on medial wall of orbit .

30. The entire middle third is thus detached from the dense cranial base.

31. Clinical Assessment of Midface fractures Extra-oral & Intra-oral examination. Inspection. Palpation.

32. Inspection of midface- Swelling & Facial Asymmetry. Bruising of upper lip and lower half of mid-face. Bilateral Circum -orbital Ecchymosis ( Racoon’s eye). Periorbital Oedema . Subconjunctival Hemorrhage. Extra-oral examination

33. Extra-oral examination Cerebrospinal fluid rhinorrhoea Lengthening of Midface Depressed midface (dish face) Saddle shaped depression of nose Enophthalmos Proptosis Diplopia

34. Subconjunctival hemorrhage- Localized (black eye) confined to preseptal soft tissues (Also seen in anterior cranial fossa, orbital & zmc fractures.) Extra-oral examination

35. Extra-oral examination Cerebrospinal Fluid Rhinorrhoea -Watery nasal or postnasal salty discharge (Ring Test- but it lacks sensitivity & specificity)

36. Enophthalmus (Le Fort III) Increase in orbital volume by displacement of Lateral orbital wall Suspensory ligament of Lockwood displaced Eyelid follows the globe in downward direction Hooding of eyes Extra-oral examination

37. Retro bulbar haemorrhage Tension builds up within the muscle cone Proptosis (Anterior displacement of eyeball) Extra-oral examination

38. Palpation - Subcutaneous Emphysema – Crepitus Tenderness Step Deformity Abnormal Mobility of bone Impairment of sensation

39. Disturbed occlusion (posterior occlusal gagging , open bite) Haematoma intraorally over root of zygoma   Haematoma in palate ( Guiren’s sign) Fractured cusps of teeth Midline diastema Intra-oral examination Inspection -

40. Mobility of whole of tooth bearing segment of upper jaw elicited at fronto -nasal suture in Le Fort II & III fracture. Palpation -

41. Mobility of whole of the upper jaw (free-floating) elicited at infraorbital margin in Le Fort II fracture.

42. Mobility of whole of the upper jaw (free-floating) elicited at fronto -zygomatic suture in Le Fort III fracture.

43. Palpable crepitation in upper buccal sulcus in Le Fort I & II fracture.

44. LEFORT- I FRACTURE Clinical features - Slight swelling of the upper lip is seen. Ecchymosis present in the buccal sulcus beneath each zygomatic arch. Disturbance in occlusion with variable amount of mobility in the tooth bearing segment of the maxilla.

45. The patient may develop open bite if the fractured segment is mobile , due to posterior gagging of occlusion. Sometimes fracture of the palate can also be associated with Le Fort I fracture.

46. In Le Fort I, the teeth and maxilla are mobile, but the nose and upper face is fixed. Percussion of the maxillary teeth results in distinctive 'cracked-pot sound', No tenderness and mobility of the zygomatic arch and bones.

47. LEFORT II FRACTURE Clinical features - The resulting gross edema of the middle third gives an appearance of "moon face" to the patient. On intraoral examination, retropositioning of the whole maxilla and gagging of the occlusion are seen. When maxillary teeth are grasped, the mid-facial skeleton moves as a pyramid and the movement can be detected at the infraorbital margin and the nasal bridge.

48. Hematoma formation is seen in the buccal sulcus opposite to the maxillary first and second molar teeth as a result of fracture of the zygomatic buttress. Step deformity at the infraorbital rims or frontonasal junction is noticed. Orbital wall fractures can cause entrapment with limitation of ocular movement.

49. CSF rhinorrhoea is possible and should be looked for. Bilateral circumorbital ecchymosis giving an appearance of 'raccoon eyes' is invariably seen in the fractures of both Le Fort II and Le Fort III. Subconjunctival hemorrhage develops rapidly in the area adjacent to the site of injury.(mostly in medial half )

50. Diplopia may be seen in cases of orbital floor injury. Pupils are at level unless there is gross unilateral enophthalmos . Anaesthesia or paraesthesia of the cheek as a result of injury to the infraorbital nerve due to the fracture of the inferior orbital rim. Obvious deformity of nose with epistaxis.

51. LE FORT III FRACTURE Clinical features - Gross oedema of the face. Bilateral circumorbital ecchymosis with subconjunctival hemorrhage. Characteristic 'dish face' appearance with lengthening of the face. Mobility of the whole of facial skeleton as a single unit.

52. When lateral displacement has taken place tilting of the occlusal plane and gagging of one side is seen. Tenderness and often separation of the bones at the frontozygomatic suture. 'Hooding of eyes' may be seen due to separation of the frontozygomatic suture. Deformity of the zygomatic arches.

53. CSF rhinorrhoea . Depression of ocular levels. Difficulty in opening the mouth, inability to move lower jaw.

54. RADIOGRAPHIC PRESENTATION OF LE FORT FRACTURES SU

55. MANAGEMENT

56. LE FORT FRACTURES - Treatment STAGES 1. Emergency care & Stabilization - ( First aid and resuscitation ) 2. Initial Assessment and Early care- 3. Definitive Treatment- 4. Rehabilitation -

57. STAGE I - Emergency care & Stabilization 1. Maintenance of airway. 2. Control of hemorrhage. 3. Prevent or control shock. 4. C-Spine stabilization. 5. Control of life-threatening injuries. 6. Head injuries, chest injuries, compound limb fractures, intra abdominal bleeding.

58. Emergency Care Evaluate the airway - Existence & identification of obstruction. Manually clear fractured teeth, blood clots, dentures. Endotracheal intubation if needed. NOTE: Altered level of consciousness is the most common cause of upper airway obstruction.

59. Treatment of Blood Loss & Shock Hemorrhage is most common cause of shock after injury. Multiple injury patients have hypovolemia . Monitor vital signs closely. Goal is to restore organ perfusion.

60. Treatment of Blood Loss & Shock External bleeding controlled by direct pressure over bleeding site. Gain prompt access to vascular system with IV catheters. Fluid replacement: Ringer’s Lactate Normal saline Transfusion.

61. Stabilization of associated injuries C-spine injury is primary concern with all maxillofacial trauma victims. Signs/symptoms of C-Spine injury Neurologic deficit. Neck pain.

62. Stabilization of associated injuries C-spine injury suspected: Avoid any movement of neck Establish & maintain proper immobilization until vertebral fractures or spinal cord injuries ruled out Lateral C-spine radiographs CT of C-spine Neurologic exam

63. STAGE II. Initial Assessment and Early care Emergency care has stabilized patient. Initial stabilization of fractures. Debridement & dressing of soft tissues. Physical exam & history. Laboratory tests. Clinical & Radiographic Assessment of Patient. Diagnosis of maxillofacial injuries. Pre-operative planning.

64. STAGE II. Initial Assessment Pre-operative planning Need for Tracheostomy Surgical Approaches to Midface Whether ‘Open’ or ‘Closed’ methods of reduction are to be employed. Necessity for & type of Maxillary fracture Fixation.

65. STAGE II. Initial Assessment Pre-operative planning Surgical Approaches to Midface

66. Supraorbital eyebrow incision ( Lefort III) Subciliary incision ( LeFort II & III) Median lower lid ( LeFort II & III) Infraorbital incision ( LeFort II & III) Transconjunctival ( LeFort II ) Zygomatic arch Transverse nasal ( LeFort II & III) Vertical nasal incision ( LeFort II & III) Medial orbital incision. Intra-oral vestibular incision. ( LeFort I) Incisions for exposure of LeFort fractures

67. Classification of methods of Maxillary Fracture Fixation A ) Internal Fixation- 1. Suspension Wires 2. Direct Osteosynthesis B) External Fixation- 1. Craniomandibular 2. Craniomaxillary

68. Internal Fixation Suspension Wires – non-rigid osteosynthesis - i . Frontal-central or laterally placed ii. Circumzygomatic iii. Zygomatic iv. Circumpalatal /palatal screw v. Infraorbital vi. Piriform Aperture vii. Peralveolar

69. Different types of Internal Fixation by Suspension wire

70. Internal Fixation Suspension Wires- Circum zygomatic wiring by Obwegeser.

71. Internal Fixation Suspension Wires- Circum zygomatic wiring by Obwegeser

72. Internal Fixation Suspension Wires- Orbital rim wiring

73. Suspension Wires- Piriform aperture wiring

74. Type of Suspension Wire Type of Le Fort Fracture 1. Frontal a. Central Le Fort III & II b. Lateral Le Fort III & II 2. Circumzygomatic Le Fort I & II 3. Zygomatic Le Fort I 4. Infraorbital Le Fort I 5. Piriform Aperture Le Fort I Summary of Suspension wiring according to fracture site

75. Disadvantages of Suspension Wiring Incomplete fixation of fractured fragments Insufficient visualization of fractures by closed reduction Compression against the cranial base No 3-dimensional stability Patients dislike intra-oral splints as it hinders oral hygiene maintainence .

76. Internal Fixation Direct Osteosynthesis - 1. Interosseous Wires. 2. Plates and Screws.

77. Direct osteosynthesis Intraosseous Wires- Maxillary ( Lefort –I ) Zygomaticomaxillary ( Lefort –II) Frontonasal ( LeFort –II &III) Zygomaticofrontal ( Lefort III) Zygomatic bone (comminuted)

78. Disadvantages - Non rigid type of osteosynthesis No 3 dimensional stability, it provides only monoplane traction. IMF is always needed Interfragmentary pressure can not be controlled. Under functional stress, wire loses rigidity, direction control and surface contact. Delayed healing because of micromovement at fracture site.

79. Direct osteosynthesis - 2 . Plates & Screws for midface fractures - Stainless steel mini-plating system Titanium mini-plating system Vitallium , Cobalt chromium, molybdenum alloy plates Bioresorbable plating system.

80. Bone plate osteosynthesis Advantages – Simple & less intraoperative time Intraoral approach is sufficient Postoperative IMF is not needed or period of IMF is reduced. Three dimensional stability and early return of function.

81. STAGE III. DEFINITIVE TREATMENT LEFORT I FRACTURE LEFORT II FRACTURE LEFORT III FRACTURE

82. STAGE III. DEFINITIVE TREATMENT LEFORT I FRACTURE SURGICAL APPROACH- MAXILLARY VESTIBULAR

83. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP

84. FIXATION- 4-point fixation with MINIPLATE.

85. IMMOBILISATION- MAXILLOMANDIBULAR FIXATION(MMF)

86. LEFORT II FRACTURE SURGICAL APPROACH- A – Subciliary incision B – Sub tarsal incision C - Infraorbital incision D - Extension of Subciliary incision

87. Existing Laceration Maxillary vestibular approach can also be taken for LeFort II fracture

88. Coronal approach Glabella approach

89. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP

90. FIXATION- 3-POINT fixation

91. IMMOBILISATION- MAXILLOMANDIBULAR FIXATION

92. STAGE III. DEFINITIVE TREATMENT LEFORT III FRACTURE- SURGICAL APPROACH- Existing Laceration

93. A . Lateral eyebrow approach B.  Upper-eyelid approach  Glabella approach

94. Coronal approach - Preauricular approach

95. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP

96. Zygoma hook

97. FIXATION- 3-point fixation

98. IMMOBILISATION- MAXILLOMANDIBULAR FIXATION if required

99. Principles of Maxillary Reconstruction Miniplates can bridge gaps of up to approximately 0.5cms Gaps >0.5cms – bone grafts Bone grafts bridging the gap should be wedged underneath the plate & held in place with screws fixed from plate directly into the graft.

100. Immediate Bone Grafting Buttress reinforcement retained by plates or screws can assist in restoring maxillary height & preventing Contour deficiencies. Rib graft Iliac crest Calvaria Mandibular bone graft Alloplastic bone graft

101. CONCLUSION : Le fort fractures are common in the trauma patient. They require accurate radiologic diagnosis and surgical management to prevent severe functional debilities and cosmetic deformity. A thorough understanding of the anatomy, craniofacial buttresses and treatment options will give the maxillofacial surgeon the optimal tools for achieving a successful result.

102. REFERENCES: Rowe NL, Williams JL. Maxillofacial Injuries. Edinburgh, Churchill Livingstone,1985. Oral and maxillofacial trauma : Fonseca vol. 2. Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962 www2.aofoundation.org

103. THANK YOU