Le Fort Fractures

Le Fort Fracture I,II,III
Clinical Features, Management, Reduction & Fixation, Complications

1. 1

2. Contents
2
•Introduction
•FacialButtresses
•Midfacialbones
•Classification
•Causes
•History andexamination
•Signs andsymptoms
•Management

3. Introduction
3
•Middlethirdoffacialskeletonisareabounded
–Superiorlybyalinedrawnacrossskullfrom
zygomaticofrontalsutureofoneside,across
frontonasalandfrontomaxillarysuturesto
zygomaticofrontalsutureonoppositeside
–Inferiorlybyocclusalplaneofupperteeth,or,if
patientisedentulous,bytheupperalveolarridge.

4. •Posteriorly,demarcatedbysphenoethmoidal
junction,includesfreemarginofpterygoid
laminaeinferiorly.
•Less frequently seen than mandibular #.
•Results in distorted facial contour, involvement
of masticatory system, ocular system.
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5. Midfacialbones
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Sphenoid(1)
Ethmoid(1)

6. Facialbuttresses
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•Thecentralmidfacehasmanyfragilebonesthat
couldeasilybecrushedwhensubjectedtostrong
forces.
•Theyaresurroundedbythickerbonesoffacial
buttresssystemlendingitsomestrengthand
stability.

7. •2 Components of Buttresssystem:
–Verticalbuttresses
–Horizontalbuttresses
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8. •Verticalbuttresses:
1.Nasomaxillary
2.Zygomaticomaxillary
3.Pterygomaxillary
•Resist occlusalload.
8

9. •Horizontalbuttresses:
1.Supraorbital rim &
Frontalbone
2.Infraorbital rim & nasal
bones
3.Hard palate &
maxillaryalveolus
•Interconnect and provide
support forvertical
buttresses.
9

10. Physical Characteristics
•Made up of considerable bones which rarely fractures in
isolation.
•All bones are comparatively fragile & articulates un most
complex fashion.
•Acts as a cushion for trauma directed towards cranium from
ant. to anterolateral direction to a “match-box” sitting below &
in front of a hard shell containing brain.
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11. Causes of facialfractures
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•Motorvehicleaccidents
•Assault/Domesticviolence
•Falls
•Sports-relatedincidents
•Pathological
•Work-relatedincidents
•Warfare

12. Types of Midfacial fractures
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13. Classifications
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•Rene LeFort:
–LeFort I, LeFort II and LeFortII.
•Erich’s (1942)-direction of the fractureline.

14. 14
•Based on relationshipof the fracture line to
the zygomatic bone -
–Subzygomaticfractures
–Suprazygomaticfracture
•Based on levelof a fractureline
–Low levelfracture
–Mid levelfracture
–High levelfracture

15. •Rowe’s & William (1985)
•A. Not involving Occlusion
➢Central Region
▪# of nasal bone/septum –Lateral/ Anterior nasal injuries
▪# of frontal process of maxilla
▪# extends to the ethmoid bone involving or not involving occlusion.
▪# extends to the frontal bone involving or not involving occlusion.
➢Lateral Region
▪# involving zygomatic bone, arch& maxilla excluding dentoalveolar
segment.
•B. Fractures involving occlusion
•Dentoalveolar
•Subzygomatic
•Suprazygomatic
15

16. MarcianiModification (1993)
•Le Fort I : Low Maxillary fracture
•Le Fort Ia: Low Maxillary fracture/ multiple segments.
•Le Fort II : Pyramidal fractures
•Le Fort IIa:Pyramidal fractures+ Nasal Fractures
•Le Fort IIb :Pyramidal fractures+ NOE Fractures
•Le Fort III : Craniofacial dysjunction
•Le Fort IIIa: Craniofacial dysjunction + Nasal Fractures
•Le Fort IIIb: Craniofacial dysjunction + NOE Fractures
•Le Fort IV : Le Fort II & III + Cranial base fracture
•Le Fort IVa: Le Fort II & III + Cranial base # + Supraorbital rim #
•Le Fort IVb: Le Fort II & III + Cranial base # + Ant. Cranial base #
•Le Fort IVc: Le Fort II & III + Cranial base # + Ant. Cranial fossa
& Orbital Wall #
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17. LeFort Ifracture
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•Resultsfromahorizontalforcedeliveredabovethe
level of the teeth (to themaxilla).
•Thefracturecoursesfromthelateralborderofthe
pyriformaperture→abovethecanine
→lateralantralwall→behindthe
eminence
maxillary
tuberosity →across the lower third of the pterygoid
plate.

18. •Almostalwaysinvolvesthepterygoidprocessof
thesphenoidbone.
•Thefractureseparatesthemaxillafromthe
pterygoidplatesandnasalandzygomatic
structures.
18

19. •Thistypeoftraumamayseparatethemaxilla
inonepiecefromotherstructures,splitthe
palate,orfragmentthemaxilla.
•Mayinvolvethemaxillarysinuses.
•Theresultant“floating”componentisthe
lowerpartofthemaxillaanditsteeth.
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20. •Le Fort I fracture may be unilateral orbilateral.
•It may occur on its own or in combination with
other midfacialfractures.
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21. Clinical signs & symptoms:
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•Swelling of the upperlipand lower part of face.
•Ecchymosis in labial & buccal vestibule.
•Laceration of upper lip & mucosa.
•Bilateral epistaxis.
•Mobility of upper dentoalveolar segment.
•Malocclusion.
•Pain in speaking & moving the jaw.
•Upward displacement of entire fragment –Telescopic #
•Classic ant. Open bite.
•Percussion of maxi. teeth: Dull Cracked cup sound.

22. LeFort II
fracture
22
•Resultsfromaforcedeliveredatalevelofthe
nasal bones in superiordirection.
•Thefracturelineoccursalongthenasofrontal
suture
orbital
→lacrimalbone→acrosstheinfra-
rimintheregionofthezygomatico-
maxillarysuture→abovethecanineeminence
→inferiorlyanddistallyalongthelateralantral
wall,butatahigherlevelthanLeForttypeI→
acrossthepterygoidplateatitsmiddle.

23. •Separationofthemaxillaandtheattached
nasalcomplexfromtheorbitalandzygomatic
structures.
23

24. Clinical Findings of LeFortII
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•Ballooning of theface: Moon face
•Lengthenening of theface
•Circumorbitalecchymosis
•Subconjunctival Haemorrhage
•Bilateral Epistaxis
•Bilateral circumorbital oedema: Black eye
•CSF leak may be present
•Step deformity at infraorbital margins.
•Paresthesia/ Anaesthesiaof cheek.

25. LeFort
III
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•Resultswhenhorizontalforcesareappliedat
alevelsuperiorenough(atorbitallevel)to
separatetheNOE)complex,thezygomas,and
themaxillafromthecranialbase(Craniofacial
separation/dysjunction).

26. •Thefracturelinecoursesthroughthe
zygomaticotemporalandzygomaticofrontal
sutures→lateralorbitalwall→inferiororbital
fissure→mediallytothenaso-frontalsuture
→fracturesthepterygoidplateatitsbase.
26

27. Clinical Findings of LeFortIII
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•Severe edema of the face “ballooning”
•Lengthening of theface
•Flattening of thecheek
•Circumorbitalecchymosis
•SubconjunctivalHaemorrhage
•Epistaxis
•Enophthalmos
•CSFrhinorrhoea

28. •Bilateralcircumorbitalecchymoses
facies,
•Bilateral subconjunctivalhaemorrhage-
Racooneyes
–panda
28

29. •Diplopia dueto:
–Edema andhematoma
–Restrictive motility disorder(mechanical)
–Cranial nerve injury(neurogenic)
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30. Radiographsneeded
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•Occipito-mental view (Water’s View)
•CTscan
–Axialscan
–Coronalscan
–Sagittal
–3dimensional

31. Treatment for LeFortfractures
31
•First aid and Preliminarytreatment
•Definitivetreatment
–Reduction
–Immobilization

32. 32
•Theprinciplesofdefinitive
LeFortfracturesconsistof
treatmentof
reductionand
fixation of the fractured bones to one another
and to theskull
–achievedbyeitherconservativeor
operativemethods.

33. 33
•Thesoonerthetreatmentiscarriedout,the
better theprognosis.
•Restoration of the occlusion is amust.
•Thebonyframeworkandbuttressesofthe
midfacemustalsoberepositionedorrestored
andfixed.

34. Methods of reduction for
LeFortfractures
34
•Manualreduction
–Simple manipulation byhand
–Dental compound on impressiontray
–Gauze or rubbercatheters
–Special instruments
•Reduction bytraction
–Conservativetreatment
–Supervised spontaneoushealing
–Openreduction

35. Manualreduction
•Simplemanipulationbyhandispossibleinfreshfractures,
maxillaisheldbetweentheindexfingerandthumbandbrought
intonormalocclusion.
•Anothermethodistofixtwodoublewiresencirclingthefirst
andsecondmaxillarymolarsandtwistingthemindividuallyon
eithersides.
35

36. 36
•Boththetwistedwireendsareheldbymeans
ofwireholdersorhemostatsand
simultaneouslydownwardmovementofthe
maxillawillhelptoachievethenormal
occlusion.

37. •Dentalcompoundloadedintoimpressiontray
wassuggestedbyDingmanandHardingin
1951,formobilizingthefracturedfragmentof
maxilla.
•Thiscanbeused,wheresomeamountof
fibrosishassetinbecauseofdelayed
treatment.
37

38. •PropescuandBurlibasain1966,described
reductionbyrubberdamsheetsorbymeans
oflongribbon/stripgauzeorrubber
catheters.
•Wheneverthemaxillaisimpactedandsimple
manualmobilizationisnotpossible,thenthis
methodcanbetried,ifsophisticated
instrumentsarenotavailable.
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39. •Therubbercatheter’sendispassedfromthe
nostrilintotheoropharynxanditisgrasped
withthehelpofhemostatandbroughtoutof
theoralcavity.
39

40. 40
•So,youhaveoneendcomingoutfromnostril
andotherendthroughtheoralcavity,same
procedureisrepeatedontheotherside
throughthenostril.
•Aftergraspingallfourendsofthecatheter
andstabilizingthehead,maxillacanbe
rockedintothenormalocclusion.

41. 41
•Reductionbyusingspecialinstruments—
Speciallyconstructeddisimpactionforcepscan
beusedtotakefirmgraspofthemaxillaand
reduceitintotheposition.

42. •Rowe’smaxillarydisimpactionforceps:
–Availableasrightandleftforceps.
–Alwaysusedinpairs.
–Thesearetwopronged(divided)forceps,
whereoneprongfitsintothenasalfloor
andanotheroneonthehardpalate.
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43. •Rowe’s DisimpactionForceps
43

44. •Anteriortractioninthecaseofasplitpalate,maybe
facilitatedbytheuseofthespecialforcepsdevisedby
HaytonWilliams.
44

45. •Appliedtothebuccalaspectofthealveolar
processandmedialcompressionexerteduntil
thetwohalvesoftheupperjaware
approximated.
45

46. •Ascrewtopisadjustedtopreventcrushingofthe
bone.
•Can be combined with Rowe’s maxillary disimpaction
forceps.
•Thestabilizedmaxillaryblockmaythenbe
disimpacted and drawnforward.
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47. Reduction bytraction
47
–Repositioningthefracturesthatarealready
inastateofpartialfusionORwhen
attemptedmanualreductionismetwith
failure,thenreductionbyelastictractionis
triedtointerdigitatethefractured
fragments.

48. 48
•Mainlyusedindelayedcases,wherethe
fractureis10to14daysoldandnolonger
sufficientlymobile.
–Intraoralelastictraction.
–Extraoralelastictractionwithappropriate
extensionbarsandsidebars.
•Intraoralintermaxillaryelastictractionmaybe
usedinanappropriatedirectiontorestore
normalocclusionthenreplacedbyIMF.

49. 49
•ConservativeTreatment
–Reductionandfixationofthefractured
midfaceisindicatedincases,wheresurgery
isnotpossibleduetopoorgeneral
conditionofthepatientorwherethereis
extensivecomminutionwithtissueloss,
makinginternalskeletalfixationimpossible.
–Alsousedasasupplementarymeasurewith
thesurgicaltreatmentofmidfacialfracture.

50. 50
•SupervisedSpontaneousHealing
–Wheremobilityatthefracturedmaxillais
onlyslight,andocclusionisnotdisturbed.
–Progressofhealingismerelysupervised.
–Thepatientshouldavoidchewingduring
thefirst2to3weeksandshouldtakea
liquid/semisoliddiet.

51. 51
❖Monomaxillaryfixation:
–Methodusedwhentoothbearingsection
ofthemaxillaisnotfracturedandtherefore
canserveasfixationpoint.
–Archbarorpalatalacrylicplatescanbe
used.
–Canbeusedforunilateralfracturesof
maxillaorhigherfractureswithoutocclusal
discrepancies.
–Maintainedfor6weeks.

52. 52
❖Intermaxillaryfixation(IMF):
❖Maintainedfor3to4weeksandattheend
ofthisperiodIMFwiresandthelowerarch
barsareremoved.

53. 53
❖Internalskeletalwiresuspension:
❖ManytimesinadditiontoIMF,additional
supportisrequiredforimmobilizationof
thejaws.
❖Craniomaxillaryorcraniomandibular
suspensioncanbecarriedoutusingstable
pointabovefractureline.
❖Selectionofsiteforsuspensionwirewillbe
dependentontheleveloffractureline.

54. 54
❖Theprocedureforinternalskeletalwire
suspension is done through a minorsurgery.
•Application of archbars
•Reduction of fracture by closed method -
occlusion ischecked
•Fixation of the midface to base of skull by
suspensionwires.

55. 55
•Fixationofthemidfacebytighteningthe
suspensorywiresandintermaxillary
fixation.
•Foredentulouspatients,available
prosthesisorGunningsplintisused.

56. •LeFortIfracture:Intermaxillaryfixationby
zygomaticarchsuspension,ifnecessary
additional suspension at the piriformaperture.
56

57. •LeFortII:Zygomaticarchsuspensionorfrontal
bonesuspension.Intraosseouswiringmaybe
doneatinfraorbitalmargins.
57

58. •LeFortIII:Intraosseouswiringat
zygomaticofrontalsutures
frontomalarsuspensionis
andbilateral
usedafterthe
applicationofarchbars.Intraosseouswiring
maybedoneattheinfraorbitalmargin,ifstep
deformityexists
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59. Maxillarysuspension
59

60. 60
•OpenReduction
–Carriedoutunderendotrachealanesthesiawith
nasalintubation.
–Intraoralvestibularincisionistakenfromfirst
molartofirstmolarregiononeitherside.
–Mucoperiostealflapisreflectedtoexposethe
fractureline.
–Afteridentifyingthefractureline,inoldfractures,
anosteotomeisinsertedtomobilizethefragment.

61. 61
–Disimpactionforcepscanbeusedandthe
fragmentisbroughtintonormalocclusionby
manipulation.
carriedoutandfracture–TemporaryIMFis
fragmentsarefixedunderdirectvisionby
intraosseouswiringorminiboneplateswith
screws.

62. Various skeletal incisions for exposure
of midface skeleton arefollows:
62
1.Supraorbital eyebrowincison
2.Subciliaryincision
3.Median lower eyelidincision
4.Infraorbitalincision
5.Transconjunctivalincision
6.Zygomatic archincision
7.Transverse nasalincision
8.Vertical nasalincision
9.Medial orbitalincision.

63. Treatment protocol Le Fort I
•UndisplacedLe Fort I with minimal occlusal discrepancy-
Simple MMF -4 wksor direct fixation with no MMF.
•Displaced Mobile Le Fort I with ant. Open bite –Direct
fixation or indirect suspension with MMF.
•Communited# not treated with plate or wire fixation -
MMF & suspension.
•Edentulous patient-Same treatment but intraosseous fixation
not feasible, a custom acrylic occlusal splint made & MMF is done.
63

64. Treatment protocol Le Fort II
•UndisplacedLe Fort II with minimal occlusal discrepancy -
Circumzygomaticsuspension + MMF-4 wksor direct fixation at
zygomaticomaxillary buttress.
•Displaced mobile Le Fort II with Ant. Open bite –Direct/ Indirect
fixation with MMF.
•Communited# not amenable to plate/wire –MMF.
64

65. References
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•ContemporaryOralandMaxillofacialSurgery6
th
Edition–Hupp,James(Chapter25Managementof
facialfractures)
•Maxillofacialinjuries–AsynopsisofBasicPrinciples,
DiagnosisandManagement-GeorgeDimitroulis,
BrianAvery(Chapter6).
•https://sites.google.com/site/drtbalusotolaryngology
/rhinology/buttress-system-of-midface ‘Buttress
systemofmidface’.Accessedon14.2.2016.
•TextbookofOralandMaxillofacialSurgery3
rd
Edition
–NeelimaAnilMalik(Chapter29+30).

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Thank s