Lefort 1 fracture

lefort 1 fracture , midface fracture

1. LEFORT I FRACTURE

2. CLASSIFICATION OF FRACTURES a ) IN 1901 , RENE LE FORT , according to the level of injury: 1. Lefort I 2. Lefort II 3. Lefort III

3. b) MARCIANI MODIFICATION 1993 Lefort I : low maxillary fracture Lefor Ia : Low maxillary fracture / multiple segment Lefort II : pyramidal fracture Lefort IIa : pyramidal and nasal fracture Lefort II b : pyramidal and NOE fracture Lefort III : Craniofacial Dysjunction Lefort IIIa : craniofacial dysjunction and nasal fracture Lefort IIIb : cd and NOE fracture

4. Lefort IV : lefort II and III # and cranial base # Lefort IV a : lefort II or III # and cranial base # + supra orbital rim # Lefort IV b : lefort II or III # and cranial base # + anterior cranial base Lefort IV c : : lefort II or III # and cranial base # + anterior cranial fossa + orbital wall #

5. HENDRICKSON CLASSIFICATION OF PALATE FRACTURE TYPE 1 : alveolar 1a : anterior alveolar ( incisiors ) 1b : posterior alveolar ( premolar molar ) TYPE II : Sagittal TYPE III : Parasagittal TYPE IV : Para alveolar TYPE V : Complex TYPE VI : Transverse

6. ACCORDING TO ROWE AND WILLIAM ( 1985) A . Fracture not involving the occlusion 1. central region a. Fracture of the nasal bone or the nasal septum - lateral nasal injuries - anterior nasal injuries b. fracture of the frontal process of the maxilla c. Fracture type a and b which extend to the ethemoid bone d. # type a , b and c, which extend into the frontal bone 2. lateral region # involving the zygomatic bone , arch and maxilla excluding dento -alveolar Component.

7. LEFORT I ( LOW LEVEL/ GUERIN/ HORIZONTAL/ FLOATING # )

8. FORCE ACTING : This type of # occurs from the application of horizontal force just above the apices of the maxillary teeth. It results due to the blow from the opposite jaw , which is often impacted.

9. This is a horizontal fracture above the level of the nasal floor including the dental component. The # line runs backward along . Laterally : lateral margin of the pyriform aperture – lateral wall of maxillary sinus – below the zygomatic buttress – lower one third of the pterygoid lamina and associated palatine bone. Medially : lower third of the nasal septum – lateral margin of the anterior nasal aperture ( lateral wall of the nose ) proceeding posteriorly to join the lateral fracture behind the tuberosity.

10. The fracture occurs at the level of the piriform aperture and involves the anterior and lateral walls of the maxillary sinus, lateral nasal walls and, pterygoid plates. The nasal septum may also be fractured and the nasal cartilage may be buckled. Sagittal fracture(s) of the palate may also be present. The pull of the medial and lateral pterygoid muscles may contribute to displacement of the fractured segment in a posterior and inferior direction, resulting in an open bite deformity. This fracture may present as an impacted, immovable, or free-floating maxillary segment.

11. EXAMINATION- firmly grasping the maxillary arch with the finger and thumb facially and palatally and attempting displacement of the maxilla in three dimensions, as well as compression and expansion of the maxillary arch.

12. SIGNS AND SYMPTOMS :

13. Swelling of upper lip and cheek ECCHYMOSIS : present in maxillary buccal sulcus from shearing of soft tissue or periosteal tear. NASAL BLOCK : mucosal tear in maxillary / ethmoid sinus may include bleeding causing a nasal block – forcing the patient to undergo oral breathing. Ocular signs are usually absent. Hypoesthesia of the infraorbital nerve may be caused by the rapid development of edema. GUERIN SIGNS : ecchymosis in the palate in the area of greater palatine foramen bilaterally- classical sign.

14. OCCLUSION : Undisplaced incomplete Lefort I # usually cause no occlusal disturbance .Complete lefort I # classically shows varying degree of anterior pen bite . This is from backward and downward distraction of posterior maxilla resulting from inferior traction of medial pterygoid muscle towards the mobile maxillary fragment. Potential gaging of occlusion is potential treat to airway. TEETH FRACTURE : Due to impaction of the mandibular teeth against the maxillary counter part , damage to the cusp of individual maxillary teeth may be seen.

15. Palatal fracture : Commonly mid palatal split is associated with Lefort ;I evident as linear mucosal tear in mid palate. The associated palatal # could be of any of the Hendrickson Classification pattern, with or without oronasal communication , depending upon the amount of separation between the fragments from the effect of bilateral medial pterygoid. Cracked-pot sound : Percussion of the maxillary teeth results in distinctive “ cracked pot sound”, similar to the sound produced when a cracked china pot is tapped with a spoon.

16. INVESTIGATIONS

17. MANAGEMENT

18. MANUAL / CLOSED REDUCTION Rowe’s maxillary Disimpaction forceps and Hayton Williams Forceps

19. FIXATION EXTERNAL FIXATION CRANIOMANDIBULAR BOX FRAME HALO FRAME PLASTER OF PARIS HEAD CAP CRANIOMAXILLARY SUPRA ORBITAL PINS ZYGOMATIC PINS HALO FRAMES

20. INTERNAL FIXATION DIRECT OSTEOSYNTHESIS TRANSOSSEOUS WIRING AT # SITE HIGH LEVEL ( FRONTOZYGOMATIC AND FRONTO NASAL) MID LEVEL ( ORBITAL RIM / ZYGOMATIC BUTRESS ) LOW LEVEL ( ALVEOLAR/MIDPALATAL) MINI PLATES TRANSFIXATION WITH KRISCHNER WIRE OR STEINMAN PIN : TRANSFACIAL ZYGOMATIC SEPTAL

21. SUSPENSION WIRE TO MANDIBLE FRONTO CENTRAL OR LATERAL CIRCUMZYGOMATIC ZYGOMATIC INFRA-ORBITAL PYRIFORM APERATURE OPEN REDUCTION AND INTERNAL FIXATION BY INTRAOSSEOUS WIRING: Introduced by Adams 1942. Reconstruction of sinus wall fragment between the two anterior pigments was omitted. Pterygoid buttress was not operated. Posterior height of mid face – Open reduction of zygomatic and naso -ethmoidal fracture was performed.

22. Changing trends in the management of mid face fracture

23. Historical approaches

24. Contemporary approach to treatment

25. OPEN REDUCTION AND INTERNAL FIXATION BY MINIPLATES , MICROPLATES , AND SCREWS CHAMPYS ET AL 1976 HARLE AND DUKER 1975 LUHR IN 1978.

26. APPROACH

27. COMPLICATIONS Infraorbital nerve paresthesia Enophthalmos Infection Exposed hardware Deviated septum Nasal obstruction Altered vision Nonunion Mal-union or Malocclusion Epiphora Foreign body reactions Scarring Sinusitis