Lefort 2 fracture

fractures in the middle third of the face

1. LE FORT II FRACTURES JOYAL JOICE FINAL YEAR PART II

2. CONTENTS INTRODUCTION FRACTURE LINES CLINICAL FEATURES MANAGEMENT REFERENCE

3. INTRODUCTION Le fort II fractures are also known as pyramidal or sub-zygomatic fractures. Violent forces usually from an anterior direction, sustained by the central region of the facial skeleton over an area extending from the glabella to the alveolar margins results in a fracture of a pyramidal shape. The force may be delivered at the level of the nasal bones.

4. Etiology OF LEFORT 2 FRACTURE Assault Falls Vehicle accidents Sports injury

5. FRACTURE LINES OF LE-FORT II The fracture runs from the thin middle area of the nasal bones down either side, crossing the frontal process of the maxillae into the medial wall of each orbit .Within each orbit the fracture line crosses the lacrimal bone behind the lacrimal sac, before turning forward to cross infraorbital margin slightly medial to or through infraorbital foramen . The fracture now extends downwards and backwards across the lateral wall of the antrum below the zygomatico -maxillary suture and divides the pterygoid laminae about halfway up. Separation of the block from the base of the skull is completed via the nasal septum and may involve the floor of anterior cranial fossa

6. CLINICAL FEATURES OF LEFORT II EXTRAORAL : Moon face Increased vertical dimension Dish face deformity Bilateral circumorbital ecchymosis Bilateral subconjuctival hemorrhage on medial half of eye Chemosis Increased intercanthal distance Epistaxis CSF rhinorrhea Tenderness Step defect infraorbital region Infraorbital nerve paresthesia/anesthesia

7. Loss of occlusion Shortening of face in case of impaction of fracture fragment into the cranial base Flat face and nasal disfigurement Airway obstruction INTRAORAL : Anterior open bite Molar gagging Midpalatal split

8. MANAGEMENT GENERAL PRINCIPLES OF TREATMENT : The complexity of the facial skeleton Associated facial bone fractures Relation to the airway Problems of fixation

9. REDUCTION OF THE MAXILLA: Manual method of reduction : Fractured maxilla maybe manipulated by hand if its within 3-4 days of fracture. Manipulation should be done in such a way so as to disimpact the mandible and move it forwards . Reduction by means of wires : If the maxilla is not very mobile or if it is impacted against the superior segment, it may be difficult to mobilize it manually. In this case , wires maybe twisted around the periodontally sound maxillary molars bilaterally . Reduction by using maxillary disimpaction forceps : Rowe’s maxillary disimpaction forceps .In case of a split in the palate, Hayton Williams forceps to first approximate the palate Reduction by means of traction : T ractional force maybe used if the fracture is not fresh one . In this case partial callus formation begins to take place between the fractured fragments and it is thus difficult to achieve manual mobilization of the maxilla

10. Open reduction and internal fixation of the maxilla Surgical approaches to the maxilla Intraoral buccal vestibular approach Infraorbital incisions : transconjuctival , subciliary , infraorbital Lateral eyebrow incision Bicoronal incision Transverse nasal incision Vertical nasal incision

11. Buttress of the midface : 1.Vertical buttress : Nasomaxillary buttress Zygomaticomaxillary buttress P terygoidmaxillary buttress 2.Horizontal buttress: Supraorbital rims Infraorbital rims Alveolar process

12. IMMOBILIZATION OF LE FORT II FRACTURES Internal fixation (immobilization within the tissues) External fixation (extra-oral immobilization)

13. Classification of methods of maxillary fixation 1.Internal fixation a. Direct osteosynthesis i . miniplates and screws ii. transosseous wires b. Suspension wires i.frontal ii.cirumzygomatic iii.zygomatic iv.infraorbital v.circumpalatal vi.piriform aperture suspension vii.peralveolar suspension CIRCUMZYGOMATIC SUSPENSION WIRES ORBITAL RIM WIRES MINIPLATES PIRIFORM APERTURE WIRING

14. 2.External fixation a. Craniomandibular i.box frame system ii.halo frame iii.Plaster of paris head cap b. Craniomaxillary i.Supraorbital pins ii.Zygomatic pins iii.Halo frame BOX FRAME HALO FRAME POP HEAD CAP WITH METAL FRAME

15. Direct osteosynthesis of the maxillary fractures : Wire osteosynthesis – transosseous wiring may be done .Fracture lines maybe be eposed by incisons . The fracture is reduced and brought into proper aligment . Holes are drilled with a bur on either side of the fracture line. A 26 gauge wire is passed through these holes to connect them and then twisted together. The cut ends are cut tucked into the nearest hole in the bone. Suspension wires for fixation of maxilla – Principle of internal suspension : 1.Direct suspension : This technique was basically designed to suspend a mobile bone to a firm and stable bone above the fracture by means of a subcutaneous wire. 2.Indirect suspension : If required it was sandwiched between the stable mandible below it. This helped in keeping it immobilized the fractured unit.

16. DIRECT OSTEOSYNTHESIS THREE POINT FIXATION

17. EXTERNAL FIXATION : The stable skull bones serves as a point of fixation for the fractures of facial skeleton. A metallic frame attached to the outer cortical bone may be used or a plaster of paris head cap is used . Craniomaxillary fixation : this is a method of fixation of the mobile maxillary segment to the stable cranium . There are connectors placed on the maxillary arch bars which connect the maxillary arch to the external head gear. This can also be used for traction and then fixation. Eg : haloframes / levant frames Craniomandibular fixation : this helps to fix the fractured maxilla to a stable cranium . The fractured maxilla may be sandiwiched in between the mandible and the stable cranium. Eg : use of box frames

18. Disadvantages : Cumbersome method Conspicous and inhibits social activity Lengthens the period of hospitalisation Contraindications : Presence of mental confusion Cerebral irritation Epilepsy Alcoholics

19. REFERENCES Fractures of middle third of face – Rowe and killey Textbook of oral and maxillofacial surgery- Neelima Anil Malik Textbook of oral and maxillofacial surgery- Chitra Chakravarthy Textbook of oral and maxillofacial surgery-Gustav O Kruger