Lefort fractures

lefort fractures are an important set of fractures to learn among midfacial fractues which requires a thorough anatomical knowlwdge for adequate management of patient as they suffer from mild to severe aesthetic deformities in addition to functional compromise which needs to be corrected with precise knowledge and care

1. LEFORT FRACTURES DEPT. OF ORAL AND MAXILLOFACIAL SURGERY, K. KRISHNA LOHITHA,Post Graduate

2. MIDDLE THIRD OF THE FACE The middle third of the face is the area bounded by: superiorly- by a line drawn from the zygomaticofrontal suture accross the frontonasal and frontomaxillary suture to the zygomaticofrontal suture of the opposite side Inferiorly- by the occlusal plane or alveolar ridge Posteriorly - as far as the frontal bone above and body of sphenoid below

3. The maxilla represents the bridge between cranial base superiorly and 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 & cosmetically important structures. Fractures of these bones is potentially life threatening as well as disfiguring.

4. BUTTRESSES OF FACIAL SKELETON VERTICAL BUTTRESSES Nasomaxillary / medial buttress Zygomaticomaxillary / lateral buttress Pterygomaxillary / posterior buttress The condyle and posterior ramus HORIZONTAL BUTTRESSES Frontal buttress Zygomatic buttress Maxillary buttress Mandibular buttress

5. ETIOLOGY RTA most common -40% Industrial mishaps -10% Assaults -15% Sports -25% Fall -10% EPIDEMIOLOGY : Most maxillary fractures occur in young men b\w 16-40 years. Peak age 21 – 25years Male : Female – 4:1

6. HISTORY : 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 In 1901 , Rene lefort carried out experienced studies on 32 cadaver heads by inflicting trauma to them. He then dissected the head region & discovered that the fractures in the middle third of the face follow complex fracture patterns which seen along the lines of weakness. Lefort noted that generally face was fractured & the skull was not. He then stated that fractures occured through three weak lines in the facial bony structures. From these lines lefort classification was devoloped .

7. Classification : Erich (1942) – As per the direction of fractureline . Horizontal fracture Pyramidal fracture Transverse fracture Depending on the relationship of fracture line to zygomatic bone. Subzygomatic Suprazygomatic Depending on level of fracture line Low level Mid level High level

8. By Rowe and Williams (1985) 1. central region a. Fractures of nasal bone l nasal septum i ) lateral nasal injuries ii) anterior nasal injuries b. Fractures of frontal process of maxilla c. Fractures of type a & b which extend into ethmoid bone ( nasoethmoid ) d.fractures of type a, b & c which extend into frontal bone ( fronto - orbito - nasal dislocation) 2. Lateral region fractures involving zygomatic bone, arch, maxilla( zygomatic complex) excluding the dento alveolar component

9. B. Fractures involving occlusion 1. dentoalveolar fracture 2. sub- zygomatic a. Lefort -I b. Lefort – II 3. supra zygomatic c. Lefort III

10. MARCIANI MODIFICATION(1993) Lefort I : low maxillary fracture Lefort Ia : low maxillary/multiple segment fracture Lefort II : pyramidal fracture IIa : pyramidal & nasal fracture IIb : pyramidal & NOE fractures Lefort III :craniofacial dysjunction IIIa : craniofacial dysjunction & nasal fractures IIIb : craniofacial dysjunction & NOE fractures Lefort IV : lefort II& III & cranial base fracture IVa : lefort IV with supraorbital rim fracture IVb : lefort IV with anterior cranial base IVc : lefort IV with anterior cranial base and orbital wall fracture

11. HENDRICKSON CLASSIFICATION OF PALATAL FRACTURES Type I : alveolar Ia : anterior alveolar ( incisors) Ib : postrior alveolar (premolar& molar) Type II : sagittal Type III : parasagittal Type IV : para alveolar Type V : complex Type VI : transverse

12. LEFORT I FRACTURE Horizontal fracture of maxilla guerin’s fracture Floating frcture Low level fracture Pterygomaxillary dysjunction Subzygomatic fracture( lefort I & lefort II)

13. LEFORT 1 FRACTURE Violent force over a more extensive area above the level of the teeth will result in lefort I fracture Horizontal fracture line is seen above the apices of maxillary teeth, detaching the tooth bearing portion of maxilla from rest of the facial skeleton The fractured fragment is freely mobile and displacement depends on the direction of force Depending upon the displacement, a variety of occlusal disharmony can be seen

14. The fracture line commences at the lateral margin of the anterior nasal aperture , passes above nasal floor, and it passes laterally above the canine fossa and traverses the lateral antral wall,dipping 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 two thirds. At the same time, from the same stating point , the fracture also passes along the lateral wall the nose to join the lateral line of fracture behind the tuberosity .

15. LEFORT 1 FRACTURE Mostly bilateral Sometimes unilateral depending upon the displacement, direction and severity of force May occur as single entity or with lefort I and II fractures

16. SIGNS AND SYMPTOMS OF LEFORT I FRACTURE EXTRAORALLY Slight swelling and edema of the lower part of the midface and the upper lip Epistaxis Pain and mobility Air emphysema in some cases Incresed vertical dimension of face

17. INTRAORALLY Floating maxilla Impacted or telescopic fracture Anterior open bite Disturbed occlusion Ecchymosis Cracked pot sound Midpalatal split in some cases GUERIN’S SIGN

18. LEFORT II FRACTURE Pyramidal or sub zygomatic fracture Violent force in the central region extending from glabella to the alveolus results in pyramidal fracture

19. The fractre line runs below the frontonasal suture from the thin middle area of the nasal bones down on the either side , crossing the frontonasal process f the maxillae and passes anteriorly across the lacrimal bones anterior to nasolacrimal canal. From this point the fracture passes downward , forward and laterally crossing the inferior orbital margin in the region of zygomaticomaxillary suture. It may or may not involve the infra orbital foramen. The fracture line extends downward and forward and lateral to the transverse wall of the antrum , just medial to the zygomaticomaxillary suture line -extends on to ptreygoid laminae in its middle portion Postromedially - separation of block from skull base is completed via nasal septum and may involve floor of ant cranial fossa

20. SIGNS AND SYMPTOMS OF LEFORT II FRACTURE EXTRAORALLY Balooning or moon face Dish face deformity Bilateral circumorbital edema or echymosis (black eye) Subconjunctival ecchymosis Edema of the conjunctiva or chemosis Detection of step deformity in the bone of infra orbital margin Mobility of the midface Anaesthesis or parasthesia of cheek Possible diplopia CSF rhinorrhea No tenderness over or disorganization and mobility of zygomatic bones and arch Elongation or lengthening of face Emphysema of soft tissues Nasal disfigurement

21. INTRAORALLY Derranged occlusion Posterior gagging of occlusion with retropositioning of maxillae with anterior open bite Airway obstruction Extensive bruising of soft palate, midplalatine split

22. LEFORT III FRACTURE High level fracture Transverse fracture Suprazygomatic fracture Craniofacial dysjunction Due to severe impact from the lateral surface

23. Frontonasal suture- accross nasal bones, lacrimal bones, orbital plate of ethmoid (medial wall of orbit) – optic foramen-downwards and laterally to posterior end of inferior orbital fissure 2 pathways of fracture lines -The first part descends accross pt aspect of maxilla accross pterygomaxillary fissure and fractures the root of pterygoid plates - the next fracture line runs accross the lat wall of the orbit separating the zygomatic bone from frontal bone at FZ region

24. SIGNS AND SYMPTOMS OF LEFORT I FRACTURE EXTRAORALLY Tenderness and separation at FZ suture Lengthening of face One or other zygomatic complex fracture with displacement Flattening and a step deformity at the infra orbital margin Movement of entire facial skeleton as a single block Enopthalmos Hooding of the eyes Profuse CSF rhinorrhoea and CSF otorrhoea Panda facies dish face deformity Battle’s sign Orbital dystopia with associated antimongoloid slant Flattening, widening and deviation of nasal bridge

25. PANDA FACIES BATTLES SIGN

26. PERIORBITAL EDEMA AND CHEMOSIS SUBCONJUNCTIVAL HAEMORRHAGE

27. HOODING OF EYE DISH FACE

28. INTRAORALLY Derranged occlusion Posterior gagging of occlusion with retro positioning of maxillae and anterior open bite Airway obstruction Sagittal fracture of the palate – variant of lefort III fracture

29. CSF RHINORRHOEA

30. MANAGEMENT OF PATIENT WITH MIDFACE INJURIES 1. EMERGENCY CARE & STABILIZATION 2. INITIAL ASSESSMENT 3. DEFINITIVE TREATMENT 4. REHABILITATION

31. INITIAL MANAGEMENT The primary survey progresses in a logical manner based on the ABC’s & D.E. A irway maintenance with cervical spine control. B reathing and adequate ventilation. C irculation with contol of hemorrhage . D egree of consciousness E xposure of patient via complete undressing to avoid overlooking injuries camoflaged clothing.

32. 1.. EMERGENCY CARE & STABILIZATION Preserve the airway. Control of haemorrhage. Prevent or control shock. C – spine stabilization. Control of life threatning injuries. Head injuries , chest injuries , compound limb fractures, intra abdominal bleeding

33. 2.INITIAL ASSESSMENT OF MAXILLOFACIAL INJURIES HISTORY: nature of & exact time CLINICAL EXAMINATION: physical signs RADIOGRAPHIC EXAMINATION SPECIAL INVESTIGATION Impressions taken : For study model To determine occlusion Fabricate capsplints

34. CLINICAL EXAMINATION Evaluate mandibular opening Palpation of buccal vestibule crepitus of lateral antral wall occlusion

35. CLINICAL ASSESSMENT OF MIDFACE FRACTURES Extra-oral & Intra-oral examination.  Inspection.  Palpation.

36. EXTRAORAL EXAMINATION 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 . Cerebrospinal fluid rhinorrhoea Lengthening of Midface Depressed midface (dish face) Saddle shaped depression of nose Enophthalmos Proptosis Diplopia

37. Subconjunctival hemorrhage - • Localized (black eye) confined to preseptal soft tissues (Also seen in anterior cranial fossa , orbital & zmc fractures.) Cerebrospinal Fluid Rhinorrhoea -Watery nasal or postnasal salty discharge (Ring Test- but it lacks sensitivity & specificity

38. Palpation - 1. Subcutaneous Emphysema – Crepitus 2. Tenderness 3. Step Deformity 4. Abnormal Mobility of bone 5. Impairment of sensation

39. INTRAORAL EXAMINATION INSPECTION 1.Disturbed occlusion (posterior occlusal gagging, open bite) 2. Haematoma intraorally over root of zygoma 3. Haematoma in palate (Guiren’s sign) 4. Fractured cusps of teeth 5. Midline diastema

40. PALPATION Mobility of whole of tooth bearing segment of upper jaw elicited at dentoalveolar segment in lefort I

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. RADIOGRAOHIC INVESTIGATIONS CT scan 3D CT scan Waters view PA skull view Reverse townes projection True Lateral view Soft tissiue lateral Intra oral occlusal radiographs Orthopantomogram submento vertex view

44. DEFINITIVE TREATMENT A. Preoperative planning: 1. Type of fixation 2. open/ closed reduction 3. Type of IMF 4. Need for tracheostomy B. Timing of pre operative procedure minimal fractures taking less operative time can be performed during emergency management being performed in operation theatre It is quite wrong at this time, to embark on any operative procedure which cannot be accomplished in a limited period of time. Timing of midfacial # : optimum time: 5-8 th postop time

45. C.OPERATIVE PROCEDURE 1. tracheostomy 2. facial lacerations:Ideally these should be sutured before too much oedema has occured ; that is within 1-8 hours of injury. 3. reduction of associated mandibular # 4. Occlusion: extractions if needed arch bars/ cap splints for mandible For maxilla after reduction of fracture 5.Zygomatic fractures eg : lefort # displaced posteriorly , allowing medial rotation of zygomatic bones Dx : lateral disimpaction & forward movement of maxilla

46. 6. Disimpaction & reduction of maxilla Rowes disimpaction forceps Walsham nasal forceps Hayton williams forceps( palatal #) Initial traction: downward displacement of pterygoid plates by cocking the wrists upwards Then traction in downward and forward direction to mobilise maxilla parallel to base of skull Rocking and rotational movements – final disimpaction

47. 7. Open reduction 8. Skeletal fixation 9. Temporary IMF 10. Nasal fractures 11. Definitive IMF D. IMMEDIATE POST OP CARE

48. E.POST OP MANAGEMENT: 1. General management 2. Maxillofacial management check external skeletal fixation for stability IMF for rigidity oral hygiene sutured lacerations, surgical wounds & incisions should be scrupulously clean timing of suture removal change of nasal plaster chemosis : 1% chloramphenicol ointment

49. 4. REHABILITATION: A. General rehabilitation B. Maxillofacial rehabilitation Secondary correction of facial scars Pschyartric support Restoration of teeth

50. Management of lefort fractures BASIC PRINCIPLES 1. reduction 2. fixation 3.immobilization 4. rehabilitation

51. REDUCTION Restoration of the fractured fragments to their original anatomical position Two types closed reduction open reduction

52. CLOSED REDUCTION Alignment without visualisation of the fracture line reduction by manipulation Reduction by wires Reduction by using maxillary disimpaction forceps reduction by traction OPEN REDUCTION Surgical reduction allows visual identification of fractured fragments

53. METHODS OF FIXATION 1. wiring 2. plates and screws 3. IMF( intermaxillary fixation) 4. internal suspension 5. craniofacial suspension

54. FIXATION In this phase, fractured fragments are fixed in their normal anatomical relationship to prevent displacement and acheive proper approximation Types Direct skeletal fixation indirect skeletal fixation ( intra oral or extra oral)

55. Direct skeletal suspension 1. external – Device is outside the tissues but inserted into the bone percutaneously Eg : bone clamps and pins 2. internal – devices are totally enclosed within the tissues and uniting the bone ends by direct approximation Eg : transosseous wiring and plating system

56. IMMOBILIZATION INTERNAL FIXATION: 1. DIRECT OSTEOSYNTHESIS a. Transosseous wiring at fracture sites i . High level ( frontozygomatic and frontonasal ) ii. Mid level ( orbital rim/ zygomatic buttress) iii. Low level ( alveolar/ midpalatal ) b. Miniplates c. Transfixation with kirschner wire or steinmann pin i . Transfacial ii. Zygomatic – septal 2. SUSPENSION WIRES TO MANDIBLE a. Frontal – central / lateral b. Circumzygomatic c. Zygomatic d. Infra orbital e. Pyriform aperture 3. SUPPORT a. Antral pack b. Antral balloon

57. EXTERNAL FIXATION 1. CRANIOMANDIBULAR a. Box frame b. Halo frame c. Plaster of paris headcap 2. CRANIOMAXILLARY a. Supra orbital pins b. Zygomatic pins c. Halo frame’ 3. SUSPENSION BY CHEEK WIRES FROM HALO FRAME OR HEAD CAP

58. TRANSOSSEOUS WIRING 1.Maxillary ( Lefort –I ) 2. Zygomaticomaxillary ( Lefort –II) 3. Frontonasal ( LeFort &III) 4. Zygomaticofrontal ( Lefort III) 5. Zygomatic bone ( comminuted )

59. 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.

60. Plates & Screws for midface fractures Stainless steel mini-plating system Titanium mini-plating system Vitallium , Cobalt chromium, molybdenum alloy plates Bioresorbable plating system Advantages – 1. Simple & less intraoperative time 2. Intraoral approach is sufficient 3. Postoperative IMF is not needed or period of IMF is reduced. 4. Three dimensional stability and early return of function.

61. Circumzygomatic suspension- obswegesor

62. INFRAORBITAL SUSPENSION PYRIFORM APERTURE SUSPENSION

63. 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 .

64. BOX FRAME

65. HALO FRAME LEVANT FRAME

66. Plaster of paris headcap

67. TREATMENT OF LEFORT I FRACTURES Aim : to reestablish anterior projection transverse width occlusion Undisplaced lefort I: MMF for 4 weeks direct mini plate fixation with no MMF Displaced lefort I : direct miniplate fixation indirect suspension with MMF Comminuted : MMF and suspension Suspension wires in lefort I: zygomatic infraorbital pyriform aperture

68. TREATMENT OF LEFORT II FRACTURES Undisplaced lefort II with minimal occlusal discrepancy: Circumzygomatic suspension with MMF for 4 weeks Direct fixation at ZM buttress Displaced mobile lefort II with anterior open bite Direct fixation or indirect suspension with MMF

69. TREATMENT OF LEFORT III FRACTURES Team approach neurosurgery ophthalmology oral & maxillofacial surgery AIM: Reestablishment of intercanthal distance Infraorbital rim fixation Orbit is reconstructed Occlusion Intubation must not interfere with ability to use IMF Exposure and visualisation of all fractures

70. APPROACHES TO LEFORT FRACTURES 1.Supraorbital eyebrow incision ( Lefort III) 2. Subciliary incision ( LeFort II & III) 3. Median lower lid ( LeFort II & III) 4. Infraorbital incision ( LeFort II & III) 5. Transconjunctival ( LeFort II ) 6. Zygomatic arch 7. Transverse nasal ( LeFort II & III) 8. Vertical nasal incision ( LeFort II & III) 9. Medial orbital incision. 10. Intra-oral vestibular incision. ( LeFort I)

71. COMPLICATIONS Non union Delayed union Mal union Infection Plate exposure Occlusal derangement Facial assymetry Meningitis Injury to lacrimal system Neurological complications

72. REFERENCES RJ FONSECA – TRAUMA VOL 2 Peterward Booth – vol 1 Rowe and Williams – vol 2 Killey’s fracture of the middle third of the facial skeleton

73. MANAGEMENT OF MIDFACE FRACTURE Maxillofacial injuries Treatment divided into following phases Emergency or initial care. Early care. Definitive care. Secondary care or revision. Emergency treatment and stabilization of the patient. Definitive treatment with reduction and fixation.

74. SOFT TISSUE LACERATIONS The most common priority for patients with fractures of the middle third is repair of soft tissue lacerations , particularly of the face. Ideally these should be sutured before too much oedema has occured ; that is within 1-8 hours of injury. ASSESS THE GENERAL CONDITION OF THE PATIENT. OCCLUSION Teeth and occlusion are the key to reconstruction. It provides the foundation upon which other facial sutures are built.

75. INITIAL MANAGEMENT The primary survey progresses in a logical manner based on the ABC’s & D.E. Airway maintenance with cervical spine control. Breathing and adequate ventilation. Circulation with contol of hemorrhage . The letters D & E have also been added. Degree of consciousness Exposure of patient via complete undressing to avoid overlooking injuries camoflaged clothing.

76. EMERGENCY CARE . EVALUATE THE AIRWAY Existence & identification of obstruction Manually clear of fractured teeth, blood clots, dentures. Endotracheal intubation & packing of oronasal airway.

77. AIRWAY MANAGEMENT Maintan an intact airway. Protect airway in jeopardy – provide an airway(tracheotomy) C – spine injury may be present. Altered level of consiousness is the most common cause of cause of upper airway obstuction . Chin lift to open intact airway. Intubation - Orotracheal : C –spine injury absent on X- Ray. Nasotracheal intubation : C-spine injury suspected or certain Surgical airway - Cricothyroidotomy – Tracheostomy .

78. TREATMENT OF BLOOD LOSS & SHOCK Extensive vascularity of head and neck may lead to massive blood loss. Monitor vital signs closely – Intravenous infusion. Penetrating injuries need to be explored - Arteriogram esophagram . Hemorrhage most common cause of shock after injury. Muktiple injury patients have hypovolemia . External bleeding controlled by direct pressure over bleeding site. Gain prompt access to vascular system with iv catheters. Fluid replacement – Ringers lactate. Normal saline – transfusion.

79. STABILIZATION OF ASSOCIATED INJURIES C – spine injury is primary concern with all maxillofacial trauma victims. Any patients with injury above clavicle or head injury resulting in unconscious state. any injury produced by high speed. Signs/symptoms of C – spine injury Neurological deficit Neck pain EARLY CARE Emergency care has stabilized patient. Initial stabilization of fractures. Debridement & dressing of soft tissues Elective tracheostomy Physical exam & history Laboratory tests Complete head and neck examination for diagnosis of maillofacial injuries.