LEFORT FRACTURES.pptx

Its a Clinical Presentation of Midface fractures-specifically, Lefort fractures. Classification, Anatomical Landmarks, Clinical Features, Diagnosis & Management protocols are discussed.

1. LEFORT FRACTURES DR. MUHAMMAD FAKHRUL ALAM MS PHASE-B RESIDENT (OMFS) DHAKA DENTAL COLLEGE

2. INTRODUCTION René Le Fort was a French Scientist In 1901 , described Lefort classification of midface fracture. Experimented with 32 cadavers . Those cadaver heads were subjected to various types of trauma. Soft tissues of those heads were then removed and the bones were examined . René Le Fort (1869-1951)

3. INTRODUCTION Le Fort stated that fractures occurred through three weak lines in the facial bony structure: 1. Those that protect the cranial cavity 2. Those that circumscribe the midface , 3. And those that cut across the face . From these three lines, the Le Fort classification system was developed René Le Fort (1869-1951)

4. LEFORT CLASSIFICATION Lefort III Fracture ( Suprazygomatic /High level Fracture or craniofacial Dysjunction ) Lefort I Fracture (Low level/ Guerin fractures or Floating Maxilla) Lefort II Fracture (Pyramidal Fractures)

5. LEFORT I FRACTURE This is a horizontal fracture above the level of the nasal floor . The fracture line extends backwards from the lateral margin of the anterior nasal aperture below the zygomatic buttress to cross the lower third of the pterygoid laminae . The fracture also passes along the lateral wall of the nose and the lower third of the nasal septum to join the lateral fracture behind the tuberosity .

6. CLINICAL FEATURES LEFORT I

7. CLINICAL FEATURES (LEFORT I) Swelling of the upper lip and cheeks

8. CLINICAL FEATURES (LEFORT I) Ecchymosis in the maxillary buccal sulcus.

9. CLINICAL FEATURES (LEFORT I) Nasal Blockage

10. CLINICAL FEATURES (LEFORT I) Guerin sign: Ecchymosis in the palate in the area of greater palatine foramen bilaterally

11. CLINICAL FEATURES (LEFORT I) • Occlusion: Anterior open bite . Posterior gagging. • Teeth fracture

12. CLINICAL FEATURES (LEFORT I) Palatal fracture: Commonly, Mid palatal split

13. CLINICAL FEATURES (LEFORT I) • Cracked-pot sound • Floating maxilla • Palpation reveals tenderness and step deformity along the pyriform aperture, buccal sulcus and tuberosity regions.

14. LEFORT II FRACTURE This fracture runs from thin middle area of the nasal bones or frontonasal junction crossing the frontal processes of the maxilla , into the medial wall of each orbit , crosses the lacrimal bone behind the lacrimal sac — turns forward to cross the infraorbital margin —slightly medial to or through the infraorbital foramen —extends downwards and backwards across the lateral wall of the antrum — below the zygomaticomaxillary suture — middle one-third of the pterygoid laminae horizontally. Separation of the block from the base of the skull is completed via the nasal septum and may involve the floor of the anterior cranial fossa.

15. LEFORT III FRACTURE Fracture line • Anteriorly: The fronto nasal suture — transversely backwards , parallel with base of the skull, to full depth of the ethmoid bone including the cribriform plate. • Posteromedially : Within the orbit—the fracture passes below the optic foramen into the posterior limit of the inferior orbital fissure . Then Backwards across the maxillary fissure to fracture the roots of the pterygoid laminae

16. LEFORT III FRACTURE • Posterolaterally : From the orbit — inferior orbital fissure — lateral wall of orbit into the frontozygomatic suture . In addition, fracture of the zygomatic arch is an integral part of Le Fort III completing the separation of facial bones from cranium .

17. CLINICAL FEATURES LEFORT II & LEFORT III

18. COMMON CLINICAL FEATURES OF LEFORT II & LEFORT III FRACTURES Swelling: Gross oedema of the middle third of the face gives an appearance of ‘ moon facies ’’ Deformity of nose, Epistaxis, Nasal obstruction

19. COMMON CLINICAL FEATURES OF LEFORT II & LEFORT III FRACTURES Bilateral circumorbital or periorbital oedema , ecchymosis giving an appearance of ‘ raccoon eyes’.

20. COMMON CLINICAL FEATURES OF LEFORT II & LEFORT III FRACTURES Bilateral Subconjunctival haemorrhage ‘ Dish face’ deformity (concave profile) with lengthening of the face

21. COMMON CLINICAL FEATURES OF LEFORT II & LEFORT III FRACTURES • CSF rhinorrhoea • Enophthalmos , limitation in ocular mobility from muscle entrapment and diplopia are possible findings • Retropositioning of the whole maxilla and posterior gagging of the occlusion are seen creating anterior open bite . • Restricted Mouth Opening • Mobility of the maxilla • Subcutaneous emphysema is sometimes evident by crepitus felt on palpation

22. SPECIFIC CLINICAL FEATURES OF LEFORT II FRACTURES • Anaesthesia or paraesthesia of the cheek • Step deformity at the infraorbital rims or nasofrontal junction . • Telecanthus , Epiphora • Zygoma and arch are intact , no loss of malar prominence unless associated with ZMC fractures • Ecchymosis or haematoma is seen in the buccal sulcus opposite to the maxillary first and second molar teeth

23. • Midline or paramedian split of the palate with mucosal tear. • Tenderness with step deformity at zygomatico -maxillary buttress regions . • Mobility of midface detectable at nasal bridge & Infraorbital margins. • Nasal Bones move with midface as a whole but often otherwise intact. SPECIFIC CLINICAL FEATURES OF LEFORT II FRACTURES

24. • Hooding of eyes • Occular signs- - Enophthalmos , - Hypoglobus , - Diplopia - Anti mongoloid slant • Saddle nose deformity . • Loss of lateral facial projection from zygomatic arch fractures. • Profuse CSF rhinorrhea SPECIFIC CLINICAL FEATURES OF LEFORT III FRACTURES

25. • Tilting of the occlusal plane with gagging of one side when lateral displacement is present . • Tenderness and step deformity present at - Frontozygomatic suture, - Zygomatic arch - Nasal bridge. • Mobility of whole facial skeleton as a single block. SPECIFIC CLINICAL FEATURES OF LEFORT III FRACTURES

26. CLINICAL EXAMINATION OF LEFORT FRACTURES Maxillary fractures are distinguished into Le Fort I, II & III based on the classical mobility • Step 1: Left palm is placed over the forehead , with the thumb over right lateral orbital rim ( frontozygomatic junction), index finger over left frontozygomatic junction or alternatively the frontonasal junction can also be assessed simultaneously.

27. CLINICAL EXAMINATION OF LEFORT FRACTURES • Step 2: The maxilla is grasped firmly at the anterior portion of alveolus and not the teeth . The maxilla is checked for mobility with concurrent mobility in bilateral frontozygomatic junction.

28. CLINICAL EXAMINATION OF LEFORT FRACTURES • Step 3: Frontonasal junction at the root of nose is grasped with left thumb and index finger while palm stabilises the cranium at forehead . • Step 4: Repeat step 2 checking for dental segment maxilla mobility with concurrent mobility in frontonasal junction.

29. CLINICAL EXAMINATION OF LEFORT FRACTURES • Step 5: Place two fingers as of left hand one on each infraorbital rim , all the time palm stabilizes the cranium at forehead . • Step 6: Repeat step 2 and check for concurrent mobility felt at both infraorbital rims .

30. Comparison of site of mobility- evident in different fracture levels CLINICAL EXAMINATION OF LEFORT FRACTURES Maxillary dental mobility Frontonasal junction Infraorbital rim Frontozygomatic junction Lefort I + - - - Lefort II + + + - Lefort III + + + +

31. INVESTIGATIONS Conventional Radiograph Computed Tomography ( CT Scan)

32. CONVENTIONAL RADIOGRAPH Common conventional radiograph done for midface fractures are- Occipito -Mental View (Standard 0° projection) Waters’ view (30° OM view) OM views are most preferred to see Lefort fractures Caldwell view (PA view) : To see the nasal & orbital Structures Lateral view : To see inward of outward displacement Orthopentomogram (OPG): To see teeth & associated structures Submentovertex view: Base of the Skull & Zygomatic arch can be seen

33. COMPUTED TOMOGRAPHY ( CT SCAN) Conventional radiographic examination is uncertain and sometimes misleading . CT scan of the face provides a vivid evaluation of facial pathology. Axial, Coronal & Sagittal views provide 3 dimensional views of a specific location in the maxillofacial region. 3D reconstruction of the CT scan aids in diagnosis and treatment planning.

34. Computed Tomography ( CT Scan) CT Scan coronal section and 3D reconstruction showing loss of continuity in anterolateral wall of sinus, lateral wall of nasal cavity with paramedian palatal split

35. Computed Tomography ( CT Scan) Right Le Fort I and II combination fracture, right nasal bone fracture and left high Le Fort I fracture with midpalatal split along with mandibular symphysis fracture . Note: pterygoid plate fracture.

36. MANAGEMENT OF LE FORT FRACTURES

37. MANAGEMENT OF LE FORT FRACTURES The aims of the treatment are as follows: 1. Restoration and preservation of functions of the vital structures mainly by establishing normal skeletal architecture . 2. Re-establishing dental occlusion, ocular position, ocular mobility and orbital volume is the primary concern of the surgeon. The two areas of reference for reconstruction are cranium and dental occlusion . 3. IMF/MMF is done to restore the dental occlusion ; it is done prior to the surgery to protect the masticatory function . MMF/IMF may be performed before or during the fracture repair , it may be removed immediately after the surgery or left in place postoperatively GENERAL PRINCIPLES

38. The timing of surgery is controversial. Some support immediate repair in a stable patient . Preferably, the fracture repair can be delayed 7–14 days allowing edema to subside . Delaying surgery beyond two weeks is not encouraged due to risk of fibrosis and healing process taking place at the fractured site. Further, late repair is difficult to operate because of the contraction of the soft tissue envelope . The results of such surgeries are not satisfactory . But, when the patient is hemodynamically unstable or has an increased intracranial pressure (ICP), the time of surgery is deferred. TIMING OF THE SURGERY

39. 1. Airway maintenance The reduction of fractures of the middle third requires GA , which can be administered through nasal intubation (Le Fort I), submental or tracheostomy (Le Fort II and III). Oral intubation can be indicated when there is extensive soft tissue injury to the nose. 2. Complexity of fractures Le Fort fractures often do not present as a fracture of single block of bone . They often present as a complex of Le Fort I, II and III types of fractures , which is extremely complicated. CHALLENGES ASSOCIATED WITH TREATMENT OF MIDDLE THIRD FRACTURE

40. 3. Fixation Fixation requires an immobile point for support . As the mandible is movable , it is not possible to fix the fractured maxilla to the mandible to stabilize the middle third of the facial skeleton. To avoid this, following accurate reduction using mandible as a guide , the middle third must be immobilized by attaching it to a fixed point . The stable point is the bone superior to the fracture. The stable bone is used to suspend the fracture segment (e.g. Circum zygomatic suspension for Le Fort I—where the zygoma is used as a stable bone) or fixation (e.g . zygomatico -maxillary and piriform buttress bone is used as points of fixation in Le Fort I). CHALLENGES ASSOCIATED WITH TREATMENT OF MIDDLE THIRD FRACTURE

41. Surgical approach of choice for Le Fort III and sometimes Le Fort II (for frontonasal fracture fixation). Provides complete degloving of the entire frontal area including the lateral orbital wall and rim, nasofrontal area and the zygomatic arches. VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION BICORONAL AND HEMICORONAL

42. Indication Le Fort I, II, III combined fractures. The technique involves a wide labio -vestibular incision in combination with release of soft tissue envelope around the piriform margin and nasal skeleton . This approach allows access to the anterior surface of maxillae, infraorbital rims, body of zygoma and the entire nasal skeleton . VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION MIDFACIAL DEGLOVING

43. Indication Le Fort II, III. These approaches are widely used for reduction and fixation of the infraorbital rim. Also facilitates the orbital floor reconstruction in orbital blowout fractures. Though the subciliary approach has less risk to the cornea and a relatively quick technique it has high risk of ectropion and visible scar. VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION TRANSCONJUNCTIVAL & SUBCILIARY

44. Transconjunctival approach is scarless , does not create ectropion and provides approach to the infraorbital rim alone. However, when combined with lateral canthotomy , it can be used to approach the frontozygomatic suture too . This approach is therefore advantageous since it avoids a second approach. VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION

45. For lateral orbital rim fracture ( Fronto -Zygomatic Suture ) in Le Fort III direct fixation , Le Fort II and I indirect ( Adam ) suspension. VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION LATERAL EYEBROW APPROACH

46. For access to the anterolateral walls of maxilla in Le Fort I and II fracture reduction and direct fixation as well as in indirect suspension. VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION TRANSORAL APPROACH

47. In loosely mobile fracture , finger manipulation is sufficient for reduction. In reduction of impacted fractures, Rowe’s disimpaction forceps is used. The unpadded blade is passed into the nostril and padded blade into the mouth and the palate is grasped tightly in between . The operator now stands behind the patient , grasps the two forceps and manipulates to disimpact the maxilla and bring it to place. LE FORT I FRACTURE MANAGEMENT 1. REDUCTION

48. Then, a rocking motion with constant anterior traction frees the impacted segment. In the figure shown, the maxillary dentulous fragment mobilized by downward and anterior traction LE FORT I FRACTURE MANAGEMENT

49. Fixation may be by direct or indirect means. Direct fixation involves transoral exposure of the fracture line and miniplate fixation at the buttress bone ( lateral piriform rim and zygomatico -maxillary buttress ). Indirect fixation involves suspension and MMF for 4–6 weeks of immobilisation . LE FORT I FRACTURE MANAGEMENT 2. FIXATION

50. • Undisplaced Le Fort I with minimal occlusal discrepancy —simple MMF for 4 weeks or direct fixation with no MMF. • Displaced mobile Le Fort I with anterior open bite —direct fixation or indirect suspension with MMF. • Comminuted fractures where plate or wire fixation not feasible — MMF and suspension. • In an edentulous patient , if intraosseous fixation is not feasible , a custom acrylic occlusal splint or patient’s own denture is used to determine the vertical dimension.. After rigid fixation, the MMF can be removed at the end of the procedure. LE FORT I FRACTURE MANAGEMENT

51. Disimpaction is similar as in Le Fort I fracture using Rowe’s disimpaction forceps . Extreme care should be taken because this fracture usually involves base of the skull , which might be further disrupted if manipulated indiscriminately. Whenever this fracture is present along with Le Fort I type, disimpaction of the tooth-bearing portion can be done with the help of Rowe’s disimpaction forceps , but it might be difficult to mobilise the remaining fragment . Mobilisation of this remaining fragment can be carried out by grasping the nasal septum with Asch’s or Walsham’s forceps and simultaneously exerting forward finger pressure from behind the soft palate. LE FORT II FRACTURE MANAGEMENT 1. REDUCTION

52. Fixation may be by direct or indirect means. Direct involves miniplate fixation at the ZM buttress , infraorbital rim and frontonasal junction including nasal bones. Indirect involves suspension and MMF for 4–6 weeks of immobilisation LE FORT II FRACTURE MANAGEMENT 2. FIXATION

53. • Undisplaced Le Fort II with minimal occlusal discrepancy — circum zygomatic suspension with MMF for 4 weeks or direct fixation at zygomaticomaxillary buttress alone may suffice. • Displaced mobile Le Fort II with anterior open bite — direct fixation or indirect suspension (Adams) with MMF. • Comminuted fractures where plate or wire fixation not feasible — MMF and suspension. • The associated complications such as CSF rhinorrhoea , lacrimal obstruction require appropriate management. LE FORT II FRACTURE MANAGEMENT

54. Le Fort III fractures usually occur in association with other fractures of the facial skeleton such as nasoethmoidal , zygomatic, orbital and Le Fort type I . When Le Fort III fractures occur in isolation the displacement is minimal and reduction is established by exposing the frontozygomatic suture . The management includes semi rigid fixation at frontozygomatic, frontonasal, orbital floor reconstruction, zygomatico -maxillary buttresses , zygomatic arch and maintaining occlusion . The associated complications such as CSF rhinorrhoea , lacrimal obstruction require appropriate management. LE FORT III FRACTURE MANAGEMENT

55. Inadequately reduced fractures may result in ‘ facial’ deformity. COMPLICATIONS OF LEFORT FRACTURES

56. Late enophthalmos develops as a consequence of expansion of the orbital volume . COMPLICATIONS OF LEFORT FRACTURES Infraorbital depression following untreated Le Fort II fracture

57. Obstruction of the nasolacrimal duct due to Le Fort II fractures results in epiphora , dacryocystitis (an infected mucocele ). Failure of recovery of oculomotor nerve and abducens nerve result in strabismus, ptosis and diplopia. Paraesthesia in the distribution of the ophthalmic and maxillary branches of the trigeminal nerve . Fractures involving cribriform plate of ethmoid may result in anosmia. Nonunion might occur in cases of extensively comminuted fractures. COMPLICATIONS OF LEFORT FRACTURES

58. Malocclusion and soft tissue entrapment Palatal fistula ( oronasal communications)

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