Treatment of le fort fractures.pptx

lefort fracture

1. Presented by:- Dr. Harpreet Kaur Dept. of Oral & Maxillofacial Surgery

2. Emergency care and stabilization Initial assessment Definitive treatment Continuing care

3. ∆ Air w a y immedia t e l y e v alu a t ed f or o b structi o n ∆ Control of oral or nasal bleeding Possibility of C – spine fracture – endotracheal incubation should not be attempted Cervical collar in case of suspected spine fractures ∆ Circulation

4. LeFort I fracture LeFort I fracture with Mandible fracture LeFort I fracture with Nasal injury LeFort II fracture Lefort III fracture Panfacial fractures Nasal Airway Edentulous Partially Dentate with space Fully Dentate Oral Airway through portal cut in Gunning splints or dentures Oral Airway with tube displaced th r ough spa c e S u r g i cal Airway Guided Nasal Intubation f i x a t e m ax i l l a and mandible switch to Oral Airway for nasal/NOE reduction

5. History Palpation of entire facial skeleton I/O Examination O p hthal m ol o gic e x am / c o n sultation Radiographic examination

6. Af t er stabilization of patients c o n dition , c o m ple t e facial examination is performed. Laceration, bruising , etc. Obvious depressions on nose, che e k, etc. Facial asymmetry, swelling Nasal discharge (Blood/ CSF)

7. Features CSF fluid Nasal secretion History Nasal or sinus surgery, head injury or intracranial tumour Sneezing, nasal stuffiness, itching in the nose or lacrimation Fl o w of d i scha r g e A f ew d r ops or a st r eam of f l ui d g u shes down when bending forward or straining; can’t be sniffed back C o n ti n u o u s . N o ef f ect of bending forward or straining. Can be sniffed back Cha r ac t er of discharge Thi n , w a t e r y and clear S l i m y (muc u s) or clear (tears) Taste Sweet Salty Su g ar c o n t ent More than 30 mg/dl (Compare with sugar in CSF after lumbar puncture as sugar is less in CSF in meningitis) Less than 10 mg/dl P r es e n c e of β2 transferrin A l w a y s p r es e nt . I t i s speci f i c f or C S F A l w a y s absent

8. Palpation of facial skeleton

9. Periorbital edema Periorbital ecchymosis Proptosis Diplopia Pupilla r y si z e and shape Sub-conjunctival haemorrhage Lid laceration Visual acuity Dystopia

10. Inspection Palpation Percussion Laceration Ecchymosis Restricted mouth opening Occlusion Tenderness M obil i ty of t eeth Crepitus M obil i ty of f r act u r ed fragment Cracked pot sound

11. OPG OM Lateral skull view O c clusa l v i ew f or split pala t e CT Scan 3d CT Scan MRI

12. McGregor-Campbell & Trapnell’s Lines

13. Dolan’s Lines

14. A c cu r a t e di agnosis Determination of priority of treatment Ea rl y r e c ons t ru c t ion W i d e e x po s u r e of v er t ica l a n d hori z on t al pi l lar of fa c e Use of bone graft to restore skeletal form Use of rigid fixation to stabilize # segment Restoration of bony support to over lying soft tissue envelop

15. ∆ Aims of treatment R elie v e pain Precise anatomical reduction of the # fragment Stable fixation of the reduced fragment Restore function R es t o r e th e denta l o c clusion

16. ∆ N eed f or su r g i ca l ai r w a y ∆ Open/closed method of reduction ∆ N e c essi t y f or and typ e i f IMF t o b e empl o y ed i n cas e f or closed reduction ∆ T yp e of os t eosy n th esis i n cas e of open method ∆ Need for internal suspension in case of communited # ∆ Timing of surgery PRE OPERATIVE PLANNING

17. ∏ Optimum time for reduction of mid face fracture is 5 th to 8 th post injury day ∏ Af t er thi s with e v e r y su c c eedi n g d a y dis i mpactio n be c ome difficult and open reduction more essential

18. Closed reduction Reduction by manipulation Reduction by traction Intra-oral traction Extra-oral traction Open reduction REDUCTION

19. Open reduction Closed reduction Displaced # Non displaced # Multiple # of facial bones G r oss l y c ommu n i t ed # Edentulous maxillary # - with severe displacement F r act u r es assoc i a t ed with sig n i f i c ant loss of soft tissues Edentulous maxillary # - opposite to Edentulous mandibular # Edentulous maxillary # Del a y of t r eatme nt In children with developing dentition Inter position of soft tissues between non contacting displaced # segment S y s t em i c c o n d i t i on c o n t r a i n d i cat i ng IMF

20. Manual reduction Reduction with wires Reduction using disimpaction forceps Reduction with bone hook Reduction with elastics

21. Simple manipulation by hand U se o f denta l c om p ound lo a ded in i m p r ession t r a y (Dingman and Harding, 1951) Use of rubber dam sheets, long ribbon/strip gauze or rubber catheter (Propescu and Burlibasa, 1966)

22. R o w e ’ s maxi l la r y d i simpact i on f o r c eps Hayton William’s disimpaction forceps

23. MOVEMENTS Downwards – to affect disimpaction of pterygoid plates down Anterior Combination of forward traction with rotational movement in both horizontal and vertical axis

24. Used in delayed cases: Int r a o r al elastic t r action Ext r a o r al elastic t r action

25. Maxillary # fixation Internal fixation Direct osterosynthesis Miniplates Intraosseous Wires high(FZ,FN) Mid(buttress,orbital rim) Low(alveolar/midpalatal) S u spension wi r es Frontal Circumzygomatic Zygomatic Circumpalatal Infraorbital Piriform aperture Peralveolar External fixation Craniomandibular Craniomaxillary Supraorbital pins Zygomatic pins POP head frame H alo f r ame 5 . Levant frame 6. Box frame

26. Int r ao s s e ous wi r es By Merville & Derome(1976)

27. Miniplates and screws semi-rigid f i x at i on device w hich Th ese a r e mo n o c o r t ica l , provide 3D stability. Desi g n s: X , H , L , T , Y Thickness:0.6-1 mm

28. Plating system depends on: Rigidit y of pla t e Width and shape D i ame t er and numb er of sc r ews Increase in width provides more stability towards rotational forces. T yp e of metal: Stainless steel Titanium Vitallium Advantages: Eas i l y adaptable Monocortical Functional stability Reduced surgical access

29. Minimum 2 screws required in each bone segment to prevent rotation in X and Y axis Farther the point of stabilization the more effective the device is in preventing rotation Large diameter screws are not used because of constraint impose d b y p articu l ar ana t omic l o cation All screw require adequate intervening bone between adjacent holes to preserve integrity of screw bone interface

30. LE FORT I FRACTURE

31. REDUCTION By Rowe Disimpaction forcep / Hayton William forcep FIXATION

32. LE FORT II FRACTURE A- Subciliary incision B- Sub tarsal incision C- Infraorbital incision D- Extension of Subciliary incision

33. Approach can also be done through Pre- existing laceration Maxillary vestibular incision CORONAL APPROACH

34. FIXATION

35. LE FORT III FRACTURES LATERAL EYEBROW APPROACH

36. Coronal approach Transverse nasal approach Vertical nasal approach FIXATION

37. Introduced by Kuffner, 1970 T w o types Central Lateral Usually used for high midface fracture.

38. Incision in lateral 3 rd /nasal process of frontal bone E x p osu r e of z y g omatic p r o c e s / o u t er cortex of frontal bone Dr i lling of bu r hole and p la c ement of screw P assa g e of SS w i r e a t tache d t o a w l; through incision into maxillary vestibule R elease of w i r e and a t tachmen t t o the arch bar

39. Indication: le fort II and III fracture Incision in maxillary vestibule above canine Subperiosteal dissection and e x pos u r e of i nf r a o r bita l r i m Drill hole and passage of wire above IO r i m and back t o o r al c a v i ty R elease of wi r e and a t tachment t o the arch bar

40. Also known as buttress wire Incision in maxillary vestibule below buttress E x posu r e of Z M jun c ti o n Drill hole and passage of wire Release of wire and attachment to the arch bar

41. 1.Most direct method; introduction of point of Rowe or Obwegeser awl used . 2.Extraorally- at the junction of frontal and temporal process of zygomatic bone. 3.Instrument pierces temporal fascia, keeping point close to the deep surface of buttress, manoeuvred to enter the buccal sulcus through I molar region 4.Wire is attached; point of instrument passed over lateral aspect of zyg arch 5.Directed downwards and forwards to emerge from buccal sulcus. 6.Wire detached and awl is withdrawn.

42. Incision in maxillary vestibule in canine fossa Subpe r i o s t eal d i ssecti o n and e x posu r e of pyriform aperture Elevation of nasal mucosa and drill hole from lateral to medial P assa g e of wi r e and a t tachment t o the a r ch bar

43. Drill hole in palatal aspect of gunning splint Direct wire through alveolus over canine region and emerge in Buccal Sulcus Passage of 0.5 mm SS wire and secure to splint

44. External fixation is used in cases where there is depressed posterior displaced fracture. Principle: External appliances relies on sandwiching the midface between base of skull and mandible to provide cantilever support to midface in 3D following disimpaction and closed reduction.

45. Disadvantage: Heavy Uncomfortable Unstable

46. Described by Crawford;modified by Mackenzie & Ray,1970 Secure the frame work to the skull directly by screw pins Advantage: L ig ht w ei g ht Adjustable Titanium Screw pin

47. ∏ More stable and rigid ∏ Other unstable fracture fragment ca n also b e a t tache d t o v er t i ca l r od

48. ∏ De v elo p ed a t R oy al Melbourne Hospital ∏ Provided simple rigid craniomaxillary f i x ati o n bet w een supraorbital rims and max i lla c o n n ec t ed by central rod attached at lower end by means of cast metal splint or acrylic splint

49. Provide dimensional stability Indications: G r oss l y c ommu n i t ed # Extensive soft tissue loss Bo n e gap>5mm Sites: Calvarium Illium Rib

50. Immediate Airway Nasal hemorrhage Ophthal mi c c omp li cat i o n s Ina c c u r a t e r educt i on Insecure fixation L a t e c ompl i cat i o n s N on u n i o n mal occlusion Cranial nerve dysfunction Secondary nasal deformity Dacrocystitis Facial asymmetry

51. O r al & maxillofac i al su r g e r y - F o n seca v ol 3 Oral & maxillofacial trauma-Rowe & Williams vol 2 Principles of Oral & maxillofacial surgery-Peterson Fractures of middle third of face-Killey & Kay