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LE FORT FRACTURES
- Dr. Dona Bhattacharya
Contents1. Introduction2. Surgical anatomy3. Classification4. Etiology 5. Clinical features6. Management7. Conclusion8. References
Introduction ∏ Area between a superior plane drawn through the FZ
sutures tangential to the skull base and inferior plane at the level of maxillary occlusal surface
∏ Triangular region with widest dimension facing anterior
Surgical Anatomy
∏ Middle 3rd of face is composed of
Paired Bones Unpaired Bones
Maxilla Vomer
Zygomatic bone Ethmoid
Zygomatic process of temporal bone
Sphenoid (Pterygoid plates)
Palatine bone
Nasal bone
Lacrimal bone
Inferior conchae
∏ Maxilla –central bone; prominent position where trauma hits face
∏ This structure is analogous to a matchbox sitting below and anterior to hard shell containing brain
∏ Act as cushion for trauma directed towards cranium from anterior or antero-lateral direction
∆ Areas of weakness act as “crumple zone”.
∆ Sutures
∆Areas of strength: pillars of face
∏ This arrangement with stands force of mastication from below and protects the vital structure
∏ Bones easily fractured from forces applied
from other directions.
∏ Clinical implications
Soft tissue attachments
1. Alphonso Guerin(1886)
2. Rene Le Fort Fracture classification (1901)
3. Rowe and william classification (1985)
4. Modified Le fort classification (Marciani,1993)
5. Donag,Endress,Mathog classification(1998)
Classification
Le fort fracture classification
Pitfalls:
a)# caused by loc penetrating missile injuries & gun shot wounds not
included.b)Only meant for bilateral # occuring at same
levelc) mid palatine split along palatal suture not
describedd)Inaccurate prediction of reduction
techniques.
Fracture not involving the occlusionCentral region
Nasal bone/ septum (lateral, anterior injuries)Frontal process of the maxillaNasoethmoidFronto-orbito-nasal dislocation
Lateral region (zygomatic complex ,arch, dento-alveolar fracture
Fracture involving the occlusionDento alveolar
Subzygomatic: Le Fort (I, II)
Supra zygomatic: Le Fort III
Rowe and William fracture classification
Marciani fracture classification
Donat, Endress, Mathog classification
From: Donat TL et al. Facial Fracture Classification According to Skeletal Support Mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314.
Aetiology
∏ Assault∏ RTA∏ Gunshot wounds∏ Sports∏ Falls∏ Industrial accidents
Prevalence of mid-face fractures
Fracture Type Prevalence
Zygomaticomaxillary complex (tripod fracture) 40 %
LeFort
I 15 %
II 10 %
III 10 %
Zygomatic arch 10 %
Alveolar process of maxilla 5 %
Smash fractures 5 %
Other 5 %
A). Le fort I/ Floating fracture/ Guerin fracture/ Low level fracture/ Subzygomatic fracture
1. Mobility of maxillary alveolar segment (floating fracture)
2. Pain and tenderness while speaking or clenching3. Ecchymosis or laceration in labial or buccal vestibule4. Ecchymosis at GP foramen (Guerin sign)5. Swelling and oedema of upper lip 6. Mal occlusion 7. Bilateral epistaxis 8. Brusing of palatal tissues (15-20% of cases)9. On palpation tenderness over buttress area10. Percussion of teeth – cracked pot sound
Clinical Features
B). Le fort II/ Pyramidal fracture/ Mid level fracture/ Subzygomatic fracture
1. Oedema mid third of face (Moon face)2. Paresthesia of cheek 3. Bilateral circumorbital ecchymosis 4. Bilateral subconjunctival haemorrhage5. Dish face deformity 6. Depressed nose 7. Epistaxis 8. CSF rhinorrhea9. Limited ocular movement (Diplopia)10. Mal occlusion 11. Inability to open mouth12. Step deformity at IO margins13. Mobility of fractured fragment at nasal bridge and IO
margins14. Percussion of teeth – cracked pot sound
C). Le fort III/ Craniofacial dysfunction/ High level fracture/ Suprazygomatic fracture
1. Oedema of face (Panda facies)2. Bilateral periorbital edema3. Bilateral circumorbital ecchymosis (Racoon eyes)4. Bilateral subconjunctival haemorrhage5. Dish face deformity 6. Depressed nose, flattening of nose7. Epistaxis 8. CSF rhinorrhea9. Limited ocular movement (Diplopia, Enophthalmos)10. Dystopia, hooding of eyes with antimongloid slant11. Haemotympanum12. CSF otorrhoea13. Mal occlusion – posterior gagging of occlusion14. Inability to open mouth15. Mobility of fractured fragment at NF, FZ sutures 16. Tenderness over zygomatic bone, arch and FZ suture17. Ecchymosis at mastoid process (Battle’s sign)
Management
1. Emergency care and stabilization 2. Initial assessment3. Definitive treatment4. Continuing care
Emergency Care
∆ Airway immediately evaluated for obstruction∆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
LeFort I fractureLeFort I fracture with Mandible fracture
LeFort I fracture with Nasal injuryLeFort II fractureLefort III fracturePanfacial 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 through space
Surgical Airway
Guided Nasal Intubation• fixate maxilla and mandible• switch to Oral Airway for nasal/NOE reduction
Submental Intubation
Premlatha Shetty et al;submental intubation in patients with panfacial fractures;Indian journal of anesthesia,vol 55,issue 3,may 2011
Initial assessment
1. History2. Palpation of entire facial skeleton3. I/O Examination4. Ophthalmologic exam / consultation 5. Radiographic examination
Facial Examination
After stabilization of patients condition, complete facial examination is performed. 1. Laceration, bruising , etc.2. Obvious depressions on nose, check, etc.3. Facial asymmetry, swelling 4. Nasal discharge (Blood/ CSF)
Features CSF fluid Nasal secretion
History Nasal or sinus surgery, head injury or intracranial tumour
Sneezing, nasal stuffiness, itching in the nose or lacrimation
Flow of discharge
A few drops or a stream of fluid gushes down when bending forward or straining; can’t be sniffed back
Continuous. No effect of bending forward or straining. Can be sniffed back
Character of discharge
Thin, watery and clear Slimy (mucus) or clear (tears)
Taste Sweet Salty
Sugar content 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
Presence of β2 transferrin
Always present. It is specific for CSF
Always absent
Palpation of facial skeleton
Bowstring test
Ophthalmologic evaluation
1. Periorbital edema2. Periorbital ecchymosis3. Proptosis4. Diplopia5. Pupillary size and shape6. Sub-conjunctival haemorrhage7. Lid laceration8. Visual acuity9. Dystopia
Intra oral examination
Inspection Palpation Percussion
Laceration EcchymosisRestricted mouth openingOcclusion
Tenderness Mobility of teethCrepitusMobility of fractured fragment
Cracked pot sound
Radiologic evaluation1. OPG 2. OM3. Lateral skull view4. Occlusal view for split
palate5. CT Scan6. 3D CT Scan7. MRI
Definitive treatment
∆ Aims of treatment
1. Relieve pain2. Precise anatomical reduction of the # fragment3. Stable fixation of the reduced fragment 4. Restore function5. Restore the dental occlusion
Preoperative planning:
∆ Need for surgical airway∆ Open/closed method of reduction∆ Necessity for and type if IMF to be employed
in case for closed reduction∆ Type of osteosynthesis in case of open method∆ Need for internal suspension in case of
communited #∆ Timing of surgery
Timing of surgery
∏ Optimum time for reduction of mid face fracture is 5th to 8th post injury day
∏ After this with every succeeding day disimpaction become difficult and open reduction more essential
Operative ProcedureOpen reduction Closed reduction
Displaced # Non displaced #
Multiple # of facial bones Grossly communited #
Edentulous maxillary # - with severe displacement
Fractures associated with significant loss of soft tissues
Edentulous maxillary # - opposite to Edentulous mandibular #
Edentulous maxillary #
Delay of treatment In children with developing dentition
Inter position of soft tissues between non contacting displaced # segment
Systemic condition contra indicating IMF
1. Accurate diagnosis 2. Determination of priority of treatment3. Early reconstruction4. Wide exposure of vertical and horizontal pillar of face5. Use of bone graft to restore skeletal form 6. Use of rigid fixation to stabilize # segment7. Restoration of bony support to over lying soft tissue
envelop
Le Fort fracture principles
Surgical access1. Intra oral
a)Vestibular 2. Extra oral
a)Lower eye lid incisioni. Sub cilliaryii. Infra orbitaliii.Trans conjunctival
b) Coronal approachc) Midface degloving approach
Subtarsal
Sub cilliary
Infra orbital
Transconjunctival
TechniqueAdvantagesDisadvantageIndication
Coronal/bi-temporal approach
TechniqueAdvantagesIndication
Degloving incision
Reduction of maxilla
1. Manual reduction2. Reduction with wires3. Reduction using
disimpaction forceps4. Reduction with bone
hook5. Reduction with elastics
Manual reduction
1. Simple manipulation by hand2. Use of dental compound loaded in impression
tray (Dingman and Harding, 1951)3. Use of rubber dam sheets, long ribbon/strip
gauze or rubber catheter (Propescu and Burlibasa, 1966)
Disimpaction and reduction of maxilla
1. Rowe’s maxillary disimpaction forceps2. Hayton William’s disimpaction forceps
Movements:
1. Downwards – to affect disimpaction of pterygoid plates down
2. Anterior 3. Combination of forward
traction with rotational movement in both horizontal and vertical axis
Universal rule
Oculocardiac reflex
Reduction by elastic traction
Used in delayed cases:
1. Intra oral elastic traction2. Extra oral elastic traction
Maxillary # fixation
Internal fixationDirect osterosynthesis
1. Miniplates 2. Intraosseous Wires
- high(FZ,FN)-
Mid(buttress,orbital rim)-
Low(alveolar/midpalatal)
Suspension wires 1. Frontal
2. Circumzygomatic 3. Zygomatic
4. Circumpalatal 5. Infraorbital
6. Piriform aperture 7. Peralveolar
External fixation
Craniomandibular
Craniomaxillary 1. Supraorbital pins
2. Zygomatic pins 3. POP head frame
4. Halo frame 5 . Levant frame
6. Box frame
Direct Osteosynthesis
Intraosseous wires
By Merville & Derome(1976)
Miniplates and screws
These are monocortical, semi-rigid fixation device which provide 3D stability.
Designs: X, H, L, T, Y
Thickness:0.6-1 mm
Plating system depends on:1. Rigidity of plate2. Width and shape3. Diameter and number of screwsIncrease in width provides more stability towards
rotational forces.
Type of metal:a. Stainless steelb. Titaniumc. Vitallium
Advantages:1) Easily adaptable2) Monocortical3) Functional stability4) Reduced surgical access
1. Minimum 2 screws required in each bone segment to prevent rotation in X and Y axis
2. Farther the point of stabilization the more effective the device is in preventing rotation
3. Large diameter screws are not used because of constraint imposed by particular anatomic location
4. All screw require adequate intervening bone between adjacent holes to preserve integrity of screw bone interface
Factor affecting screw stability
Le fort I: L plates at zygomatic buttress Curved plate at pyriform aperture 3D plate sometimes to fix buttress #
Le fort II: Linear/Y plate/curved plate along intra orbital rim L plate at buttress
Le fort III: Linear/Y plate at FN and ZF junction
Location of fixation
Harle & duker(1975;Luhr(1979)
0.3-0.6 mm
Used for :a. FN region b. Frontal bonec. Frontal process of maxilla
Sites of application:
d. Linear/T/Y plate at FN regione. Long curve plate for frontal process of maxilla or frontal bone
Micro plates
Used for retention and
alignment of small fragments or bone grafts.
Sites of application:
1. Anterior and lateral wall of maxilla
2. Anterior table of frontal bone
Mesh fixation
Suspension Wires
Introduced by Kuffner, 1970Two types
1. Central2. Lateral
Usually used for high midface fracture.
Frontal wire
Incision in lateral 3rd/nasal process of frontal bone
Exposure of zygomatic proces/outer cortex of frontal
bone
Drilling of bur hole and placement of screw
Passage of SS wire attached to awl; through incision into
maxillary vestibule
Release of wire and attachment to the arch bar
Indication: le fort II and III fracture
Infraorbital rim wire
Incision in maxillary vestibule above canine
Subperiosteal dissection and exposure of infra orbital rim
Drill hole and passage of wire above IO rim and back to oral
cavity
Release of wire and attachment to the arch bar
Also known as buttress wire
Zygomatic wire
Incision in maxillary vestibule below buttress
Exposure of ZM junction
Drill hole and passage of wire
Release of wire and attachment to the arch bar
Circum zygomatic wire
Cubero Technique
Introduced by Bowerman and Conroy, 1981
Simple technique for fixing gunning splint to maxilla
Superior retention, stability and decreased discomfort
Nasal spine wire
Incision in maxillary vestibule over nasal spine
Exposure of ANS
Drill hole and passage of wire
Release of wire and attachment to the arch bar
Pyriform aperture wire
Incision in maxillary vestibule in canine fossa
Subperiosteal dissection and exposure of pyriform aperture
Elevation of nasal mucosa and drill hole from lateral to medial
Passage of wire and attachment to the arch bar
Peralveolar
Drill hole in palatal aspect of splint
Direct wire through alveolus over canine region and emerge in Buccal Sulcus
Passage of 0.5 mm SS wire and secure to splint
Trend towards ORIF has changedExternal fixation is used in cases where there is depressed posterior displaced #
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.
Disadvantages:
Extra cranial fixation forms
POP head cap with metal frame
Disadvantage:
1. Heavy 2. Uncomfortab
le3. Unstable
Method of application
Halo frameDescribed by Crawford;modified by Mackenzie & Ray,1970
Secure the frame work to the skull directly by screw pins
Advantage:1. Light weight2. Adjustable3. Titanium Screw pin
Box frame
∏ More stable and rigid
∏ Other unstable fracture fragment can also be attached to vertical rod
Levant frame
∏ Developed at Royal Melbourne Hospital
∏ Provided simple rigid craniomaxillary fixation between supraorbital rims and maxilla connected by central rod attached at lower end by means of cast metal splint or acrylic splint
Bone grafts1. Provide dimensional stability
2. Indications:1. Grossly communited #2. Extensive soft tissue loss3. Bone gap>5mm
3. Sites:1. Calvarium2. Illium3. Rib
Recent Advancements
1. Resorbable plates2. Endoscopic management(Harold Hopkins)3. Distraction osteogenesis(Ilizarov)
Complications
Immediate
1. Airway2. Nasal hemorrhage3. Ophthalmic
complications4. Inaccurate reduction5. Insecure fixation
Late complications
1. Non union2. mal occlusion3. Cranial nerve
dysfunction4. Secondary nasal
deformity5. Dacrocystitis6. Facial asymmetry
Conclusion
Due to the complex 3D arrangement of the structures of middle third of face,management is complicated.Proper reduction of the # fragments remains the key component.
A proper understanding of the anatomy,fracture patterns, its clinical presentation and the available treatment modalities is necessary to successfully treat Le Fort Fractures.
References
1. Oral & maxillofacial trauma-Fonseca & walker vol 22. Oral & maxillofacial surgery-Fonseca vol 33. Oral & maxillofacial trauma-Rowe & Williams vol 24. Principles of Oral & maxillofacial surgery-Peterson5. Fractures of middle third of face-Killey & Kay6. Oral & maxillofacial surgery-Fragiskos7. Maxillofacial trauma & facial reconstruction-Peter Ward Booth8. Oral & maxillofacial surgery-Peter Ward Booth: vol 29. Chen Lee et al ;Applications of the Endoscope in Facial fracture
Management, seminars in plastics surgery/volume 22, number 1 2008
9. Manual of internal fixation-J Prein10. Donat TL et al. Facial Fracture Classification According to
Skeletal Support Mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314.
11. Mirko S. Gilardino et al;Choice of Internal Rigid Fixation materials in the treatment of facial fractures; craniomaxillofacial trauma & reconstruction/volume 2, number 1 2009
12. Khaled M Emara et al ;Methods to shorten the duration of an external fixator in the management of fractures; World J Orthop 2011 September 18; 2(9): 85-92
13. Chan hum park et al;resorbable skeletal fixation systems for treating maxillofacial bone fractures; arch otolaryngol head neck surg/vol 137 (no. 2), feb 2011
14. Premlatha Shetty et al;submental intubation in patients with panfacial fractures;Indian journal of anesthesia,vol 55,issue 3,may 2011.