le fort fracture by dr. amit t. suryawanshi, oral surgeon, pune

LE FORT

FRACTURES

Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

• Introduction

• History

• Surgical Anatomy of Maxilla

• Etiology of Lefort fractures

• Epidemiology

• Classification & LeFort fracture lines

• Clinical examination

• Clinical features

• Diagnostic radiography

CONTENTS

• Management

- Emergency care

- Early care

- Definitive care

• Complications

• Controversies

• Conclusion.

INTRODUCTION:

The maxilla represents the bridge between the

cranial base superiorly and the 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 and

cosmetically important structure.

Fracture of these bones is potentially life-

threatening as well as disfiguring. Hence we

being maxillofacial surgeons need to do

systematic and timely repair of these

fractures to correct deformity and prevent

unfavorable sequalae.

• 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.

HISTORY

• In 1901 , Rene Le Fort published his landmark work, a

three-part experiment using 32 cadavers.

• The heads of the cadavers were subjected to low velocity

forces; the soft tissue were then removed and the bones

were examined.

HISTORY

• Le Fort noted that generally face was fractured and the

skull was not. He then stated that fractures occurred

through three weak lines in the facial bony structure. From

these three lines the Le Fort classification system was

developed.

HISTORY

External Fixation

Craniomaxillary fixation- Wassmund’s(1927) maxillary splint

with side bars attached to a head cap

SURGICAL ANATOMY OF MIDFACE

• Lacrimal fossa is partially formed by maxilla .Hence fracture can cause injury to nasolacrimal duct.

• Damage to infraorbital nerve can occur unilaterally or bilaterally in fracture of maxilla.

• Fracture involving orbital walls may give rise the change in the ocular level due to separation above the attachment of suspensory ligament of lockwood. (LeFort III)

• If orbital floor is fractured, there will be herniation of orbital content into maxillary sinus.

ETIOLOGY -

• Road traffic accidents (most common) -40%

• Industrial accidents- 10 %

• Assault -15%

• Sports.- 25 %

• Fall.- 10 %

• Most maxillary fractures occur in young men aged

between 16 to 40 years.

• Peak age- 21 - 25 years

• Male : Female - 4:1

Lefort fracture classification

Rene LeFort (1901) discovered the

complex fracture patterns of Maxilla which

is broadly classified as

1. Lefort I

2. Lefort II

3. Lefort III

IMPORTANT POINTS TO REMEMBER

(i) These fractures may occur unilaterally or may be

associated independently with a fracture of the zygomatic

complex.

(ii) There may be a midline separation of the maxillae or

extension of the fracture pattern into the frontal or

temporal bones.

LIMITATIONS OF THE lefort CLASSIFICATION

• The LeFort classification has proven to be less satisfactory

to describe more complex fracture patterns, comminuted,

incomplete, combination maxillary fractures or to describe

fractures of the part bearing the occlusal segment.

• Need for newer system:

• Midface fracture patterns now are far more complex than those

produced in Le Fort's laboratory.

• Fractures involving the cranial base and other midface fracture

configurations, including severely comminuted segments of the

facial skeleton, are not accurately classifiable using the traditional

Le Fort scheme.

• A more precise system of describing fracture patterns is necessary

to establish an accurate diagnosis & determine potential surgical

approaches.

• MODIFIED LEFORT CLASSIFICATION:

Proposed by Marciani (1993)

• Le Fort I Low maxillary fracture

Ia Low maxillary fracture/multiple segments

• Le Fort II Pyramidal fracture

IIa Pyramidal and nasal fracture

IIb Pyramidal and NOE fracture

• Le Fort III Craniofacial disjunction

IIIa Craniofacial disjunction and nasal fracture

IIIb Craniofacial disjunction and NOE fracture.

(From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962.)

• Le Fort IV LeFort II or III fracture and

cranial base fracture

IV a + Supraorbital rim fracture

IV b + Anterior cranial fossa and

supraorbital rim fracture

IV c + Anterior cranial fossa and

orbital wall fracture

• There is separation of complete

dentoalveolar part of maxilla

(Pterygomaxillary dysjunction) and

the fractured fragment is held only by

means of soft tissues.

• Cause -

A violent force applied over more

extensive area of maxilla above the

level of maxillary teeth results in

Lefort I fracture.

Fracture line –

The fracture line commences at

the point on the lateral margin

of the anterior nasal aperture,

passes above the nasal floor,

passes laterally above the canine

fossa and traverses the lateral

antral wall, dips 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 2/3 rd.

LE FORT II

Cause –

Violent force, usually

from an anterior

direction, sustained by

the central region of the

middle third of the facial

skeleton over an area

extending from glabella

to the alveolar margins

results in fracture of

pyramidal shape .

The fracture line runs below frontonasal suture from the thin middle area of nasal bones down on either side crossing the frontal process of maxilla and passes anteriorly across the lacrimalbone, immediately anterior to nasolacrimal canal. Then fracture line passes downward, forward and laterally crossing the inferior orbital margin in the region of zygomaticomaxillarysuture

Fracture line -

• . It may or may not involve

infraorbital foramen. Then

fracture line now extends

downward, forward and

laterally to traverse the

lateral wall of antrum, just

medial

zygomaticomaxillary

suture line.

As in Lefort I , this fracture line

passes beneath the Zygomatic

buttress, inclines abruptly traversing

the pterygomaxillary fissure at a

higher level and fracturing

the pterygoid laminae approximately

midway from its base. Seperation of

entire pyramidal block from the base

of the skull is completed via nasal

Septum.

Le Fort III

Cause -

Due to force from the lateral direction with a severe impact.

Here , the initial impact is taken by Zygomatic bone

resulting in depressed fracture. Then entire middle third will

then hinge about the fragile ethmoid bone and the impact

will then be transmitted to the contralateral side resulting in

laterally displaced zygomatic fracture of opposite side.

(Craniofacial dysjunction)

FRACTURE LINE -

• Line commences near the

frontonasal suture, causes

dislocation of the nasal

bones and disruption of

cribriform plate of the

ethmoid bone.Then line

crosses both the nasal bones

and frontal process of

maxilla, near the frontonasal

and frontomaxillary sutures

and then traverses the upper

limit of the lacrimal bones .

• continuing posteriorly, the

line crosses the thin orbital

plate of the ethmoid bone

constituting part of the

medial wall of the orbit. As

optic foramen is surrounded

by a dense ring of bone,

Then fracture line gets

deflected downward and

laterally to reach the medial

aspect of the posterior limit

of the inferior orbital fissure.

• From this point , fracture

descends across the upper

posterior aspect of maxillae in

the region of sphenopalatine

fossa and upper limit of

pterygomaxillary fissures and

fractures the roots of pterygoid

laminae at its base.

From anterior and lateral aspect of

inferior orbital fissure, line passes

across the lateral wall of orbit ,

adjacent to the junction of zygomatic

bone with greater wing of sphenoid

.The fracture line seperates

zygomatic bone from frontal bone

near suture and then inclines laterally

, running abruptly downwards across

the infratemporal surface, thus in

effect joins the previous line of

fracture seen on medial wall of orbit .

The entire middle third is

thus detached from the

dense cranial base.

CLINICAL ASSESSMENT OF MIDFACE FRACTURES

• Extra-oral & Intra-oral examination.

Inspection.

Palpation.

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.

EXTRA-ORAL EXAMINATION

• Cerebrospinal fluid rhinorrhoea

• Lengthening of Midface

• Depressed midface (dish face)

• Saddle shaped depression of nose

• Enophthalmos

• Proptosis

• Diplopia

• 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)

• Enophthalmus (Le Fort III)

Increase in orbital volume by displacement of Lateral orbital wall

Suspensory ligament of Lockwood displaced

Eyelid follows the globe in downward direction

Hooding of eyes

EXTRA-ORAL EXAMINATION

Retro bulbar haemorrhage

Tension builds up

within the muscle cone

Proptosis

(Anterior displacement of eyeball)

EXTRA-ORAL EXAMINATION

Palpation -

1. Subcutaneous Emphysema – Crepitus

2. Tenderness

3. Step Deformity

4. Abnormal Mobility of bone

5. Impairment of sensation

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

INTRA-ORAL EXAMINATION

INSPECTION -

• Mobility of whole of tooth bearing segment of upper jaw elicited at

fronto-nasal suture in Le Fort II & III fracture.

Palpation -

• Mobility of whole of the upper jaw (free-floating) elicited at

infraorbital margin in Le Fort II fracture.

• Mobility of whole of the upper jaw (free-floating) elicited at

fronto-zygomatic suture in Le Fort III fracture.

• Palpable crepitation in upper buccal sulcus in Le Fort I & II

fracture.

Clinical features -

• Slight swelling of the upper lip is seen.

• Ecchymosis present in the buccal sulcus beneath each zygomatic

arch.

• Disturbance in occlusion with variable amount of mobility in the

tooth bearing segment of the maxilla.

• The patient may develop open bite if the fractured segment is

mobile , due to posterior gagging of occlusion.

• Sometimes fracture of the palate can also be associated with

Le Fort I fracture.

• In Le Fort I, the teeth and maxilla are mobile, but the nose and

upper face is fixed.

• Percussion of the maxillary teeth results in distinctive 'cracked-pot

sound',

• No tenderness and mobility of the zygomatic arch and bones.

Clinical features -

• The resulting gross edema of the middle third gives an appearance of

"moon face" to the patient.

• On intraoral examination, retropositioning of the whole maxilla and

gagging of the occlusion are seen.

• When maxillary teeth are grasped, the mid-facial skeleton moves as a

pyramid and the movement can be detected at the infraorbital margin and

the nasal bridge.

• Hematoma formation is seen in the buccal sulcus opposite to the

maxillary first and second molar teeth as a result of fracture of the

zygomatic buttress.

• Step deformity at the infraorbital rims or frontonasal junction is

noticed.

• Orbital wall fractures can cause entrapment with limitation of ocular

movement.

• CSF rhinorrhoea is possible and should be looked for.

• Bilateral circumorbital ecchymosis giving an appearance of

'raccoon eyes' is invariably seen in the fractures of both Le Fort II

and Le Fort III.

• Subconjunctival hemorrhage develops rapidly in the area adjacent to

the site of injury.(mostly in medial half )

• Diplopia may be seen in cases of orbital floor injury.

• Pupils are at level unless there is gross unilateral enophthalmos.

• Anaesthesia or paraesthesia of the cheek as a result of injury to the

infraorbital nerve due to the fracture of the inferior orbital rim.

• Obvious deformity of nose with epistaxis.

LE FORT III FRACTURE

Clinical features -

• Gross oedema of the face.

• Bilateral circumorbital ecchymosis with subconjunctival

hemorrhage.

• Characteristic 'dish face' appearance with lengthening of the face.

• Mobility of the whole of facial skeleton as a single unit.

• When lateral displacement has taken place tilting of the

occlusal plane and gagging of one side is seen.

• Tenderness and often separation of the bones at the

frontozygomatic suture.

• 'Hooding of eyes' may be seen due to separation of the

frontozygomatic suture.

• Deformity of the zygomatic arches.

• CSF rhinorrhoea.

• Depression of ocular levels.

• Difficulty in opening the mouth, inability to move lower

jaw.

RADIOGRAPHIC PRESENTATION OF LE FORT FRACTURES

MANAGEMENT

LE FORT FRACTURES - TREATMENT STAGES

1. Emergency care & Stabilization -

( First aid and resuscitation )

2. Initial Assessment and Early care-

3. Definitive Treatment-

4. Rehabilitation -

STAGE I - Emergency care & Stabilization

1. Maintenance of airway.

2. Control of hemorrhage.

3. Prevent or control shock.

4. C-Spine stabilization.

5. Control of life-threatening injuries.

6. Head injuries, chest injuries, compound limb

fractures, intra abdominal bleeding.

EMERGENCY CARE

• Evaluate the airway -

• Existence & identification of obstruction.

• Manually clear fractured teeth, blood clots,

dentures.

• Endotracheal intubation if needed.

NOTE:

• Altered level of consciousness is the most

common cause of upper airway obstruction.

TREATMENT OF BLOOD LOSS &

SHOCK

• Hemorrhage is most common cause of

shock after injury.

• Multiple injury patients have

hypovolemia.

Monitor vital signs closely.

• Goal is to restore organ perfusion.

TREATMENT OF BLOOD LOSS &

SHOCK

• External bleeding controlled by direct pressure

over bleeding site.

• Gain prompt access to vascular system with IV

catheters.

• Fluid replacement:

• Ringer’s Lactate

• Normal saline

• Transfusion.

STABILIZATION OF ASSOCIATED INJURIES

• C-spine injury is primary concern with all

maxillofacial trauma victims.

• Signs/symptoms of C-Spine injury

• Neurologic deficit.

• Neck pain.

STABILIZATION OF ASSOCIATED INJURIES

• C-spine injury suspected:

• Avoid any movement of neck

• Establish & maintain proper immobilization until vertebral fractures or spinal cord injuries ruled out

• Lateral C-spine radiographs

• CT of C-spine

• Neurologic exam

STAGE II. Initial Assessment and Early care

• Emergency care has stabilized patient.

• Initial stabilization of fractures.

• Debridement & dressing of soft tissues.

• Physical exam & history.

• Laboratory tests.

• Clinical & Radiographic Assessment of Patient.

Diagnosis of maxillofacial injuries.

• Pre-operative planning.

STAGE II. Initial Assessment

Pre-operative planning

1. Need for Tracheostomy

2. Surgical Approaches to Midface

3. Whether ‘Open’ or ‘Closed’ methods of reduction are to

be employed.

4. Necessity for & type of Maxillary fracture Fixation.

STAGE II. Initial Assessment

Pre-operative planning

• Surgical Approaches to Midface

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)

Incisions for exposure of LeFort

fractures

CLASSIFICATION OF METHODS OF MAXILLARY

FRACTURE FIXATION

A ) Internal Fixation-

1. Suspension Wires

2. Direct Osteosynthesis

B) External Fixation-

1. Craniomandibular

2. Craniomaxillary

Internal Fixation

Suspension Wires – non-rigid osteosynthesis -

i. Frontal-central or laterally placed

ii. Circumzygomatic

iii. Zygomatic

iv. Circumpalatal/palatal screw

v. Infraorbital

vi. Piriform Aperture

vii. Peralveolar

DIFFERENT TYPES OF INTERNAL FIXATION BY SUSPENSION

WIRE

Internal Fixation

Suspension Wires- Circumzygomatic wiring by Obwegeser.

Internal Fixation

Suspension Wires-

Circumzygomatic wiring by Obwegeser

Internal Fixation

Suspension Wires- Orbital rim wiring

Suspension Wires-

Piriform aperture wiring

Type of Suspension Wire Type of Le Fort Fracture

1. Frontal

a. Central Le Fort III & II

b. Lateral Le Fort III & II

2.

Circumzygomatic

Le Fort I & II

3. Zygomatic Le Fort I

4. Infraorbital Le Fort I

5. Piriform Aperture Le Fort I

Summary of Suspension wiring according to fracture site

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.

Internal Fixation

Direct Osteosynthesis -

1. Interosseous Wires.

2. Plates and Screws.

Direct osteosynthesis

Intraosseous Wires-

1. Maxillary (Lefort –I )

2. Zygomaticomaxillary (Lefort –II)

3. Frontonasal (LeFort –II &III)

4. Zygomaticofrontal (Lefort III)

5. Zygomatic bone (comminuted)

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.

Direct osteosynthesis-

2. Plates & Screws for midface fractures -

Stainless steel mini-plating system

Titanium mini-plating system

Vitallium, Cobalt chromium, molybdenum alloy plates

Bioresorbable plating system.

BONE PLATE OSTEOSYNTHESIS

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.

• STAGE III. DEFINITIVE TREATMENT

LEFORT I FRACTURE

LEFORT II FRACTURE

LEFORT III FRACTURE

• STAGE III. DEFINITIVE TREATMENT

LEFORT I FRACTURE

SURGICAL APPROACH- MAXILLARY VESTIBULAR

REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP

FIXATION- 4-point fixation with MINIPLATE.

IMMOBILISATION- MAXILLOMANDIBULAR FIXATION(MMF)

LEFORT II FRACTURE

SURGICAL APPROACH-

A – Subciliary incision

B – Sub tarsal incision

C - Infraorbital incision

D - Extension of

Subciliary incision

Existing

Laceration

Maxillary vestibular

approach can also be

taken for LeFort II

fracture

CORONAL APPROACH

GLABELLA

APPROAC

H

REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP

FIXATION- 3-POINT fixation

• IMMOBILISATION- MAXILLOMANDIBULAR FIXATION

• STAGE III. DEFINITIVE TREATMENT

LEFORT III FRACTURE-

SURGICAL APPROACH-

Existing

Laceration

A . LATERAL EYEBROW

APPROACH

B. UPPER-EYELID

APPROACH

GLABELLA

APPROAC

H

CORONAL APPROACH -PREAURICULAR APPROACH

REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP

ZYGOMA HOOK

FIXATION- 3-point fixation

• IMMOBILISATION- MAXILLOMANDIBULAR FIXATION if

required

PRINCIPLES OF MAXILLARY

RECONSTRUCTION

• Miniplates can bridge gaps of up to approximately 0.5cms

• Gaps >0.5cms – bone grafts

• Bone grafts bridging the gap should be wedged

underneath the plate & held in place with screws fixed

from plate directly into the graft.

IMMEDIATE BONE GRAFTING

Buttress reinforcement retained by plates or screws can

assist in restoring maxillary height & preventing

Contour deficiencies.

• Rib graft

• Iliac crest

• Calvaria

• Mandibular bone graft

• Alloplastic bone graft

CONCLUSION:

Le fort fractures are common in the trauma patient. They

require accurate radiologic diagnosis and surgical

management to prevent severe functional debilities and

cosmetic deformity.

A thorough understanding of the anatomy, craniofacial

buttresses and treatment options will give the maxillofacial

surgeon the optimal tools for achieving a successful result.

REFERENCES:

1. Rowe NL, Williams JL. Maxillofacial Injuries.

Edinburgh, Churchill Livingstone,1985.

2. Oral and maxillofacial trauma : Fonseca vol. 2.

3. Marciani RD. Management of Midface

Fractures: fifty years later. J Oral Maxillofac

Surg 1993;51:962

4. www2.aofoundation.org

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