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

Vestibular

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.