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LE FORT 
FRACTURES 
Dr. Amit T. Suryawanshi 
Oral and Maxillofacial Surgeon 
Pune, India 
Contact details : 
Email ID - am...
CONTENTS 
• Introduction 
• History 
• Surgical Anatomy of Maxilla 
• Etiology of Lefort fractures 
• Epidemiology 
• Clas...
• 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 in...
Fracture of these bones is potentially life-threatening as 
well as disfiguring. Hence we being maxillofacial 
surgeons ne...
HISTORY 
• The first clinical examination of a maxillary fracture was 
recorded in 2500 BC. 
• In 1822 Charles Fredrick Wi...
• In 1901 , Rene Le Fort published his landmark work, a 
three-part experiment using 32 cadavers. 
• The heads of the cada...
• Le Fort noted that generally face was fractured and the 
skull was not. He then stated that fractures occurred 
through ...
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 nasolacr...
ETIOLOGY - 
• Road traffic accidents (most common) -40% 
• Industrial accidents- 10 % 
• Assault -15% 
• Sports.- 25 % 
• ...
• Most maxillary fractures occur in young men aged 
between 16 to 40 years. 
• Peak age- 21 - 25 years 
• Male : Female - ...
Lefort fracture classification 
Rene LeFort (1901) discovered the complex 
fracture patterns of Maxilla which is broadly 
...
IMPORTANT POINTS TO REMEMBER 
(i) These fractures may occur unilaterally or may be 
associated independently with a fractu...
LIMITATIONS OF THE lefort CLASSIFICATION 
• The LeFort classification has proven to be less satisfactory 
to describe more...
• Need for newer system: 
• Midface fracture patterns now are far more complex than those 
produced in Le Fort's laborator...
• MODIFIED LEFORT CLASSIFICATION: 
Proposed by Marciani (1993) 
• Le Fort I Low maxillary fracture 
Ia Low maxillary fract...
• Le Fort IV LeFort II or III fracture and 
cranial base fracture 
IV a + Supraorbital rim fracture 
IV b + Anterior crani...
• There is separation of complete 
dentoalveolar part of maxilla 
(Pterygomaxillary dysjunction) and 
the fractured fragme...
Fracture line – 
The fracture line commences at 
the point on the lateral margin 
of the anterior nasal aperture, 
passes ...
LE FORT II 
Cause – 
Violent force, usually from an 
anterior direction, sustained 
by the central region of the 
middle t...
Fracture line - 
The fracture line runs below 
frontonasal suture from the 
thin middle area of nasal 
bones down on eithe...
• . It may or may not involve 
infraorbital foramen. Then 
fracture line now extends 
downward, forward and 
laterally to ...
As in Lefort I , this fracture line 
passes beneath the Zygomatic 
buttress, inclines abruptly traversing 
the pterygomaxi...
Le Fort III 
Cause - 
Due to force from the lateral direction with a severe impact. 
Here , the initial impact is taken by...
FRACTURE LINE - 
• Line commences near the 
frontonasal suture, causes 
dislocation of the nasal 
bones and disruption of ...
• continuing posteriorly, the 
line crosses the thin orbital 
plate of the ethmoid bone 
constituting part of the 
medial ...
• From this point , fracture 
descends across the upper 
posterior aspect of maxillae in 
the region of sphenopalatine 
fo...
From anterior and lateral aspect of 
inferior orbital fissure, line passes 
across the lateral wall of orbit , 
adjacent t...
The entire middle third is thus 
detached from the dense cranial 
base.
CLINICAL ASSESSMENT OF MIDFACE FRACTURES 
• Extra-oral & Intra-oral examination. 
 Inspection. 
 Palpation.
EXTRA-ORAL EXAMINATION 
Inspection of midface- 
• Swelling & Facial Asymmetry. 
• Bruising of upper lip and lower half of ...
• Cerebrospinal fluid rhinorrhoea 
• Lengthening of Midface 
• Depressed midface (dish face) 
• Saddle shaped depression o...
• Subconjunctival hemorrhage- 
• Localized (black eye) confined to preseptal soft tissues 
(Also seen in anterior cranial ...
• Cerebrospinal Fluid Rhinorrhoea 
-Watery nasal or postnasal salty discharge 
(Ring Test- but it lacks sensitivity & spec...
EXTRA-ORAL EXAMINATION 
• Enophthalmus (Le Fort III) 
Increase in orbital volume by displacement of Lateral orbital wall 
...
EXTRA-ORAL EXAMINATION 
Retro bulbar haemorrhage 
Tension builds up 
within the muscle cone 
Proptosis 
(Anterior displace...
Palpation - 
1. Subcutaneous Emphysema – Crepitus 
2. Tenderness 
3. Step Deformity 
4. Abnormal Mobility of bone 
5. Impa...
INTRA-ORAL EXAMINATION 
INSPECTION - 
1. Disturbed occlusion (posterior occlusal gagging , open bite) 
2. Haematoma intrao...
Palpation - 
• Mobility of whole of tooth bearing segment of upper jaw elicited at 
fronto-nasal suture in Le Fort II & II...
• 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 z...
• The patient may develop open bite if the fractured segment is 
mobile , due to posterior gagging of occlusion. 
• Someti...
• In Le Fort I, the teeth and maxilla are mobile, but the nose and 
upper face is fixed. 
• Percussion of the maxillary te...
Clinical features - 
• The resulting gross edema of the middle third gives an appearance of 
"moon face" to the patient. 
...
• Hematoma formation is seen in the buccal sulcus opposite to the 
maxillary first and second molar teeth as a result of f...
• CSF rhinorrhoea is possible and should be looked for. 
• Bilateral circumorbital ecchymosis giving an appearance of 
'ra...
• Diplopia may be seen in cases of orbital floor injury. 
• Pupils are at level unless there is gross unilateral enophthal...
LE FORT III FRACTURE 
Clinical features - 
• Gross oedema of the face. 
• Bilateral circumorbital ecchymosis with subconju...
• When lateral displacement has taken place tilting of the 
occlusal plane and gagging of one side is seen. 
• Tenderness ...
• 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 Ass...
STAGE I - Emergency care & Stabilization 
1. Maintenance of airway. 
2. Control of hemorrhage. 
3. Prevent or control shoc...
EMERGENCY CARE 
• Evaluate the airway - 
• Existence & identification of obstruction. 
• Manually clear fractured teeth, b...
TREATMENT OF BLOOD LOSS & 
SHOCK 
• Hemorrhage is most common cause of 
shock after injury. 
• Multiple injury patients ha...
TREATMENT OF BLOOD LOSS & 
SHOCK 
• External bleeding controlled by direct pressure 
over bleeding site. 
• Gain prompt ac...
STABILIZATION OF ASSOCIATED INJURIES 
• C-spine injury is primary concern with all 
maxillofacial trauma victims. 
• Signs...
STABILIZATION OF ASSOCIATED INJURIES 
• C-spine injury suspected: 
• Avoid any movement of 
neck 
• Establish & maintain 
...
STAGE II. Initial Assessment and Early care 
• Emergency care has stabilized patient. 
• Initial stabilization of fracture...
STAGE II. Initial Assessment 
 Pre-operative planning 
1. Need for Tracheostomy 
2. Surgical Approaches to Midface 
3. Wh...
STAGE II. Initial Assessment 
 Pre-operative planning 
• Surgical Approaches to Midface
Incisions for exposure of LeFort fractures 
1. Supraorbital eyebrow incision (Lefort III) 
2. Subciliary incision (LeFort ...
CLASSIFICATION OF METHODS OF MAXILLARY 
FRACTURE FIXATION 
A ) Internal Fixation- 
1. Suspension Wires 
2. Direct Osteosyn...
Internal Fixation 
Suspension Wires – non-rigid osteosynthesis - 
i. Frontal-central or laterally placed 
ii. Circumzygoma...
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
Summary of Suspension wiring according to fracture site 
Type of Suspension Wire Type of Le Fort Fracture 
1. Frontal 
a. ...
DISADVANTAGES OF SUSPENSION WIRING 
• Incomplete fixation of fractured fragments 
• Insufficient visualization of fracture...
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...
Disadvantages - 
 Non rigid type of osteosynthesis 
 No 3 dimensional stability, it provides only 
monoplane traction. 
...
Direct osteosynthesis- 
2. Plates & Screws for midface fractures - 
 Stainless steel mini-plating system 
 Titanium mini...
BONE PLATE OSTEOSYNTHESIS 
Advantages – 
1. Simple & less intraoperative time 
2. Intraoral approach is sufficient 
3. Pos...
• 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 - ...
Existing Laceration 
Maxillary vestibular approach 
can also be taken for LeFort II 
fracture
CORONAL APPROACH 
GLABELLA 
APPROACH
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 
APPROACH
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...
IMMEDIATE BONE GRAFTING 
Buttress reinforcement retained by plates or screws can 
assist in restoring maxillary height & p...
CONCLUSION: 
Le fort fractures are common in the trauma patient. They 
require accurate radiologic diagnosis and surgical ...
REFERENCES: 
1. Rowe NL, Williams JL. Maxillofacial Injuries. 
Edinburgh, Churchill Livingstone,1985. 
2. Oral and maxillo...
THANK YOU
Le fort fracture  by  Dr. Amit Suryawanshi .Dentist in Kolhapur (MDS). Oral & Maxillofacial Surgeon in Kolhapur, India
Le fort fracture  by  Dr. Amit Suryawanshi .Dentist in Kolhapur (MDS). Oral & Maxillofacial Surgeon in Kolhapur, India
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Le fort fracture by Dr. Amit Suryawanshi .Dentist in Kolhapur (MDS). Oral & Maxillofacial Surgeon in Kolhapur, India

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Le fort fracture by Dr. Amit Suryawanshi .Dentist in Kolhapur (MDS). Oral & Maxillofacial Surgeon in Kolhapur, India

  1. 1. LE FORT FRACTURES Dr. Amit T. Suryawanshi Oral and Maxillofacial Surgeon Pune, India Contact details : Email ID - amitsuryawanshi999@gmail.com Mobile No - 9405622455
  2. 2. CONTENTS • Introduction • History • Surgical Anatomy of Maxilla • Etiology of Lefort fractures • Epidemiology • Classification & LeFort fracture lines • Clinical examination • Clinical features • Diagnostic radiography
  3. 3. • Management - Emergency care - Early care - Definitive care • Complications • Controversies • Conclusion.
  4. 4. 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.
  5. 5. 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.
  6. 6. HISTORY • 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.
  7. 7. • 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
  8. 8. • 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
  9. 9. External Fixation Craniomaxillary fixation- Wassmund’s(1927) maxillary splint with side bars attached to a head cap
  10. 10. 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.
  11. 11. ETIOLOGY - • Road traffic accidents (most common) -40% • Industrial accidents- 10 % • Assault -15% • Sports.- 25 % • Fall.- 10 %
  12. 12. • Most maxillary fractures occur in young men aged between 16 to 40 years. • Peak age- 21 - 25 years • Male : Female - 4:1
  13. 13. 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
  14. 14. 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.
  15. 15. 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.
  16. 16. • 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.
  17. 17. • 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.)
  18. 18. • 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
  19. 19. • 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.
  20. 20. 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.
  21. 21. 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 .
  22. 22. Fracture line - 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 lacrimal bone, immediately anterior to nasolacrimal canal. Then fracture line passes downward, forward and laterally crossing the inferior orbital margin in the region of zygomaticomaxillary suture
  23. 23. • . 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.
  24. 24. 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.
  25. 25. 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)
  26. 26. 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 .
  27. 27. • 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.
  28. 28. • 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.
  29. 29. 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 .
  30. 30. The entire middle third is thus detached from the dense cranial base.
  31. 31. CLINICAL ASSESSMENT OF MIDFACE FRACTURES • Extra-oral & Intra-oral examination.  Inspection.  Palpation.
  32. 32. EXTRA-ORAL EXAMINATION 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.
  33. 33. • Cerebrospinal fluid rhinorrhoea • Lengthening of Midface • Depressed midface (dish face) • Saddle shaped depression of nose • Enophthalmos • Proptosis • Diplopia
  34. 34. • Subconjunctival hemorrhage- • Localized (black eye) confined to preseptal soft tissues (Also seen in anterior cranial fossa, orbital & zmc fractures.)
  35. 35. • Cerebrospinal Fluid Rhinorrhoea -Watery nasal or postnasal salty discharge (Ring Test- but it lacks sensitivity & specificity)
  36. 36. EXTRA-ORAL EXAMINATION • 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
  37. 37. EXTRA-ORAL EXAMINATION Retro bulbar haemorrhage Tension builds up within the muscle cone Proptosis (Anterior displacement of eyeball)
  38. 38. Palpation - 1. Subcutaneous Emphysema – Crepitus 2. Tenderness 3. Step Deformity 4. Abnormal Mobility of bone 5. Impairment of sensation
  39. 39. INTRA-ORAL EXAMINATION INSPECTION - 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
  40. 40. Palpation - • Mobility of whole of tooth bearing segment of upper jaw elicited at fronto-nasal suture in Le Fort II & III fracture.
  41. 41. • Mobility of whole of the upper jaw (free-floating) elicited at infraorbital margin in Le Fort II fracture.
  42. 42. • Mobility of whole of the upper jaw (free-floating) elicited at fronto-zygomatic suture in Le Fort III fracture.
  43. 43. • Palpable crepitation in upper buccal sulcus in Le Fort I & II fracture.
  44. 44. 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.
  45. 45. • 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.
  46. 46. • 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.
  47. 47. 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.
  48. 48. • 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.
  49. 49. • 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 )
  50. 50. • 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.
  51. 51. 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.
  52. 52. • 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.
  53. 53. • CSF rhinorrhoea. • Depression of ocular levels. • Difficulty in opening the mouth, inability to move lower jaw.
  54. 54. RADIOGRAPHIC PRESENTATION OF LE FORT FRACTURES
  55. 55. MANAGEMENT
  56. 56. LE FORT FRACTURES - TREATMENT STAGES 1. Emergency care & Stabilization - ( First aid and resuscitation ) 2. Initial Assessment and Early care- 3. Definitive Treatment- 4. Rehabilitation -
  57. 57. 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.
  58. 58. 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.
  59. 59. 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.
  60. 60. 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.
  61. 61. 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.
  62. 62. 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
  63. 63. 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.
  64. 64. 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.
  65. 65. STAGE II. Initial Assessment  Pre-operative planning • Surgical Approaches to Midface
  66. 66. Incisions for exposure of LeFort fractures 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)
  67. 67. CLASSIFICATION OF METHODS OF MAXILLARY FRACTURE FIXATION A ) Internal Fixation- 1. Suspension Wires 2. Direct Osteosynthesis B) External Fixation- 1. Craniomandibular 2. Craniomaxillary
  68. 68. 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
  69. 69. DIFFERENT TYPES OF INTERNAL FIXATION BY SUSPENSION WIRE
  70. 70. Internal Fixation Suspension Wires- Circumzygomatic wiring by Obwegeser.
  71. 71. Internal Fixation Suspension Wires- Circumzygomatic wiring by Obwegeser
  72. 72. Internal Fixation Suspension Wires- Orbital rim wiring
  73. 73. Suspension Wires- Piriform aperture wiring
  74. 74. Summary of Suspension wiring according to fracture site 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
  75. 75. 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.
  76. 76. Internal Fixation Direct Osteosynthesis - 1. Interosseous Wires. 2. Plates and Screws.
  77. 77. 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)
  78. 78. 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.
  79. 79. 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.
  80. 80. 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.
  81. 81. • STAGE III. DEFINITIVE TREATMENT  LEFORT I FRACTURE  LEFORT II FRACTURE  LEFORT III FRACTURE
  82. 82. • STAGE III. DEFINITIVE TREATMENT LEFORT I FRACTURE  SURGICAL APPROACH- MAXILLARY VESTIBULAR
  83. 83. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
  84. 84. FIXATION- 4-point fixation with MINIPLATE.
  85. 85. IMMOBILISATION- MAXILLOMANDIBULAR FIXATION(MMF)
  86. 86. LEFORT II FRACTURE  SURGICAL APPROACH-A – Subciliary incision B – Sub tarsal incision C - Infraorbital incision D - Extension of Subciliary incision
  87. 87. Existing Laceration Maxillary vestibular approach can also be taken for LeFort II fracture
  88. 88. CORONAL APPROACH GLABELLA APPROACH
  89. 89. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
  90. 90.  FIXATION- 3-POINT fixation
  91. 91. • IMMOBILISATION- MAXILLOMANDIBULAR FIXATION
  92. 92. • STAGE III. DEFINITIVE TREATMENT LEFORT III FRACTURE-  SURGICAL APPROACH-Existing Laceration
  93. 93. A . LATERAL EYEBROW APPROACH B. UPPER-EYELID APPROACH GLABELLA APPROACH
  94. 94. CORONAL APPROACH - PREAURICULAR APPROACH
  95. 95. REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
  96. 96. ZYGOMA HOOK
  97. 97.  FIXATION- 3-point fixation
  98. 98. • IMMOBILISATION- MAXILLOMANDIBULAR FIXATION if required
  99. 99. 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.
  100. 100. 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
  101. 101. 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.
  102. 102. 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
  103. 103. THANK YOU

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