Le fort fracture(2)

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  • Tuberoplasty,sinus lift
  • Le fort fracture(2)

    1. 1. - Dr. Dona Bhattacharya
    2. 2. 1. Introduction2. Surgical anatomy3. Classification4. Etiology5. Clinical features6. Management7. Conclusion8. References
    3. 3. ∏ Area between a superior plane drawn through the FZ suturestangential to the skull base and inferior plane at the level ofmaxillary occlusal surface∏ Triangular region with widest dimension facing anterior
    4. 4. ∏ Middle 3rd of face is composed ofPaired Bones Unpaired BonesMaxilla VomerZygomatic bone EthmoidZygomatic process oftemporal boneSphenoid (Pterygoid plates)Palatine boneNasal boneLacrimal boneInferior conchae
    5. 5. ∏ Maxilla –central bone; prominentposition where trauma hits face∏ This structure is analogous to amatchbox sitting below and anteriorto hard shell containing brain∏ Act as cushion for trauma directedtowards cranium from anterior orantero-lateral direction
    6. 6. ∆ Areas of weakness act as “crumple zone”.∆ Sutures∆Areas of strength: pillars of face
    7. 7. ∏ This arrangement with stands force of masticationfrom below and protects the vital structure∏ Bones easily fractured from forces applied fromother directions.∏ Clinical implications
    8. 8. Soft tissue attachments
    9. 9. 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)
    10. 10. Pitfalls:a) # caused by loc penetrating missile injuries & gunshot wounds notincluded.b) Only meant for bilateral # occuring at same levelc) mid palatine split along palatal suture not describedd) Inaccurate prediction of reduction techniques.
    11. 11. Fracture not involving the occlusionCentral regionNasal bone/ septum (lateral, anterior injuries)Frontal process of the maxillaNasoethmoidFronto-orbito-nasal dislocationLateral region (zygomatic complex ,arch, dento-alveolar fractureFracture involving the occlusionDento alveolarSubzygomatic:Le Fort (I, II)Supra zygomatic:Le Fort III
    12. 12. From: Donat TL et al. Facial Fracture Classification According to Skeletal SupportMechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314.
    13. 13. ∏ Assault∏ RTA∏ Gunshot wounds∏ Sports∏ Falls∏ Industrial accidents
    14. 14. Prevalence of mid-facefracturesFracture Type PrevalenceZygomaticomaxillary complex (tripod fracture) 40 %LeFortI 15 %II 10 %III 10 %Zygomatic arch 10 %Alveolar process of maxilla 5 %Smash fractures 5 %Other 5 %
    15. 15. A). Le fort I/ Floating fracture/ Guerin fracture/ Low levelfracture/ Subzygomatic fracture1. 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 lip6. Mal occlusion7. Bilateral epistaxis8. Brusing of palatal tissues (15-20% of cases)9. On palpation tenderness over buttress area10. Percussion of teeth – cracked pot soundClinical Features
    16. 16. B). Le fort II/ Pyramidal fracture/ Mid level fracture/ Subzygomaticfracture1. Oedema mid third of face (Moon face)2. Paresthesia of cheek3. Bilateral circumorbital ecchymosis4. Bilateral subconjunctival haemorrhage5. Dish face deformity6. Depressed nose7. Epistaxis8. CSF rhinorrhea9. Limited ocular movement (Diplopia)10. Mal occlusion11. 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
    17. 17. C). Le fort III/ Craniofacial dysfunction/ High level fracture/Suprazygomatic fracture1. Oedema of face (Panda facies)2. Bilateral periorbital edema3. Bilateral circumorbital ecchymosis (Racoon eyes)4. Bilateral subconjunctival haemorrhage5. Dish face deformity6. Depressed nose, flattening of nose7. Epistaxis8. 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 sutures16. Tenderness over zygomatic bone, arch and FZ suture17. Ecchymosis at mastoid process (Battle’s sign)
    18. 18. 1. Emergency care and stabilization2. Initial assessment3. Definitive treatment4. Continuing care
    19. 19. ∆ Airway immediately evaluated for obstruction∆Control of oral or nasal bleedingPossibility of C – spine fracture – endotracheal incubationshould not be attemptedCervical collar in case of suspected spine fractures∆Circulation
    20. 20. LeFort I fractureLeFort I fracture with Mandible fractureLeFort I fracture with Nasal injuryLeFort II fractureLefort III fracturePanfacial fracturesNasal AirwayEdentulous Partially Dentatewith spaceFully DentateOral Airwaythrough portalcut in Gunningsplints ordenturesOral Airwaywith tubedisplacedthrough spaceSurgicalAirwayGuided NasalIntubation• fixate maxillaand mandible• switch to OralAirway fornasal/NOEreduction
    21. 21. Premlatha Shetty et al;submental intubation in patients with panfacial fractures;Indian journal of anesthesia,vol55,issue 3,may 2011
    22. 22. 1. History2. Palpation of entire facial skeleton3. I/O Examination4. Ophthalmologic exam / consultation5. Radiographic examination
    23. 23. After stabilization of patients condition, complete facialexamination is performed.1. Laceration, bruising , etc.2. Obvious depressions on nose, check, etc.3. Facial asymmetry, swelling4. Nasal discharge (Blood/ CSF)
    24. 24. Features CSF fluid Nasal secretionHistory Nasal or sinus surgery, head injury orintracranial tumourSneezing, nasal stuffiness,itching in the nose orlacrimationFlow of discharge A few drops or a stream of fluid gushesdown when bending forward orstraining; can’t be sniffed backContinuous. No effect ofbending forward orstraining. Can be sniffedbackCharacter ofdischargeThin, watery and clear Slimy (mucus) or clear(tears)Taste Sweet SaltySugar content More than 30 mg/dl (Compare withsugar in CSF after lumbar puncture assugar is less in CSF in meningitis)Less than 10 mg/dlPresence of β2transferrinAlways present. It is specific for CSF Always absent
    25. 25. Palpation of facial skeletonBowstringtest
    26. 26. 1. Periorbital edema2. Periorbital ecchymosis3. Proptosis4. Diplopia5. Pupillary size and shape6. Sub-conjunctival haemorrhage7. Lid laceration8. Visual acuity9. Dystopia
    27. 27. Inspection Palpation PercussionLacerationEcchymosisRestricted mouthopeningOcclusionTendernessMobility of teethCrepitusMobility of fracturedfragmentCracked pot sound
    28. 28. 1. OPG2. OM3. Lateral skull view4. Occlusal view for split palate5. CT Scan6. 3D CT Scan7. MRI
    29. 29. ∆ Aims of treatment1. Relieve pain2. Precise anatomical reduction of the # fragment3. Stable fixation of the reduced fragment4. Restore function5. Restore the dental occlusion
    30. 30. Preoperative planning:∆ Need for surgical airway∆ Open/closed method of reduction∆ Necessity for and type if IMF to be employed in case forclosed reduction∆ Type of osteosynthesis in case of open method∆ Need for internal suspension in case of communited #∆ Timing of surgery
    31. 31. ∏ Optimum time for reduction of mid face fracture is 5th to 8thpost injury day∏ After this with every succeeding day disimpaction becomedifficult and open reduction more essential
    32. 32. Open reduction Closed reductionDisplaced # Non displaced #Multiple # of facial bones Grossly communited #Edentulous maxillary # - with severedisplacementFractures associated with significantloss of soft tissuesEdentulous maxillary # - opposite toEdentulous mandibular #Edentulous maxillary #Delay of treatment In children with developing dentitionInter position of soft tissues betweennon contacting displaced # segmentSystemic condition contra indicatingIMF
    33. 33. 1. Accurate diagnosis2. Determination of priority of treatment3. Early reconstruction4. Wide exposure of vertical and horizontal pillar of face5. Use of bone graft to restore skeletal form6. Use of rigid fixation to stabilize # segment7. Restoration of bony support to over lying soft tissue envelop
    34. 34. 1. Intra orala) Vestibular2. Extra orala) Lower eye lid incisioni. Sub cilliaryii. Infra orbitaliii. Trans conjunctivalb) Coronal approachc) Midface degloving approach
    35. 35. TechniqueAdvantagesDisadvantageIndication
    36. 36. TechniqueAdvantagesIndication
    37. 37. 1. Manual reduction2. Reduction with wires3. Reduction using disimpactionforceps4. Reduction with bone hook5. Reduction with elastics
    38. 38. 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 orrubber catheter (Propescu and Burlibasa, 1966)
    39. 39. 1. Rowe’s maxillary disimpaction forceps2. Hayton William’s disimpaction forceps
    40. 40. Movements:1. Downwards – to affect disimpactionof pterygoid plates down2. Anterior3. Combination of forward tractionwith rotational movement in bothhorizontal and vertical axisUniversal ruleOculocardiac reflex
    41. 41. Used in delayed cases:1. Intra oral elastic traction2. Extra oral elastic traction
    42. 42. Maxillary # fixationInternal fixationDirect osterosynthesis1. Miniplates2. Intraosseous Wires- high(FZ,FN)- Mid(buttress,orbital rim)- Low(alveolar/midpalatal)Suspension wires1. Frontal2. Circumzygomatic3. Zygomatic4. Circumpalatal5. Infraorbital6. Piriform aperture7. PeralveolarExternal fixationCraniomandibularCraniomaxillary1. Supraorbital pins2. Zygomatic pins3. POP head frame4. Halo frame5 . Levant frame6. Box frame
    43. 43. Intraosseous wiresBy Merville & Derome(1976)
    44. 44. Miniplates and screwsThese are monocortical, semi-rigid fixation device whichprovide 3D stability.Designs: X, H, L, T, YThickness:0.6-1 mm
    45. 45. 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. VitalliumAdvantages:1) Easily adaptable2) Monocortical3) Functional stability4) Reduced surgical access
    46. 46. 1. Minimum 2 screws required in each bone segment to preventrotation in X and Y axis2. Farther the point of stabilization the more effective the deviceis in preventing rotation3. Large diameter screws are not used because of constraintimposed by particular anatomic location4. All screw require adequate intervening bone between adjacentholes to preserve integrity of screw bone interface
    47. 47. Le fort I: L plates at zygomatic buttressCurved plate at pyriform aperture3D plate sometimes to fix buttress #Le fort II: Linear/Y plate/curved plate along intra orbital rimL plate at buttressLe fort III: Linear/Y plate at FN and ZF junction
    48. 48. Harle & duker(1975;Luhr(1979)0.3-0.6 mmUsed for :a. FN regionb. Frontal bonec. Frontal process of maxillaSites of application:a. Linear/T/Y plate at FN regionb. Long curve plate for frontal process of maxilla or frontal bone
    49. 49. Used for retention and alignmentof small fragments or bonegrafts.Sites of application:1. Anterior and lateral wall ofmaxilla2. Anterior table of frontal bone
    50. 50. Introduced by Kuffner, 1970Two types1. Central2. LateralUsually used for high midfacefracture.
    51. 51. Incision in lateral 3rd/nasal process offrontal boneExposure of zygomatic proces/outercortex of frontal boneDrilling of bur hole and placement ofscrewPassage of SS wire attached to awl;through incision into maxillaryvestibuleRelease of wire and attachment to thearch bar
    52. 52. Indication: le fort II and III fractureIncision in maxillary vestibule abovecanineSubperiosteal dissection andexposure of infra orbital rimDrill hole and passage of wire aboveIO rim and back to oral cavityRelease of wire and attachment tothe arch bar
    53. 53. Also known as buttress wireIncision in maxillary vestibule below buttressExposure of ZM junctionDrill hole and passage of wireRelease of wire and attachment to the arch bar
    54. 54. Cubero Technique
    55. 55. Introduced by Bowerman andConroy, 1981Simple technique for fixinggunning splint to maxillaSuperior retention, stability anddecreased discomfortIncision in maxillary vestibule over nasalspineExposure of ANSDrill hole and passage of wireRelease of wire and attachment to the archbar
    56. 56. Incision in maxillary vestibule in canine fossaSubperiosteal dissection and exposure ofpyriform apertureElevation of nasal mucosa and drill hole fromlateral to medialPassage of wire and attachment to the archbar
    57. 57. Drill hole in palatal aspect of splintDirect wire through alveolus over canine region andemerge in Buccal SulcusPassage of 0.5 mm SS wire and secure to splint
    58. 58. Trend towards ORIF has changedExternal fixation is used in cases where there is depressed posteriordisplaced #Principle:External appliances relies on sandwiching the midface between base ofskull and mandible to provide cantilever support to midface in 3Dfollowing disimpaction and closed reduction.Disadvantages:
    59. 59. Disadvantage:1. Heavy2. Uncomfortable3. UnstableMethod ofapplication
    60. 60. Described by Crawford;modified byMackenzie & Ray,1970Secure the frame work to the skulldirectly by screw pinsAdvantage:1. Light weight2. Adjustable3. Titanium Screw pin
    61. 61. ∏ More stable and rigid∏ Other unstable fracture fragmentcan also be attached to vertical rod
    62. 62. ∏ Developed at RoyalMelbourne Hospital∏ Provided simple rigidcraniomaxillaryfixation betweensupraorbital rims andmaxilla connected bycentral rod attachedat lower end by meansof cast metal splint oracrylic splint
    63. 63. 1. Provide dimensional stability2. Indications:1. Grossly communited #2. Extensive soft tissue loss3. Bone gap>5mm3. Sites:1. Calvarium2. Illium3. Rib
    64. 64. 1. Resorbable plates2. Endoscopic management(Harold Hopkins)3. Distraction osteogenesis(Ilizarov)
    65. 65. Immediate1. Airway2. Nasal hemorrhage3. Ophthalmic complications4. Inaccurate reduction5. Insecure fixationLate complications1. Non union2. mal occlusion3. Cranial nerve dysfunction4. Secondary nasal deformity5. Dacrocystitis6. Facial asymmetry
    66. 66. Due to the complex 3D arrangement of the structures of middlethird of face,management is complicated.Proper reduction ofthe # fragments remains the key component.A proper understanding of the anatomy,fracture patterns, itsclinical presentation and the available treatment modalities isnecessary to successfully treat Le Fort Fractures.
    67. 67. 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 fractureManagement, seminars in plastics surgery/volume 22, number 12008
    68. 68. 9. Manual of internal fixation-J Prein10. Donat TL et al. Facial Fracture Classification According to SkeletalSupport Mechanisms. Arch Otolaryngol Head Neck Surg1998;124:1306-1314.11. Mirko S. Gilardino et al;Choice of Internal Rigid Fixationmaterials in the treatment of facial fractures; craniomaxillofacialtrauma & reconstruction/volume 2, number 1 200912. Khaled M Emara et al ;Methods to shorten the duration of anexternal fixator in the management of fractures; World J Orthop2011 September 18; 2(9): 85-9213. Chan hum park et al;resorbable skeletal fixation systems fortreating maxillofacial bone fractures; arch otolaryngol head necksurg/vol 137 (no. 2), feb 201114. Premlatha Shetty et al;submental intubation in patients withpanfacial fractures;Indian journal of anesthesia,vol 55,issue 3,may2011.

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