1. midface trauma la forte #

Dr. Simon Rock
12/28/2020Dr.Simon Rock

 The middle third face is composed of bones:
1. Vomer (1)
2. Maxilla (2)
3. Zygomata (2)
4. Nasal (2)
5. Lacrimals (2)
6. Palatines (2)
7. Inferior Nasal Conchae (2)

Three buttresses
allow face to absorb
the force of
mastication; not from
other direction
Nasomaxillary (medial)
buttress
Zymaticomaxillary
(lateral) buttress
Pyterigomaxillary
(posterior) buttress
12/28/2020 Dr.Simon Rock

 The relative fragility of the midfacial skeleton, it act as
cushion for trauma directed to cranium.
 The bones of midface skeleton articulate with base of skull at
an inclined plane (45°)
 This may cause downwards& backwards displacement of the
detached midface which leads to
lenthening of the face
airway obstruction

LeFort I Transverse Maxillary
Lefort II Pyramidal
Lefort III Craniofacial Dysjunction
Zygomatic Complex
Orbital Floor
Nasal Fractures
Naso-orbital/Ethmoid

Evaluate for laceration
Obvious depression in skull
Asymmetry
Discharge from nose or ear
 Assume CSF leak
Palpation to note bone
discontinuity
 Bimanually in systematic
manner

Evaluate mandibular
opening
Palpation of buccal vestibule
Crepitus of lateral antral wall
Occlusion evaluated
Absence and quality
of dentition noted
Ecchymosis common finding
Pharynx evaluated for
laceration & bleeding

Orbits evaluated
 Periorbital edema and ecchymosis
 Gross visual acuity determined
 Diplopia
 Pupillary size & shape
 Subconjunctival hemorrhage
 Funduscopic evaluation

Orbits evaluated
 Lid lacerations
 Attachment of medial canthal
tendon
Rounding of lacrimal
lake
Increased
intercanthal distance
Epiphora
 Prompt Ophthamology consult

 Plain Films
 Lateral Skull
 Waters View
 Posteroanterior view of skull
 Submental vertex
 CT Scan (the standard)
 1.5 mm cuts
 axial and coronal views

Lateral skull Water’s View

CT Scan 3D CT

Stereolithography
allows actual model
of defect. A nice
reconstruction tool
to use if available

 Weakest areas of midfacial complex when assaulted from a
frontal direction at different levels (Rene’ Lefort, 1901)
 Lefort I: above the level of teeth
 Lefort II: at level of nasal bones
 Lefort III: at orbital level

Provides uniform method to describe
the level of major fracture lines
Allows references regarding the
probable points of stability for
surgical treatment
Does not incorporate vertical or
segmental fractures, comminution or
bone loss

 Le Forte I
 Definition:
 Fracture above level of maxillary
teeth involving alveolar process,
palate and pterygoid plates.
 Allows motion of the maxilla while
the nasal bridge remains stable.
 Also known as low level or Guerin
#

 Pyramidal fracture across nasal bones and frontal processes of
maxilla, extending laterally through lacrimal bones, inferior
rim of orbit near zygomaticomaxillary suture, lateral walls of
maxilla and pterygoid plates.

 Mobility of maxilla
Noted by grasping
maxillary incisors
 ‘Cracked pot’ sound
 Maxilla displaced posteriorly and inferiorly
Open bite deformity
 Palpable crepitation in upper sulcus
 Malocclusion

 Clinical evaluation provides only a rough impression since
swelling hides the underlying bony structures
 Plain film radiographs and axial and coronal CT images are
the basis for precise diagnosis & treatment plan

Bilateral circumorbital
ecchymosis (black eyes-
panda eyes)
 Bilateral subconjuctival
hemorrhage (red eyes)
Step deformity palpated
in nasofrontal area
CSF rhinorrhea
Epistaxis
Gagging of posterior
teeth
Possible diplopia &
enophthalmous

 Step deformity palpated on the infraorbital rim
 Mobility of the midface detectablea at nasal bridge & infraorbital
margin
 Parasthesia of cheek

 Tenderness & separation over FZ suture & zygomatic arch
 Lenthening of face
 Depression of occular level
 Pseudoptosis
 Mobility of whole facial skeleton

 Reduction
 Fixation
 Immobilization

 Mobilization
 Manual reduction
 Rowe’s disimpaction forceps
 Open reduction

 1-Direct fixation:
-transosseous wiring
-rigid fixation

Direct exposure of
all involved fractures
Reduction and
anatomic
realignment of the
maxillary buttresses
to reestablish
Anterior projection
Transverse width
Occlusion
Restoration of
occlusion using IMF12/28/2020 Dr.Simon Rock

 Fractures should be treated as early as the general condition of the
patient allow
 Intubation must not interfere with ability to use IMF
 Exposure & visualization of all fractures
 Approaches to inferior rim
 Infraorbital
 Subciliary
 Transconjunctival
 Mid lower lid
 Coronal approach
 Gingivobuccal incision

Teeth and occlusion
are the key to
reconstruction and
provide the
foundation upon
which other facial
structures are built

Severely comminuted fractures
preliminary approximation may be
performed with wire
Establishment of the correct
occlusion
Correct reconstruction of the outer
facial frame for proper facial
dimensions
Correct position for nasoethmoidal
complex

Reestablishment of the correct
intercanthal distance
Infraorbital rim fixated
Orbit is reconstructed
Occlusion unit with IMF is fixated

 2-Indirect fixation:
-suspension
-supporting
-external pin fixation
-halo frame
-box frame
-plaster of Paris head cap

Thank You

1. midface trauma la forte #

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