These slides include Le fort 1 2 3 fractures -by prajakta joshi (sinhgad denat college and hospital pune)

1. LEFORT
FRACTURES
- PRAJAKTA JOSHI ( IV YEAR )

2. FRACTURE LINES
LEFORT–I (LOW LEVEL OR GUERIN
FRACTURE)HORIZONTAL FRACTURE ABOVE THE LEVEL OF NASAL FLOOR
FRACTURE LINE- EXTENDS FROM PYRIFORM FOSSA BACKWARD ALONG THE MAXILLA
LATERALLY-LATERAL MARGIN OF ANTERIOR NASAL APERTURE-LATERAL WALL OF
MAXILLARY SINUS BELOW ZYGOMATIC BUTTRESS-LOWER 1/3RD OF PTERYGOID LAMINAE
AND ASSOCIATED PALATINE BONE
MEDIALLY-LOWER 1/3RD OF NASAL SEPTUM-LATERAL MARGIN OF ANTERIOR NASAL
APERTURE-PROCEED POSTERIORLY TO JOIN LATERAL FRACTURE BEHIND TUBEROSITY
FORCE-HORIZANTAL FORCE JUST ABOVE THE APICES OF MAXILLARY TEETH
-TRANSMISSION OF BLOW FROM OPPOSITE JAW

3. LEFORT II- PYRAMIDAL FRACTURE
 FRACTURE LINE
 ATERIORLY-FRONTONASAL JUNCTION-CROSSES FRONTAL PROCESS OF MAXILLA-
ENTER INTO MEDIAL WALL OF EACH ORBIT-CROSSES LACRIMAL BONE BEHIND THE
LACRIMAL SAC –TURNS FORWARD AND CROSSES INFRAORBITAL MARGIN-TRAVEL
MEDIAL TO OR THROUGH INFRAORBITAL FORAMEN-EXTENDS DOWNWARD AND
BACKWARD ACROSS LATERAL WALL OF ANTRUM-BELOW ZYGOMATIC SUTURE-TO
MEDIAL 1/3RD OF PTERYGOID LAMINAE HORIZONTALLY
 POSTEROMEDIALLY-SEPERATION OF BLOCK FROM BASE OF SKULL VIA NASAL SEPTUM
AND MAY INVOLVE FLOOR OF ANTERIOR CRANIAL FOSSA
 FORCE-NEAR THE LEVEL OF NASAL BONE

4. LEFORT III # -
SUPRAZYGOMATIC FRACTURE /
CRANIOFACIAL DYSJUNCTION
 FRACTURE LINE
 ANTERIORLY-FRONTONASAL SUTURE-TRANSVERSLY BACKWARDS,PARALLEL WITH
BASE OF SKULLS-TO FULL DEPTH OF ETHMOIDAL BONE INCLUDING CRIBIFORM PLATE
 POSTEROMEDIALLY-WITHIN THE ORBIT FRACTURE LINE PASSES BELOW THE OPTIC
FORAMEN INTO THE POSTERIOR LIMIT OF INFERIOR ORBITAL FISSURE-FROM HERE
LINE EXTENDS INTO 2 DIRECTIONS 1)BACKWARDS ACROSS THE MAXILLARY FISSURE
TO FRACTURE THE ROOTS OF PTERYGOID LAMINAE
 2)LATERALLY ACROSS THE LATERAL WALL OF ORBIT SEPERATING THE
ZYGOMATIC BONE FROM FRONTAL BONE
 POSTEROLATERALLY-FROM THE ORBIT-TO THE INFERIOR ORBITAL FISSURE –
LATERAL WALL OF ORBIT INTO FRONTOZYGOMATIC SURTURE –SEPERATION OF
FACIAL BONE(MIDDLE THIRD) FROM CRANIUM
 FORCE - AT THE LEVEL OF ORBIT

5. SIGNS AND SYMPTOMS- LEFORT I
 1.SWELLING-OF UPPER LIP AND CHEEKS
 2.ECCHYMOSIS-IN MAXILARRY BUCCAL SULCUS DUE TO SHEARINF OF SOFT TISSUE
OR PERIOSTEL TEAR
 3.NASAL BLOCK-MUCOSAL TEAR IN MAXILLARY SINUS OR ETHMOID SINUS- CAUSES
BLEEDING-NASAL BLOCK
 4.GUERIN SIGN-ECCYMOSIS IN PALATE IN THE AREA OF GREATER PALATINE FORAMEN
BILATERALLY
 5.OCCLUSION-
 A. INCOMPLETE LEFORT I#-NO OCCLUSAL DISTURBANCES
 B. COMPLETE LEFORT#-a)ANTERIOR OPEN BITE b)BACKWARD AND DOWNWARD
DISTRACTION OF POSTERIOR MAXILLA c)POSTERIOR GAGGING OF OCCLUSION THAT
CAN CAUSE THREAT TO AIRWAY
 6.TEETH FRACTURE- DAMAGE TO CUSP OF MAXILLARY TEETH DUE TO IMPACTION OF
MANDIBULAR TEETH AGAINST MAXILLARY COUNTERPART

6. SIGNS AND SYMPTOMS- LEFORT I
 7.PALATAL FRACTURE-”MIDPALATAL SPLIT” DUE TO LINEAR MUCOSAL TEAR IN
MIDPALATE
-WITH OR WITHOUT ORONASAL COMMUNICATION DEPENDING ON AMOUNT OF
SEPERATION OF FRAGMENTS
 8.CRACKED-POT SOUND-ON PERCUSSSION OF MAXILARY TEETH
-SOUND PRODUCED WHEN A CRACKED CHINA POT IS TAPPED WITH SPOON
 9.FLOATING MAXILLA-MOBILITY OF DENTULOUS SEGMENT OF MAXILLAE
 10.TENDERNESS AND STEP DEFORMITY ALONG PYRIFORM APERTURE,BUCCAL SULCUS
AND TUBEROSITY REGION

7. SIGNS AND SYMPTOMS -LEFORT II #
 1.SWELLING-APPEARANCES OF “MOON FACIES“ (ROUNDED APPEARANCE OF FACE)
-GROSS OEDEMA OF MIDDLE THIRD OF FACE
 2.SUBCUTANEOUS EMPHYSEMA-CREPITUS FELT ON PALPATION DUE TO DIRECT
COMMUNICATION BETWEEN SINUS AND SOFT TISSUE OF FACE
 3.TELECANTHUS-SWELLING OVER THE NASAL BRIDGE GIVING THE ILLUSION OF
TELECANTHUS(PSEUDO)
TRUE TELECANTHUS IS ASSOCIATED WITH NOE FRACTURE
 4.EPSTAXIS,EPIPHORA-IN CASE OF DISPLACED FRACTURE OF MAXILLA INVOLVING
LACRIMAL SAC OR NASOLACRIMAL DUCT
 5.BILATERAL CIRCUMORBITAL OR PERIORBITAL OEDEMA,ECCHYMOSIS-
GIVE APPERANCE OF ‘RACOON EYES’ (SEEN IN BOTH LEFORT II & III #)
 6.SUBCONJUCTIVAL HAEMORRAGE-DEVELOPES RAPIDLY AND RESTRICTED TO MEDIAL
ASPECT OF EYEBALL

8. SIGNS AND SYMPTOMS -LEFORT II #
 7.CHEMOSIS OR OEDEMA OF CONJUCTIVA
 8.CSF RHINORRHEA-(NOT SEEN ALWAYS AS IN LEFORT III )
 9.ENOPHTHALMOS,LIMITATION IN OCULAR MOBILITY DUE TO MUSCLE
ENTRAPEMAENT,DIPLOPIA,
 10.INJURY TO INFRAORBITAL NERVE –ANESTGESIA/PARASTHESIA OF CHEEK
 11.STEP DEFORMITY AT INFRAORBITAL RIMS OR NASOFRONTAL JUNCTION
 12.ECCHYMOSIS OR HEMATOMA-IN MAXILLARY BUCCAL SINUS
 13.MASSIVE NASAL OR PHARYNGEAL HEMORRHAGE-UPPER AIRWAY OBSTRUCTION
 14.MIDPALATAL SPLIT OR PARAMEDIAN SPLIT OF PALATE DUE TO MUCOSAL TEAR
 15.RETROPOSITIONING OF WHOLE MAXILLA AND GAGGING OF OCCLUSION CAUSING
ANTERIOR OPEN BITE;CLASS III MALOCCLUSION;DISH FACE DEFORMITY
 16.WHEN MAXILLARY ALVEOUS IS GRASPED ANTERIORLY THE MIDFACIAL SKELETON
MOVES AS A PYRAMID
 17.PALPATION OF VESTIBULE-TENDERNESS WITH STEP DEFORMITY AT ZMBUTTRESS
REGION

9. SIGNS AND SYMPTOMS -LEFORT III #
 ALL CLINICAL FINDINGS OF LEFORT II WILL BE PRESENT ALONG WITH FOLLOWING-
 1.RACOON EYES,DISH FACE DEFORMITY(CONCAVE PROFILE),LENGTHENING OF FACE
 2.HOODING OF EYES DUE TO SEPERATION OF FRONTOZYGOMATIC SUTURE
 3.ENOPHTHLAMUS,HYPOGLOBUS,DIPLOPIA WITH ALTERED CANTHAL POSITION
 4.SUBCONJUCTIVAL HEMORRHAGE INVOLVING ENTIRE EYE WITH NO POSTERIOR
LIMIT
 5.SADDLE NOSE DEFORMITIY COMMONLY ASSOCIATED WITH NOE #
 6.CSF RHINORRHEA;CSF OTORRHEA ASSO WITH SKULL BASE FRACTURE
 7.LOSS OF LATERAL FACIAL PROJECTION FROM ZYGOMATIC ARCH #
 8.DECREASED MOUTH OPENING FROM ZYGOMA IMPINGING ON CORONOID PROCESS
AND SEVERE POSTERIOR GAGGING OF TEETH
 9OCCLUSION-DERANGED WITH SEVERE ANTERIOR OPEN BITE;CLASS III
MALOCCLUSION ASSO WITH TEETH OR DENTOALVEOLAR FRACTURE #
 10.WHWN LATERAL DISPLACEMENT TAKES PLACE –TILTING OF OCCLUSAL PLANE
AND GAGGING OF ONE SIDE

10. MANAGEMENT OF LEFORT I #
 TREATMENT STAGES
 1.EMERGENCY CARE AND STABILIZATION-
AIRWAY MAINTENANCE,CONTROL OF HEMORRHAGE,PREVENT OR CONTROL SHOCK,
STABILIZATION OF ASSOCIATED INJURIES.
 2.INITIAL ASSESSMENT AND EARLY CARE-
INITIAL STABILIZATION OF FRACTURE,DEBRIDEMENT AND DRESSING OF WOUND,
PHYSICAL EXAMINATION AND HISTORY,CLINICAL & RADIOGRAPHIC ASSESSMENT
LAB.TEST
 3.DEFINITIVE TREATMENT-
SURGICAL APPROACH, REDUCTION, FIXATION, IMMOBILIZATION
 4.REHABILITATION

11. INVESTIGATION
 INVESTIGATIONS-
1.CT SCAN-BEST OPTION FOR MID FACE FRACTURE,PLANE RADIOGRAPH MAY BE
HELPFUL
2.RADIOGRAPHIC EXAMINATION-
i)WATER’S VIEW-PA VIEW WITH CEPHALIC ANGULATION
ii)A CALDWELL VIEW-PA VIEW
iii)LATERAL VIEW
iv)SUBMENTOVERTEX VIEW
 WATER’S PROJECTION GIVES DETAILED EVALUATION OF FACIAL SKELETON
3.COMPUTED TOMOGRAPHY
4.3D RECONSTRUCTION OF CT SCAN

12. MC GRIGOR & CAMPBELL(1950)-4 LINES FOR
EXAMINATION OF OCCIPITO-MENTAL FILM
 1.FIRST LINE ACROSS ZYGOMATICOFRONTAL SUTURE,THE SUPERIOR MARGIN OF ORBIT
AND FRONTAL SINUS
 2.SECOND LINE ACROSS THE ZYGOMATIC ARCH,ZYGOMATIC BODY,INFERIOR ORBITAL
MARGIN & NASAL BONE
 3.THIRD LINE ACROSS THE CONDYLE,CORONOID PROCESS AND MAXILLARY SINUS
 4.FOURTH LINE ACROSS THE MANDIBULAR RAMUS,OCCLUSAL PLANE
 5.FIFTH LINE( TRAPNELL’S LINE) ACROSS THE INFERIOR BORDER OF MANDIBLE FROM
ANGLE TO ANGLE

13. MANAGEMENT OF LEFORT 1#
 REDUCTION-
1.FINGER MANIPULATION
2.ROWE’S DISIMPACTION AND HAYTON WILLIAM’S FORCEPS
 FIXATION-1.DIRECT MEANS-i)TRANSORAL EXPOSURE OF FRACTURE LINE
ii)MINIPLATES
iii)TRANSOSSEOUS WIRING
2.INDIRECT MEANS-i)SUSPENTION
ii)MMF WITH 4-6 WEEKS OF IMMOBILIZATION

14. CHART
 I.UNDISPLACED LEFORT I +
MINIMAL OCCLUSAL DISCREPANCY-i)SIMPLE MMF FOR 4 WEEKS OR
ii)DIRECT FIXATION WITHOUT MMF
 DISPLACED MOBILE LEFORT I +
ANTERIOR OPEN BITE -i)DIRECT FIXATION OR
ii)INDIRECT SUSPENSION WITH MMF
 COMMINUTED FRACTURE- MMF AND SUSPENSION WIRING
 EDENTULUOUS PATIENT-i)CUSTOM ACRYLIC OCCLUSAL SPLINT
ii)PATIENTS OWN DENTURE FOR DETERMINING VERTICAL
DIMENTIONS

15. MANAGEMENT OF LEFFORT II#
 REDUCTION-SIMILAR TO LEFORT I
 FIXATION-DIRECT FIXATION-i)MINIPLATES
ii)TRANSOSSEOUS WIRE FIXATION AT ZM BUTTRESS,
INFRA ORBITAL RIM & FRONTONASAL JUNCTION
INDIRECT FIXATION-i)SUSPENSION
ii)MMF
 IMMOBILIZATION

16. CHART
 UNDISPLACED LEFORT II +
MINIMAL OCCLUSAL DISCREPANCY-i)CIRCUMZYGOMATIC SUSPENSION
WITH MMF FOR 4 WEEKS
ii)DIRECT FIXATION AT ZM BUTTRESS
 DISPLACED MOBILE LEFORT II +
ANTERIOR OPEN BITE-i) DIRECT FIXATION
ii)INDIRECT SUSPENSION( ADAMS) WITH
MMF
 COMMINUTED FRACTURE-SUSPENTION WITH MMF
 ASSOCIATED COMPLICATIONS SUCH AS CSF RHINORRHEA,LACRIMAL
OBSTRUCTION REQUIRE APPROPIATE MANAGEMENT

17. MANAGEMENT OF LEFFORT III#
 USUALLY OCCURE IN ASSO WITH OTHER FRACTURES OF FACIAL SKELETON SUCH
AS NOE,ZYGOMATIC,ORBITAL AND LEFORT I
 REDUCTION-SAME AS PREVIOUS
 FIXATION-SEMIRIGID FIXATION AT FRONTOZYGOMATIC,FRONYONASAL
SUTURE,ORBITAL FLOOR RECONSTRUCTION,ZM BUTTRESSES,ZYGOMATIC ARCH
AND MAINTAINING OCCLUSION