Le Fort Fracture I,II,III Clinical Features, Management, Reduction & Fixation, Complications

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2. Contents
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• Introduction
• Facial Buttresses
• Midfacial bones
• Classification
• Causes
• History and examination
• Signs and symptoms
• Management

3. Introduction
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• Middle third of facial skeleton is area bounded
– Superiorly by a line drawn across skull from
zygomaticofrontal suture of one side, across
frontonasal and frontomaxillary sutures to
zygomaticofrontal suture on opposite side
– Inferiorly by occlusal plane of upper teeth, or, if
patient is edentulous, by the upper alveolar ridge.

4. • Posteriorly, demarcated by sphenoethmoidal
junction, includes free margin of pterygoid
laminae inferiorly.
• Less frequently seen than mandibular #.
• Results in distorted facial contour, involvement
of masticatory system, ocular system.
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5. Midfacial bones
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Sphenoid (1)
Ethmoid (1)

6. Facial buttresses
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• The central midface has many fragile bones that
could easily be crushed when subjected to strong
forces.
• They are surrounded by thicker bones of facial
buttress system lending it some strength and
stability.

7. • 2 Components of Buttress system:
–Vertical buttresses
–Horizontal buttresses
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8. • Vertical buttresses:
1. Nasomaxillary
2. Zygomaticomaxillary
3. Pterygomaxillary
• Resist occlusal load.
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9. • Horizontal buttresses:
1. Supraorbital rim &
Frontal bone
2. Infraorbital rim & nasal
bones
3. Hard palate &
maxillary alveolus
• Interconnect and provide
support for vertical
buttresses.
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10. Physical Characteristics
• Made up of considerable bones which rarely fractures in
isolation.
• All bones are comparatively fragile & articulates un most
complex fashion.
• Acts as a cushion for trauma directed towards cranium from
ant. to anterolateral direction to a “match-box” sitting below &
in front of a hard shell containing brain.
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11. Causes of facial fractures
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• Motor vehicle accidents
• Assault/Domestic violence
• Falls
• Sports- related incidents
• Pathological
• Work- related incidents
• Warfare

12. Types of Midfacial fractures
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13. Classifications
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• Rene LeFort:
– LeFort I, LeFort II and LeFortII.
• Erich’s (1942)- direction of the fracture line.

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• Based on relationship of the fracture line to
the zygomatic bone -
–Subzygomatic fractures
–Suprazygomatic fracture
• Based on level of a fracture line
–Low level fracture
–Mid level fracture
–High level fracture

15. • Rowe’s & William (1985)
• A. Not involving Occlusion
➢ Central Region
▪ # of nasal bone/septum – Lateral/ Anterior nasal injuries
▪ # of frontal process of maxilla
▪ # extends to the ethmoid bone involving or not involving occlusion.
▪ # extends to the frontal bone involving or not involving occlusion.
➢ Lateral Region
▪ # involving zygomatic bone, arch& maxilla excluding dentoalveolar
segment.
• B. Fractures involving occlusion
• Dentoalveolar
• Subzygomatic
• Suprazygomatic
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16. Marciani Modification (1993)
• Le Fort I : Low Maxillary fracture
• Le Fort Ia : Low Maxillary fracture/ multiple segments.
• Le Fort II : Pyramidal fractures
• Le Fort IIa :Pyramidal fractures+ Nasal Fractures
• Le Fort IIb :Pyramidal fractures+ NOE Fractures
• Le Fort III : Craniofacial dysjunction
• Le Fort IIIa: Craniofacial dysjunction + Nasal Fractures
• Le Fort IIIb: Craniofacial dysjunction + NOE Fractures
• Le Fort IV : Le Fort II & III + Cranial base fracture
• Le Fort IVa: Le Fort II & III + Cranial base # + Supraorbital rim #
• Le Fort IVb: Le Fort II & III + Cranial base # + Ant. Cranial base #
• Le Fort IVc: Le Fort II & III + Cranial base # + Ant. Cranial fossa
& Orbital Wall #
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17. LeFort I fracture
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• Results from a horizontal force delivered above the
level of the teeth (to the maxilla).
• The fracture courses from the lateral border of the
pyriform aperture →above the canine
→lateral antral wall → behind the
eminence
maxillary
tuberosity → across the lower third of the pterygoid
plate.

18. • Almost always involves the pterygoid process of
the sphenoid bone.
• The fracture separates the maxilla from the
pterygoid plates and nasal and zygomatic
structures.
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19. • This type of trauma may separate the maxilla
in one piece from other structures, split the
palate, or fragment the maxilla.
• May involve the maxillary sinuses.
• The resultant “floating” component is the
lower part of the maxilla and its teeth.
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20. • Le Fort I fracture may be unilateral or bilateral.
• It may occur on its own or in combination with
other midfacial fractures.
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21. Clinical signs & symptoms:
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• Swelling of the upper lip and lower part of face.
• Ecchymosis in labial & buccal vestibule.
• Laceration of upper lip & mucosa.
• Bilateral epistaxis.
• Mobility of upper dentoalveolar segment.
• Malocclusion.
• Pain in speaking & moving the jaw.
• Upward displacement of entire fragment – Telescopic #
• Classic ant. Open bite.
• Percussion of maxi. teeth: Dull Cracked cup sound.

22. LeFort II
fracture
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• Results from a force delivered at a level of the
nasal bones in superior direction.
• The fracture line occurs along the nasofrontal
suture
orbital
→ lacrimal bone → across the infra-
rim in the region of the zygomatico-
maxillary suture → above the canine eminence
→ inferiorly and distally along the lateral antral
wall, but at a higher level than Le Fort type I →
across the pterygoid plate at its middle.

23. • Separation of the maxilla and the attached
nasal complex from the orbital and zygomatic
structures.
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24. Clinical Findings of LeFort II
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• Ballooning of the face : Moon face
• Lengthenening of the face
• Circumorbital ecchymosis
• Subconjunctival Haemorrhage
• Bilateral Epistaxis
• Bilateral circumorbital oedema : Black eye
• CSF leak may be present
• Step deformity at infraorbital margins.
• Paresthesia/ Anaesthesia of cheek.

25. LeFort
III
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• Results when horizontal forces are applied at
a level superior enough (at orbital level) to
separate the NOE) complex, the zygomas, and
the maxilla from the cranial base (Craniofacial
separation/dysjunction).

26. • The fracture line courses through the
zygomaticotemporal and zygomaticofrontal
sutures→ lateral orbital wall→ inferior orbital
fissure→ medially to the naso-frontal suture
→ fractures the pterygoid plate at its base.
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27. Clinical Findings of LeFort III
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• Severe edema of the face “ballooning”
• Lengthening of the face
• Flattening of the cheek
• Circumorbital ecchymosis
• Subconjunctival Haemorrhage
• Epistaxis
• Enophthalmos
• CSF rhinorrhoea

28. • Bilateral circumorbital ecchymoses
facies,
• Bilateral subconjunctival haemorrhage-
Racoon eyes
– panda
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29. • Diplopia due to:
–Edema and hematoma
–Restrictive motility disorder (mechanical)
–Cranial nerve injury (neurogenic)
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30. Radiographs needed
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• Occipito-mental view (Water’s View)
• CT scan
–Axial scan
–Coronal scan
–Sagittal
–3 dimensional

31. Treatment for LeFort fractures
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• First aid and Preliminary treatment
• Definitive treatment
–Reduction
–Immobilization

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• The principles of definitive
LeFort fractures consist of
treatment of
reduction and
fixation of the fractured bones to one another
and to the skull
–achieved by either conservative or
operative methods.

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• The sooner the treatment is carried out, the
better the prognosis.
• Restoration of the occlusion is a must.
• The bony framework and buttresses of the
midface must also be repositioned or restored
and fixed.

34. Methods of reduction for
LeFort fractures
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• Manual reduction
– Simple manipulation by hand
– Dental compound on impression tray
– Gauze or rubber catheters
– Special instruments
• Reduction by traction
– Conservative treatment
– Supervised spontaneous healing
– Open reduction

35. Manual reduction
• Simple manipulation by hand is possible in fresh fractures,
maxilla is held between the index finger and thumb and brought
into normal occlusion.
• Another method is to fix two double wires encircling the first
and second maxillary molars and twisting them individually on
either sides.
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• Both the twisted wire ends are held by means
of wire holders or hemostats and
simultaneously downward movement of the
maxilla will help to achieve the normal
occlusion.

37. • Dental compound loaded into impression tray
was suggested by Dingman and Harding in
1951, for mobilizing the fractured fragment of
maxilla.
• This can be used, where some amount of
fibrosis has set in because of delayed
treatment.
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38. • Propescu and Burlibasa in 1966, described
reduction by rubber dam sheets or by means
of long ribbon/strip gauze or rubber
catheters.
• Whenever the maxilla is impacted and simple
manual mobilization is not possible, then this
method can be tried, if sophisticated
instruments are not available.
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39. • The rubber catheter’s end is passed from the
nostril into the oropharynx and it is grasped
with the help of hemostat and brought out of
the oral cavity.
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• So, you have one end coming out from nostril
and other end through the oral cavity, same
procedure is repeated on the other side
through the nostril.
• After grasping all four ends of the catheter
and stabilizing the head, maxilla can be
rocked into the normal occlusion.

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• Reduction by using special instruments—
Specially constructed disimpaction forceps can
be used to take firm grasp of the maxilla and
reduce it into the position.

42. • Rowe’s maxillary disimpaction forceps:
–Available as right and left forceps.
–Always used in pairs.
–These are two pronged (divided) forceps,
where one prong fits into the nasal floor
and another one on the hard palate.
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43. • Rowe’s Disimpaction Forceps
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44. • Anterior traction in the case of a split palate, may be
facilitated by the use of the special forceps devised by
Hayton Williams.
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45. • Applied to the buccal aspect of the alveolar
process and medial compression exerted until
the two halves of the upper jaw are
approximated.
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46. • A screw top is adjusted to prevent crushing of the
bone.
• Can be combined with Rowe’s maxillary disimpaction
forceps.
• The stabilized maxillary block may then be
disimpacted and drawn forward.
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47. Reduction by traction
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– Repositioning the fractures that are already
in a state of partial fusion OR when
attempted manual reduction is met with
failure, then reduction by elastic traction is
tried to interdigitate the fractured
fragments.

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• Mainly used in delayed cases, where the
fracture is 10 to 14 days old and no longer
sufficiently mobile.
–Intraoral elastic traction.
–Extraoral elastic traction with appropriate
extension bars and side bars.
• Intraoral intermaxillary elastic traction may be
used in an appropriate direction to restore
normal occlusion then replaced by IMF.

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• Conservative Treatment
–Reduction and fixation of the fractured
midface is indicated in cases, where surgery
is not possible due to poor general
condition of the patient or where there is
extensive comminution with tissue loss,
making internal skeletal fixation impossible.
–Also used as a supplementary measure with
the surgical treatment of midfacial fracture.

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• Supervised Spontaneous Healing
–Where mobility at the fractured maxilla is
only slight, and occlusion is not disturbed.
–Progress of healing is merely supervised.
–The patient should avoid chewing during
the first 2 to 3 weeks and should take a
liquid/semisolid diet.

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❖Monomaxillary fixation:
–Method used when tooth bearing section
of the maxilla is not fractured and therefore
can serve as fixation point.
–Arch bar or palatal acrylic plates can be
used.
–Can be used for unilateral fractures of
maxilla or higher fractures without occlusal
discrepancies.
–Maintained for 6 weeks.

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❖Intermaxillary fixation (IMF):
❖Maintained for 3 to 4 weeks and at the end
of this period IMF wires and the lower arch
bars are removed.

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❖Internal skeletal wire suspension:
❖Many times in addition to IMF, additional
support is required for immobilization of
the jaws.
❖Craniomaxillary or craniomandibular
suspension can be carried out using stable
point above fracture line.
❖Selection of site for suspension wire will be
dependent on the level of fracture line.

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❖The procedure for internal skeletal wire
suspension is done through a minor surgery.
• Application of arch bars
• Reduction of fracture by closed method -
occlusion is checked
• Fixation of the midface to base of skull by
suspension wires.

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• Fixation of the midface by tightening the
suspensory wires and intermaxillary
fixation.
• For edentulous patients, available
prosthesis or Gunning splint is used.

56. • LeFort I fracture: Intermaxillary fixation by
zygomatic arch suspension, if necessary
additional suspension at the piriform aperture.
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57. • LeFort II: Zygomatic arch suspension or frontal
bone suspension. Intraosseous wiring may be
done at infraorbital margins.
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58. • LeFort III: Intraosseous wiring at
zygomaticofrontal sutures
frontomalar suspension is
and bilateral
used after the
application of arch bars. Intraosseous wiring
may be done at the infraorbital margin, if step
deformity exists
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59. Maxillary suspension
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• Open Reduction
– Carried out under endotracheal anesthesia with
nasal intubation.
– Intraoral vestibular incision is taken from first
molar to first molar region on either side.
– Mucoperiosteal flap is reflected to expose the
fracture line.
– After identifying the fracture line, in old fractures,
an osteotome is inserted to mobilize the fragment.

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– Disimpaction forceps can be used and the
fragment is brought into normal occlusion by
manipulation.
carried out and fracture– Temporary IMF is
fragments are fixed under direct vision by
intraosseous wiring or minibone plates with
screws.

62. Various skeletal incisions for exposure
of midface skeleton are follows:
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1. Supraorbital eyebrow incison
2. Subciliary incision
3. Median lower eyelid incision
4. Infraorbital incision
5. Transconjunctival incision
6. Zygomatic arch incision
7. Transverse nasal incision
8. Vertical nasal incision
9. Medial orbital incision.

63. Treatment protocol Le Fort I
• Undisplaced Le Fort I with minimal occlusal discrepancy-
Simple MMF -4 wks or direct fixation with no MMF.
• Displaced Mobile Le Fort I with ant. Open bite – Direct
fixation or indirect suspension with MMF.
• Communited # not treated with plate or wire fixation -
MMF & suspension.
• Edentulous patient- Same treatment but intraosseous fixation
not feasible, a custom acrylic occlusal splint made & MMF is done.
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64. Treatment protocol Le Fort II
• Undisplaced Le Fort II with minimal occlusal discrepancy -
Circumzygomatic suspension + MMF- 4 wks or direct fixation at
zygomaticomaxillary buttress.
• Displaced mobile Le Fort II with Ant. Open bite – Direct/ Indirect
fixation with MMF.
• Communited # not amenable to plate/wire – MMF.
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65. References
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• Contemporary Oral and Maxillofacial Surgery 6th
Edition – Hupp, James (Chapter 25 Management of
facial fractures)
• Maxillofacial injuries – A synopsis of Basic Principles,
Diagnosis and Management - George Dimitroulis,
Brian Avery (Chapter 6 ).
• https://sites.google.com/site/drtbalusotolaryngology
/rhinology/buttress-system-of-midface ‘Buttress
system of midface’. Accessed on 14.2.2016.
• Textbook of Oral and Maxillofacial Surgery 3rd Edition
– Neelima Anil Malik (Chapter 29 + 30).

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Thanks