midface trauma is a commonly encountered fracture, this presentation entails all the clinical features and treatment of midface fractured

1. Le Forte Fractures
PRESENTED BY: GAURI BARGOTI
MODERATED BY: DR SHIVAM AGGARWAL

2. Contents
Introduction
Anatomy of mid-face
Leforte 1 and treatment
Leforte 2 and treatment
Leforte 3 and treatment
References

3. Introduction
The midface is important functionally and cosmetically.
 It serves an important role in vocal resonance within the sinuses of the facial bones as well as
in the function of the ocular, olfactory, respiratory, and digestive systems
The face is also fundamental to interpersonal recognition and the perception of self-image

4. Anatomy
The midfacial complex is constructed of a series of vertical pillars that primarily provide
protection from vertically directed forces.
These include the nasomaxillary (nasofrontal), zygomaticomaxillary, and pterygomaxillary
buttress
These vertical pillars are further supported by the horizontal buttresses—the supraorbital or
frontal bar, infraorbital rims, and zygomatic arches.

6. Classification Of Leforte
Rene Le Fort’s cadaver studies in the early twentieth century defined the three weakest levels of
the midfacial complex when assaulted from a frontal direction.
He defined the three most common “linea minoros resistentiae,” which
are classified as the Le Fort I, Le Fort II, and Le Fort III fractures.

7. LeForte 1: results from force directed above
the maxillary teeth resulting in floating palate
LeForte 2: It results from the forces
directed at the nasal bone, resulting in
midface through orbit and midface region
LeForte 3: Fracture directed at orbital level,
resulting in craniofacial dysfunction

8. EMERGENCY CARE
Initial evaluation of the severely injured midface can be an intimidating experience.
Emergency care should be immediately initiated, applying the principles of Advanced Trauma Life
Support (ATLS).
The airway is immediately evaluated for obstruction
The oropharynx must be manually cleared of any fractured teeth, dentures, and/or blood clots. If
stable, the patient may be placed in a lateral decubitus position and mild Trendelenburg position to
allow optimal drainage. If oral or nasal bleeding is encountered, these sites should be packed.
If bleeding is uncontrollable, a definitive airway should be established immediate

9. Emergency care
Any patient with facial trauma is presumed to have a cervical spine injury and should be
stabilized with a rigid collar until ruled out by appropriate examination
A cricothyroidotomy is also an appropriate option for establishing an emergency definitive
airway in this setting.
If nonurgent airway control is needed in the setting of cervical spine fracture, an awake
fiberoptic intubation is likely the safest option because no atlantooccipital extension is required
with this technique
After definitive airway control is obtained, the ATLS protocol may continue

10. Facial examination
Asymmetry and facial lacerations
Otorrhea and Rhinorrhea
Palpation of craniofacial skeleton
Ocular examination
Zygomatic arches, nasal area
Mandibular opening
Maxillary arches

11. Le Fort type I fractures are caused by a
force delivered above the apices of the
teeth

12. CLINICAL EXAMINATION OF LEFORTE 1
Mobility and malocclusion of maxilla
Hypoesthesia in infraorbital region
Fracture of palatal suture line
Palatal ecchymosis
Nasal septum may be fractures or buckled

14. This fracture pattern involves the nasofrontal
suture, nasal and lacrimal bones,
infraorbital rim in the region of the
zygomaticomaxillary suture,
maxilla, and pterygoid plates

17. Treatment
ORIF is advantageous for treatment of these fractures.
If the nasofrontal suture area is intact and continuous with the maxillary segment, bilateral
intraoral exposure allows appropriate four-point fixation.
 However, the orbital floor, inferior orbital rim, or nasofrontal region often requires exploration
and repair

18. Basic Incisions

19. LE FORT TYPE III FRACTURE

20. Classic dish face deformity
Mobility of the zygomaticomaxillary
complex
CSF leakage, edema, periorbital
ecchymosis, traumatic telecanthus, and
epiphora may be observed

21. Treatment
As a general principle, treatment should begin once the edema from the initial insult has begun to
subside but should not be delayed for more than 10 to 14 days.
Gruss et al have proposed a method of reconstruction whereby reconstruction begins with the outer
framework and progresses to the inward facial structures, from stable to unstable areas
A second school of thought, popularized by Markowitz and Manson,2 focused on reestablishing facial
width at the NOE complex and proceeding in laterally
Marciani and Gonty have summarized the four factors contributing to positive outcomes following
reconstruction of craniomaxillofacial trauma. These are early definitive treatment, anatomic and
functional repair of NOE injuries, wide exposure of fractured segments, and anatomic repositioning
and stable fixation in all planes

23. Complications
Complications following midfacial trauma are fairly common.
A retrospective study of 20 patients requiring secondary reconstruction for periorbital
deformities following initial midfacial trauma repair has concluded that the primary reason for
orbital complications is a malpositioned zygoma.
Other notable complications include paresthesia of the infraorbital nerve, orbital dystopia,
enophthalmos, diplopia, malunion, and lacrimal system dysfunction. These are discussed in the
following sections.

24. References
Oral and Maxillofacial Trauma,Fonseca Walker 4E (2013)