maxillary fractures........ le forte 1 le fort 2.. managment... surgeries

1. *

2. *
*Introduction
*History
*Surgical Anatomy of Maxilla
*Etiology of Lefort fractures
*Epidemiology
*Classification & LeFort fracture lines
*Clinical examination
*Clinical features
*Diagnostic radiography

3. • Management
* - Emergency care
* - Early care
* - Definitive care
• Complications
• Controversies
• Conclusion.

4. *
The maxilla represents the bridge between the cranial
base superiorly and the dentition inferiorly. Its
intimate association with the oral cavity, nasal cavity,
and orbits and the important structures adjacent to it
make the maxilla a functionally and cosmetically
important structure.

5. *Fracture of these bones is potentially life-
threatening as well as disfiguring. Hence we
being maxillofacial surgeons need to do
systematic and timely repair of these fractures
to correct deformity and prevent unfavorable
sequalae.

6. *
*The first clinical examination of a maxillary fracture was recorded in
2500 BC.
*In 1822 Charles Fredrick William Reiche provided the first detailed
description of maxillary fractures.
*In 1823 Carl Ferdinand van Graefe described the use of a head frame for
treating a maxillary fracture.

7. *In 1901 , Rene Le Fort published his landmark work,
a three-part experiment using 32 cadavers.
*The heads of the cadavers were subjected to low
velocity forces; the soft tissue were then removed
and the bones were examined.

8. *

9. *
*Lacrimal fossa is partially formed by maxilla .Hence fracture can
cause injury to nasolacrimal duct.
*Damage to infraorbital nerve can occur unilaterally or bilaterally
in fracture of maxilla.
*Fracture involving orbital walls may give rise the change in the
ocular level due to separation above the attachment of
suspensory ligament of lockwood. (LeFort III)
*If orbital floor is fractured, there will be herniation of orbital
content into maxillary sinus.

10. *

11. *
*It is the second largest bone of the face
*It forms the upper jaw with the fellow of the
opposite side
*It also contributes to the formation of
1. Floor of the nose and the orbit
2. Roof of the mouth
3. Lateral wall of the nose
4. Pterigopalatine and infratemporal fossae
5. Pterigomaxillary and infraorbital fissures

12. *The anatomy of the maxilla has two main parts:
1. Body(pyramidal shape)
* Anterior surface
* Posterior surface
* Orbital surface
* Nasal surface
2. Processes
* Zygomatic
* Frontal
* Alveolar
* Palatine

14. *Road traffic accidents (most common) -40%
*Industrial accidents- 10 %
*Assault -15%
*Sports.- 25 %
*Fall.- 10 %

15. *EPIDEMIOLOGY
*Most maxillary fractures occur in young men aged
between 16 to 40 years.
*Peak age- 21 - 25 years
*Male : Female - 4:1

16. *Umair Karral

17. *Rene LeFort (1901) discovered the complex
fracture patterns of Maxilla which is broadly
classified as
1. Lefort I
2. Lefort II
3. Lefort III

18. *
*The LeFort classification has proven to be less
satisfactory to describe more complex fracture
patterns, comminuted, incomplete, combination
maxillary fractures or to describe fractures of the
part bearing the occlusal segment.

19. *
*A more precise system of describing fracture patterns
is necessary to establish an accurate diagnosis &
determine potential surgical approaches.

20. *
*Le Fort I Low maxillary fracture
Ia Low maxillary fracture/multiple segments
*Le Fort II Pyramidal fracture
IIa Pyramidal and nasal fracture
IIb Pyramidal and NOE fracture
* Le Fort III Craniofacial disjunction
IIIa Craniofacial disjunction and nasal fracture
IIIb Craniofacial disjunction and NOE fracture.

21. * Le Fort IV LeFort II or III fracture and
cranial base fracture
IV a + Supraorbital rim fracture
IV b + Anterior cranial fossa and
supraorbital rim
fracture
IV c + Anterior cranial fossa and
orbital wall
fracture

22. *

23. *
*There is separation of complete dentoalveolar part of
maxilla (Pterygomaxillary dysjunction) and the fractured
fragment is held only by means of soft tissues.
*Cause -
A violent force applied over more extensive area of
maxilla above the level of maxillary teeth results in Lefort
I fracture.

24. *
*The fracture line commences at the point on the
lateral margin of the anterior nasal aperture, passes
above the nasal floor, passes laterally above the
canine fossa and traverses the lateral antral wall, dips
down below the zygomatic buttress and then inclines
upward and posteriorly across the pterygomaxillary
fissure to fracture the pterygoid laminae at the
junction of their lower third and upper 2/3 rd

26. *
Cause –
Violent force, usually from an anterior
direction, sustained by the central region of
the middle third of the facial skeleton over an
area extending from glabella to the alveolar
margins results in fracture of pyramidal shape
.

27. *It may or may not involve infraorbital foramen. Then
fracture line now extends downward, forward and
laterally to traverse the lateral wall of antrum, just
medial zygomaticomaxillary suture line.

28. As in Lefort I , this fracture line
passes beneath the Zygomatic
buttress, inclines abruptly traversing
the pterygomaxillary fissure at a
higher level and fracturing
the pterygoid laminae approximately
midway from its base. Seperation of
entire pyramidal block from the base
of the skull is completed via nasal
Septum.

29. *

30. *
*Extra-oral & Intra-oral examination.
Inspection.
Palpation.

31. *
Inspection of midface-
*Swelling & Facial Asymmetry.
*Bruising of upper lip and lower half of mid-face.
*Bilateral Circum-orbital Ecchymosis ( Racoon’s
eye).
*Periorbital Oedema.
*Subconjunctival Hemorrhage

32. *

33. *Cerebrospinal fluid rhinorrhoea
*Lengthening of Midface
*Depressed midface (dish face)
*Saddle shaped depression of nose
*Enophthalmos
*Proptosis
* Diplopia

34. * Subconjunctival hemorrhage-
* Localized (black eye) confined to preseptal soft tissues
(Also seen in anterior cranial fossa, orbital & zmc
fractures.)

35. * Cerebrospinal Fluid Rhinorrhoea
-Watery nasal or postnasal salty discharge
(Ring Test- but it lacks sensitivity & specificity)

36. *
1. Subcutaneous Emphysema – Crepitus
2. Tenderness
3. Step Deformity
4. Abnormal Mobility of bone
5. Impairment of sensation

37. *
1. Disturbed occlusion (posterior occlusal gagging ,
open bite)
2. Haematoma intraorally over root of zygoma
3. Haematoma in palate (Guiren’s sign)
4. Fractured cusps of teeth
5. Midline diastema

38. *
*Mobility of whole of tooth bearing segment of
upper jaw elicited at fronto-nasal suture in Le
Fort II & III fracture.

39. *Mobility of whole of the upper jaw (free-
floating) elicited at infraorbital margin in Le Fort
II fracture

40. *Mobility of whole of the upper jaw (free-
floating) elicited at fronto-zygomatic suture in
Le Fort III fracture.

41. *

42. *
Clinical features -
*Slight swelling of the upper lip is seen.
*Ecchymosis present in the buccal sulcus beneath each
zygomatic arch.
*Disturbance in occlusion with variable amount of mobility in
the tooth bearing segment of the maxilla.

43. *The patient may develop open bite if the fractured segment is
mobile , due to posterior gagging of occlusion.
*Sometimes fracture of the palate can also be associated with
Le Fort I fracture.

44. *In Le Fort I, the teeth and maxilla are mobile, but the
nose and upper face is fixed.
*Percussion of the maxillary teeth results in
distinctive 'cracked-pot sound',
* No tenderness and mobility of the zygomatic arch
and bones

45. *
Clinical features -
* The resulting gross edema of the middle third gives an appearance of "moon
face" to the patient.
*On intraoral examination, retropositioning of the whole maxilla and gagging of
the occlusion are seen.
*When maxillary teeth are grasped, the mid-facial skeleton moves as a pyramid
and the movement can be detected at the infraorbital margin and the nasal
bridge.

46. * Hematoma formation is seen in the buccal sulcus opposite to the maxillary
first and second molar teeth as a result of fracture of the zygomatic buttress.
* Step deformity at the infraorbital rims or frontonasal junction is noticed.
* Orbital wall fractures can cause entrapment with limitation of ocular
movement.

47. *CSF rhinorrhoea is possible and should be looked for.
*Bilateral circumorbital ecchymosis giving an appearance of
'raccoon eyes' is invariably seen in the fractures of both Le
Fort II and Le Fort III.
*Subconjunctival hemorrhage develops rapidly in the area
adjacent to the site of injury.(mostly in medial half )

48. * Diplopia may be seen in cases of orbital floor injury.
* Pupils are at level unless there is gross unilateral enophthalmos.
* Anaesthesia or paraesthesia of the cheek as a result of injury to the
infraorbital nerve due to the fracture of the inferior orbital rim.
* Obvious deformity of nose with epistaxis.

49. *

50. *
* LE FORT FRACTURES - Treatment STAGES
1. Emergency care & Stabilization -
( First aid and resuscitation )
2. Initial Assessment and Early care-
3. Definitive Treatment-
4. Rehabilitation -

51. STAGE I - Emergency care & Stabilization
1. Maintenance of airway.
2. Control of hemorrhage.
3. Prevent or control shock.
4. C-Spine stabilization.
5. Control of life-threatening injuries.
6. Head injuries, chest injuries, compound limb
fractures, intra abdominal bleeding.

52. *Evaluate the airway -
*Existence & identification of obstruction.
*Manually clear fractured teeth, blood clots, dentures.
*Endotracheal intubation if needed.
NOTE:
*Altered level of consciousness is the most common
cause of upper airway obstruction

53. * Treatment of Blood Loss & Shock
*Hemorrhage is most common cause of shock
after injury.
*Multiple injury patients have hypovolemia.
 Monitor vital signs closely.
*Goal is to restore organ perfusion

54. *External bleeding controlled by direct
pressure over bleeding site.
*Gain prompt access to vascular system
with IV catheters.
*Fluid replacement:
*Ringer’s Lactate
*Normal saline
*Transfusion.

55. * Stabilization of associated injuries
*C-spine injury is primary concern with all maxillofacial
trauma victims.
*Signs/symptoms of C-Spine injury
*Neurologic deficit.
*Neck pain.

56. *Stabilization of associated injuries
*C-spine injury suspected:
*Avoid any movement of neck
*Establish & maintain proper immobilization until
vertebral fractures or spinal cord injuries ruled out
*Lateral C-spine radiographs
*CT of C-spine
*Neurologic exam

57. *
*Emergency care has stabilized patient.
*Initial stabilization of fractures.
*Debridement & dressing of soft tissues.
*Physical exam & history.
*Laboratory tests.
*Clinical & Radiographic Assessment of Patient.
Diagnosis of maxillofacial injuries.
* Pre-operative planning.

58. *

59. * STAGE II. Initial Assessment
 Pre-operative planning
1. Need for Tracheostomy
2. Surgical Approaches to Midface
3. Whether ‘Open’ or ‘Closed’ methods of reduction
are to be employed.
4. Necessity for & type of Maxillary fracture
Fixation.

60. *
1. Supraorbital eyebrow incision (Lefort
III)
2. Subciliary incision (LeFort II & III)
3. Median lower lid (LeFort II & III)
4. Infraorbital incision (LeFort II & III)
5. Transconjunctival (LeFort II )
6. Zygomatic arch
7. Transverse nasal (LeFort II & III)
8. Vertical nasal incision (LeFort II &
III)
9. Medial orbital incision.
10. Intra-oral vestibular incision. (LeFort
I

61. *
A ) Internal Fixation-
1. Suspension Wires
2. Direct Osteosynthesis
B) External Fixation-
1. Craniomandibular
2. Craniomaxillary

62. *

63. *
*Suspension Wires- Circumzygomatic wiring by
Obwegeser

64. Internal Fixation
Suspension Wires- Orbital rim wiring

65. *
*Incomplete fixation of fractured fragments
*Insufficient visualization of fractures by closed
reduction
*Compression against the cranial base
*No 3-dimensional stability
*Patients dislike intra-oral splints as it hinders oral
hygiene maintainence.

66. *
Intraosseous Wires-
1. Maxillary (Lefort –I )
2. Zygomaticomaxillary (Lefort –II)
3. Frontonasal (LeFort –II &III)
4. Zygomaticofrontal (Lefort III)
5. Zygomatic bone (comminuted)

67. *
. Plates & Screws for midface
fractures -
 Stainless steel mini-plating system
 Titanium mini-plating system
 Vitallium, Cobalt chromium, molybdenum alloy plates
 Bioresorbable plating system

68. *
Advantages –
1. Simple & less intraoperative time
2. Intraoral approach is sufficient
3. Postoperative IMF is not needed or period of
IMF is reduced.
4. Three dimensional stability and early return
of function.

69. *
LEFORT I FRACTURE
 SURGICAL APPROACH- MAXILLARY VESTIBULAR

70. *

71. *

72. *
 SURGICAL APPROACH-
A – Subciliary incision
B – Sub tarsal incision
C - Infraorbital incision
D - Extension of Subciliary
incision

73. Existing
Laceration
Maxillary vestibular
approach can also be
taken for LeFort II
fracture

74. CORONAL APPROACH GLABELLA APPROACH

75. *

76. *

77. *THANK
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