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- Dr. Dona Bhattacharya


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1. Introduction

2. Surgical anatomy

3. Classification

4. Etiology

5. Clinical features6. Management

7. Conclusion

8. References


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Area between a superior plane drawn through the FZ suturestangential to the skull base and inferior plane at the level ofmaxillary occlusal surface

Triangular region with widest dimension facing anterior


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Middle 3rd of face is composed of

Paired Bones Unpaired Bones

Maxilla Vomer

Zygomatic bone Ethmoid

Zygomatic process of

temporal bone

Sphenoid (Pterygoid plates)

Palatine bone

Nasal bone

Lacrimal bone

Inferior conchae


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Maxilla central bone; prominentposition where trauma hits face

This structure is analogous to amatchbox sitting below and anteriorto hard shell containing brain

Act as cushion for trauma directedtowards cranium from anterior orantero-lateral direction


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Areas of weakness act as crumple zone. Sutures

Areas of strength: pillars of face


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This arrangement with stands force of mastication

from below and protects the vital structure

Bones easily fractured from forces applied fromother directions.

Clinical implications


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Soft tissue attachments


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1. Alphonso Guerin(1886)

2. Rene Le Fort Fracture classification (1901)

3. Rowe and william classification (1985)

4. Modified Le fort classification (Marciani,1993)

5. Donag,Endress,Mathog classification(1998)


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Pitfalls:

a) # caused by loc penetrating missile injuries & gunshot wounds not

included.b) Only meant for bilateral # occuring at same levelc) mid palatine split along palatal suture not describedd) Inaccurate prediction of reduction techniques.


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Fracture not involving the occlusionCentral region

Nasal bone/ septum (lateral, anterior injuries)Frontal process of the maxillaNasoethmoidFronto-orbito-nasal dislocation

Lateral region (zygomatic complex ,arch, dento-alveolar fracture

Fracture involving the occlusionDento alveolar

Subzygomatic:Le Fort (I, II)

Supra zygomatic:

Le Fort III


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From: Donat TL et al. Facial Fracture Classification According to Skeletal SupportMechanisms. Arch Otolaryngol Head Neck Surg 1998;124:1306-1314.


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Assault

RTA

Gunshot wounds

Sports

Falls

Industrial accidents


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Prevalence of mid-face

fractures

Fracture Type Prevalence

Zygomaticomaxillary complex (tripod fracture)

40 %

LeFort

I 15 %

II 10 %

III 10 %

Zygomatic arch

10 %

Alveolar process of maxilla 5 %

Smash fractures 5 %

Other 5 %


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A). Le fort I/ Floating fracture/ Guerin fracture/ Low levelfracture/ Subzygomatic fracture

1. Mobility of maxillary alveolar segment (floating fracture)

2. Pain and tenderness while speaking or clenching3. Ecchymosis or laceration in labial or buccal vestibule

4. Ecchymosis at GP foramen (Guerin sign)

5. Swelling and oedema of upper lip

6. Mal occlusion7. Bilateral epistaxis

8. Brusing of palatal tissues (15-20% of cases)

9. On palpation tenderness over buttress area

10. Percussion of teeth cracked pot sound

Clinical Features


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B). Le fort II/ Pyramidal fracture/ Mid level fracture/ Subzygomaticfracture

1. Oedema mid third of face (Moon face)

2. Paresthesia of cheek

3. Bilateral circumorbital ecchymosis

4. Bilateral subconjunctival haemorrhage

5. Dish face deformity6. Depressed nose

7. Epistaxis

8. CSF rhinorrhea

9. Limited ocular movement (Diplopia)10. Mal occlusion

11. Inability to open mouth

12. Step deformity at IO margins

13. Mobility of fractured fragment at nasal bridge and IO margins

14. Percussion of teeth cracked pot sound


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C). Le fort III/ Craniofacial dysfunction/ High level fracture/Suprazygomatic fracture

1. Oedema of face (Panda facies)

2. Bilateral periorbital edema

3. Bilateral circumorbital ecchymosis (Racoon eyes)

4. Bilateral subconjunctival haemorrhage

5. Dish face deformity

6. Depressed nose, flattening of nose

7. Epistaxis

8. CSF rhinorrhea

9. Limited ocular movement (Diplopia, Enophthalmos)

10. Dystopia, hooding of eyes with antimongloid slant

11. Haemotympanum

12. CSF otorrhoea

13. Mal occlusion posterior gagging of occlusion

14. Inability to open mouth

15. Mobility of fractured fragment at NF, FZ sutures

16. Tenderness over zygomatic bone, arch and FZ suture17. Ecchymosis at mastoid process (Battles sign)


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1. Emergency care and stabilization

2. Initial assessment

3. Definitive treatment4. Continuing care


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Airway immediately evaluated for obstruction

Control of oral or nasal bleedingPossibility of C spine fracture endotracheal incubationshould not be attempted

Cervical collar in case of suspected spine fractures

Circulation


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LeFort I fracture

LeFort I fracture with Mandible fracture

LeFort I fracture with Nasal injury

LeFort II fractureLefort III fracturePanfacial fractures

Nasal Airway

Edentulous Partially Dentatewith space

Fully Dentate

Oral Airway

through portalcut in Gunningsplints ordentures

Oral Airway

with tubedisplacedthrough space

Surgical

Airway

Guided Nasal

Intubation fixate maxillaand mandible switch to OralAirway fornasal/NOEreduction


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Premlatha Shetty et al;submental intubation in patients with panfacial fractures;Indian journal of anesthesia,vol

55,issue 3,may 2011


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1. History

2. Palpation of entire facial skeleton3. I/O Examination

4. Ophthalmologic exam / consultation

5. Radiographic examination


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After stabilization of patients condition, complete facial

examination is performed.

1. Laceration, bruising , etc.

2. Obvious depressions on nose, check, etc.

3. Facial asymmetry, swelling

4. Nasal discharge (Blood/ CSF)


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Features CSF fluid Nasal secretion

History Nasal or sinus surgery, head injury orintracranial tumour Sneezing, nasal stuffiness,itching in the nose orlacrimation

Flow of discharge A few drops or a stream of fluid gushesdown when bending forward orstraining; cant be sniffed back

Continuous. No effect ofbending forward orstraining. Can be sniffed

back

Character ofdischarge

Thin, watery and clear Slimy (mucus) or clear(tears)

Taste Sweet Salty

Sugar content More than 30 mg/dl (Compare withsugar in CSF after lumbar puncture assugar is less in CSF in meningitis)

Less than 10 mg/dl

Presence of 2transferrin

Always present. It is specific for CSF Always absent


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Palpation of facial skeleton

Bowstring

test


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1. Periorbital edema

2. Periorbital ecchymosis3. Proptosis4. Diplopia5. Pupillary size and shape

6. Sub-conjunctival haemorrhage7. Lid laceration8. Visual acuity9. Dystopia


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Inspection Palpation Percussion

Laceration

EcchymosisRestricted mouthopeningOcclusion

Tenderness

Mobility of teethCrepitusMobility of fracturedfragment

Cracked pot sound


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1. OPG

2. OM

3. Lateral skull view

4. Occlusal view for split palate

5. CT Scan

6. 3D CT Scan

7. MRI


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Aims of treatment

1. Relieve pain2. Precise anatomical reduction of the # fragment

3. Stable fixation of the reduced fragment

4. Restore function

5. Restore the dental occlusion


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Preoperative planning:

Need for surgical airway

Open/closed method of reduction Necessity for and type if IMF to be employed in case for

closed reduction

Type of osteosynthesis in case of open method

Need for internal suspension in case of communited # Timing of surgery


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Optimum time for reduction of mid face fracture is 5thto 8thpost injury day

After this with every succeeding day disimpaction becomedifficult and open reduction more essential


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Open reduction Closed reduction

Displaced # Non displaced #

Multiple # of facial bones Grossly communited #

Edentulous maxillary # - with severe

displacement

Fractures associated with significant

loss of soft tissuesEdentulous maxillary # - opposite toEdentulous mandibular #

Edentulous maxillary #

Delay of treatment In children with developing dentition

Inter position of soft tissues betweennon contacting displaced # segment

Systemic condition contra indicatingIMF


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1. Accurate diagnosis

2. Determination of priority of treatment

3. Early reconstruction4. Wide exposure of vertical and horizontal pillar of face

5. Use of bone graft to restore skeletal form

6. Use of rigid fixation to stabilize # segment

7. Restoration of bony support to over lying soft tissue envelop


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1. Intra orala) Vestibular

2. Extra orala) Lower eye lid incision

i. Sub cilliaryii. Infra orbital

iii. Trans conjunctivalb) Coronal approachc) Midface degloving approach


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https://www2.aofoundation.org/wps/portal/!ut/p/c1/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3Q1dDA08XN59Qz8AAQwMDA6B8JJK8haGFgYFnqKezn7GTH1DahIBuP4_83FT9gtyIcgBttnJy/dl2/d1/L2dJQSEvUUt3QS9ZQnB3LzZfQzBWUUFCMUEwR0dSNTAySkowOFVIRzIwVDQ!/?contentUrl=/srg/92/04-Approaches/A20_1-maxillary-vestibular.enl.jsp&soloState=lb&bone=CMF&segment=Midface&subStep=22


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TechniqueAdvantagesDisadvantage

Indication


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TechniqueAdvantages

Indication


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1. Manual reduction

2. Reduction with wires3. Reduction using disimpaction

forceps

4. Reduction with bone hook

5. Reduction with elastics


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1. Simple manipulation by hand

2. Use of dental compound loaded in impression tray(Dingman and Harding, 1951)

3. Use of rubber dam sheets, long ribbon/strip gauze orrubber catheter (Propescu and Burlibasa, 1966)


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1. Rowes maxillary disimpaction forceps2. HaytonWilliams disimpaction forceps


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Movements:

1. Downwards to affect disimpactionof pterygoid plates down

2. Anterior

3. Combination of forward tractionwith rotational movement in bothhorizontal and vertical axis

Universal rule

Oculocardiac reflex


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Used in delayed cases:

1. Intra oral elastic traction

2. Extra oral elastic traction

Maxillary # fixation


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y

Internal fixation

Direct osterosynthesis

1. Miniplates

2. Intraosseous Wires

- high(FZ,FN)

- Mid(buttress,orbital rim)

- Low(alveolar/midpalatal)

Suspension wires

1. Frontal

2. Circumzygomatic

3. Zygomatic

4. Circumpalatal

5. Infraorbital

6. Piriform aperture

7. Peralveolar

External fixation

Craniomandibular

Craniomaxillary1. Supraorbital pins

2. Zygomatic pins

3. POP head frame

4. Halo frame

5 . Levant frame6. Box frame


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Intraosseous wires

By Merville & Derome(1976)


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Miniplates and screws

These are monocortical, semi-rigid fixation device whichprovide 3D stability.

Designs: X, H, L, T, Y

Thickness:0.6-1 mm


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Plating system depends on:

1. Rigidity of plate

2. Width and shape3. Diameter and number of screws

Increase in width provides more stability towards rotational forces.

Type of metal:a. Stainless steel

b. Titanium

c. Vitallium

Advantages:

1) Easily adaptable

2) Monocortical

3) Functional stability

4) Reduced surgical access


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1. Minimum 2 screws required in each bone segment to preventrotation in X and Y axis

2. Farther the point of stabilization the more effective the deviceis in preventing rotation

3. Large diameter screws are not used because of constraintimposed by particular anatomic location

4. All screw require adequate intervening bone between adjacent

holes to preserve integrity of screw bone interface


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Le fort I: L plates at zygomatic buttress

Curved plate at pyriform aperture

3D plate sometimes to fix buttress #

Le fort II: Linear/Y plate/curved plate along intra orbital rim

L plate at buttress

Le fort III: Linear/Y plate at FN and ZF junction


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Used for retention and alignmentof small fragments or bone

grafts.

Sites of application:

1. Anterior and lateral wall ofmaxilla

2. Anterior table of frontal bone


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Introduced by Kuffner, 1970

Two types

1. Central

2. Lateral

Usually used for high midfacefracture.


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Incision in lateral 3rd/nasal process offrontal bone

Exposure of zygomatic proces/outercortex of frontal bone

Drilling of bur hole and placement ofscrew

Passage of SS wire attached to awl;through incision into maxillary

vestibule

Release of wire and attachment to thearch bar


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Indication: le fort II and III fractureIncision in maxillary vestibule above

canine

Subperiosteal dissection and

exposure of infra orbital rim

Drill hole and passage of wire aboveIO rim and back to oral cavity

Release of wire and attachment tothe arch bar


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Also known as buttress wire

Incision in maxillary vestibule below buttress

Exposure of ZM junction

Drill hole and passage of wire

Release of wire and attachment to the arch bar


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Cubero Technique


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Introduced by Bowerman andConroy, 1981

Simple technique for fixinggunning splint to maxilla

Superior retention, stability and

decreased discomfort

Incision in maxillary vestibule over nasalspine

Exposure of ANS

Drill hole and passage of wire

Release of wire and attachment to the archbar


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Incision in maxillary vestibule in canine fossa

Subperiosteal dissection and exposure ofpyriform aperture

Elevation of nasal mucosa and drill hole from

lateral to medial

Passage of wire and attachment to the archbar


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Drill hole in palatal aspect of splint

Direct wire through alveolus over canine region andemerge in Buccal Sulcus

Passage of 0.5 mm SS wire and secure to splint


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Trend towards ORIF has changedExternal fixation is used in cases where there is depressed posteriordisplaced #

Principle:

External appliances relies on sandwiching the midface between base ofskull and mandible to provide cantilever support to midface in 3Dfollowing disimpaction and closed reduction.

Disadvantages:


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Disadvantage:

1. Heavy2. Uncomfortable3. Unstable

Method of

application


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Described by Crawford;modified by

Mackenzie & Ray,1970

Secure the frame work to the skulldirectly by screw pins

Advantage:1. Light weight2. Adjustable3. Titanium Screw pin


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More stable and rigid

Other unstable fracture fragmentcan also be attached to vertical rod


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Developed at RoyalMelbourne Hospital

Provided simple rigidcraniomaxillaryfixation betweensupraorbital rims andmaxilla connected bycentral rod attachedat lower end by meansof cast metal splint oracrylic splint


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1. Provide dimensional stability

2. Indications:1. Grossly communited #2. Extensive soft tissue loss3. Bone gap>5mm

3. Sites:1. Calvarium

2. Illium3. Rib


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1. Resorbable plates

2. Endoscopic management(Harold Hopkins)

3. Distraction osteogenesis(Ilizarov)


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Immediate

1. Airway2. Nasal hemorrhage3. Ophthalmic complications4. Inaccurate reduction

5. Insecure fixation

Late complications

1. Non union2. mal occlusion3. Cranial nerve dysfunction4. Secondary nasal deformity

5. Dacrocystitis6. Facial asymmetry


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Due to the complex 3D arrangement of the structures of middle

third of face,management is complicated.Proper reduction ofthe # fragments remains the key component.

A proper understanding of the anatomy,fracture patterns, itsclinical presentation and the available treatment modalities is

necessary to successfully treat Le Fort Fractures.


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1. Oral & maxillofacial trauma-Fonseca & walker vol 22. Oral & maxillofacial surgery-Fonseca vol 33. Oral & maxillofacial trauma-Rowe & Williams vol 24. Principles of Oral & maxillofacial surgery-Peterson5. Fractures of middle third of face-Killey & Kay6. Oral & maxillofacial surgery-Fragiskos7. Maxillofacial trauma & facial reconstruction-Peter Ward Booth

8. Oral & maxillofacial surgery-Peter Ward Booth: vol 29. Chen Lee et al ;Applications of the Endoscope in Facial fracture

Management, seminars in plastics surgery/volume 22, number 12008


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9. Manual of internal fixation-J Prein

10. Donat TL et al. Facial Fracture Classification According to SkeletalSupport Mechanisms. Arch Otolaryngol Head Neck Surg1998;124:1306-1314.

11. Mirko S. Gilardino et al;Choice of Internal Rigid Fixationmaterials in the treatment of facial fractures; craniomaxillofacialtrauma & reconstruction/volume 2, number 1 2009

12. Khaled M Emara et al ;Methods to shorten the duration of anexternal fixator in the management of fractures; World J Orthop2011 September 18; 2(9): 85-92

13. Chan hum park et al;resorbable skeletal fixation systems fortreating maxillofacial bone fractures; arch otolaryngol head necksurg/vol 137 (no. 2), feb 2011

14. Premlatha Shetty et al;submental intubation in patients withpanfacial fractures;Indian journal of anesthesia,vol 55,issue 3,may

2011.


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