Dr V.RAMKUMAR

CONSULTANT DENTAL &FACIOMAXILLARY SURGEON

REG NO: 4118 –TAMILNADU- INDIA (ASIA)

LeFort fracture  Fracture of middle third

CLASSIFICATION:

A.Fractures not involving occlusion1.Centralregion:

a. Fractures of the nasal bones and / or nasalseptum

b. Fractures of the frontal process of the maxilla.

c.Fractures of type ‘a’ and ‘b’ which extent into the ethmoid bone (nasoethmoid).

2. Lateral regions : Fractures involving the zygomatic bone, arch and maxilla (zygomatic complex) excluding the dentoalveolar component.

d. Fractures of types ‘a’, ‘b’ and ‘c’ which extent into the frontal bone (fronto-orbito-nasaldislocation).

B. Fractures involving the occlusion

1.Dentoalveolar 

2.Subzygomatic

a)LefortI(low–level) .Unilateral

.Bilateral

b)LeFortII(pyramidal) .Unilateral

.Bilateral

3.Suprazygomatic:

LeFort III (high level or cranio facial dysfunction): .Unilateral .Bilateral

Signs and symptoms of LeFort I fracture

1.    Floating maxilla

2.    Swelling of upper lip

3.    Posterior gagging of occlusion

4.    Bleeding from nose

5.    Echymosis of palatal region (molar area)

6. Derangement of occlusion

LeFortIIfractureLeFortIIfracture

This is otherwise called a pyramidal fracture This is otherwise called a pyramidal fracture because of the nature of the fracturelines. because of the nature of the fracturelines. The top portion of the pyramid is at the nasal The top portion of the pyramid is at the nasal bones and the fracture line runs laterally involving bones and the fracture line runs laterally involving the lascimal bones, the medial wall of the orbit the lascimal bones, the medial wall of the orbit and the infraorbital border, fracturing through or and the infraorbital border, fracturing through or medial to the infraorbital foramen and runs medial to the infraorbital foramen and runs backward beneath the zygomaticomaxillary backward beneath the zygomaticomaxillary buttress through the lateral wall of the maxillary buttress through the lateral wall of the maxillary sinus.sinus. It also fractures the pterygoid plates. The zygoma It also fractures the pterygoid plates. The zygoma femains intact with the base of the skull.femains intact with the base of the skull.

Signs and symptoms of LeFort II fracture

1.Gross oedema of soft tissue of middle 3rd of face

2.Bilateral circumorbital echymosis

3.Bilateral subconjunctival echymosis

4.Deformity of nose

5.Bleeding from nose with without nasal obstruction

6.Dish face deformity of face

7.Retro positioning of maxilla with posterior gagging

8.mobility of upper jaw at LeFort II level

9.Limitation of ocular movements

10.CSF rhinorrhoea, appreciated by salty taste

11.Tenderness and sepration of infraorbital margin and zygomatic buttress.

LeFortIIIFracture

These fractures are often called craniofacial disjunction and the fracture actually separates the entire facial bones from the cranial base.

The fracture runs parallel to the base of the skull.

This is sometimes termed ‘high level’ fracture or transverse fracture

The fracture line runs through the nasal

bone and continues posteriorly involving the

lacrimal bones and the full depth of the

ethmoid bone, and runs around the optic

foramen, involves the inferior orbital fissure,

the pterygomaxillary fissure and later orbital

wall involving the frontozygomatic suture,

LeFort III fractureszygomatic arch also.

Sings and symptoms of LeFort III fracture

1. Tenderness and separation at frontozygomatic suture and zygomatic arc.

2. Lengthening of face

3. Enophthalmos

4. Hooding of eyes

5.CSF rhinorrhoea

6.Tilting of occlusal plane

7.Mobility of whole facial skeleton as a single block

Management of middle third fracture DIRECT /INTERNAL FIXATION OF MAXILLA

A. Direct osteosynthesis :

a) Transosseous wiring at fracture :

i. LeFort I (Alveolar /midpalatal)

ii.  LeFort II (orbital rim /zygomatic buttress)

iii.LeFort III (dentozygomatic and pentonasal)

b) Miniplates:

i. Stainless steel plate /titanium plate

ii. Microplating

iii. Compression plates

. Dynamic . Eccentric

iv. Polyglycolic acid resorbable plates

c) Transfixators with kinschnes wire or steinman pin

i. Transfacial

ii. Zygomatic septal

B. Supression wires to mandible

a. Frontal

1.  Central 2.  Lateral

b. Circumzygomatic

c. Zygomatic

d. Intraorbital

C. Support

a) Antral pack b) Antral ballon

  External Fixation of maxilla

1. Craniomandibular

a. Box frame

b. Halo frame

c. Plaster of paris head layer

2.Craniomaxillary

a.Supraorbital pins

b.Zygomatic pins

c. Haloframe

INTERNAL SUSPENSION

Internal suspension for stabilization of middle third fracture is of following types :

a. Circumzygomatic suspension

b. Zygomatic suspension

c. Intraorbital suspension

d.  Pyriform aperture suspension

e.  Frontal

1.  Central 2. Lateral

(A) Circumzygomatic suspension

This technique is used in subzygomatic fractures where the zygoma is intact. The wire is passed around the zygomatic arch.

Technique

An obwegeser bone awl is pierced extraorally at the point of the junction of the temporal and frontal processes of the zygomatic bone.

It is directed beneath the zygoma intraorally in such a way as to enter the oral cavity in the buccal sulcus at the first molar region.

The wire is attached and the bone awl is withdrawn to a level where is tip lies just above the arch without emerging from the skin.

The awl is then passed over the lateral aspect and directed downwards to enter the oral cavity at the original point in the buccal sulcus.

 Instead of a bone awl a wide born spinal needle can also be used for the purpose.

The wire is sawed so as to cut through the soft tissue and come in contact with the zygomatic bone.

The wire is then fixed to the arch bar or splint, either to the maxilla or mandible in the premolar area.

(b) Zygomatic suspension:

The inferior ridge of the zygomatic buttress is used for suspension.

The area is approached through the buccal sulcus.

(c)Infraorbitalsuspension

A small hole is drilled through the lower border of the orbit and the wire is suspended from the border.

The area is approached through a 2.5 cm, semilunar incision beneath the orbit.

intraoral approach through the buccal sulcus above can also be used for this purpose.

A 3 cm incision is placed above the canine fossa.

During drilling of the hole and threading the wire the eyeball should be well protected by malleable retractors.

(d) Pyriform aperture suspension

A 2 cm incision is placed transverse above the lateral incisor and the bony pyriform aperture is exposed.

A drill hole is made 1 cm from the free border to the lateral side.

The wires are then fixed to the appropriate loop or splint on the arch.

This method is useful in cases of LeFort I type of fractures.

 

(i)Lateral

An incision is made in the lateral border of the eyebrow to expose the zygomatic process of the frontal bone just above the frontozygomatic suture.   

Frontal suspension

A bur hole is drilled about 5 mm above the suture line.

The wire is passed and the both ends together

are passed downward and forward behind the

zygomatic bone using a Rowe's zygomatic bone

awl to emerge in the buccal sulcus near the first

molar tooth.

A pullout wire is incorporated at the region

where the wire passes through the bone hole.

This facilitates easy removal of the wire after the

completion of the treatment.

This type of suspension is used in cases where

the fracture is supra zygomatic .

(ii)Central

This method was introduced by Kufner (1970). A 2 cm incision is made horizontally on the forehead just above the frontal sinus.

A Roger Anderson pin is introduced in an oblique downward direction engaging the inner table of theskull.

A 2 cm subcutaneous tunnel is created below the pin. An level is passed through the vestibule of the cavity in the upper canine region and passing lateral to the pyriform margin of the nose in front of the lacrimal gland and emerges through the subcutaneous tissue tunnel.

The two ends of the wire (looped around the pin) is engaged in the awl and withdrawn.

The same procedure is repeated on the opposite side and wires are pulled to remove any slackness.

After reduction of the fracture the wires are fixed to the maxillary or mandibular splints or loops for fixation.

Duration of treatment:

The duration of treatment varies depending on the site of fracture, condition of each case and the treatment modality.

As a general rule the intermaxillary fixation has to be kept in position for a period of three to four weeks in children and adolescents.

In adults the period of IMF is 5 to 6 weeks.

In old patients and in infected cases the period of fixation has to be increased from 7 to 10 days more.

.COMPLICATIONSIn properly treated maxillofacial injuries complications are comparatively rare.

The complications seen are :

1 Anaesthesia:

Anaesthesia of the lower lip occurs in cases of neuropraxia, axonotmesis or neurotmesis of the mandibular nerve.

If the infraorbital nerve is involved anaesthesia occurs in the region of lower eyelid, lateral part of the nostril, upper lip on the affected side and the anterior teeth.

This may occur in fracture of the body of the mandible.

Neuropraxis will usually recover in a period of few weeks.

But if the nerve is severed it may take about 1 to 2 years for recovery.

2. Malunion and deformities

Deformities of the face occur if the reduction is not satisfactory or malunion occurs.

In the case of mandible, functional remodelling takes place very rapidly in a matter of months.

Proper remodelling does not take place in the instance when the fracture at one side of the genial tubercle is malpositioned.

This results in a marked asymmetry.

In the middle third injuries, improper reduction can result in flattening of the face, dish face deformity and anterior open bite with gagging of the molar teeth.

Anterior open bite with gagging of the molar teeth occurs in bilateral condylar fractures also.

Infection is a very rare complication. It occurs if the root stumps are left in the fracture line or in cases where the general resistance of the patient is poor.

Infection can also occur when there is improper fixation causing mobility at the fracture site.

3.INFECTION

4. Superior orbital fissure syndrome

Trauma to the zygomatic complex sometimes may damage the contents of the superior orbital fissure.

Haematoma or aneurysm within the fissure affects the 3rd, 4th and 6th cranial nerves, resulting ophthalmoplegia, ptosis, proptosis and a fixed dilated pupil.Unless the nerve is traumatized there is complete or partial recovery.

5. Non-union and delayed union

Nonunion is comparatively rare in the maxillofacial region. However, non-union or delayed union occurs in the following conditions :

(a)If a tooth has been left in the fracture line.

(b)The fracture is infected due to some other reasons.

(c)Inadequateimmobilization.

(d) Patients debilitated by systemic diseases and deficiencies.

  6. Derangement of the occlusion6. Derangement of the occlusion

In a satisfactorily performed treatment, occlusal In a satisfactorily performed treatment, occlusal derangement is minimal and this gets corrected derangement is minimal and this gets corrected by itself as the patient starts using the teeth.by itself as the patient starts using the teeth.

If there is a persistence of traumatic occlusion If there is a persistence of traumatic occlusion selective grinding is done.selective grinding is done.

If occlusal derangement is severe in neglected If occlusal derangement is severe in neglected fractures refracutural of the fragment and fractures refracutural of the fragment and correction is performed.correction is performed.

 7. Ankylosis of the temporomandibular joint

This is comparatively higher in young children.

The chances are more if there is an intracapsular fracture.

Prolonged immobilization also may result in ankylosis of the temporomandibular joint.

8. Other complications

Diplopia, enophthalmos, strabismus, etc. are certain other complications associated with injuries of the orbit.

Deviated nasal septum my result in blockade of the nares.

Damage to the nasolacrimal duct result in epiphora.

Anosmia occurs if the olfactory nerve is affected due to the communication of the cribriform plate of ethmoid.