Le Fort’s maxillary fractures

 

Le Fort’s fractures are the fractures of the mid-face which collectively involve separation of all or a portion of the mid face from the skull base. In order to be separated from the skull base, pterygoid bones of the sphenoid bone need to be involved as these connect midface to the sphenoid bone dorsally.

Le Fort’s classification system based on the plane of injury:

-- Le Fort type 1 (horizontal) : Horizontal maxillary fracture separating the teeth from the upper face. Fracture line passes through the alveolar ridge, lateral nose and inferior wall of the maxillary sinus. Also known as the Guerin fracture.

-- Le Fort type 2 (pyramidal) : Pyramidal fracture with the teeth at its base, and naso-frontal suture at its apex. Fracture line passes through the posterior alveolar ridge, lateral walls of the maxillary sinuses, infra orbital rim and nasal bones. Upper most fracture line can pass through the naso-frontal junction or the frontal process of the maxilla.

-- Le Fort type 3 (transverse) : Cranio-facial disjunction. Transverse fracture line passes through naso-frontal suture, maxillo-frontal suture, orbital wall and zygomatic arch/zygomaticofrontal suture. Because of the involvement of zygomatic arch, there is a risk of Temporalis impingement. Unsurprisingly type 3 fractures have the highest rate of CSF leak.

Any combinations of these fractures is possible. It should be noted that Le Fort fractures are often associated with other facial fractures, neuromuscular injury and dental avulsions. Le Fort fractures most frequently result from high speed deceleration crashes in which the midface or maxilla strike a stationary object. Forces directed at the mid face straight on tend to cause Le Fort 1 and 2 fractures. If the force is directed slightly downwards a Le Fort 3 fracture may result.

Management:

Physical exam: Head and Neck trauma examination with special attention to,

1. Visual acuity or ocular exam.

2. Occlusion, look for anterior open bite and mid-facial mobility.

3. Careful inspection of the dentition, remove any dental fragments from the mouth.

4. Bony facial symmetry and palpable step off’s in the nasal dorsum, infraorbital rims, zygomaticofrontal suture area and zygomatic arch.

5. Cranial nerve V2 sensation.

Emergency intervention: Airway patency must be addressed promptly. If the airway is compromised or associated injuries dictate the need for assisted ventilation, best way to secure an airway is with a naso-tracheal intubation over a flexible bronchoscope or with a tracheostomy. The patient will likely need a tracheostomy for definitive treatment in any case. If the patient is being taken emergently to the operating room for other injuries, that is frequently an opportunity to perform a tracheostomy and intermaxillary fixation if the definitive repair of the facial fractures cannot be done at that time. Ideally intermaxillary fixation should not be placed before the patient has had a CT scan. Antibiotics with anaerobic and strep coverage should begin at admission.

Radiographic investigation: Facial films may be adequate, however they frequently lack the details of orbital and palatal involvement seen on the CT. If a CT scan is to be obtained, most routine facial films will add no further information.

Management : The definitive management of all Le Fort fractures centers around restoration of functional occlusion and reconstruction of stable bony contour. At present the most common way of internally fixating the fractures of the midface is with small plates and screws. Efforts should be made to apply the plates parallel to the nasomaxillary and zygomaticomaxillary buttresses. Once the tooth bearing segments have been aligned with intermaxillary fixation and these segments have been rigidly fixated with plates and screws, the intermaxillary fixation can be frequently removed. If needed Rowe dis-impaction forceps are used to mobilize the maxillary segment.

                             This is followed by exposure of fractures. Once all fractures have been visualized fixation is begun by plating to the most superior stable bone and working downwards. In all cases a plate should be placed over both zygomaticomaxillary buttresses. If the fracture crosses infraorbital rim, it is also plated. After all fractures have been stabilized, the intermaxillary wires can be removed and the patient’s occlusion checked. Titanium and Vitallium plates and screws are not removed. Stainless steel plates and screws which are rarely used should be removed after 6-12 months.

About the author:

Name: Dr. Abhilash Dandy

Qualification: B.D.S

I graduated as a Dentist from Sibar Institute of Dental Sciences, Guntur. I have done my externship program at Rutgers school of dental medicine, New Jersey, USA. I have clinical experience of 3 years and currently working as Administrative head — Dental wing in MediCub India, Hyderabad.