Thursday, January 17, 2008

Le Fort Fractures

The maxilla is the central keystone of the face. It links the cranial base superiorly with the occlusal plane of the lower jaw inferiorly. The maxilla has 4 processes: zygomatic, frontal, palatine, and alveolar. The maxillary sinus is housed within the maxilla and varies in size depending on the degree of pneumatization.

The fractures can be of significant functional and aesthetic importance. Functional problems can lead to disorders of occlusion, nasal obstruction, and trigeminal-nerve sensation. Aesthetic losses include decreased midface height, facial width, facial projection, and malar eminence. These losses can lead to a dish-face deformity.

Renee LeFort (1901) provided the earliest classification system of maxillary fractures. His model described "great lines of weakness in the face" using low-velocity impact forces directed against cadaver skulls. A discussion of fractures of the maxilla would not be complete without a description of LeFort's work.

LeFort Classification of Midfacial Fxs/Signs/Symptoms

Lefort I or transverse fracture of the maxilla (A in picture)

  • The result is a "floating palate" with mobility of tooth bearing segment of upper jaw
  • Disturbed occlusion
  • Palpable crepitation in upper buccal sulcus
  • ‘cracked pot’ percussion note from upper teeth

LeFort II or pyramidal fracture (B in picture)

  • produces a separation and mobility of the midface
  • Gagging on posterior teeth
  • Anterior open bite
  • Periorbital ecchymosis/hematoma
  • There may be diplopia and /or subconjunctival hemorrhage
  • There may be Infra-orbital nerve damage

LeFort III or craniofacial dysjunction (C in picture)

  • Mobile middle third of face
  • Similar symptoms as LeFort II
  • There may be CSF Rhinorrhea (25-50% of II and III fractures)

Maxillary fractures today are often the result of motor vehicle accidents. These high-velocity injuries many times produce fracture patterns not classified by the standard LeFort system, but are described simply by the anatomic structure fractured and the degree of comminution present.

Ocular injury is also commonly associated with midfacial trauma. In a report by Al-Qurainy in 1991, 90.1% of their 363 patients with midfacial trauma had some form of ocular injury. Of those, 63% had transient or minor ocular injury, 16% moderately severe injury, 12% severe ocular injury (angle recession, retinal or vitreous injury, optic nerve damage). In those patients with ocular injury 2.5% lost vision in the affected eye. This data stresses the need for a high index of suspicion for ocular injuries in patients with midfacial trauma. So a thorough eye exam should be performed including visual acuity, inspection of the anterior chamber and the retina, pupillary reflexes, and extraoccular movements. An ophthalmologic consultation may be indicated.

IMAGING

Plain film x-rays have largely been replaced by CT scans. As with zygomatic fractures, a full facial analysis from the top of the head through the mandible with 1.5 mm axial cuts will allow coronal reformatting without additional scanning. Sagittal reformatting is useful in assessing the effect of a complex orbital fracture on the inferomedial bulge of the orbital floor. If the patient presents with neurologic compromise (head injury or intoxication) and cannot comply with a complete physical examination, it is prudent to obtain a complete scan at the time that the head CT scan is obtained.

MANAGEMENT OF THE AIRWAY

Surgical management of Le Fort fractures will require correction of the occlusion and intraoperative intermaxillary fixation. Nasal intubation and tracheotomy are often the preferred approaches, as they will not interfere with the maxillomandibular fixation. The following table was adapted from a flow sheet found in the Stewart text (5th reference):

DentitionFracture Type
Nasal Airway *Le Fort I Fx
*Le Fort I Fx with Mandible Fx
Oral Airway through portal cut in Cunning splints or denture

Edentulous

Le Fort I / nasal Injury

Le Fort II Fx

Le Fort III Fx

Panfacial Fx

Oral Airway with tube displace through space

Partially Dentate with Space

Le Fort I / nasal Injury

Le Fort II Fx

Le Fort III Fx

Panfacial Fx

Guided Nasal Intubation

*Fix Maxilla / Mandible

*Switch to Oral Airway for Nasal/NOE reduction

Fully Dentate

Le Fort I/ nasal Injury

Le Fort II Fx

Le Fort III Fx

Panfacial Fx

Surgical Airway

Le Fort I /nasal Injury

Le Fort II Fx

Le Fort III Fx

Panfacial Fx

SURGICAL TREATMENT

The goals of surgical treatment 1)re-establish midfacial height and projection, 2) establish occlusal relationship, and 3) maintain integrity of nose and orbits. All patients with midface fractures are given antibiotics, because these fractures are considered open or compound. Violation of the paranasal sinus or alveolus and open soft-tissue wounds are inevitable sequelae of midface fractures. Antibiotics have been shown to decrease the incidence of infection after midface fractures.

Exposure is crucial in repair of the midface fracture. Generally speaking, a Le Fort I fracture is approached from a sublabial exposure, a Le Fort II fracture is approached with a combination of sublabial and periorbital exposure, and a Le Fort III fracture requires a combination of sublabial and bicoronal fracture for adequate exposure.

The surgical approaches to fractures of the midface have changed radically in the past 20 years. The technology has now evolved to allow for miniplate fixation to the midface instead of bulky external hardware. Complex internal wiring used to be the standard of care 10 years ago, but due to poor cosmetic results and extended periods of IMF, newer technologies (mini-plate technology) have replaced it. If large bone deficiencies are present, bone grafting may be necessary.

The following general guidelines are meant for edentulous patients, but are good start for planning for all. Those with teeth can also be treated with arch bars, etc while their general health improves. Remember most of these patients with have serious (head, neck, chest, etc) injuries also.

No Displacement

  • Soft Diet for 2-3 weeks
  • Incorporation of dentures

Displacement, Patient Stable, Good General Condition

  • Open reduction
  • Reconstruction of midfacial buttresses
  • Miniplate osteosynthesis with simultaneous preprosthetic surgery if necessary

Displacement, Patient in poor general condition

Le Fort I Level--

  • No active therapy
  • Le Fort I osteotomy later

Le Fort II or III Level--

  • Minimal therapy, repositioning of nose and orbital rim
  • Le Fort I osteotomy later

COMPLICATIONS

Early

  • Extensive hemorrhage
  • Airway obstruction
  • Infection--When given appropriate antibiotics, the risk of meningitis is small (less than 1%). Sinusitis occurs in 1-2%.
  • CSF leak
  • Ocular Problems -- Approximately 17-25% of patients with severe fractures will suffer some type of ocular problem--blindness (1-2%), diplopia, enophthalmos, epiphora, blurred vision, lacrimal drainage problems.

Late

  • Palpable or exposed hardware
  • Non-union/ Malunion
  • CN V2 Anesthesia -- The incidence of an immediate postoperative infraorbital nerve deficit from Le Fort I and II fractures has been reported at 65%. It is directly related to fracture displacement of 1 mm or more. Patients with less than 1 mm displacement regain normal sensation after 3 months. 30% of those with displacement of greater than 1 mm have a persistent sensory deficit at 1 year.
  • Disturbances of Smell and Taste may occur in 23-38% of patients with up to 80% of Le Fort III patients reporting disturbance of smell.
  • Extra-Occular Muscle Imbalance
  • Malocclusion may result from fixation of improperly reduced fractures or insufficient fixation.
  • Secondary Facial Deformities result from inadequate reduction and stabilization of the nasal bones. Nasal deformities are reported in 12-33% of upper midface fractures.

REFERENCES

Le Fort Fractures by Anil R Shah, MD and Galdino Valvassori, MD --eMedicine Article, Oct 27, 2006

Facial Trauma, Maxillary and Le Fort Fractures by David W Kim, MD and Kristin K Egan, MD --eMedicine Article, June 8, 2006

Maxillary and Periorbital Fractures by Gordon Shields MD and Francis B Quinn MD; Grand Rounds Presentation, UTMB; January 7, 2004

Atlas of Emergency Medicine; Kevin J. Knoop, Lawrence B. Stack, Alan B. Storrow; Google Books

Head, Face, and Neck Trauma: Comprehensive Management; Michael G. Stewart, MD; Google Books

Facial Fractures; Core Curriculum Syllabus: Emergencies in Otolaryngology-Head and Neck Surgery; Baylor College of Medicine

Facial Fractures: The Upper Face by Dough Humphreys, MD; Dalhousie University (PDF file)

Maxillo-facial Injuries; PatientPlus

19 comments:

entdr said...

very informative. thank you

Haley said...

What an intriguing picture of a Lefort fracture. So that's how they do it, from underneath the upper lip. i am having that done to my maxilla to fix an open bite. a 3-piece Lefort, actually. Kind of scared because I hear multi-segment Leforts are more risky in terms of complications.

rlbates said...

Haley, best wishes to you. Do what your surgeons ask of you in terms of mouth rinses, eating soft foods until they allow you to chew, etc.

Anonymous said...

Hi, Came upon your site......I am having my hardware removed after 18 years.....I had a Lefort 1 in 1991...been having a really hard time with my sinuses especially my right side.....do you know what I can expect at all......getting it down this coming Friday.Plate grew into the bone of my nose can't breath at all through my right nostril, and growth all around the plate ( growth about 2cm by 4cm....thanks for "listening) God bless Sue

rlbates said...

Sue, you are looking at pain and swelling postop. Hopefully, it won't be too difficult to "chip" away the bone that has grown over the plate, etc. Plan on elevating your head (sleep in a recliner), don't bend over postop to pick up dropped items (squat), and use lots of ice the first few days. Good luck to you. Hope it all goes smoothly.

Anonymous said...

Thanks so much for responding.I have to say that I have found little to no information regarding the removal of the plates. What little I did read about were cases that happened within 6 months after post op.......I have 8 kids ages 1,2,3,5,8,10,11,12 and I was wondering what to expect for diet, and such.....the doctor, I think is just being conservative, maybe because he doesn't know what to expect either once he gets in there.....have you ever had to remove hardware..?? I have had nothing but problems with my surgery....cut a nerve, had necrosis of my upper jaw.thanks to Hyperbaric Oxygen therapy my upper jaw was saved......I am the one percent........:) thanks for your comments, they really do mean a lot, especailly when I can find NO info out there....do you know of any sites or support web pages that I can read up on "what to expect?" God bless again....Sue

rlbates said...

Sue, feel free to e-mail me. The link is on the sidebar.

Your surgeon probably doesn't know exactly what he will find. Be prepared for it to be similar to when it was first fractured, as far as diet, etc go. Prepare for the worst and hope for the best.

I don't know of any great sites to send you to for information. Look for information on post-fx care. Go with that.

chinderella said...

Hello! Your blog and this post in particular is very informative, thank you. I'm looking for info on Lefot I in particular: I had one +BSSo about 5 weeks ago and I'm a bit worried about my maxilla, which was perfectly positioned post-surgery, and which has now moved. My midline is now at least 1mm to the right. I'm trying to find out if this will be fixable by orthodontics only or if it'll need a second surgery.. keeping my fingers crossed that it won't!

mylene

rlbates said...

Cinderella, it will depend on how much bone healing you have. See your surgeon ASAP.

bob said...

Hi, In 1974 I was in a mva and suffered a combined Leforte 2 and 3,so I had the est hardware and int wires. Except for loss of lat rect muscle use(with resulatant diplopia) sec to abduscen nerve function loss, I am doing great and celebrated the 34 year aniv. yesterday from the mva and have been working as an er doc for the past 18 years.

Bob

Anonymous said...

I have had three lefort 1 osteotomies in a year. This first was Dec 2009, the second September 2010 and the third one week later again in September 2010. Please can you let me know if I will ever regain any sensation in my lip/gums/nose. This is really bothering. However, I do have immense pain in my cheekbones (Zygomatic bone?). Have emailed my surgeon but think they think I am just complaining, Which I am not. Please can you offer any help???

rlbates said...

Anon (11-5-10), it's difficult to answer you question, but I believe you when you say you aren't simply complaining. The infra-orbital nerve (most likely if teeth involved in pain/numbness) or zygomatic branch of the facial nerve could have been injured at the initial fracture or at any of the surgeries.

Make an appointment with the surgeon. Sketch out the area of your numbness/pain for him on a facial drawing or a printed photo of yourself. Make a list of your questions and take it with you.

If you don't feel they are listening to you/answering your questions, ask for a referral.

Dawn Sweet said...

Hello! I have a combined LeFort 2&3 as the result of a 1997 mva and as a result I have severe lacrimal drainage problems that require me to 'manually drain' my eye several times daily and also causes frequent eye infections. Even worse however is the surgical opening along my top gum line that never closed and causes near constant sinus drainage into my mouth. Have you ever heard of these problems and can you please advise if anything can be done to help me? Many thanks, Dawn ( dawnmichellesweet@yahoo.com)

rlbates said...

Dawn, you really need to go back to your surgeon or see another one.

Anonymous said...

My girl had a Le Fort III done recently. I am currently screwing the distractors 3 times a day. Can anyone share similar experience with me? Thanks.

Alissa...Our greatest glory is not in never falling, but in getting up every time we do. - Confucius said...

I am a Surgical Tech student and I came upon your site while doing research for a paper on the LeFort III procedure. What a great blog! Is there a good place I can look for more Le Fort III info? I mostly find I & II info. Thanks, Alissa

rlbates said...

Alissa, please, reread the post. LeFort III info is included. You can search the blog for facial fractures and find info on other: mandibular, blowout, etc.

Anonymous said...

Hi, my Mom had a Le Fort I ORIF yesterday. The surgeon gave her antibiotics (IV) before and during surgery. The surgery was 7 days post-injury due to a C5 contusion the neuro was worried about. My question is, should she continue more antibiotics at home? I'm worried about infection. To my knowledge, the antibiotics during surgery were the only ones she had.

Thanks, Jen

rlbates said...

Jen, your and your Mom should ask her surgeon about post-op antibiotics. That will be up to him/her. Best to your mom.