LEFORT-III FRACTURE & ITS MANAGEMENT

PRESENTED BY CHAIRPERSON
DR.MUSTAHSINUL BARI PROF. DR. ISMAT ARA HAIDER
DR.FARIHA RAHMAN NIZUM HONORABLE HOD (OMS)
DHAKA DENTAL COLLEGE & HOSPITAL
DR. MALIHA KADER
“Fracture well cured make us
more strong”
-René Le Fort
CONTENTS
• Introduction
• Surgical anatomy of mid face
• Etiology & prevalence
• Fracture lines
• Clinical features
• Management
• Aftercare
• Complications
• References
 INTRODUCTION

• Mid face fracture is classically described as Le Fort I, II

& III by a French surgeon René Le Fort in 1901 in Paris.

• As experiment Le Fort used intact skull of cadaver and

tried to fracture it by using low velocity forces.
• Le Fort discovered that the complex fracture pattern
could be subdivided into three groups.

1. Le Fort -I fracture/ Low level fracture/

Guerin fracture/ Dento-facial fracture.

2. Le Fort -II fracture/ Mid level fracture/

Subzygomatic fracture/ Pyramidal fracture.

3. Le Fort -III fracture /High level fracture/

Suprazygomatic fracture/ Craniofacial
dysjunction/ Transverse fracture.
• Forces directed at the mid face from straight
on tend to cause Le Fort-I & Le Fort-II fracture.

• If the force is directed slightly downward a Le

Fort-III fracture is more frequently results.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
3. Two Zygomatic bones.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
3. Two Zygomatic bones.
4. Two Zygomatic process of temporal bone.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
3. Two Zygomatic bones.
4. Two Zygomatic process of temporal bone.
5. Two Nasal bones.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
3. Two Zygomatic bones.
4. Two Zygomatic process of temporal bone.
5. Two Nasal bones.
6. Two Lacrimal bones.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
3. Two Zygomatic bones.
4. Two Zygomatic process of temporal bone.
5. Two Nasal bones.
6. Two Lacrimal bones.
7. The Ethmoid bone.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
3. Two Zygomatic bones.
4. Two Zygomatic process of temporal bone.
5. Two Nasal bones.
6. Two Lacrimal bones.
7. The Ethmoid bone.
8. Two Inferior conchae.
SURGICAL ANATOMY OF MIDFACE
1. Two Maxillae.
2. Two Palatine bones.
3. Two Zygomatic bones.
4. Two Zygomatic process of temporal bone.
5. Two Nasal bones.
6. Two Lacrimal bones.
7. The Ethmoid bone.
8. Two Inferior conchae.
9. The Vomer.
Etiology & prevalence
Etiology:

• Road traffic accident.

• Fall from height.
• Sports injury.
• Urban violences.
• Gun shot injury
 Prevalence:

Zygomatic bone & arch

30%
Le Fort- I

Le Fort- II
53%

4% Le Fort-III

8%
Others
4%
Here, diagramatic representation of the strength of the bones of skull and face

 Impact force A is transmitted directly to

the brain producing the most severe
injury .
 Impact force C is transmitted directly to
the cranial base via the rigid structure of
mandible.
 The “match-box” structure of mid facial
skeleton cushions the effect of impact
force B .
LE FORT-I FRACTURE LINE
• Horizontal fracture runs above the nasal floor.

• Along the lateral wall of the antrum from the

anterior nasal aperture.

• Runs below the zygomatic buttress.

• Travels the posterior wall of the maxillary sinus

across the pterygomaxillary fissure.

• And fracture the lower one third of pterygoid plate.

LE FORT-II FRACTURE LINE
• The fracture runs through the mid portion of nasal bone.

• Crossing nasal bone, frontal process of maxilla & lacrimal

bone.

• And enter floor of the orbit, passes anteriorly to the infra

orbital rim.

• And curves laterally below the zygomatic buttress over

the posterior wall of maxilla.

• Crossing pterygomaxillary fissure and ended by fracture

in the mid portion of pterygoid plate
LE FORT-III FRACTURE LINE
•Fracture line commences near the fronto-nasal
suture, separates nasal bone and frontal process of
maxilla with its full depth. So cribriform plate of
ethmoid bone is involved.

•And then traverses the upper limit of lacrimal bone.

Continuing posteriorly the line crosses the orbital plate
of ethmoid bone constituting part of the medial wall of
orbit.

•As the optic foramen is surrounded by a dense ring

of bone so fracture line gets deflected downwards and
laterally to reach the infra-orbital fissure.
 •From the base of the infra-orbital fissure fracture
line extends in two directions-

Backwards across the pterygomaxillary fissure

to fracture the root of pterygoid plate.

Laterally across the lateral wall of the orbit

separating the zygomatic bone from frontal bone.
Video illustration of Le Fort – I,II and III fracture
CLINICAL FEATURES
INSPECTION
 EXTRAORAL FEATURES
•Gross edema of face (Panda face)
•Deformity of face-
 Raccoon eyes
 Dish face deformity
 Lengthening of face
• Nasal signs-
 Flattening of nose
 Nasal bleeding
 CSF rinorrhoea
•Eye signs-
 Subconjunctival haemorrhage
 Peri-orbital ecchymosis
 Difficulty in eye opening
 Enopthalamous
 Retrobulbar haemorrhage
 May increase inter-canthal distance
 Imapairment of vision.
 Diplopia
 INTRAORAL FEATURES
• Disturbed/ De-arranged occlusion
• Decreased mouth opening
• Tilting of occlusal plane
• Anterior open bite
• Class –III malocclusion
• Pharyngeal bleeding (Due to naso-
pharyngeal tear)
• Occasional hematoma of palate
PALPATION
• Step deformity on-
o Nasion
o Fronto-zygomatic suture
o Zygomatico-temporal suture
• Mid face may act as a single block
• Tenderness at –
o Fronto-zygomatic suture
o Zygomatic arches
• Tapping of teeth will give a typical “cracked pot”
sound.
Facial deformity

Raccoon eyes
Dish face deformity
Lengthening of face
 CSF RHINORRHEA

• In Le Fort-III there is fracture of

ethmoid bone including the
cribriform plate, that causes CSF
rhinorrhea.

• The mixed blood and CSF leaking

from the nose produces a
“tramline” pattern.
 DIPLOPIA
• Diplopia is usually caused by interference with the action of extra ocular
muscle

• in most cases results from edema & haemorrhage in & around these
muscle. This type of diplopia is usually temporary.
 ENOPTHALMOS

Enopthalmos is the inward sinking of

eye. It can occurs due to-

• Increase in the volume of the

bony orbit due to the fracture
of its wall.

• Loss/Decrease of volume of
orbital contents herniation of
orbital soft tissues in the
maxillary sinus or medial wall.
 SUBCONJUNCTIVAL HAEMORRHAGE

• Bleeding underneath the conjunctiva.

•The conjunctiva contains many small, fragile

blood vessels that are easily raptured by
trauma.

• Blood leaks into the space between the

conjunctiva and sclera and causes
subconjunctival haemorrhage.
 RETROBULBAR HAEMORRHAGE

• Retrobulbar haemorrhage brings about temporary blindness or diminished

vision.
 INCREASE IN THE INTER-CANTHAL DISTANCE

In Le Fort –III there is an associated fracture of the frontal process of maxilla which runs into
the both medial walls of both the orbit, so there is an increase in the inter-canthal distance.
 MID FACE ACT AS A SINGLE BLOCK

Movement of entire face can be felt when index finger and thumb of left hand are placed
on the fronto-nasal suture region & the right hand grasps & moves the upper anterior
alveolus.
 CRACKED POT SOUND

In these types of fracture tapping of teeth gives a typical “cracked pot sound”
MANAGEMENT

Management of “Le Fort –III” fracture can be described under the following
broad headings-
I. Emergency care
II. Immediate management
III. Preliminary examination & determination of priorities
IV. History & local examination
V. Radiographic workup
VI. Definitive treatment
1. EMERGENCY CARE
• Emergency care involves “Advanced Trauma Life Support (ATLS)” protocol.
The primary survey of emergency care are following-

 A= Airway maintenance with cervical spine control

 B= Breathing & adequate ventilation

 C= Circulation with control of haemorrhage

 D= Degree of consciousness assessment

 E= Exposure of patient by complete undressing to avoid over

looking injuries camouflaged by clothing
2. IMMEDIATE Mx:

• Cover external wound with a clean dressing

• Maintenance of patent airway
• Body fluid replacement
• Antibiotic prophylaxis
• Tetanus prophylaxis
• Monitoring of vital signs
• Assessing neurological status
• Evaluation of cervical spine
• Control of pain
• Immediately provide some form of immobilization
3. PRELIMINARY EXAMINATION & DETERMINATION OF PRIORITIES:

After the operator has established a satisfactory airway and controlled

hemorrhage a full examination of patient should be carried out. The
examination consists of-

• Evaluation of head injury

• Examination of eye
• Examination of the spine
• Examination of the limbs
• Examination of abdomen and chests
• Soft tissue laceration
3. HISTORY & LOCAL EXAMINATION:

• History
a) If the patient is conscious & cooperative history can be
obtained from himself.

b) If the patient is unconscious then history can be obtained

from eye witnesses, ambulance men or medical and dental
practitioners who may have attended the patient following
the injury.
• Local examination
 Intraoral examination
Inspection Palpation Percussion
Laceration Tenderness Cracked pot sound
Dearranged occlusion Mobility of fractured
fragment
Posterior gagging Step deformity
Decreased mouth
opening
 Extra-oral examination

INSPECTION PALPATION

Edema Tenderness
Ecchymosis Step deformity
Soft tissue laceration Unnatural mobility
Hemorrhage
CSF leakage
Eye signs
4. RADIOLOGICAL WORK UP:

1. Skull P/A view

2. Occipito-mental view for PNS
3. Occlusal view of maxilla
4. Submentovertex view
5. Orthopantomogram (OPG)
6. CT scan with 3D reconstruction
 OCCIPITO-MENTAL VIEW FOR PNS

Occipito-mental view showing the mid face with maxilla and frontal bone related
sinuses
CT SCAN WITH 3D RECONSTRUCTION
5. DEFINITIVE TREATMENT
Target:
To restore the form and function.

Principles:
1. Recognition
2. Reduction
3. Fixation
4. Immobilization
5. Rehabilitation
 RECOGNITION
 After doing the clinical examination & radiographic examination
fracture site is identified.

REDUCTION
1. Close reduction
a) Manual reduction
b) Reduction by traction
2. Open reduction
 CLOSE REDUCTION

a) Manual reduction
Manual reduction can be carried out in all fresh fractures and where
the fragments are not impacted. As a rule, arch bars are first applied to
the teeth. The lower jaw serves as a template, so that the occlusion can
be checked.
Manual reduction can be done in following ways-
i. Simple manipulation by hand
ii. Manipulation by wire
iii. Reduction by using disimpaction forceps
 SIMPLE MANIPULATION BY HAND
It is possible in fresh fractures ,maxilla is held between the index finger and
thumb and brought into normal occlusion.

MANIPULATION BY WIRE
Another method is to fix two double wires encircles the first and second
maxillary molars and twisting them individually on either side .Both the
twisted wire ends are held by means of wire holders and simultaneously
downward movement of maxilla will help to achieve the normal occlusion.
 REDUCTION BY USING DISIMPACTION FORCEP
ROWE’S MAXILLARY DISIMPACTION FORCEP

These forceps are available as right and left forceps and always used in
pairs. These are two pronged forceps where one pronged fits into the
nasal floor and another one on hard palate
ROWE’S DISIMPACTION FORCEPS
 HAYTON WILLIAM’S DISIMPACTION FORCEP

Anterior traction incase of a split palate may be facilitated by the use of the
special forceps. These are applied to buccal aspect of alveolar process and
medial compression exerted until two halves of upper jaw are
approximated.
HYTON WILLIAM’S DISIMPACTION FORCEPS
 COMBINED APPROACH

It is possible to combine the use of these two forceps simultaneously. The

stabilized maxillary block may then be disimpacted and drawn forward.
 REDUCCTION BY TRACTION

This is mainly used in delayed cases where the

fracture is 10-14 days old and no longer
sufficiently mobile.

•Intraoral elastic traction

•Extraoral elastic traction

Once satisfactory occlusion is achived it is

replaced by intermaxillary fixation (IMF).
 OPEN REDUCTION
•Open reduction is carried under endo-tracheal anesthesia with nasal
intubation.
•Various surgical approaches are available for management of maxillary
fracture through open reduction and fixation-

Coronal and hemi-coronal : Surgical approach of choice for

Le Fort-III fractures
Midfacial degloving : Indicated in combined Le Fort I,II and
III
Transconjunctival : Indicated in Le Fort II and III
Transantral : Indicated in orbital floor fracture
 FIXATION
INTERNAL FIXATION
1. Direct osteosynthesis
a) Transosseous wiring at fracture site.
i. High level ( Fronto-zygomatic and fronto-nasal)
ii. Mid level ( Orbital rim/Zygomatic buttress )
iii. Low level ( Alveolar / Mid palatal)
b) Miniplates (Usually used 5 mm length and 2 mm width)
c) Microplates
d) Transfixation with Kirschner wire or Steinmann pin
i. Transfacial
ii. Zygomatic septal
2. Suspension wires to mandible – In case of comminuted fracture
a. Frontal - Central / Lateral
b. Circumzygomatic
c. Zygomatic
d. Infraorbital
e. Pyriform aperture
3. Support
a) Antral pack
b) Antral ballon
Fixation of Le Fort –III fracture by miniplates
 EXTERNAL FIXATION

1. Craniomandibular
a) Box-frame
b) Halo-frame
c) Plaster of paris headcap
2. Cranio maxillary
a) Supra orbital pins
b) Zygomatic pins
c) Halo -frame
Box frame fixation
Halo frame fixation
 IMMOBILIZATION

 Usually immobilization is done for 3-6 weeks depending on the types of

fixation and patient’s age

 In case of young adult immobilization is done for 3 weeks.

 Patient above 40 years immobilization is done for 4-5 weeks.

 If the patient came more than 10 days after the incident a week is added to
normal immobilization timing.
 AFTER CARE
1. Inquiry about general comfort of patient.
2. Examine the wound site , dressing , discharge.
3. Monitor the vital signs.
4. Post operative positioning – upright position.
5. Diet – either fluid or semi solid diet is provided depending on the type of
the fixation.
6. Oral hygiene – In early stages irrigation of mouth should be carried out
after every meal , using a Higginson’s syringe and warm 2% sodium bi
carbonate solution. Later patient can use soft brush.
7. Nose blowing – avoided for 10 days.
8. Medication – nasal decongestions , antibiotics , analgesics , steroids ,
opthalmic ointment.
9. Opthalmological examination
10. Post operative imaging – 3D imaging ( CT scan , CBCT )
11. Inform patient about surgery prognosis , investigation results , possible
date of discharge.
 COMPLICATIONS
1. Immediate complications –
 Airway obstructions
 Extensive haemorrhage
 CSF leakage
 Nasal bleeding
 Injury to muscles , tendons , vessels and nerves .
 Opthalmic complications
 Shock
 Multiple organ system failure (MOSF)
 Infection
2. Late complication
 In bone
• Malunion
• Delayed union
• Non union
• Refracture
 Mal- occlusion
 Cosmetic deformity
• Over long face
• Flattening of entire profile
 From head injury
• Post concussional syndrome
• Meningitis
• Epilepsy
 Opthalmic complications
• Diplopia
• Ptosis
• Partial/ complete blindness
 Cranial nerve dysfunction
 Persistent joint stiffness (TMJ)
REFERANCES
• Killey’s fractures of middle third of the facial skeleton (5th Edition)

• Textbook of Oral and Maxillofacial Surgery by Dr. Neelima Anil Malik (3rd
Edition)

• Textbook of Oral and Maxillofacial surgery by S M Balaji (2nd Edition)

• Illustrated manual of Oral and Maxillofacial surgery by Geeti Vajdi Mitra

• Atlas of human anatomy