Le Fort fractures management guide

Le Fort fractures and
management
Dr. G.P. Kumar.,Dr. G.P. Kumar.,
11

SURGICAL ANATOMY
Facial Skeleton roughlyFacial Skeleton roughly
divided in todivided in to 3 Areas3 Areas
1.Upper Third1.Upper Third – Frontal– Frontal
2.Lower Third2.Lower Third _ Mandible_ Mandible
3.Middle Third3.Middle Third – In-– In-
between Frontal bonebetween Frontal bone
and Mandibleand Mandible
Dr.GPK, OMFSDr.GPK, OMFS 22

MATCH BOXMATCH BOX

SKELETAL ARCHITECTURE

MIDDILE THIRD OF FACE
The middle third of the face is the area bounded by :
superiorly by a line drawn from the zygomaticofrontal suture
across the frontonasal &frontomaxillary suture to the
zygomaticofrontal suture at the opposite side.
Inferiorly by the occlusal plane or the alveolar ridge, and
Posteriorly as far as the frontal bone above and body of
sphenoid below.

MIDDLE THIRD
A. Central middle ThirdA. Central middle Third
B. Lateral middle ThirdB. Lateral middle Third

BONES CONTRIBUTING MIDDLE 3BONES CONTRIBUTING MIDDLE 3rdrd
OFOF
THE FACETHE FACE
PAIRED BONES
1. Two maxillae
2. Two Zygomatic bones
3. Two Zygomatic Processes of the Temporal Bones
4. Two Palatines Bones
5. Two nasal Bones
6. Two Lacrimal Bones
UNPAIRED BONES
7. The vomer
8. The ethmoid and its attached conchae
9. The inferior conchae
10.The pterygoid plates of the sphenoid

Depending on the level of a fracture lineDepending on the level of a fracture line
Low level fractureLow level fracture
Mid level fractureMid level fracture
High level fractureHigh level fracture

Erich’s classification (1942)
Based on the direction of the facture line:
Horizontal fracture
Pyramidal fracture
Transverse fracture

CLASSIFICATION OF MIDFACECLASSIFICATION OF MIDFACE
FRACTURES BYFRACTURES BY RENE LEFORT 19011901
AA. Lefort I. Lefort I -Low level fracture (-Low level fracture (Guerin FractureGuerin Fracture))
B.B. Lefort IILefort II -Pyramidal or subzygomatic Fracture-Pyramidal or subzygomatic Fracture
C.C. Lefort III –High Transverse or suprazygomatic fracture (Cranio–High Transverse or suprazygomatic fracture (Cranio
Facial Dysjunction)Facial Dysjunction)
LIMITATIONSLIMITATIONS
1.Inability to accurately predict reduction techniques1.Inability to accurately predict reduction techniques
2.Asymmetric fracture patterns2.Asymmetric fracture patterns

MODIFIED LEFORT CLASSIFICATIONS
BY MARCIANI RD 1993
Lefort I – Low Maxillary Fractures
I a _ Low maxillary Fracture /Multiple Segments
Lefort II- Pyramidal Fracture
II a - Pyramidal and nasal Fractures
II b - Pyramidal and naso Orbito ethmoidal (NOE) Fracture
Lefort III - Craniofacial Dysjunction
Lefort III a- Craniofacial Dysjunction and Nasal Fracture
Lefort III b- Craniofacial Dysjunction and NOE
Lefort IV - Lefort II or III fracture and cranial base fracture
Lefort IV a- Supra orbital fracture
Lefort IV b – Anterior Cranial Fossa and Supra Orbital Rim
Fracture
Lefort IV c - Anterior Cranial Fossa and Orbital wall fracture

GENERAL CLINICAL FEATURES
1. Airway obstruction
2. Epistaxis
3. CSF Rhinorrhea
4. Facial oedema
5. Emphysema
6. Circumorbital echymosis
7. Subconjuctival haemorrhage
8. Occlusal disturbances
9. Facial disfigurement
10. Orbital symptoms
11. Abnormal opening of mouth
12. Oronasal openings

Le Fort fractures
Le FortLe Fort IIIIII
Le FortLe Fort IIII
Le FortLe Fort II

Le Fort I

Le Fort fracture I
Also called asAlso called as
Horizontal fracture of the maxilla orHorizontal fracture of the maxilla or
Guerin’s fractureGuerin’s fracture oror
Floating fracture orFloating fracture or
Low level fractureLow level fracture oror
Pterygomaxillary dysjunctionPterygomaxillary dysjunction oror
Subzygomatic fracture (Le Fort I & Le Fort II)Subzygomatic fracture (Le Fort I & Le Fort II)

Le Fort I fracture
Violent force over a more extensive area above the level of the
teeth will result in Le Fort I fracture
Horizontal fracture line seen above the apices of the maxillary
teeth, detaching the tooth bearing portion of the maxilla from
the rest of the facial skeleton.
The fractured fragment is freely mobile and displacement will
depend on the direction of the force.
Depending upon the displacement, a variety of occlusal disharmony
can be seen in this type of Le Fort I fracture.

Le Fort I fracture
The fracture line commences at the point on the lateral margin of the
anterior nasal aperture, passes above the nasal floor, and it
passes laterally above the canine fossa and traverses the lateral
antral wall, dipping down below the zygomatic buttress and then
inclines upward and posteriorly across the pterygomaxillary
fissure to fracture the pterygoid laminae at the junction of
their lower thrid and upper 2 /3rds.
At the same time, from the same starting point, the fracture also passes
along the lateral wall of the nose to join the lateral line of
fracture behind the tuberosity.

LEFORT I

Le Fort I fracture
Mostly bilateral
Sometimes unilateral depending upon the displacement, direction
and severity of force
May occur as single entity or with Le Fort I and II fractures.

SIGNS AND SYMPTOMS OF LEFORT ISIGNS AND SYMPTOMS OF LEFORT I
FRACTUREFRACTURE
EXTRAORALLYEXTRAORALLY
Slight swelling and edema of the lower part of the mid
face and the upper lip.
Epistaxis may be observed.
Pain and mobility .
Air emphysema in some cases.

SIGNS AND SYMPTOMS OF
LEFORT I FRACTURE
INTRA ORALLYINTRA ORALLY
Floating Maxilla
Impacted or Telescopic fracture
Anterior open bite
Disturbed occlusion
Echymosis
CRACKED POT SOUND
Midpalatal split in some cases
Damaged or subluxed teeth.
GUERIN’S SIGN

GUERIN’S SignGUERIN’S Sign
Characterised by ecchymosis in the region of greaterCharacterised by ecchymosis in the region of greater
palatine vesselspalatine vessels..

Le Fort II

Le Fort II fracture
Pyramidal or subzygomatic fracture
Violent force in the central region extending from glabella
to the alveolus results in pyramidal fracture

Le Fort II fracture
The fracture line runs below the frontonasal suture from the thin
middle area of the nasal bones down on either side, crossing the
frontal process of the maxillae and passes anteriorly across the
lacrimal bones anterior to nasolacrimal canal. From this point the
fracture line passes downward, forward and laterally crossing
the inferior orbital margin in the region of zygomaticomaxillary
suture. May or may not involve the infra orbital foramen. The
fracture line extends downward and forward and lateral to the
transverse wall of the antrum, just medial to the
zygomaticomaxillary suture line.

LEFORT II

LEFORT II FRACTURE
EXTRAORALLY
BALOONING or MOON FACE
Bilateral circumorbital edema and echymosis (Black eye)
Subconjuctival echymosis
Oedema of the conjunctiva or chemosis
Detection of a step deformity in the bone of the Infra-orbital margin.
(Most important in differentiating LEFORT III FRACTURE)
Mobility of the midface
Anaesthesia or parasthesia of cheek
Posible Diplopia
CSF Rhinorrhea
NO tenderness over or disorganization and mobility of Zygomatic bones and
arch.
Elongation or lengthening of the face.
Emphysema of soft tissues.
Nasal disfigurement.

BALOONINGBALOONING OROR MOONMOON OROR
FOOT BALLFOOT BALL FACEFACE

CSF RHINNORHEACSF RHINNORHEA

LEFORT II FRACTURE
INTRAORALLY
Disturbed or Deranged Occlusion
Posterior Gagging of occlusion with retro positioning of
maxillae with Anterior open bite.
Airway obstruction.

Le Fort III

Le Fort III fracture
High level fracture
Transverse fracture or
Suprazygomatic fracture or
Craniofacial dysjunction.
Due to severe impact from the lateralDue to severe impact from the lateral
surfacesurface

LEFORT IIILEFORT III

Le Fort III fracture
The fracture line begins at the frontozygomatic suture along the
lateral aspect of the internal orbit along the sphenozygomatic
suture line to the inferior orbital fissure, extends medially
across the floor of the orbit up the medial wall of the orbit
towards the dorsum of the nose where it crosses and proceeds to
the opposite side in the same manner. Various amounts of the
pterygoid plates will usually remain attached to the posterior
maxilla.

LEFORT III FRACTURE
EXTRAORALLY
Tenderness and separation at FZ suture
Lengthening of the face
One or other Zygomatic complex fracture with Displacement
Flattening and a step deformity at the Infra-orbital margin
Movement of the entire facial skeleton as a single block.
Enoptholmos
HOODING of the eyes
Profuse CSF Rhinorrhea and CSF Otorrhea
PANDA FACIES
DISH FACE deformity
BATTLE’S SIGN
Haemotympanum
Orbital dystopia with associated Antimongoloid slant
Flattening, widening and deviation of nasal bridge

PERIORBITAL EDEMA AND ECHYMOSIS

SUBCONJUNCTIVAL HAEMORRHAGE
AND CHEMOSIS

PANDA FACIESPANDA FACIES
Raccoon eye/eyesRaccoon eye/eyes (also known in(also known in
thethe United KingdomUnited Kingdom andand IrelandIreland
asas panda eyespanda eyes,, though that termthough that term
commonly refers to excess orcommonly refers to excess or
smeared dark make-up around thesmeared dark make-up around the
eyeseyes or to dark rings around theor to dark rings around the
eyes) oreyes) or periorbital ecchymosisperiorbital ecchymosis isis
aa signsign ofof basal skull fracturebasal skull fracture oror
subgaleal hematomasubgaleal hematoma

BATTLE’S SIGN
Battle's sign, also
mastoid ecchymosis, is
an indication of fracture of
posterior cranial fossa of
the skull, and may
suggest underlying brain
trauma.

HOODING OF THE EYE

DISH FACE

LEFORT III FRACTURE
INTRAORALLYINTRAORALLY
Disturbed or Deranged OcclusionDisturbed or Deranged Occlusion
Posterior Gagging of occlusion with retroPosterior Gagging of occlusion with retro
positioning of maxillae with Anterior open bite.positioning of maxillae with Anterior open bite.
Airway obstruction.Airway obstruction.
SAGITTAL FRACTURE OF THE PALATE-SAGITTAL FRACTURE OF THE PALATE- aa
variant of LEFORT III Fracturevariant of LEFORT III Fracture

LEFORT III

DENTOALVEOLAR FRACTURES
CLINICAL FEATURES
 Anterior teeth injury associated with laceration of the upper lip or
degloving of the alveolus.
 Posterior tooth injury may include vertical splitting of one or more
teeth
 Mobility of teeth.
 Teeth may be irretrievably damaged or avulsed
 Fragments of teeth may become embedded in lip or tongue
lacerations or they may be swallowed or rarely inhaled.

Immediate management of a patient with
midfacial fractures
1. Maitenence of patent airway
2. Temporary cessation of haemorrhage
3. Blood fluid replacement
4. Antibiotic prophylaxis
5. Tetanus prophylaxis
6. Monitoring vitals
7. Assesing neurologic status(Glassgow coma scale)
8. Evaluation of cervical spine
9. Control of pain

GLASGOW COMA SCALEGLASGOW COMA SCALE
Eye (E)Eye (E)
4 - open eyes spontaneously.4 - open eyes spontaneously.
3 - open eyes to voice.3 - open eyes to voice.
2 - open eyes to pain.2 - open eyes to pain.
1 - no eye opening.1 - no eye opening.
Best Motor respose (M)
6 - Obeys commands.6 - Obeys commands.
5 - Localizes to pain.5 - Localizes to pain.
4 - Withdraws to pain.4 - Withdraws to pain.
3 - Abnormal flexion.3 - Abnormal flexion.
2 - Extension.2 - Extension.
1 - No response1 - No response
Best Verbal response (V)
5 - Appropriate & oriented5 - Appropriate & oriented
4 - Confused conversation.4 - Confused conversation.
3 - in appropriate words.3 - in appropriate words.
2 - Incomprehensible sounds.2 - Incomprehensible sounds.
1 - No sounds.1 - No sounds.

GOLDEN HOURGOLDEN HOUR
The vernacular term “golden hour” is widely attributed to
R. Adams Cowley, founder of Baltimore’s Shock Trauma
Institute.
In a 1975 article, he stated, “the first hour after injury will
largely determine a critically-injured person’s chances for
survival.”

Management of midface fracture
Maxillofacial Injuries
Treatment divided into following phases –
Emergency or initial care
Early care
Definitive care
Secondary care or revision

Management of midface fracture
Emergency treatment and stabilization of the patient.
Definitive treatment with reduction and fixation

SOFT-TISSUE LACERATIONS
The most common priority for patients with fractures of
the middle third is repair of soft –tissue lacerations,
particularly of the face. Ideally these should be sutured
before too much oedema has occurred; that is within 1- 8
hours of injury.
ASSESS THE GENERAL CONDITION OF THE
PATIENT

Occlusion
Teeth and occlusion are the key to Reconstruction. ItTeeth and occlusion are the key to Reconstruction. It
provides the foundation upon which other facialprovides the foundation upon which other facial
structures are builtstructures are built

Initial management
The primary survey progresses in a logical manner based on the
ABC’s & D,E.
Airway maintenance with cervical spine control
Breathing and adequate ventilation
Circulation with control of hemorrhage
The letters D and E have also been added:
Degree of consciousness
Exposure of the patient via complete undressing to avoid
overlooking injuries camouflaged by clothing

Emergency care
Preserve the airway
Control of haemorrhage
Prevent or control shock
C Spine stabilization‐
Control of life threatening injuries‐
Head injuries, chest injuries, compound limb fractures,
intra abdominal bleeding‐

Evaluate the airway
Existence & identification of obstruction
Manually clear of fractured teeth, blood clots, dentures
Endotracheal intubation & packing of oronasal airway

Airway ManagementAirway Management
Maintain an intact airway
Protect airway in jeopardy – Provide an
airway(cricothyroidotomy/tracheotomy)
C Spine injury may be present‐
Altered level of consciousness is the most common
cause of upper airway obstruction

Airway management
Chin lift to open intact airwayChin lift to open intact airway
IntubationIntubation
– Orotracheal: C spine injury absent on X-Ray‐– Orotracheal: C spine injury absent on X-Ray‐
Nasotracheal intubation: C spine injury suspected or‐Nasotracheal intubation: C spine injury suspected or‐
certaincertain
Surgical AirwaySurgical Airway
– Cricothyroidotomy – Tracheosotomy– Cricothyroidotomy – Tracheosotomy

Treatment of Blood Loss & Shock
Extensive vascularity of head & neck may lead to massive blood
loss
Monitor vital signs closely – Intravenous infusion
Penetrating injuries need to be explored – Arteriogram
Esophagram
Hemorrhage most common cause of shock after injury
Multiple injury patients have hypovolemia
Goal is to restore organ function & perfusion
External bleeding controlled by direct pressure over bleeding site
Gain prompt access to vascular system with IV catheters
Fluid replacement – Ringer’s Lactate
Normal saline – Transfusion

Stabilization of associated injuries
C spine injury is primary concern with all maxillofacial‐
trauma victims
Any patient with injury above clavicle or head injury
resulting in unconscious state
Any injury produced by high speed
Signs/symptoms of C Spine injury‐
• Neurologic deficit
• Neck pain

Early Care
Emergency care has stabilized patient
– Initial stabilization of fractures
– Debridement & dressing of soft tissues
– Elective tracheostomy
Physical exam & history
Laboratory tests
Complete head & neck examination • Diagnosis of
maxillofacial injuries

AFTER STABILIZING THE PATIENT----
(A) THOROUGH HISTORY(A) THOROUGH HISTORY
Who?
How?
When?
Where?
What symptoms?
What?
LOC? Retrograde or anterograde amnesia

Positioning the patient

(B) PHYSICAL EVALUATION
1.Eyes1.Eyes
2.Spine2.Spine
3.Limbs3.Limbs
4.Abdomen and chest4.Abdomen and chest
5.Pelvic areas5.Pelvic areas
(C) Face and cranium for
1.Lacerations1.Lacerations
2.Abrasions2.Abrasions
3.Contusions3.Contusions
4.Edema or haematoma formation4.Edema or haematoma formation
5.Possible contour defects5.Possible contour defects
6.Vision6.Vision
7.Extraocular movements7.Extraocular movements
8.Pupillary reaction to light8.Pupillary reaction to light
9.Assessement of mobility of maxilla9.Assessement of mobility of maxilla
10.Medial intercanthal width10.Medial intercanthal width
11.Internal aspects of the nose11.Internal aspects of the nose

Facial Examination
Evaluate mandibular opening
Palpation of buccal vestibule Crepitus of lateral antral
wall
Occlusion evaluated Absence and quality of dentition
noted
Ecchymosis
Pharynx evaluated for laceration & bleeding

Orbital ExaminationOrbital Examination
Orbits evaluated
Periorbital edema and ecchymosis
Gross visual acuity determined
Diplopia
Pupillary size & shape
Subconjunctival hemorrhage
Funduscopic evaluation

Clinical examinationClinical examination

CLINICAL EXAMINATION

INTRA ORALLY
Mucosal laceration
Echymosis
Occlusion
Teeth

RADIOGRAPHIC EVALUATION
Cervical spine(severe injuries)
Water’s view
Submentovertex view
PA skull view
Lateral skull view

Imaging
1- Occipitomental (standard ,10°, 15° and 30°)1- Occipitomental (standard ,10°, 15° and 30°)
2- True lateral2- True lateral
3- Soft tissue lateral3- Soft tissue lateral
4- Occlusal4- Occlusal
5- Intra orals5- Intra orals
6- Sub mento-vertex6- Sub mento-vertex
7- C.T Scan7- C.T Scan
8- 3D C.T Scan8- 3D C.T Scan
9- MRI(to detect CSF leaks and fistula)9- MRI(to detect CSF leaks and fistula)

CAMPBELL’S AND TRAPNELL’S LINES
1. First line across the
zygomaticofrontal, the superior
margin of the orbit and the frontal
sinus
2. Second line across the zygomatic
arch, zygomatic body, inferior
orbital margin and nasal bone
3. Third line across the condyles,
coronoid process and the
maxillary sinus
4. Fourth line across the mandibular
ramus, occlusal plane
5. Fifth line (trapnell's line) across
the inferior border of the mandible
from angle to angle

RADIOGRAPHIC EVALUATIONRADIOGRAPHIC EVALUATION
The minimum radiographs required areThe minimum radiographs required are::
(A) FOR BONES OF THE MID-FACE(A) FOR BONES OF THE MID-FACE::
I . Occipitomental 10° and 30°I . Occipitomental 10° and 30°
II . True lateral at 6 feetII . True lateral at 6 feet
III. Soft tissue lateral at 6 feet.III. Soft tissue lateral at 6 feet.
IV. Occlusal view of maxillaeIV. Occlusal view of maxillae
V. Intra- oralV. Intra- oral

Radiographic evaluationRadiographic evaluation
Lateral viewLateral view
a) Occipitofrontal with tube angled 25 degree to
the feet.
b) Fronto-occipital( Townes projection)
c) Isolated features of the orbital floor are
diagnosed on a Waters view.
d) Xeroradiographs and CT

X-RAY CERVICAL SPINE

Submentovertex viewSubmentovertex view

30 Degree Occipitomental30 Degree Occipitomental

PA SKULLPA SKULL

REVERSE TOWNE’S PROJECTION

True lateral skull radiograph

Soft tissue lateralSoft tissue lateral

XERO RADIOGRAPHYXERO RADIOGRAPHY

INTRA-ORAL OCCLUSAL RADIOGRAPHINTRA-ORAL OCCLUSAL RADIOGRAPH

CT SCANCT SCAN

3D CT3D CT

Stereo Lithographic model

SUMMARY OF RADIOGRAPHS INSUMMARY OF RADIOGRAPHS IN
MIDFACE FRACTURESMIDFACE FRACTURES

Treatment for dentoalveolar fracturesTreatment for dentoalveolar fractures
Fractured teeth without exposure of the pulp
Fractured teeth with exposure of the pulp
Subluxated teeth
Fractures of the alveolus(tuberosity)

Treatment for Le Fort fracturesTreatment for Le Fort fractures
Basic principlesBasic principles
1.1.ReductionReduction
2.2.FixationFixation
3.3.ImmobilizationImmobilization
- for re-establishment of form, function and occlusion- for re-establishment of form, function and occlusion
with minimum morbiditywith minimum morbidity

ReductionReduction
Restoration of the fractured fragments to theirRestoration of the fractured fragments to their
original anatomical positionoriginal anatomical position
Two typesTwo types
– Closed reductionClosed reduction
– Open reductionOpen reduction

Closed reductionClosed reduction
Alignment without visualization of the fracture lineAlignment without visualization of the fracture line
i.i. Reduction by manipulationReduction by manipulation
ii.ii. Reduction by traction.Reduction by traction.
iii.iii. A.Intra-oral tractionA.Intra-oral traction
B.Extra-oral tractionB.Extra-oral traction
Open reductionOpen reduction
Surgical reduction allows visual identification ofSurgical reduction allows visual identification of
fractured fragmentsfractured fragments

Treatment of Le Fort I fractures
Direct exposure of all involved fractures
Reduction and anatomic realignment of the maxillary buttresses to
re establish
• Anterior projection
• Transverse width
• Occlusion
Restoration of occlusion using
IMF
Internal fixation using miniplate fixation

Plating along the Buttress

Treatment of Le Fort II and III fractures
Fractures should be treated as early as the generalFractures should be treated as early as the general
condition of the patient allowscondition of the patient allows
Team approach to treatmentTeam approach to treatment
–– NeurosurgeryNeurosurgery
–– OphthalmologyOphthalmology
– Oral & Maxillofacial surgery– Oral & Maxillofacial surgery

–– Reestablishment of the correct intercanthal distanceReestablishment of the correct intercanthal distance
–– Infraorbital rim fixatedInfraorbital rim fixated
–– Orbit is reconstructedOrbit is reconstructed
–– Occlusion unit with IMF is fixatedOcclusion unit with IMF is fixated
Treatment of Le Fort II and III fractures

Intubation must not interfere with ability to useIntubation must not interfere with ability to use
IMFIMF
Exposure & visualization of all fracturesExposure & visualization of all fractures
Approaches to inferior rimApproaches to inferior rim
•• InfraorbitalInfraorbital
•• SubciliarySubciliary
• Transconjunctival• Transconjunctival
•• Mid lower lidMid lower lid
Coronal approachCoronal approach
Gingivobuccal incisionGingivobuccal incision

APPROACHES TO MID FACEAPPROACHES TO MID FACE

Vestibular approachVestibular approach

Lower eye lid approachLower eye lid approach

Subconjunctival approachSubconjunctival approach

Lateral Eyebrow approachLateral Eyebrow approach

Bicoronal/Coronal approach

Bicoronal degloving

ROWE’S DISIMPACTION FORCEPS

Methods of FixationMethods of Fixation
1.1. WiringWiring
2.2. Plates and screwsPlates and screws
3.3. IMF(intermaxillary fixation)IMF(intermaxillary fixation)
4.4. Internal suspension: e.g. circumzygomatic, infraorbitalInternal suspension: e.g. circumzygomatic, infraorbital
5.5. Craniofacial Suspension: e.g. supraorbital pins, boxCraniofacial Suspension: e.g. supraorbital pins, box
frame, Halo frameframe, Halo frame

FixationFixation
In this phase fractured fragments are fixed in theirIn this phase fractured fragments are fixed in their
normal anatomical relationship to prevent displacementnormal anatomical relationship to prevent displacement
and achieve proper approximationand achieve proper approximation
TypesTypes
– Direct skeletal fixationDirect skeletal fixation
– Indirect skeletal fixation(can be intra-oral orIndirect skeletal fixation(can be intra-oral or
extra oral)extra oral)

Direct skeletal fixationDirect skeletal fixation
1.1.ExternalExternal – device is outside the tissues but– device is outside the tissues but
inserted into the boneinserted into the bone
percutaneously.eg;Bone clamps and Pinspercutaneously.eg;Bone clamps and Pins
2.2.InternalInternal – devices are totally enclosed within– devices are totally enclosed within
the tissues and uniting the bone ends bythe tissues and uniting the bone ends by
direct approximation.eg;Transosseous wiringdirect approximation.eg;Transosseous wiring
and plating system.and plating system.

INTERNAL FIXATION
I. Direct Osteosynthesis
:
a) Tran osseous wiring at fracture sites:
i)High level(frontozygomatic and frontonasal)
ii)Mid level(orbital rim/zygomatic buttress)
iii)Low level(alveolar / palatal)
b) Miniplates
c) Transfixation with kirschner wire or Steinmann pin:
i) Transfacial
ii) Zygomatic- -septal
II. Suspension wires to mandible
ia.. Frontalo -central or lateral
b. Circumzygomatic
c. Zygomatic
d. Infra orbital
e. Pyriform aperture

INTERNAL FIXATIONINTERNAL FIXATION
III. SUPPORTIII. SUPPORT
a. Antral packa. Antral pack
b. Antral balloonb. Antral balloon

Circumzygomatic-mandibularCircumzygomatic-mandibular

Infra-orbital-mandibular internal suspension

Lateral frontomandibular internalLateral frontomandibular internal
suspensionsuspension

PYRIFORM APERTUREPYRIFORM APERTURE

Plate fixationPlate fixation

External fixationExternal fixation
1. CRANIOMANDIBULAR1. CRANIOMANDIBULAR
a. Box- framea. Box- frame
b.Halo- frameb.Halo- frame
c.Plaster of Paris head capc.Plaster of Paris head cap
2. CRANIOMAXILLARY2. CRANIOMAXILLARY
a.Supraorbital pinsa.Supraorbital pins
b.Zygomatic pinsb.Zygomatic pins
c.Halo-framec.Halo-frame
3. Suspension by cheek wires from halo-frame3. Suspension by cheek wires from halo-frame
or headcapor headcap

Box and Levant framesBox and Levant frames

THE ROYAL BERKSHIRE HALO FRAMETHE ROYAL BERKSHIRE HALO FRAME

Plaster of Paris head capPlaster of Paris head cap

TRACTIONTRACTION

Plates and ScrewsPlates and Screws

COMPLICATIONSCOMPLICATIONS
Intraoperative complicationsIntraoperative complications
Immediate post-operative complicationsImmediate post-operative complications
Late post-operative complicationsLate post-operative complications

Post operative complications
1. Non- union
2. Delayed union
3. Malunion
4. Infection
5. Plate exposure
6. Occlusal derangement
7. Facial asymmetry
8. Meningitis
9. Injury to lacrimal system
10. Neurological complications

References
R J Fonseca – Trauma 2 Vol.
Peter Ward Booth - 1 Vol.
Rowe And William - 2 Vol.
Killey s Fractures Of The Middle Third Of The Facial‟
Skeleton
Text book of Oral and Maxillofacial surgery – Neelima
Anil Malik

Le Fort fractures management guide

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