LeFort Fractures Flashcards
Description of photo image
Anterior open bite with repaired R brow laceration
Description of CT
- Transverse fracture across maxilla involving the ZM and NM buttresses bilaterally, c/w a LeFort I fracture
- Fracture extending from R NM buttress to the infraorbital rim w/o displacement of the NF junction, c/w a type IA naso-orbital ethmoid (NOE) fracture
What CT images are necessary to confirm the diagnosis?
Coronal images on CT
On history, important are the
MOI to help determine the severity of impact and trajectory of force - changes in vision, occlusion, breathing, and hearing -and previous facial trauma
On examination, I would start with a trauma work-up
starting with the ABCs and in order to identify any potentially life-threatening injuries, ensuring to take spinal precautions and r/o a cervical injury
After the trauma work-up, I would perform a detailed examination of the face
- palpating for tenderness/crepitus/step-offs
- sensory and motor examinations
- eye, nasal, and intraoral examinations -and examinations of the the ears and tympanic membrane
After performing a detailed examination of the face, I would evaluate the state of dentition
-looking for fractured, missing, or rotten teeth, as well as the occlusal pattern
After evaluating the dentition, I would assess mid face instability by
-stabilizing the face at the nasal root (w/ L hand) and grasping the upper anterior alveolar arch (w/ R hand) and pulling forward and down
If the mid face is mobile with stability at the nasal root, it is indicative of
a LeFort I fracture
If there is also mobility at the NF suture, it is indicative of
a LeFort II fracture
If there is also mobility at the ZF suture, it is indicative of
a LeFort III fracture
The imaging of preference would be a
high-resolution maxillofacial CT scan with axial and coronal images
The sine qua non of LeFort fractures on (coronal) CT
is fracture of the pterygoid plates
On CT, a LeFort I fracture would present as
a transverse fracture fo the maxilla involving the ZM and NM buttresses
On CT, a LeFort II fracture would present as
a pyramidal fracture involving the ZM buttresses, inferior orbital rim, inferior and medial orbital wall, and NF region
On CT, a LeFort III fracture would present as
craniofacial dysjunction, involving the zygomatic arch, lateral orbital rim, lateral orbital wall, orbital floor, medial orbital wall, and NF region
A LeFort III fracture does not involve the
ZM buttress
If there is an orbital fracture, I would consult
ophthalmology to r/o ophthalmic injury prior to operative intervention because intra-op manipulation may exacerbate an eye injury
In managing a LeFort fracture, I would start with
ATLS protocol and ensuring all emergent injuries are managed first. I would start antibiotic therapy.
Definitive treatment of facial fractures may be delayed up to
2 weeks w/o compromising results
Delaying definitive treatment of facial fractures for more than 2 weeks increases the risk of
infection and need for osteotomies
If a LeFort fracture is non displaced and stable, it can be managed
non operatively with a soft, non-chew diet for 4-6 weeks, ensuring close follow up to monitor occlusion remains good
Displaced, unstable fractures require
ORIF to ensure return of normal occlusion
In repairing the fracture I would perform MMF using
dental wear facets as guides, using arch bars
I would bone graft
bone gaps at buttresses, particularly gaps > 5 mm
In repairing a LeFort fracture, I would
nasally intubate the patient, ensuring the absence of a cranial base injury prior to doing so
After performing a nasal intubation, I would perform
- bilateral gingiolabial incisions 5-10 mm from the apex of the sulcus
- expose the maxilla subperiosteally (with coronal incision if the fracture is comminuted)
- establish occlusion with MMF
- reduce the fracture, with the use of Rowe disimpaction forces if the fracture is impacted or difficult to reduce
- stabilize the fracture
In stabilizing a LeFort I fracture, I would plate the
ZM and NM buttresses
In stabilizing a LeFort II fracture, I would plate the
ZM and infraortbital rims
In stabilizing a LeFort II fracture, plating of the NF junction is necessary if
this region is significantly displaced
In stabilizing a LeFort III fracture, I would plate the
ZF (lateral orbital rim) and NF junction
After stabilizing a LeFort fracture
MMF is released and occlusion is checked with the mandibular condyles seated in the glenoid fossa
10-15% of LeFort fractures also have
palatal fractures, which may be managed with fixation or splinting for 6 weeks
LeFort II fractures may be exposed with a combination of
gingivobuccal and lower eyelid incisions (alternatively: coronal incision)
Complication: malocclusion
due to improper reduction or stabilization with MMF
Complication: nonunion/malunion/fibrous union
requires debridement of the fracture, and possibly bone grafting and refixation
Complication: infection
I would start antibiotics and be cautious about removing hardware if complete healing has not occurred, as this can result in loss of reduction
