lefort 1 fracture , midface fracture

2. a) IN 1901 , RENE LE FORT , according to the level
of injury:
1. Lefort I
2. Lefort II
3. Lefort III

3. b) MARCIANI MODIFICATION 1993
Lefort I : low maxillary fracture
Lefor Ia : Low maxillary fracture / multiple segment
Lefort II : pyramidal fracture
Lefort IIa : pyramidal and nasal fracture
Lefort II b : pyramidal and NOE fracture
Lefort III : Craniofacial Dysjunction
Lefort IIIa: craniofacial dysjunction and nasal fracture
Lefort IIIb : cd and NOE fracture

4. Lefort IV : lefort II and III # and cranial base #
Lefort IV a : lefort II or III # and cranial base # + supra
orbital rim #
Lefort IV b : lefort II or III # and cranial base # + anterior
cranial base
Lefort IV c : : lefort II or III # and cranial base # + anterior
cranial fossa + orbital wall #

5. HENDRICKSON CLASSIFICATION OF PALATE FRACTURE
TYPE 1 : alveolar
1a : anterior alveolar (incisiors )
1b : posterior alveolar ( premolar molar )
TYPE II : Sagittal
TYPE III : Parasagittal
TYPE IV : Para alveolar
TYPE V : Complex
TYPE VI : Transverse

6. ACCORDING TO ROWE AND WILLIAM ( 1985)
A . Fracture not involving the occlusion
1. central region
a. Fracture of the nasal bone or the nasal septum
- lateral nasal injuries
- anterior nasal injuries
b. fracture of the frontal process of the maxilla
c. Fracture type a and b which extend to the ethemoid bone
d. # type a , b and c, which extend into the frontal bone
2. lateral region
# involving the zygomatic bone , arch and maxilla excluding dento-
alveolar Component.

9. FORCE ACTING :
 This type of # occurs from the application of horizontal
force just above the apices of the maxillary teeth.
 It results due to the blow from the opposite jaw , which
is often impacted.

10. This is a horizontal fracture above the level of the nasal floor
including the dental component.
The # line runs backward along .
Laterally : lateral margin of the pyriform aperture – lateral wall
of maxillary sinus – below the zygomatic buttress – lower one
third of the pterygoid lamina and associated palatine bone.
Medially : lower third of the nasal septum – lateral margin of the
anterior nasal aperture ( lateral wall of the nose ) proceeding
posteriorly to join the lateral fracture behind the tuberosity.

11. The fracture occurs at the level of the piriform aperture and involves the
anterior and lateral walls of the maxillary sinus, lateral nasal walls and,
pterygoid plates.
The nasal septum may also be fractured and the nasal cartilage may be
buckled.
 Sagittal fracture(s) of the palate may also be present.
The pull of the medial and lateral pterygoid muscles may contribute to
displacement of the fractured segment in a posterior and inferior direction,
resulting in an open bite deformity.
This fracture may present as an impacted, immovable, or free-floating
maxillary segment.

13. EXAMINATION- firmly grasping the maxillary arch
with the finger and thumb facially and palatally and
attempting displacement of the maxilla in three
dimensions, as well as compression and expansion of
the maxillary arch.

15.  Swelling of upper lip and cheek
 ECCHYMOSIS : present in maxillary buccal sulcus from shearing of
soft tissue or periosteal tear.
 NASAL BLOCK : mucosal tear in maxillary / ethmoid sinus may
include bleeding causing a nasal block – forcing the patient to
undergo oral breathing.
 Ocular signs are usually absent. Hypoesthesia of the infraorbital
nerve may be caused by the rapid development of edema.
 GUERIN SIGNS : ecchymosis in the palate in the area of greater
palatine foramen bilaterally- classical sign.

16.  OCCLUSION :
Undisplaced incomplete Lefort I # usually cause no occlusal
disturbance .Complete lefort I # classically shows varying degree of
anterior pen bite . This is from backward and downward distraction of
posterior maxilla resulting from inferior traction of medial pterygoid muscle
towards the mobile maxillary fragment.
Potential gaging of occlusion is potential treat to airway.
 TEETH FRACTURE :
Due to impaction of the mandibular teeth against the maxillary counter
part , damage to the cusp of individual maxillary teeth may be seen.

17. • Palatal fracture :
Commonly mid palatal split is associated with Lefort ;I evident as linear
mucosal tear in mid palate.
The associated palatal # could be of any of the Hendrickson Classification
pattern, with or without oronasal communication , depending upon the amount
of separation between the fragments from the effect of bilateral medial
pterygoid.
• Cracked-pot sound :
Percussion of the maxillary teeth results in distinctive “ cracked pot sound”,
similar to the sound produced when a cracked china pot is tapped with a spoon.

20. MANUAL / CLOSED REDUCTION
Rowe’s maxillary Disimpaction forceps and Hayton Williams Forceps

22. Maxilla is held with two pairs of
Rowe’s Disimpaction forceps.
Each unpadded blade is passed up a
nostril and the padded blade enters the
mouth and grips the palate
Head of operating table - operator
grasps the handle of each of the two
pair of forceps and manipulates the
fragments into place.

23. A deliberate rocking and
rotatory movement in
transverse and sagittal plane is
done.
A forward traction is applied
once the fracture is mobile.
Special attention should be given to correct
any inferior displacement of posterior
aspect of the maxilla- to relieve “gagging “
of posterior teeth and anterior open bite.

24. FIXATION
EXTERNAL FIXATION
CRANIOMANDIBULAR
• BOX FRAME
• HALO FRAME
• PLASTER OF PARIS HEAD
CAP
CRANIOMAXILLARY
• SUPRA ORBITAL PINS
• ZYGOMATIC PINS
• HALO FRAMES

25. INTERNAL FIXATION
DIRECT OSTEOSYNTHESIS
• TRANSOSSEOUS WIRING AT # SITE
1. HIGH LEVEL ( FRONTOZYGOMATIC AND FRONTO NASAL)
2. MID LEVEL ( ORBITAL RIM / ZYGOMATIC BUTRESS )
3. LOW LEVEL ( ALVEOLAR/MIDPALATAL)
• MINI PLATES
• TRANSFIXATION WITH KRISCHNER WIRE OR STEINMAN PIN :
 TRANSFACIAL
 ZYGOMATIC SEPTAL

26. SUSPENSION WIRE TO
MANDIBLE
• FRONTO CENTRAL OR
LATERAL
• CIRCUMZYGOMATIC
• ZYGOMATIC
• INFRA-ORBITAL
• PYRIFORM APERATURE
OPEN REDUCTION AND INTERNAL
FIXATION BY INTRAOSSEOUS WIRING:
Introduced by Adams 1942.
• Reconstruction of sinus wall fragment
between the two anterior pigments was
omitted.
• Pterygoid buttress was not operated.
• Posterior height of mid face – Open
reduction of zygomatic and naso-
ethmoidal fracture was performed.

31. HISTORICAL APPROACHES
Common to delay surgery for 7-14 days
Closed reduction in most instances
Long periods of Intermaxillary fixation
Small local incisions with restricted access for open
reduction (if used )
Accuracy of reduction sometimes estimated , esp in vertical
dimension
Wire osteosynthesis , wire suspension (craniomandibular ) or
external fixation (craniomandibular )

32. CONTEMPORARY APPROACH TO TREATMENT
Earlier one stage repair advocated
Emphasis on open reduction
No Intermaxillary fixation ( or short period only )
Wide exposure to all fracture sites
Anatomical reduction of structural pillars of the face
Simi-rigid miniplates and microplates internal fixation (with
primary bone grafting in some situations )

33. OPEN REDUCTION AND INTERNAL FIXATION BY
MINIPLATES , MICROPLATES , AND SCREWS
• CHAMPYS ET AL 1976
• HARLE AND DUKER 1975
• LUHR IN 1978.

34. APPROACH

38.  Infraorbital nerve paresthesia
 Enophthalmos
 Infection
 Exposed hardware
 Deviated septum
 Nasal obstruction
 Altered vision
 Nonunion
 Mal-union or Malocclusion
 Epiphora
 Foreign body reactions
 Scarring
 Sinusitis