Le Fort Fractures Research Articles

Use of copolymer polylactic and polyglycolic acid resorbable plates in repair of orbital floor fractures.

The fractures of the orbital floor are common after craniofacial trauma. Repair with resorbable plates is a viable reconstructive option; however, there are few reports in the literature. This study describes our experience using copolymer polylactic and polyglycolic acid (PLLA/PGA) orbital reconstruction plates (LactoSorb, Lorenz Surgical, Jacksonville, FL) in 29 cases of the orbital floor fracture repair. We conducted a retrospective review of 29 orbital floor fractures at a single institution repaired through transconjunctival, preseptal dissection using PLLA/PGA plates fashioned to repair the orbital floor defect. Associated fractures included zygomaticomaxillary, LeFort, and nasoethmoid fractures. There were six patients with complications. Four patients had transient diplopia with complete resolution of symptoms within 1 year. One patient had diplopia postoperatively, but was later lost to follow-up. Two patients have had persistent enophthalmos since 1 year. In each of these cases, the floor fracture was coincident with significant panfacial or neurotrauma. We did not encounter any adverse inflammatory reactions to the implant material itself. The study concluded that orbital floor fracture repair with resorbable plates is safe, relatively easy to perform, and in the majority of cases was effective without complications. In the presence of severe orbital trauma, more rigid implant materials may be appropriate.

Lateral pterygoid plate fractures associated with mandible fractures.

Classically, pterygoid plate fractures have been associated with fractures of the mid-face and skull base. When isolated pterygoid plate fractures are identified on imaging that only extends to the level of the skull base, other related facial fractures may be missed. We sought to evaluate isolated lateral pterygoid plate fractures on computed tomography (CT) scans in conjunction with mandible fractures and to propose a mechanism of fracture unrelated to the classic dissociating mid-face Le Fort fractures. In this retrospective case series, 7 patients who sustained facial trauma from 2006 to 2012 were found to have isolated lateral pterygoid plate fractures. All patients had an ipsilateral subcondylar fracture, 2 had symphyseal fracture, 2 had body fracture, and 1 had coronoid fracture. On the basis of these cases, isolated lateral pterygoid fractures noted on CT of the head may be suggestive of an unappreciated mandibular fracture. The suspected mechanism is due to force transduction through the medial and lateral pterygoid muscles when acute displacing force is placed on the mandible. In patients with identified isolated pterygoid plate factures, a dedicated CT of the mandible may be indicated to assess for associated mandibular fracture, even in patients whose clinical examinations have had negative results.

Assessment of changing patterns of Le fort fracture lines using computed tomography scan: an observational study

Objectives. To assess the changing mid-face fracture patterns using a computed tomography scan. Methodology: Fifty patients with mid-face trauma requiring open reduction and fixation were studied using 1.6 mm axial, sagittal, coronal and 3D images. Images were evaluated clinically, intra-operatively and finally were compared with standard Le Fort lines. Results. The male population dominated the female at a ratio of 11.5:1. The majority of the mid-face fractures were seen in the age group of 21–30 years. Road traffic accident (78%) was the major etiological factor followed by work-related accidents (12%) and assaults (10%). The CT scan analysis included categorizing the patients into three groups: (1) Fracture patterns resembling Le Fort lines (24%); (2) Fracture patterns partially resembling Le Fort lines (56%); and (3) Fracture patterns that do not resemble Le Fort lines (20%). Conclusion. With the change in the velocity of wounding object, there is a change in the mid-face fracture patterns. The majority of the cases present as a variant of classical Le Fort fractures. Computed tomography is a valuable diagnostic tool in assessing the fractures of the mid-face. 2D images are more sensitive than 3D images. However, both the images are required in delivery of an optimal treatment plan.

Management of Lefort Fractures

Fractures of the maxillary facial bones, also described as LeFort fractures, are potentially disfiguring and potentially lethal injuries that require careful examination and expectant management skills. This review article provides an overview of fracture patterns, patient assessment, and the specific management of patients with LeFort fractures.

Multidetector computed tomographic evaluation of maxillofacial trauma

Introduction: Maxillofacial injuries are one of the most frequently encountered entities accounting for a large proportion of patients in emergency department. Present study was performed to assess the role of multidetector computed tomography (MDCT) in patients of maxillofacial trauma and to describe the spectrum of various patterns of injuries in maxillofacial region in this part of Nepal. Methods: The study was carried out on a prospective basis over a period of one year. All the patients referred for evaluation of maxillofacial trauma were included in the study. MDCT was done in patients of maxillofacial injury and the data was recorded and analyzed. Volumetric MDCT scan of the maxillofacial region was performed in axial plane with multiplanar reconstruction in coronal and sagittal planes were obtained wherever required. Results: Out of 60 patients of maxillofacial trauma 42 (70%) were males and 18 (30%) were females and age ranges from 12 to 70 years. The 11?30 years age group has the highest percentage (55%) of maxillofacial trauma, followed by 31?40 (20%). The common cause of injuries in our study was road traffic accidents (58.33%), fall from height (20%), physical assault (16.66%) and sport injuries (5%). Out of 60 patients there was total of 115 fractures. The frequency and types of fracture was as follows: orbital floor fracture in 21 (35%), maxillary sinus wall fracture in 18 (30%), nasal bone fracture in 17 (28.33%), jaw fracture in 15 (25%), zygomatic bone fracture in 13 (21.66%), orbital wall fracture in 11 (18.33%), naso?ethmoidal fractures in 9 (15%), frontal sinus fracture in 7 (11.66%), Lefort fracture in 1 (1.66%) and others 3 (5%). The highest percentage of fracture was of orbital floor (35%) followed by fracture of wall of maxillary sinus (30%) and nasal bone fracture (28.33%). Three cases had simultaneous injury of the globe and cervical spine; they underwent computed tomography/magnetic resonance imaging for the assessment of spine. Conclusion: Injuries to maxillofacial region is one of the most common emergency requiring accurate and early diagnosis for preventing unnecessary investigations and proper management. MDCT has high sensitivity and specificity and has high accuracy for detection of fracture. DOI: http://dx.doi.org/10.3126/ajms.v5i4.9561 Asian Journal of Medical Sciences 2014 Vol.5(4); 39-43

C-23 Clinical Case Slide – Football

HISTORY: A 27 year old female, an athletic trainer for a Division I softball team, was in the dugout during practice when she was struck in the face with a line drive foul ball that caused a laceration to her upper lip and a loose tooth. There was no loss of consciousness. An initial headache resolved after 30 minutes. There was no dizziness, nausea, vomiting, or any changes in vision. She was seen in the university emergency department a maxillofacial CT scan showed no evidence of an orbital floor or maxillary fracture. An ENT surgeon closed the facial laceration to the right upper lip. The patient complained of the loose tooth, but the surgeon said it could be due to the swelling from the trauma and to just observe it. He expected it would firm up in several days. The next morning, while preparing for a road trip, part of her tooth fell off. This became a management issue to determine whether she needed emergent dental management or could travel with the team. PHYSICAL EXAMINATION: Initial exam in the ED revealed a 2.5 cm obliquely oriented laceration to the right upper lip (almost to the oral mucosa) with a loose right maxillary incisor (tooth #7). The laceration did not cross the vermillion border. Laceration was repaired using a two layer closure with a running locked stitch (5-0 prolene) externally. Tooth #7 was slightly loose on palpation but appeared intact in the socket. The next day the facial suture appears clean, dry, and intact. Rather than tooth #7 being loose in the socket, it had an oblique fracture involving the majority of the crown. The root and pulp remained intact. DIFFERENTIAL DIAGNOSIS: Le Fort Fracture, Orbital Fracture, Luxation of the tooth, Avulsion of the tooth, Crown fracture, Root fracture, Facial laceration TEST AND RESULTS: Maxillofacial CT scan without contrast - Mild to moderate sinus disease - Negative for acute bony abnormality - Minimal soft tissue air seen in the upper lip FINAL WORKING DIAGNOSIS: Oblique crown fracture of tooth number 7 TREATMENT AND OUTCOMES: 1. Since the root was intact, it was not an emergency and saw the dentist two days later. Exam then revealed root and pulp were intact. 2. Root canal was done. Plan for follow up in 3 weeks to allow resolution of swelling. 3. Sutures from facial laceration removed after 1 week with good approximation. 4. Crown placed over oblique dental fracture of tooth at follow up visit.

Life-threatening oronasal hemorrhage managed by transcatheter embolization of bilateral maxillary arteries in an elderly patient with comminuted LeFort I fracture

Massive orofacial hemorrhage mostly occurs in younger individuals unilaterally and is associated with extensive LeFort fractures. Here we describe a 91-year-old man who sustained a life-threatening hemorrhage of the bilateral internal maxillary artery (IMA) system with a comminuted LeFort I fracture caused by a road traffic accident while he was driving. His injury severity score was high (34), but no severe brain injury was sustained. Transarterial embolization (TAE) was performed to control the intractable hemorrhage. The patient survived and has an acceptable outcome. Although rare, this case may be representative of a trend in maxillofacial injuries in the elderly resulting from worldwide motorization and steady aging of more active populations. Life-threatening hemorrhage of the bilateral IMA system occurs even in LeFort I fractures. Controlling an intractable oronasal hemorrhage with TAE would lead to survival with less severe morbidity, even for the very elderly with no severe brain injuries.

Imaging Evaluation of Facial Complex Strut Fractures

High-resolution multidetector computed tomography with multiplanar reformations and 3-D postprocessing often provides the detail necessary for preoperative assessment of facial injuries. Maxillofacial fractures are classified in the following manner: upper face fractures, midface fractures (the most frequent), Le Fort fractures, and lower face or mandible fractures. The facial skeleton is a framework of vertical and horizontal buttresses that ensures a better resistance to trauma, but serves also as reference for maxillofacial surgery to restore facial size and shape. Radiologists should know how to diagnose and report the main types of facial fracture.

Prevalência e considerações sobre a intubação submentual no tratamento das fraturas faciais

The submental intubation is a technique for maintaining the patient's airway during surgery, when the oral and nasal intubation is contraindicated, the need for maxillomandibular block of dentate patients, the presence of complex fractures of the middle third of face, skull base or some kind of nasal anatomic change, being an alternative to tracheostomy. ObjectivesThe authors propose to evaluate the prevalence submental performing intubation in patients with facial fractures treated under general anesthesia, relating to gender, age, etiology, types of fractures and complications during and after surgery to facilitate the understanding and the correct indication predictability of this technique. Materials and methodsObservational epidemiological, descriptive and retrospective study of medical records of patients seen at the Oral and Maxillofacial Surgery and Traumatology Service of the Bauru Hospital Complex (Brazil) in the period January 2011 to January 2012. ResultsThe incidence of submental intubation was 2.02%. The male was the most affected with 83.3% and age of the third decade of life (66.6%). The etiology was more prevalent motorcycle accidents (66.6%) followed by automotive (33.3%), and Le Fort fracture type II the most prevalent (28.5%). No complications were observed. Conclusionssubmental intubation has proved satisfactory for the resolution of surgical cases of extensive facial fractures, when the oral and nasal intubation is contraindicated, with a simple, rapid implementation and low morbidity.

Utility of Digital Volume Tomography in Maxillofacial Trauma

To assess the diagnostic quality of images generated using the newly developed digital volume tomography (DVT) system and comparing them with conventional images from patients with maxillofacial trauma. The study population included 22 male patients aged 18 to 60 years with a history of maxillofacial trauma. Each patient had undergone conventional radiographic and DVT examinations to analyze the number of fracture lines in the jaws and to compare the images for their diagnostic quality by an oral radiologist and a general radiologist using the χ(2) test. A statistically significant difference was found between the number of fracture lines evaluated on the conventional radiographs and on DVT, especially for condylar head (7) and the midface (4.41 to 4.57), zygomaticomaxillary complex and Le Fort fractures, respectively. The detection of fracture lines and visualization within the mandibular-maxillary area using DVT was superior to using conventional radiographs.

René Le Fort 1869–1951

Over a century ago, The French surgeon René Le Fort described the anatomical basis for fractures of the mid-face. His nomenclature is still used today using the eponym "Le Fort fractures." Although Le Fort's name is well known in association with the fractures that he described, little is known of his life. Therefore, the present article will discuss the background of this important individual in craniofacial trauma.

Violence-related facial trauma: analysis of multidetector computed tomography findings of 727 patients

The multidetector CT (MDCT) findings of facial trauma in victims of interpersonal violence were assessed. All MDCT requests for suspected facial injury during a 62 month period were retrieved; 727 cases met the inclusion criteria. Images were interpreted by two researchers by consensus. Of the 727 patients (aged 15-86 years old, mean 37), 583 (80.2%) were male and 144 (19.8%) female. Of all the patients, 74% had a fracture, and of these 44% had multiple non-contiguous fractures. Violence is a very common cause of facial injury. Nasal and orbital fractures predominate. Males are more often involved; they are younger, sustain fractures more often and significantly more often present with high-energy fracture patterns. LeFort fractures are often unilateral or asymmetrical, and are frequently accompanied by other, clinically significant fractures. Up to 25% of patients with fractures do not have paranasal sinus effusions.

Bleeding From Posterior Superior Alveolar Artery in Le Fort I Fracture

This article describes a patient in whom significant oronasal bleeding developed after an injury to posterior superior alveolar artery of the maxillary artery in Le Fort I fracture.A 34-year-old man had a facial injury after an explosion of a furnace. Computed tomography demonstrated Le Fort I fracture, right open zygomatic tripod fracture, and open nasal bone fracture. Blood pressure, hemoglobin, and hematocrit levels had fallen to 110/60 mm Hg, 5.7 mg/dL, and 16.1%, respectively, 10 hours after injury despite continuous blood transfusion. Selective digital angiography confirmed an injury to the posterior superior alveolar artery, with extravasated pooling of contrast material in the maxillary sinus. The distal internal maxillary artery was embolized with n-butyl cyanoacrylate and lipiodol. Postembolization angiogram showed resolution of the contrast leak, and the patient's oronasal bleeding resolved.We suggest that if the oronasal bleeding continues in Le Fort fracture, bleeding from the posterior superior alveolar artery should be suspected. In case the vital sign is not stable, selective angiography should be performed before surgery.

Interpersonal Violence and Facial Fractures

Interpersonal violence is a major health hazard that contributes to the high volume of trauma seen in the emergency department. It is also one of the principal causes of maxillofacial fractures. The present study was a retrospective analysis of patients referred to, and treated at, the Oral and Maxillofacial Surgery Unit at Christchurch Hospital during an 11-year period (1996 to 2006). The variables examined included patient demographics, fracture types, mode of injury, and treatment delivered. An increase was found in the number of fractures due to interpersonal violence in the second half of the study, although the proportion remained the same. The age of the patients ranged from 9 to 89 years (mean 28). The male-to-female ratio was 9:1. Of the patients, 87% had alcohol involvement. The mandible was the most common site of fracture, followed by the zygoma. Other midface fractures, including Le Fort fractures, were less frequently observed. Of the patients, 59% were hospitalized and 56% required surgery, with internal fixation necessary in 41% of patients. An increase occurred in the number of facial fractures associated with interpersonal violence during the study period. Young male adults were the most affected demographic group, with alcohol a main contributing factor. Violence-related facial fracture is a health hazard that deserves more public awareness and implementation of preventive programs.

Submental tracheal intubation in oromaxillofacial surgery

Background:Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying.Materials and Methods:The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil′s forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only.Results:The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively.Conclusion:In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.

CT evaluation and classification of the Le Fort fracture

目的 探讨Le Fort型骨折的CT表现及其分型.方法 对62例Le Fort型骨折患者进行薄层螺旋CT扫描和三维重组分析.结果 在62例中,Le Fort Ⅰ型10例,Ⅱ型9例,Ⅲ型8例,复合型35例(其中Ⅰ+Ⅱ型18例,Ⅰ+Ⅱ+Ⅲ型7例,Ⅱ+Ⅲ型10例);55例同时伴发颌面部其他骨折.Le Fort型骨折在二维CT上表现为颌面部多发且杂乱的骨折,虽然在发现细小和深部结构的骨折方面优于三维CT成像,但难以作出Le Fort型骨折的诊断;三维CT成像能清晰立体地显示Le Fort型骨折的整体形状及走向,并可明确作出分型.结论 三维CT成像是Le Fort型骨折最有效的诊断方法,对临床制定治疗方案具有指导意义,但是对细小骨折诊断不如二维CT。

Mucociliary clearance and sense of smell following management of Le Fort maxilla fractures

To assess mucociliary transport and olfaction in patients after Le Fort fractures. Forty-one patients were enrolled who had sustained a Le Fort fracture during the preceding five years. Control group consisted of students. Olfaction and mucociliary transport were examined in all subjects. A capillary with saccharine was placed on the inferior nasal concha, and time was recorded in which the subject tasted sweetness in the mouth. Results were subject to statistical analysis. Patients with allergy, sinus disease and smokers were excluded from the examination. Disturbance of mucociliary transport and olfaction turned out to be statistically dependent on the type of fracture and management. Le Fort fracture might be complicated by compromised mucociliary clearance and olfactory disturbances.

Diagnosis of Midface Fractures with CT: What the Surgeon Needs to Know

Computed tomography is commonly used to evaluate patients with blunt facial trauma. With the high definition of the current scanners, even small fractures of the facial skeleton can be visualized. In complex midface injuries, it can be difficult for the radiologist to know which fractures are important to point out to the surgeon. An understanding of the anatomically relevant and surgically accessible craniofacial buttresses is critical for management of these injuries. Naso-orbitoethmoid fractures are classified according to the degree of injury to the medial canthal attachment. If the nasofrontal ducts are disrupted, surgical obliteration of the frontal sinus is needed to prevent formation of a mucocele. Displaced fractures of the zygomaticomaxillary complex often increase orbital volume due to angulation of the lateral orbital wall at the zygomaticosphenoid suture. If the zygomatic arch is severely comminuted or angulated, surgical exposure is indicated. In orbital fractures, the position and shape of the medial and inferior rectus muscles can indicate whether entrapment and diplopia are likely. Pediatric "trapdoor" orbital fractures and fractures of the orbital apex associated with decreasing vision represent surgical emergencies. Le Fort fractures involve disruption of the pterygoid plates from the posterior maxilla; any combination of Le Fort I, II, and III patterns can occur.

Comparison of the Severity of Bilateral Le Fort Injuries in Isolated Midface Trauma

The Le Fort classification pattern established in 1901 by the French surgeon Rene Le Fort is commonly used in describing midface fractures. This frequently used classification system is based on predictable patterns of midface fractures initially described for blunt trauma. The purpose of this study was to compare the profile and outcome of patients with isolated bilateral Le Fort I, II, and III fractures. All patients presenting to the emergency department (ED) at Legacy Emanuel Hospital (Level I trauma center) in Portland, OR, between December 1990 and December 2003 with isolated bilateral Le Fort I, II, or III fractures with or without concomitant nonfacial injuries were identified retrospectively using the Hospital Trauma Registry. Patients were classified into study groups I (n = 22), II (n = 22), or III (n = 23) corresponding to the Le Fort classification, respectively. Sixty-seven patients had a diagnosis of isolated bilateral Le Fort I, II, or III fracture. The average Injury Severity Score (ISS) and hospital length of stay were 18.8 +/- 8.9 and 9.5 +/- 11.9 days, respectively. Blood alcohol was detected in 19 patients. Sixty-four injuries (95.5%) were secondary to blunt trauma, and the remaining 3 (4.5%), penetrating injuries. More than half of the patients (n = 35, 52.2%) were admitted to the intensive care unit (ICU), 18 patients (26.8%) were transferred to the hospital trauma ward from the ED, and 14 patients (20.9%) were taken directly to the operating room. Fifteen (22.4%) patients required a tracheostomy secondary to their maxillofacial injuries. A statistically significant difference in the ISS was detected between patients with Le Fort I versus those with II or III injuries ( P < .0001). Patients with Le Fort II or III fractures had a significantly higher probability of ICU admission or immediate operative intervention. Ten patients (43.5%) with Le Fort III injuries required tracheostomy versus 3 patients (13.6%) with Le Fort I, and 2 patients (9.1%) with Le Fort II injuries. This was statistically significant. None of the patients with Le Fort I injuries had a negative outcome (death); however, 1 patient with Le Fort II injuries (4.5%) and 2 with Le Fort III injuries (8.7%) had a negative outcome. No statistically significant differences or emerging trends were observed among the 3 groups for age, gender, length of stay, number of operations, and number of associated injuries. Patients with higher Le Fort injuries are characterized by an overall greater severity of injuries as measured by the ISS and the more frequent need for a surgical airway. Patients with Le Fort III injuries have a higher chance of requiring neurosurgical intervention or of experiencing vision-threatening ocular trauma. Immediate operative intervention and/or ICU care is more frequently indicated in these patients.

How to Simplify the CT Diagnosis of Le Fort Fractures

The numerous components seen in the Le Fort fractures make classification difficult. Our objective is to simplify the task of classifying Le Fort fractures. Each of the Le Fort fractures has at least one unique component that is easily recognizable: I, the anterolateral margin of the nasal fossa; II, the inferior orbital rim; and III, the zygomatic arch. Classification of the Le Fort fractures is simplified by using these unique components to establish a tentative classification that is then confirmed.