Le Fort fracture of skull

A maxillary fracture ( fracture of maxillary lat, Fractura ossis maxillae, Maxillafraktur or mandibular fracture of the maxilla, Eng. Maxillary fracture ) is a fracture of the maxilla. The upper jaw fracture has typical curves of the fracture lines that run along weaknesses in the maxilla. This fracture can occur inside or outside the row of teeth. The classification of maxillary fractures that are not the upper teeth involving occurs after Le Fort ( Le Fort fractures of type I to III).

• 5.1 examination and clinical diagnosis
• 5.2 eye
• 5.3 X-ray diagnosis
• 5.4 Differential Diagnosis

• 7.1 Initial treatment
• 7.2 operation
• 7.3 reduction
• 7.4 Technology of operative fixation
• 7.5 Maxillo - mandibular fixation

Anatomical bases

The upper jaw (maxilla ) illustrates the connection between the base of the skull and the upper row of teeth, which in turn influence the occlusion and the position of the lower rows of teeth and the lower jaw. The anatomical structures of the upper jaw are closely related to the oral cavity, the nasal cavity and the orbit.

The maxilla is a paired bone with the shape of a pyramid, which is the cornerstone of the facial skeleton. In the vertical direction, the upper jaw connects the higher-lying cranio- fronto- ethmoidal complex ( skull, frontal, ethmoid ) with the lying down " Kaukomplex " ( palate, alveolar ridge, teeth, mandible ). In the transverse direction of the upper jaw connects the two zygomatico - orbital complexes. The shape of the upper jaw away from a corresponding 5 - sided pyramid, the base of the lateral nasal wall. The remaining four sites are the orbital floor (top), the alveolar ridge ( below), the front wall of the maxillary sinus (front) and the front surface of the pterygopalatine fossa ( behind; wing palate pit).

Causes of maxillary fracture

Maxilla fractures often result from blunt force, which acts with high energy on the facial skeleton. Typical causes of these traumas are traffic accidents ( car, motorcycle, bicycle), sports accidents slashed disputes (very often kicks ), fall from height and falls. Are rarely, maxillary fractures result of a gunshot wound or from Huftritten.

Frequency

From the facial fractures approximately 6-25 % are maxillary fractures. Because of the small number of cases and the different counts in the number of cases, depending on whether the survey is carried out in a trauma surgery clinic, a dental clinic or a pine clinic, the distribution of frequencies of the different sources vary widely.

Classification

The upper jaw fracture is one of the midface fractures. These are divided into central and lateral midface fractures. The lateral midfacial fractures include the zygomatic fracture, the zygomatic arch and the orbital floor. One of the central midface fractures are the three types of Le Fort fracture, the Transversalbrüche of the upper jaw outside the row of teeth, respectively. The Le Fort fracture is also called Craniofacial avulsion of the midface.

Le Fort fractures

• Le Fort I fracture: red line
• Le Fort II fracture: blue line
• Le Fort III fracture: green line

Le Fort fractures are named after René Le Fort (1869-1951), a French surgeon from Lille, who introduced the far the most common classification of maxillary fractures with the typical fracture lines in the transverse direction above the rows of teeth.

Le Fort published his work in 1901 with the classification of maxillary fractures. During his studies continued Le Fort corpse skulls from various blunt force impacts ( metal ball on a long pendulum) from different directions and varying intensity. Then he examined the injury and typical profiles of the cleavages.

Le Fort was three standard pattern for the upper jaw fracture, which accounted for the largest part of the breaches:

• The horizontal Le Fort I fracture,
• The pyramidal Le Fort II fracture,
• The transverse Le Fort III fracture.

While the Le Fort I fractures and Le Fort II fractures are strictly confined to the central midface, the Le Fort III fractures extend both the central as well as on the lateral midface.

LeFort I fracture

The central midface fracture type Le Fort I (abbreviated as Le Fort I ) is an horizontal maxillary fracture ( see picture, red line). The alveolar process of the maxilla is separated from the rest of the upper jaw and skull. These transverse fractures of the upper jaw with a horizontal avulsion of the alveolar process (lat. alveolar process of the maxilla ) runs in the height of the nose and maxillary sinus floor. The bone fragment is reminiscent of a maxillary complete denture.

In the horizontal Le Fort I fracture, the fracture line of the nasal septum to the lateral edge of the Apertura enough piriformis, horizontally just above the apices of the maxillary teeth, she then crosses below the suture zygomaticomaxillaris ( the suture between the maxilla and zygomatic bone ), crosses the suture pterygomaxillary and on the lateral and medial pterygoid processus (both left and right side of the face ).

For the palpatory diagnosis is important that the fracture line through the Nasenapertur (right and left of the nose wing - movement and associated pain triggered ) extends, but not through the inner or outer corner of the eye.

Cause of the fracture are horizontal, slightly downward forces acting on the alveolar process of the maxilla.

Le Fort II fracture

The Le Fort II fracture is a central midface fractures with a pyramidal Oberkieferabsprengung ( Pyramidalfraktur ) of the upper jaw massif. The fracture line runs along or below the suture frontomaxillary (with or without involvement of the nasal skeleton ), by the frontal process of the maxilla, the medial wall of the orbit (medial canthus ) along lacrimale by the os, through the orbital floor, the lower orbital rim, by the infraorbital foramen or near past it, obliquely downward through the anterior wall of the maxillary sinus. Next, the fracture line runs under the cheekbone, along the pterygomaxillary fissure and the medial and lateral pterygoid lamina.

The Le Fort II fracture separates the nasoethmoidal block from the rest of the skull. You can both sides (classical form) or occur unilaterally.

Cause of this fracture are force to the lower or middle part of the upper jaw.

Le Fort III fracture

The centrolateral midface fracture type Le Fort III is a complete tear of the midface from the skull base. This high avulsion of the maxilla in the upper part of the midface.

The entire upper jaw, sometimes even more bone, so the entire midface are blasted at the Le Fort III fracture of the craniofacial skeleton. Therefore, these transverse Le Fort fracture is also known as craniofacial separation (removal of the face from the cranium).

The fracture edges extending through the nasal skeleton ( suture and suture nasofrontalis frontomaxillary ), along the medial wall of the orbit (medial canthus ), through the ethmoid bone ( ethmoid ). The thick sphenoid ( sphenoid ) prevents continuation of the fracture line to the back of the optic canal. The fracture line continues along the orbital floor continues, further superior -lateral to the lateral wall of the orbit (distal corner of the eye ) through which zygomaticofrontal suture and the zygomatic arch.

With involvement of the zygomatic bone and / or the zygomatic arch is called a zygomatico - maxillary fracture. It also unilateral Le Fort III fractures are possible.

Within the nose, the fracture extends through the base of the ethmoid, through the vomer and by connecting the lamina lateralis and medialis of the lamina of the pterygoid process of the sphenoid bone to the base of the sphenoid bone.

Cause of this fracture are force to the maxilla or the bridge of the nose.

Critique of Le Fort classification

In today's clinical practice, the Le Fort classification proves to be an oversimplification of the maxillary fractures. The idealized Krafteinwikungen that left Le Fort act in his experiments on the skull, often do not correspond to the actual, complex forces. The energy that acts on the central face during a traffic accident, is much stronger than the forces that Le Fort 1901 expended in his attempts to corpse skulls.

Another criticism of the Le Fort classification is that some fractures are not taken into account, such as sagittal fractures, zygomatic fractures and Jochbogenfrakturen.

From the Le Fort Classification small maxillary fractures are not recognized. With these fractures (caused by weaker acts of violence, which are limited to small area) just blasted a small isolated fragment, for example by a hammer blow. In particular, the alveolar ridge, the anterior wall of the antrum or the suture nasomaxillaris are typical locations for this type of fracture.

In addition, submental forces ( " blow to the chin "), which are directed upwards, leading to severe, isolated, vertical fractures through one of the horizontal supporting structures of the upper jaw (eg, alveolar, infraorbital bone edge = Rima infraorbital, zygomatic arch ). These fractures are not covered by the Le Fort classification.

Today maxillary fractures are usually a combination of different Le Fort types ( mixed types ), unilateral fractures and atypical fractures. The fracture lines tend to differ from those described classical gradients. In case of severe trauma to the facial skeleton still mandibular fractures and / or skull fractures, in addition to the upper jaw fractures occur.

Guérin - fractures

A lesser known, older classification of maxillary fracture goes to the Parisian surgeon Alphonse Guérin (1801-1866) back (1866 online). This fracture is called fracture Guérin. The fracture is a transverse fracture maxilla and runs horizontally through the Apertura pirifomis ( the front boundary of the bony nasal cavity ). There is a broad agreement with the Le Fort I fracture.

Wassmund fractures

Overlap in the classification, there are also between the Wassmund fractures ( Martin Wassmund, German dental surgeon, 1892-1956 ) and the Le Fort fractures. Both are mid-facial fractures. The Wassmund fractures of type II correspond to the Le Fort fractures of type II Wassmund fractures of type IV correspond to the Le Fort fractures of type III. The Wassmund fractures of type III is also similar to the Le Fort fractures of type III.

Sagittalbruch of the maxilla

In addition to the Le Fort fractures, there are considerably less frequent, isolated Sagittalbrüche of the maxilla. This fracture extends sagittal ( from front to rear through the upper jaw ). The fracture line is usually close to the palatal ( cruciate suture ).

Alveolar process

Fractures within the row of teeth are often combined with Alveolarfrakturen and / or tooth fractures.

Modern classification of midfacial fractures

The current classification of midfacial fractures differs lateral ( zygomatic fracture ), centrolateral (Le Fort III fracture ) and central midface fractures ( Le Fort I fracture, Le Fort II fracture, nasal bone fracture and sagittal maxillary fracture). However, these newer classification has not completely replaced the older Le Fort classification.

Diagnosis

Examination and clinical diagnosis

The external recognition of facial fractures is usually complicated by the fact that after serious accidents, the face shape and the position of the facial bones due to massive swelling (edema ) of the face soft tissue, bruises, abrasions, extensive bleeding and bruising ( hematoma) is often only be guessed. The enormous face swelling after severe trauma can make this classical clinical diagnostic assessment often impossible.

Possible symptoms of maxillary fracture are abnormal mobility of the otherwise rigid upper jaw dislocation of the bone fragment, bone crunching ( crepitus ) during movement of the bone fragment, hematoma, swelling, sensory disturbances (especially infraorbital nerve ) compression pain, bleeding, occlusion. In the percussion of the teeth a dull knocking sound can be heard.

Clinically, the diagnosis is made by triggering pain and mobility control in the slight movement of the upper jaw fragment. (-: Gray point in the image, the two large incisors ) shaken with thumb and forefinger purpose is slightly on the upper front teeth. The other hand gropes with his thumb and forefinger about a possible move to the typical course places the break lines.

( Image description: Le Fort I: mobility only to the blue dots, Le Fort II: mobility only on the green points, Le Fort III: Mobility at the green and red dots )

The mobility of the midface can be checked by the upper central incisors are firmly gripped and shaken them while the patient's forehead is held with the other hand to stabilize the head. The size and location of the mobile bone fragment can show the doctor to a Le Fort fracture into account what type itself. However, it can also lead to errors if the bone fragment because of the high force in its dislocated position firmly impacted ( wedged ), and apparently there is no bone mobility.

Periorbital swelling may indicate a Le Fort II fracture or Le Fort III fracture.

There should be a thorough nasal and intraoral examination should be performed. In Le Fort II fractures, the nasal bones are typically highly mobile, together with the remaining pyramidal upper jaw fragment. In the intranasal inspection can be observed from cerebrospinal fluid fresh or old bleeding, Septumhämatome or rhinorrhea ( nasal discharge ).

Wherein the intraoral study the intact occlusion is monitored, the condition of the individual teeth, the stability of the alveolar process, and the hard palate. It is important also to injuries of the soft palate. In addition, intraoral scanning with your fingers, the contour of the upper jaw to detect possible damage to the anterior bony wall of the antrum or at zygomaticomaxillären or nasomaxillary pillars.

In severe associated injuries with airway obstruction or traumatic brain injury, the investigation of the upper jaw and facial bones must be deferred until the more severe injuries are controlled.

Localized swelling or hematoma may be related to the fracture line. A periorbital swelling may indicate a Le Fort II or III fracture.

A shift back of the fractured midface requires a flattened facial shape in Anglo-Saxon literature as a dish -face (also Pan -face, uncommon translation: dish face) is called. This Gesichtsdeformierung occurs after large on LeFort II or LeFort III fractures, but is initially masked by the facial swelling. The fractured maxillary segment is displaced backward and downward. This can lead to premature contacts in the molar region, which are accompanied by an anterior open bite. In severe cases, may be hampered by the partial obstruction of the upper airway breathing. In these cases it may be necessary to the nasal floor and the hard palate as quickly as possible to decompress ( reducible ) to move the dislocated bone fragment back to the front, and thus to open the airway again.

In Le Fort II fractures, the bones are nasalia typically highly mobile, they move together with the free-floating, pyramid-shaped bone fragment of the upper jaw. At Le Fort III fractures, the fracture line also passes through the lateral orbital rim and the zygomatic bone.

Eye

At the eye socket, the strength of the rim of the orbit and the orbital floor is examined, and the visual acuity ( visual acuity ), checked the extraocular movement, the position of the eyeball and the interkanthale distance ( distance between the Lidwinkeln - eyelid ). Impairment of visual acuity can to damage to the optic canal, indicating damage to the retina or in the eyeball, or to other neurological problems. An impairment of the mobility of the eyes or a enophthalmos may be signs of a fracture of the orbital floor ( blow- out fracture ). In an enlarged inter kant halen distance of the suture frontomaxillary or tears leg is connected to a displacement of the bone in the area to think, or canthale to a demolition of the medial ligament.

Can helpful for surgical planning and patient counseling any existing photos from the patient be, which were made even before the accident.

Occasionally the patient is on demand that such pain in the upper jaw ( at root of nose; outer corner of the eye ) can be triggered already own print of the mandible to the maxilla when biting.

X-ray diagnosis

The X-ray examination is performed with a orthopantomography and with a maxillary radiograph (film intraorally, horizontal, occlusal radiograph, X-ray 90 ° or 65 ° ( to the occlusal plane ) from above - extraoral). The occipito - nasal skull radiograph ( mixed-flow adjustment ) represents the entire midface is good ( orbital rims, frontozygomatic suture, zygomatic, zygomatic, nasal sinuses ).

For the first study simple radiographs are indicated. It also includes a submental recording with vertical beam path and lateral views, as well as a follow-up radiograph of the cervical spine. Radiographs of the maxillary sinuses at the same time provide the zygomatic arch and the nasal bones dar. To a clear idea of ​​the three-dimensional anatomy and expansion to obtain the fracture, the radiographs of the various projections have to be compared.

With the computed tomography ( CT), the possibilities for imaging diagnosis of maxillary fractures have improved significantly. The CT often provides the fracture path is accurate and helps in surgical planning.

Differential Diagnosis

The differential diagnosis is always to think of a skull fracture that needs to be excluded radiologically. A skull fracture is much more serious than a maxillary fracture. Often both occur together. Glasses hematoma can be a sign of skull base fractures, as well as bleeding from the nose and ear. It should be clarified whether the blood-brain water is added.

The treatment of the skull has priority, while the treatment of maxillary fracture must often wait for another 1-2 weeks in severely injured polytrauma. After stabilization of the general condition is usually done a CT scan of the facial bones to diagnose a midface fracture.

Associated injuries

Maxilla fractures often occur in severe trauma. Therefore, to investigate further harm to the patient. Acute life-threatening possible relocation of the airways can be. Because of the involvement of the orbit should be inspected for damage to the eyes ( enophthalmos - sunken eye, diplopia - double vision - especially with looking upwards ). Impaired skin sensitivity under the eye indicates an injury to the infraorbital nerve. Also, hearing and dental occlusion are examined.

Functional failures may clues for the location of the fracture type - for example, respiratory disorders, reduced visual acuity, cranial nerves, occlusion, hearing.

Changes in consciousness or an anamnestic information a loss of consciousness may be signs of intracranial injury.

Therapy

The treatment of maxillary fracture occurs by reduction, fixation, retention and immobilization. Midfacial fractures usually require operative treatment. This is performed by an oral and maxillo -facial surgeon, otolaryngologist or plastic surgeon.

The displaced fragment is reduced and fixed by mini-plate osteosynthesis (osteosynthesis ). Before the advent of plate fixation was the fixation with wire osteosynthesis, which also brought good results.

Initial treatment

The accident care must ensure the vital functions first. If the airway can not be exposed impacted maxillary fragment must dislocated, be repositioned emergency basis. If this is not possible, may be a tracheotomy to be performed. The moderate emergency splinting for a longer transport can be done with a ruler, bites down on the patient with his molars and the ends of which are on both sides of the mouth. This ruler ends can be provisionally fixed to the top - with a napkin tied over the skull.

Since maxillary fractures are often caused by vehicle accidents, they are often accompanied by other, potentially life-threatening injuries. The diagnosis of maxillary fracture is then during the initial phase of treatment is not in the foreground. Because of the severity of the upper jaw fractures and other injuries of these patients must be frequently intubated to ensure respiration. A midface fracture is treated always stationary, at least in the initial phase.

At a rearward displacement of the lower jaw and related breathing problems rapid, temporary decompression of the upper jaw must be done, in particular of the palate. To the compressed fragment is pulled by tongs and the front hook whereas the compressed portion is decompressed again in the hard palate.

Operation

In the surgical treatment, the attempts to eliminate defects and achieving reconstruction of the aesthetic face. These unstable bone fragment may be attached to stable parts of the skull. An important goal of therapy is to restore a normal dental occlusion, mastication and speech function.

Since intraoperative occlusion must be checked, is a normal intubation through the mouth of the question. Instead resorted to nasal intubation. A rare intubation is the submandibular intubation. It is led out from the oral cavity after intubation through the mouth, the tube through a surgically created opening in the front floor of the mouth in the submental area.

Reduction

Fragment shifts by muscle pull, which often occur in fractures in the extremities range are not observed in the upper jaw fractures, because the muscles which are attached on the upper jaw are attached at its other end mainly on the skin. So there is no Fragmentverschiebungden by muscle pull and also the reduction will not be complicated by muscle pull. However, often occurs a fragment displacement on by the great violence during fracture and the fracture edges are a reduction often in the way, as they are strongly serrated and have a complicated three-dimensional course.

Technology of operative fixation

Mini plates, wire suspension

Surgical approach:

• Le Fort I: vestibular
• Le Fort II: medial eyebrow, infraorbital or transconjunctivally, vestibular
• Le Fort III: medial and lateral eyebrows

The aim is a stable splinting ( plate fixation ) of the fragment.

The best cosmetic results in terms of the scars are obtained by two-layer suture closure to reduce the train to the skin and thus to achieve a smaller scar. The sutures are after 5 - 10 days away.

Maxillo - mandibular fixation

The maxillo - mandibular fixation ( MMF ) of the teeth of the mandible and maxilla (or IMF = intermaxillary fixation, or IMV = Intermaxillary lacing ) may be necessary in the treatment of maxillary fracture. This fixation is usually intraoperatively after reduction and fixation of the fragments. For anesthesia Recovery stretched between the upper jaw and lower jaw rubber rings but are removed to give the anesthesiologist complications access to the throat of the patient - for eg in case of vomiting of the patient ( re- intubation required or aspiration of secretions ).

For the time in the maxillo - mandibular fixation worn the (approximately three to eight weeks ) is ensuring food security through a transnasal feeding tube.

A mandibulo - maxillary fixation ( lacing ) is especially necessary when the upper jaw fragment could not be stably fixed to the skull.

A mandibulofacial maxillary fixation is also only possible when a proper repositioning and alignment of the fragment is possible. If the complete repositioning of the maxilla fragment surgically not succeed, the real occlusion of the patient can be set back by an additional Le Fort I osteotomy.

Complications

Complications after maxillary fractures may remain permanent deformities.

Despite outright healing " on the radiograph " it can lead to damage of the neurovascular bundles - the supraorbital, infraorbital nerve, facial nerve (right frontal ). There is the possibility of subsequent infections, which are favored by extended Weichgewebsdefekte, hematoma, open fractures and comminuted fractures. Frequently than a Nichtverwachsung the bone fragments, there is a Fehlverwachsung. To prevent this, any bone grafts are needed.

The best chance of good functional and aesthetic results have early surgical intervention.

Osteotomies

In osteotomies for the change in occlusion or of the facial skeleton in maxillary facial deformities ( orthognathic surgery ), the transection of the bone is analogous to the fracture lines after Le Fort I (Le Fort I osteotomy - for retroposition of the maxilla, eg after deformation due to an operated clp-column, possibly carried out in combination with a Velopharyngoplastik ) or Le Fort III.

Swell