Le Fort occlusofacial fractures
I/ INTRODUCTION : Le Fort occlusofacial fractures have in common the separation of the palatal plateau and the base of the skull at a variable height. They mobilize and displace the maxillary dental arch, creating an occlusal disorder. They classically follow the Le Fort classification.
All these fractures pass through natural cavities of the face (nasal fossae, maxillary sinuses, ethmoid cells) and must therefore be considered as open fractures.
Due to the violence of the shock causing the fractures, all these patients must be considered as head trauma patients, at least mild.
- Le Fort I fracture
The Le Fort I fracture detaches the palatine plateau from the rest of the facial mass by a horizontal fracture line passing flush with the pyriform orifice, breaking the nasal septum, the lateral walls of the nasal fossae, the anterior and posterior walls of the two maxillary sinuses and the bottom of the pterygoid processes.
1. Pathophysiology
Violent subnasal shock.
2. Clinic
- Functional impotence: frozen appearance, half-open mouth, lower facial pain exaggerated when attempting occlusion.
- Dental articulation disorder: bilateral premature molar contacts and anterior pseudo-open bite due to recoil and tilting down and back of the palatal plate (fig. 4.48).
- Painful palpation of the bottom of the upper vestibule.
- “Horseshoe” bruise at the bottom of the upper vestibule.
- Epistaxis indicating injuries to the mucous membrane of the nasal cavities and/or maxillary haemo-sinuses.
- Isolated mobility of the entire palatal plateau and upper dental arch relative to the rest of the facial mass, triggering exquisite pain.
A median sagittal fracture (maxillary disjunction) or paramedian fracture may be associated, possibly resulting in a wound of the palatine fibromucosa or a submucosal hematoma.
Examination of the rest of the face is normal.
3. X-ray
Standard images (Blondeau, Waters, facial mass in profile)
- Rupture of the harmonious rounding of the bilateral zygomatomaxillary arches.
- Bilateral maxillary hemo-sinuses.
- Recoil, downward and backward tilt of the palatine plateau and fracture of the pterygoid process on the profile.
Axial CT scan and frontal reconstructions
It is often necessary to clarify the lesions.
4. Complications
Early complications
They are few in number, apart from possible massive epistaxis.
Late complications
- Occlusal sequelae: in the absence of well-conducted treatment, a sequelae disorder of dental occlusion may be found.
- Amnesic sequelae due to the associated head trauma.
5. Therapeutic principles
- Antibiotic prophylaxis (open fracture).
- Under general anesthesia.
- Reduction of the fracture based on the restoration of the pre-existing dental occlusion and taking into account a possible associated sagittal fracture which tends to widen the dental arch in the transverse direction.
- Contention in reduced position either by osteosynthesis (screws and miniplates) or, failing that, by performing a maxillomandibular block associated with a perizygomatic or frontal suspension for six weeks.
- Le Fort II fracture
The Le Fort II fracture solidly detaches the palatine plateau and the nasal pyramid from the rest of the facial mass. The fracture line passes more or less symmetrically through the nasal bones or the frontonasal junction, the frontal processes of the maxillae, the medial wall and floor of the two orbits, the infraorbital margins, the anterior and posterior walls of the maxillary sinuses, the zygomatomaxillary arches and the pterygoid processes behind. The two zygomatic bones remain in place.
From the front, it produces a pyramidal fracture with a palatal base and a glabellar apex.
1. Pathophysiology
Identical to the previous fracture.
2. Clinic
- Erasure of the root of the nose which is embedded between the two orbits.
- Dental occlusion disorder: identical to Le Fort I fracture (bilateral premature molar contacts) and linked to the recession and tilting of the maxillary dental arch.
- Periorbital ecchymosis in glasses, indicating the spread of fracture hematomas (ethmoidal cells and nasal bones) into the orbital celluloadipous spaces.
- Periorbital subcutaneous emphysema indicating the presence of air in the orbits (pneumorbits) in relation to fractures of the orbital walls (floors and medial walls).
- Epistaxis due to involvement of the nasal pyramid.
- Palpation of a “stair step” at the level of the infraorbital rims.
- Painful palpation of fracture sites: root of the nose, infraorbital rims, zygomatomaxillary arches.
- Mobility of the entire palate, maxillary dental arch and nasal pyramid detached from the rest of the face. The zygomas are stable.
- Hypoesthesia in the territory of the infraorbital nerves (V2), the fracture line most often passing close to the infraorbital foramens.
- Possible diplopia due to damage to the extrinsic muscles of the eyes (medial rectus, inferior oblique, superior oblique, inferior rectus).
- Tearing due to damage to the walls of the lacrimal sac.
- Visual disturbances related to possible associated contusion of the eyeballs or damage to the optic nerve by intraorbital compression (edema, hematoma) or contusion at the level of the optic canal (irradiation of fractures of the floor of the orbit at the level of the apex of the orbital cone).
- Possibility of cerebrospinal rhinorrhea in case of irradiation of the horizontal fracture of the root of the nose at the anterior level of the base of the skull.
- Possibility of anosmia linked to the irradiation of the fracture to the cribriform plate of the ethmoid.
3. Radiography
Standard images are systematically supplemented by a craniofacial scan. This examination makes it possible to specify the location of the fracture lines, particularly in relation to the ethmoid structures (labyrinths, cribriform plate).
4. Therapeutic principles
- Antibiotic prophylaxis (open fracture, risk of meningitis in case of fracture of the base of the skull).
- Treatment of epistaxis.
- Under general anesthesia and after the edema has subsided.
- Fracture reduction based on restoration of pre-existing dental occlusion.
- Contention in reduced position either by osteosynthesis (screws and miniplates) or, failing that, by performing a maxillomandibular block associated with a perizygomatic or frontal suspension for six weeks.
- Possible repair of fractures of the medial and inferior walls of the orbits.
Le Fort occlusofacial fractures
- Le Fort III fracture
it separates the entire facial mass (maxilla, zygomatic bones, nasal region) from the base of the skull. The fracture line is horizontal, passing along the midline at the level of the frontonasal junction or the nasal bones (as in the Le Fort II fracture), then laterally through the frontal processes of the maxillae, the medial then lateral walls of the two orbits, fracturing the floor of the orbit at any level, the frontal then temporal processes of the zygomatic bones, and ends posteriorly at the level of the pterygoid processes.
In practice, this type of fracture is often associated with other fractures: bilateral laterofacial, centrofacial, occlusofacial type Le Fort I or II, mandibular fracture(s), alveolodental fracture(s).
The association of a complex occlusofacial fracture with one or more mandibular fractures constitutes a panfacial fracture
Pathophysiology
Violent facial shock.
Clinic
- Sunken face with global edema and multiple ecchymoses resulting in a “moon” facies.
- Collapse of the nasal pyramid.
- Mobility of the entire face relative to the skull, including the zygomatic bones. In the mouth, mobilization is difficult due to frequent bone entanglements at the fracture sites.
- Epistaxis or even stomatorrhagia due to damage to the nasal pyramid. This bleeding can be severe.
- Dental articulation disorder identical to Le Fort I and II fractures.
- Exquisite pain on palpation and mobilization of fracture foci: root of the nose, frontozygomatic sutures, temporal processes.
- Cerebrospinal rhinorrhea is common due to associated skull base fractures.
- Some signs described in Le Fort II fracture (periorbital ecchymosis and emphysema, possible diplopia, tearing, visual acuity disorders, anosmia) can also be encountered in Le Fort III fractures.
- X-ray
- Standard incidences are systematically supplemented (or even replaced) by a computed tomography examination in axial sections with frontal and sagittal reconstructions, in order to explore the orbital and intraorbital lesions and the base of the skull. This examination is also essential for the diagnosis of any associated brain lesions.
Complications
Apart from the sensory sequelae in the V2 territory, the same complications as those described in Le Fort II fractures are possible, with a very particular frequency of risks of meningitis (frequency of fractures irradiated to the anterior level of the base of the skull) and neurological and sensory sequelae due to the intensity of the initial shock.
Therapeutic principles
They are identical to those of Le Fort II fractures, except that if orthopedic treatment is started, the suspension must be performed at the frontal level, the only intact structure in this type of fracture.
Le Fort occlusofacial fractures
Bibliography :
- BEZIAT JL, CRESSAUX P.: Facial fractures, diagnosis. Rev Prat., 1994,44, 817-824 p.
- DINGMAN RO, NATVIG P: Surgery of facial fractures. W. B. Saunders: Philadelphia 1964: 142,145.
- DUHAMEL P, GIRAUD O, DENHEZ F et al.: Examination of a facial trauma patient. Encycl Méd Chir., Stomatology, 22-068-A-05, 2002, 24 p.
- PHARABOZ C.: Facial trauma [online].
- REVOL M, SERVANT JM.: Maxillofacial trauma. In: Manual of reconstructive and aesthetic plastic surgery. Paris: Pradel, 1993, p. 295-332.
Le Fort occlusofacial fractures
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.