LeFort Fractures

Question 1

Description of photo image

Answer 1

Anterior open bite with repaired R brow laceration

Question 2

Description of CT

Answer 2

• 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

Question 3

What CT images are necessary to confirm the diagnosis?

Answer 3

Coronal images on CT

Question 4

On history, important are the

Answer 4

MOI to help determine the severity of impact and trajectory of force - changes in vision, occlusion, breathing, and hearing -and previous facial trauma

Question 5

On examination, I would start with a trauma work-up

Answer 5

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

Question 6

After the trauma work-up, I would perform a detailed examination of the face

Answer 6

• palpating for tenderness/crepitus/step-offs
• sensory and motor examinations
• eye, nasal, and intraoral examinations -and examinations of the the ears and tympanic membrane

Question 7

After performing a detailed examination of the face, I would evaluate the state of dentition

Answer 7

-looking for fractured, missing, or rotten teeth, as well as the occlusal pattern

Question 8

After evaluating the dentition, I would assess mid face instability by

Answer 8

-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

Question 9

If the mid face is mobile with stability at the nasal root, it is indicative of

Answer 9

a LeFort I fracture

Question 10

If there is also mobility at the NF suture, it is indicative of

Answer 10

a LeFort II fracture

Question 11

If there is also mobility at the ZF suture, it is indicative of

Answer 11

a LeFort III fracture

Question 12

The imaging of preference would be a

Answer 12

high-resolution maxillofacial CT scan with axial and coronal images

Question 13

The sine qua non of LeFort fractures on (coronal) CT

Answer 13

is fracture of the pterygoid plates

Question 14

On CT, a LeFort I fracture would present as

Answer 14

a transverse fracture fo the maxilla involving the ZM and NM buttresses

Question 15

On CT, a LeFort II fracture would present as

Answer 15

a pyramidal fracture involving the ZM buttresses, inferior orbital rim, inferior and medial orbital wall, and NF region

Question 16

On CT, a LeFort III fracture would present as

Answer 16

craniofacial dysjunction, involving the zygomatic arch, lateral orbital rim, lateral orbital wall, orbital floor, medial orbital wall, and NF region

Question 17

A LeFort III fracture does not involve the

Answer 17

ZM buttress

Question 18

If there is an orbital fracture, I would consult

Answer 18

ophthalmology to r/o ophthalmic injury prior to operative intervention because intra-op manipulation may exacerbate an eye injury

Question 19

In managing a LeFort fracture, I would start with

Answer 19

ATLS protocol and ensuring all emergent injuries are managed first. I would start antibiotic therapy.

Question 20

Definitive treatment of facial fractures may be delayed up to

Answer 20

2 weeks w/o compromising results

Question 21

Delaying definitive treatment of facial fractures for more than 2 weeks increases the risk of

Answer 21

infection and need for osteotomies

Question 22

If a LeFort fracture is non displaced and stable, it can be managed

Answer 22

non operatively with a soft, non-chew diet for 4-6 weeks, ensuring close follow up to monitor occlusion remains good

Question 23

Displaced, unstable fractures require

Answer 23

ORIF to ensure return of normal occlusion

Question 24

In repairing the fracture I would perform MMF using

Answer 24

dental wear facets as guides, using arch bars

Question 25

I would bone graft

Answer 25

bone gaps at buttresses, particularly gaps > 5 mm

Question 26

In repairing a LeFort fracture, I would

Answer 26

nasally intubate the patient, ensuring the absence of a cranial base injury prior to doing so

Question 27

After performing a nasal intubation, I would perform

Answer 27

1. bilateral gingiolabial incisions 5-10 mm from the apex of the sulcus 2. expose the maxilla subperiosteally (with coronal incision if the fracture is comminuted) 3. establish occlusion with MMF 4. reduce the fracture, with the use of Rowe disimpaction forces if the fracture is impacted or difficult to reduce 5. stabilize the fracture

Question 28

In stabilizing a LeFort I fracture, I would plate the

Answer 28

ZM and NM buttresses

Question 29

In stabilizing a LeFort II fracture, I would plate the

Answer 29

ZM and infraortbital rims

Question 30

In stabilizing a LeFort II fracture, plating of the NF junction is necessary if

Answer 30

this region is significantly displaced

Question 31

In stabilizing a LeFort III fracture, I would plate the

Answer 31

ZF (lateral orbital rim) and NF junction

Question 32

After stabilizing a LeFort fracture

Answer 32

MMF is released and occlusion is checked with the mandibular condyles seated in the glenoid fossa

Question 33

10-15% of LeFort fractures also have

Answer 33

palatal fractures, which may be managed with fixation or splinting for 6 weeks

Question 34

LeFort II fractures may be exposed with a combination of

Answer 34

gingivobuccal and lower eyelid incisions (alternatively: coronal incision)

Question 35

Complication: malocclusion

Answer 35

due to improper reduction or stabilization with MMF

Question 36

Complication: nonunion/malunion/fibrous union

Answer 36

requires debridement of the fracture, and possibly bone grafting and refixation

Question 37

Complication: infection

Answer 37

I would start antibiotics and be cautious about removing hardware if complete healing has not occurred, as this can result in loss of reduction