Le Fort II, linear fracture

BY: SARA MASSOUD MOHAMED EL DAHALN.

SECTION: 03
Contents:

 1) General considerations.
 2) Observation.
 3) Closed treatment.
 4) Open reduction internal fixation.
 5) Approach.
 6) Aftercare.
 General considerations

This is a very rare isolated

fracture pattern. More often it
occurs in combination with
other midface fractures (Le
Fort I and Le Fort III).
 Observation
Main indication
Non- or minimally mobile Le Fort
II fractures with unaffected
occlusion in compliant patients
with good dentition.

Further Indications:

Nondisplaced stable fractures

with premorbid occlusion in
compliant patients
Edentulous patient with minimal
fracture displacement
General condition of the
patient not allowing for surgical
intervention
 Closed treatment
Non- or minimally displaced fractures in a
compliant patient amenable to MMF.
Fractures with minor malocclusion readily correctable with
maxillary manipulation, and not grossly mobile after
repositioning may be treated closed. However, closed
reduction is more commonly used in conjunction with
other stabilization techniques (skeletal suspension, external
fixators, etc.).

Further indications
-Premorbid or unstable medical condition preventing
general anesthetic.
-Conditions making open reduction and internal fixation
difficult.
-Patient refusal of operative treatment (eg, for
religious/cultural or financial reasons)
Unavailability of plates and screws. Special consideration: MMF may be
contraindicated in patients with psychiatric
disorders, seizure disorders, and alcoholics.
 Open reduction internal fixation
Displaced Le Fort II
fractures resulting in
malocclusion or
facial deformity.

Ideally, any displaced Le Fort II

fracture should be treated by
open reduction internal fixation.
The number of approaches
depends on the extent of
dislocation and comminution,
and the degree of stability
following reduction.
Approach.

 Approaches to the maxilla

 Lower eyelid - transcutaneous
 Lower eyelid - transconjunctival
 Glabellar approach
 Coronal approach
 Use of existing lacerations
 Not recommended
Approaches to the maxilla
Maxillary vestibular approach
In the surgical treatment of facial trauma, the
skeleton of the lower midface is commonly
exposed using a transoral approach in the
maxillary vestibule.
A horizontal incision (possibly with hockey stick
endings) through the maxillary vestibular
mucoperiosteum is made slightly above the
mucogingival junction. The subsequent
subperiosteal dissection can be advanced to
access the entire anterolateral bony surfaces
from the zygomaticotemporal suture over the
facial antral wall to the borders of the piriform
aperture and up to the infraorbital rim including
the infraorbital nerve exit. Relevant to the required exposure in trauma of
the midface two different approaches are
possible: the maxillary vestibular approach and
the midfacial degloving approach.
Lower eyelid - transcutaneous
Principles
Subciliary (A, synonym: lower blepharoplasty)
Subtarsal (B, synonym: lower or mideyelid)
Infraorbital (C, synonym: inferior orbital rim)
The subciliary approach can be extended
laterally to gain access to the lateral orbital
rim (D).
The course of the incisions is aligned to the
slope of the natural skin creases which
become more apparent with age.
The skin of the eyelid is the thinnest in the
human body. It has little or no dermis and
almost no subdermal fat.
Hypertrophic scarring and keloid formation is There are three basic approaches through the
very uncommon following lower lid skin external skin of the lower eyelid to give access to
incisions. In general, the scars become the inferior, lower medial, and lateral aspects of
inconspicuous with time. the orbital cavity: subciliary (A), subtarsal (B),
and infraorbital (C) approaches.
Lower eyelid - transconjunctival
Transconjunctival lower-eyelid approaches are
performed in several ways.
A) Transconjunctival (inferior fornix
transconjunctival using a retroseptal or preseptal
route)
B) Transcaruncular (=medial transconjunctival)
C) Transconjunctival with lateral skin
extension(lateral canthotomy/”swinging eyelid”)
D) Combination of inferior (A) and medial (B)
transconjunctival
E) C-shaped incision (ie, Combination of inferior
(A) and medial transconjunctival (B) plus lateral
skin extension (C))
The advantage of transconjunctival incisions is the
superior cosmesis due to lack of a cutaneous
scarring. A disadvantage maybe a limited access
of non-extended or non-combined approaches in
comparison to lower-eyelid skin incision.
 Glabellar approach

The glabellar approach can be particularly

advantageous in elderly patients who have
developed horizontal glabellar furrows due to the
action of the procerus muscle. This approach may
also be considered in order to avoid a coronal
incision where only limited exposure is needed in a
younger patient with a receding hairline, or in a bald
patient.
An example of where a limited exposure may be
necessary in the nasofrontal area is a Le Fort II or III
fracture.
The most common approach for reduction of NOE
fractures is a combined approach of coronal incision,
lower eyelid incision, and a maxillary vestibular
incision. This combined approach is often required to
obtain stabilization of the extensive comminuted
fracture. Some surgeons use these combined The glabellar approach can be particularly
incisions, but substitute the glabellar approach for the advantageous in elderly patients who have
coronal incision. developed horizontal glabellar furrows due to the
action of the procerus muscle.
 Coronal approach

The extent and position of the incision, as well as the

layer of dissection, depends on the particular surgical
procedure and the anatomic area of interest. The
coronal approach is placed remotely in order to
avoid visible facial scars.
The subperiosteal or subgaleal planes are commonly
used for coronal flap dissection. The scalp incision is
extended lateroinferiorly into the preauricular region
to gain access to the zygomatic arch and/or
temporomandibular joint (TMJ). To protect the
temporal branch of the facial nerve when the
zygoma and the zygomatic arch are accessed, the
superficial layer of the temporalis fascia is divided
along an oblique line from the level of the tragus to
the supraorbital ridge to enter the temporal fat pad.
The dissection below this fascial splitting line is carried
out just inside the fat pad deep to the superficial layer The coronal or bitemporal incision is used to
of temporalis fascia until the zygomatic arch and approach the anterior cranial vault, the forehead,
zygoma are subperiosteally exposed. and the upper and middle regions of the facial
skeleton.
 Use of existing lacerations

Facial fractures are often associated with

lacerations. These existing soft-tissue injuries
can be used to access directly the facial
bones for management of the fractures

The surgeon may elect to extend the laceration to

attain enough access to the fractured area, placing
additional incisions starting from the wound margins
along the relaxed skin tension lines (RSTL).
Bacterial contamination is not a contraindication for
the use of existing lacerations for surgical approach.
Access to infraorbital rim and orbital floor through a
horizontal lower lid laceration is shown.

.
 Not recommended

The ethmoidal approach is generally not

recommended.
The ethmoidal approach allows for
excellent visibility in the area of the medial
canthus. Unfortunately, it commonly results
in a very obvious scar contraction band
(web) in the medial canthal area.
This medial canthal band is particularly
obvious in younger patients. Therefore, we
do not recommend the use of this
approach except in circumstances where
the other common approaches are
inadequate.
.
 Aftercare

Aftercare following open reduction and internal fixation of Le Fort II and Le Fort
III fractures:
Evaluation of the patients vision is performed as soon as
they are awakened from anesthesia and then at regular
intervals until they are discharged from the hospital.
A swinging flashlight test may serve in the unconscious
and/or noncooperative patient; alternatively
electrophysiological examination has to be performed but is
dependent on the appropriate equipment (VEP).
 Aftercare

Postoperative positioning
Keeping the patient’s head in an upright position both
preoperatively and postoperatively may significantly
improve periorbital edema and pain.

Nose-blowing
To prevent orbital emphysema, nose-blowing should be
avoided for at least 10 days following orbital fracture
repair.
 Aftercare
Medication
The use of the following perioperative medication is controversial. There is little evidence to make strong
recommendations for postoperative care.

•No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days

•Analgesia as necessary
•Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one
antibiotic, and the recommended duration of treatment is debatable.)
•Nasal decongestant may be helpful for symptomatic improvement in some patients.
•Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have
noted increased complications with perioperative steroids.
•Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of
periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant
conjunctival irritation.
•Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.
 Aftercare
Ophthalmological examination
Postoperative examination by an ophthalmologist may be requested. The following signs and symptoms are usually
evaluated:

• Vision (except for alveolar ridge fracture, palatal fracture)

• Extraocular motion (motility) (except alveolar ridge fracture, palatal fracture)
• Diplopia (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Globe position (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Perimetric examination (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Lid position
• If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked.

Note: In case of postoperative double vision, ophthalmological assessment has to clarify the cause. Use of prism foils on
existing glasses may be helpful as an early aid.
 Aftercare
Postoperative imaging
Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended
to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging.
Especially in fractures involving the alveolar area, orthopantomograms (OPG) are helpful.
Wound care
Remove sutures from skin after approximately 5 days if nonresorbable sutures have been used.
Apply ice packs (may be effective in a short term to minimize edema).
Avoid sun exposure and tanning to skin incisions for several months.
Diet
Diet depends on the fracture pattern.
Soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision.
Intranasal feeding may be considered in cases with oral bone exposure and soft-tissue defects.
Patients in MMF will remain on a liquid diet until such time the MMF is released.
 Aftercare
Clinical follow-up
Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems.
With patients having fracture patterns including periorbital trauma, issues to consider are the following:
• Globe position
• Double vision
• Other vision problems

Other issues to consider are:

• Facial deformity (incl. asymmetry)
• Sensory nerve compromise
• Problems of scar formation

Issues to consider with Le Fort fractures, palatal fractures and alveolar ridge fractures include:
• Problems of dentition and dental sensation
• Problems of occlusion
• Problems of the temporomandibular joint (TMJ), (lack of range of motion, pain)
 Aftercare
Eye movement exercises
Following orbital fractures, eye movement exercises should be considered.
Implant removal
Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or
visible. In some countries it will be more commonly requested. There have been cases where patients have complained of
cold sensitivity in areas of plate placement. It is controversial whether this cold sensitivity is a result of the plate, a result of
nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of cold sensitivity generally
improve or resolve with time without removal of the hardware.
Generally, orbital implant removal is not necessary except in the event of infection or exposure. Readmission might be
indicated if long term stability of the orbital volume has not been maintained.

MMF
The duration and/or use of MMF is controversial and highly dependent on the particular patient and complexity of the
trauma. In some cases where long-term MMF may be recommended, the surgeon may choose to leave the patient out of
MMF immediately postoperatively because of concerns of edema, postoperative sedation, and airway. In these cases the
surgeon may choose to place the patient in MMF after these concerns have been resolved.
The need and duration of MMF is very much dependent on:
• Fracture morphology
• Type and stability of fixation (including palatal splints)
• Dentition
• Coexistence of mandibular fractures
• Premorbid occlusion
 Aftercare
Oral hygiene
Patients with arch bars and/or intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures.
The presence of the arch bars or elastics makes this a more difficult procedure. A soft toothbrush (dipped in warm water to
make it softer) should be used to clean the surfaces of the teeth and arch bars. Elastics are removed for oral hygiene
procedures. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth.
For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen
peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used,
care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.
Follow-up
The patient needs to be examined and reassessed regularly and often. Additionally, ophthalmological, ENT, and
neurological/neurosurgical examination may be necessary. If any clinical signs for meningitis or mental disturbances develop,
professional help has to be sought. A regular follow-up CT scan is recommended 3-6 months after the trauma to assure
proper pneumatization of the sinuses (particularly, mucocele formation has to be ruled out), sealing of the skull base and
stability of fragment position.
Note: Posttrauma meningitis can occur even decades following trauma.
Special considerations for orbital fractures
Travel in commercial airlines is permitted following orbital fractures. Commercial airlines pressurize their cabins. Mild pain on
descent may be noticed. However, flying in military aircraft should be avoided for a minimum of six weeks.
No scuba diving should be permitted for at least six weeks.