LeFort II fractures extend from one lateral maxillary buttress through the maxilla into the infraorbital rim and nasofrontal junction and are aptly described as pyramidal fractures. Displacement of the maxilla is more likely to be encountered when the fracture extends beyond both the medial and lateral maxillary buttresses. LeFort I fractures are in the horizontal plane inferior to the maxillary sinus and inferior orbital rim, but superior to the teeth ( Figs. Often, fractures extend through the maxillary sinus, as well as the medial and lateral buttresses. They can be unilateral or bilateral, symmetrical or asymmetrical, and are often concomitant with other facial fractures. The initial classification was based on injury patterns caused by low-velocity and low-energy inciting events however now, LeFort fractures are predominately caused by MVAs or other high-energy collisions. This is attributed to the change in injury mechanisms over the past 100 years. Hence, midface fractures often occur in recognizable patterns.įirst described in 1901 by Rene LeFort, LeFort fractures I through III are commonly encountered by the plastic surgeon, but rarely in the pure forms as described by LeFort.
The anatomy of the maxillary and surrounding structures is such that energy is dissipated by fracturing the midface so as to reduce the inertial burden, thus protecting the globe and brain. If any abnormalities are encountered on the exam that may suggest an underlying fracture, craniofacial computed tomography (CT) scans should be ordered and read by the surgeon.įractures of the midface require considerable force and are often caused by MVAs and assaults. Ask the patient to open and close, and then clench the jaw and see if there is any sensation of the bite being “off.” Even the smallest change in occlusion can be readily appreciated by the patient and is more sensitive than the examiner's assessment. Apply downward pressure on the top of the tooth to assess for depression in the socket.Įxamination of the patient's occlusion is vital and should be done in a neutral position. Alternating pressure should be applied to assess for mobility of the tooth. The blunt ends of two instruments should be placed against the facial and lingual aspect of the base of the tooth. The mobility test may be used to assess the stability of the tooth. In cases of acute respiratory failure in which the patient has sustained facial injuries, an aspirated tooth may be the underlying cause. If the tooth was swallowed and passed below the diaphragm, the patient is likely to pass the tooth without incident. To prevent the formation of lung abscesses, aspirated teeth should be endoscopically removed. In the case of neurologic impairment, this may be difficult to ascertain, and radiography of the chest is necessary to evaluate for either swallowed or aspirated teeth. In the case of missing teeth, ask the patient if he or she remembers either losing the tooth, aspirating the tooth, or swallowing the tooth. Each tooth should be assessed for mobility and documentation of broken and/or absent teeth is crucial. An injury to the mucosa may suggest either alveolar or palatal fractures. The oral cavity should be assessed for mucosal lacerations, ecchymosis, and the presence of bone fragments. Ecchymosis, facial edema, subcutaneous hematomas, and epistaxis are often seen in maxillary fractures. If the nasal complex moves along with the maxilla, a LeFort II fracture is likely. If only the maxilla moves, it is likely to be a LeFort I fracture. Assessing the stability of the upper jaw may be achieved by firmly pressing one hand against the patient's forehead and manipulating the maxilla with the other. Both external and internal palpation of the maxilla is necessary. When examining the maxilla, bilateral palpation is often helpful to help assess for step-offs. On physical exam, LeFort fractures are often appreciated as facial distortion and elongation, maxillary mobility, midface instability, and malocclusion.Ī bony examination should follow. A preinjury photograph (state-issued identification cards work well) is often helpful in comparing the patient's preinjury anatomy to postinjury appearance.
Contusions and ecchymosis may suggest underlying bony involvement.
#CAUSES OF A LE FORT FRACTURE FULL#
To obtain the best physical examination of the face, it is important that any caked-on blood or debris be washed off to expose the full extent of the injury. This may require different vantage points and is often hindered by bleeding or significant ecchymosis. First, the surgeon should inspect the patient's face and assess symmetry. Like any other portion of the physical examination, the examination of the midface must be systematic.
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