Le fort fracture12/28/2023 ![]() Mobilization and reduction of osseous segments can be challenging in the delayed setting due to bone fragment impaction and soft tissue contraction. Early reconstruction allows for optimal restoration of the preinjury appearance as determined by the relationship between bone and soft tissue. In addition, unrepaired orbital fractures of Le Fort II and III injuries can lead to enophthalmos, diplopia, and impaired lacrimal drainage. Failure to repair Le Fort fractures can result in midface retrusion, midface elongation, and anterior open bite due to the posteroinferior pull of the medial pterygoid on the posterior maxilla ( Figure 76-2, C ). Goals of treatment include reestablishing premorbid occlusion and facial width, projection, and height. Preoperative assessment includes clinical examination and radiographic evaluation with noncontrast computed tomography reformatted in three planes with a slice thickness of 1 mm or less ( Figure 76-2, A and B ). Ideally, surgical management of midfacial fractures should be completed as soon as the patient’s medical status allows. The continuum from Le Fort I to Le Fort III reflects an increasing severity of injury, increasing complexity of repair (with additional access requirements), and increasing likelihood for concomitant neurologic and ocular injury. The facial skeleton is separated from the cranial base, with the fracture line extending medially through the perpendicular plate of the ethmoid, the vomer, and base of sphenoid, and laterally through the nasofrontal suture, medial orbital wall, orbital floor, zygomaticofrontal junction, and zygomatic arch. The Le Fort III fracture or craniofacial dysjunction results from high-impact blunt trauma to the nasofrontal junction and upper lateral orbital rims. The central midface and maxilla are mobilized from the facial skeleton with the fracture line extending through the nasofrontal suture, frontal process of maxilla, lacrimal bone, inferior orbital rim, anterior wall of the maxillary sinus, and pterygoid plates. The Le Fort II fracture pattern describes a pyramidal fracture resulting from blunt trauma to the infraorbital rim and nasofrontal junction. It involves the nasal septum, lateral nasal walls, anterior and lateral walls of the maxillary sinus, and pterygoid plates. The Le Fort I fracture is a horizontal maxillary fracture resulting from a blow to the maxilla above the root apices. Maxillary fractures most frequently occur as a result of blunt trauma from assault, sporting injuries, and motor vehicle accidents. Gruss (1982) and Manson and colleagues (1985) discussed the stabilization of buttresses with miniplates and proposed systematic approaches to the treatment of midfacial and panfacial fractures. The principles of monocortical miniplate fixation without axial compression that were proposed by Michelet and Moll (1971) and Champy and Lodde (1976) have been applied to the midface. Automatic compression plates were introduced by Luhr in 1968 and standardized by Spiessel in 1971. The development of osteosynthesis heralded the advent of modern traumatology. In 1942, Adams introduced internal fixation for maxillary fractures, using suspension wires from the zygomatic process of the frontal bone, inferior orbital rim, or zygomatic bone. During World War II, Le Fort fractures were treated by external fixation from metal splints to a headcap through rods and machined universal joints. During World War I, Fry and Gillies pioneered the treatment of maxillofacial injuries with collaboration between the anesthetist and surgeon. Major advancements in the management of maxillary fractures in the twentieth century coincided with times of war. The Le Fort classification of maxillary fracture patterns.
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