The treatment of facial fractures includes many facial bones, including fractures of the upper jaw, and among the classifications of fractures of the upper jaw, the Le Fort classification is the most famous classification. The scientist Le Fort conducted his experiments that identified structurally weak areas in the upper jaw, which he described as “lines of weakness.” According to these findings, there are three basic types of fractures (transverse, pyramidal, and craniofacial separation).
Treatment of facial fractures results in cosmetic and functional deficits if not performed properly.
What are Le Fort fractures?
Le Fort fractures are a group of facial fractures that affect the middle third of the face and collectively cause partial or complete separation of the middle third of the face from the skull.
The middle third of the face refers to the area between the outer corners of the eyes and the corners of the mouth, which consists of the nose, cheeks, and the area above the upper lip. Le Fort fractures usually include the pterygoid plates of the sphenoid bones, which form the base of the skull, and extend behind the eye and down the front of the brain .
The pterygoid plates are spurs in the sphenoid bone that connect the middle face to the sphenoid bone. Le Fort fractures may cause airway obstruction that could be life-threatening if not recognized and treated properly by a medical professional.
There are three types of Le Fort fractures that can be classified according to the level of injury, in the first type of Le Fort fracture, the level of injury is horizontal and usually results in the separation of the teeth from the upper part of the face, the horizontal fracture line generally passes through the alveolar margin, which is the socket The bony bearing the teeth, the lateral nose and the lower part of the maxillary sinus, which is one of the four paranasal sinuses near the nose.
Of the Le Fort fractures, only the first type involve the anterolateral margin of the nasal fossa. Therefore, the absence of a fracture in this region excludes a Le Fort type I fracture.
Le Fort type II is characterized by a pyramidal-shaped fracture. The upper teeth form the base and the frontonasal suture (which connects the frontal bone to the nasal bone) forms the top of the pyramidal fracture. A pyramidal fracture can occur at the alveolar margin and the maxillary sinuses, but usually also extends through the orbital margin (cavity of the eye) and the nasal bones.
Patients with type II are often admitted to the hospital unconscious, and attention should be paid to the presence of foreign bodies such as teeth or tooth fragments that may block the airways and may be accompanied by severe bleeding or leakage of cerebrospinal fluid.
In a Le Fort type III fracture, the level of injury is transverse or horizontal, such as Type I; However, in type III, the injury usually begins in the nasofrontal region and extends through the orbital walls, zygomatic arch, and pterygoid plates.
A Le Fort fracture of the third type is the most extensive because it can lead to a complete separation of the middle third of the face from the base of the skull, and is therefore known as a craniofacial separation.
What causes facial fractures?
Facial fractures most often occur in car accidents where the middle third of the face collides with a fixed object, such as a steering wheel, so it is always recommended to use a seat belt in order to reduce the risk of facial fractures. It can also occur if the middle of the face is hit by a hard object, such as a baseball bat.
If the force is directed towards the center of the face directly, it produces type I or II Le Fort fractures, but if the force is directed downward, it usually produces type III.
This has been confirmed Study There is a close association between frontal injuries and Le Fort fractures.
How are facial fractures diagnosed?
A review of the individual's medical history and a thorough physical examination is essential in diagnosing Le Fort fractures. Clinical examination of the fracture, along with some of the various signs and symptoms, can help in obtaining an accurate fracture diagnosis in order to begin the process of treating facial fractures:
- A pterygoid plate fracture is essential in the diagnosis of facial fractures.
- Anterior lateral margin of the nasal fossa: If it is fractured, the fracture is of the first type of Le Fort fracture, but if it is healthy, then the first type must be excluded.
- The lower edge of the orbit: if it is broken, the fracture is of the second type of Le Fort fracture, but if it is healthy, then the second type must be excluded.
- The zygomatic arch: if it is broken, the fracture is of the third type of Le Fort fracture, but if it is healthy, then the third type must be excluded.
- Injury to the nasofrontal suture indicates a type II or III fracture.
- In many patients with Le Fort fractures, traumatic neuritis is more pronounced in the infraorbital branches of the trigeminal nerve, and in some cases, continuous and prolonged spontaneous electrical excitation occurs in the teeth of the side affected by a Lefort fracture.
- A group of fractures may occur on one side of the face.
- Bilateral but asymmetrical fractures may occur.
- It may be associated with fractures in other facial bones.
Type 1 fractures usually present with slight swelling of the upper lip, bruising of the buccal surface (the area of the cheek on the inside of the mouth), irregularities of the teeth (malocclusion), and loosening of the teeth (due to weakness of the supporting structures of the teeth such as the gums).
Type II fractures usually appear with significant deformity and swelling in the middle of the face, widening of the space between the inner corners of the eyelids (ie, the space between the two epiglottis), the upper jaw and nose become movable, and we notice malocclusion of the teeth.
Additionally, one may experience swelling around the eyes (periorbital edema), melasma and bruising around the eyes (periorbital bruising), nosebleeds (epistaxis), bruising in the vestibule of the mouth (the area between the front surface of the teeth and the back surface of the lip), and from Also common is a leak of cerebrospinal fluid through the nose (CSF rhinorrhea), which often appears as a profuse watery nose.
Finally, type III Le Fort fractures usually present with symptoms similar to type II, in addition to marked lengthening and flattening of the face due to displacement of the fractured jaw downward or inward (backward), soreness when trying to close the teeth, and malocclusion.
In addition to bleeding from the mouth, increased skin on the upper eyelid, and bruising in the mastoid (the area behind the ear), individuals may also experience auricular drainage and blood in the middle ear (tympanic hemorrhage). ).
A CT scan of the facial bones is often needed to get an overall idea of the extent of the injury.
Treatment of facial fractures usually requires rapid stabilization of the fracture followed by surgery, in order to restore the typical orientation of the face, restore the correct position of the teeth, restore the affected sinuses, and reunite the nose and eye sockets.
Surgery to treat facial fractures
Surgical care is provided by surgical specialists in clinics or in the maxillofacial departments of hospitals, care should be given primarily to those affected who need it according to their vital signs.
These include patients with signs of shock, bleeding, acute blood loss, and suffocation. For example, if the case is bleeding from large vessels in the maxillofacial area, the usual dressing cannot be relied upon to stop bleeding when treating facial fractures.
Therefore, all patients with injuries of the maxillofacial region are divided into three groups:
- Group I - requires only surgical care (connective tissue wounds without true defects, degree II burns); For them, this stage of treatment is final.
- Group II - requiring specialized surgical care (connective tissues have wounds that require surgical treatment in addition to plastic surgery, such as: maxillofacial damage, III-IV degree burns); After providing emergency surgical care, they are transferred to maxillofacial hospitals for plastic surgery.
- The third group - those injured who are not transmissible, as well as people who suffer injuries associated with injuries to other areas of the body (especially the heart muscle).
One of the reasons why re-surgical treatment is needed is that immediate surgical intervention occurred without a preliminary radiographic examination, which are essential in the diagnosis.
When providing surgical care for the treatment of facial fractures to victims of the second group who will be sent to specialized medical institutions (if they do not have contraindications to transportation), the surgeon must:
- Use of prolonged anesthesia at the fracture site.
- Use of antibiotics.
- Ensuring that there is no bleeding from a wound may constitute a reason to render the injured immovable.
- Ensuring that the injured patient is appropriately transferred to a specialized medical institution, accompanied by the medical team members (determining the method of transportation, and the patient’s position).
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In cases where there are obstacles that prevent the patient from being transferred to another medical institution (the third group), he is provided with initial assistance that qualifies him to be transferred to the surgery department with the participation of dentists in hospitals, in the presence of:
- A general surgeon and orthopedic surgeon, who must be familiar with the basics of maxillofacial fracture care, in order to comply with the principles of treating facial fractures, as well as to be able to assess the patient’s condition, determine the group to which he belongs, and ensure that there is a reason preventing him from transferring if he belongs to the third group.
- Oral and maxillofacial surgeon, in which patients' facial fractures must be treated in hospital with the participation of an maxillofacial surgeon.
- A dentist to be able to determine the extent of tooth injury and change its regularity to start a postoperative treatment plan.
If facial fractures are not treated and repaired, extensive fractures in the middle third of the face are often associated with significant functional and cosmetic abnormalities.
Although fractures eventually need to be repaired surgically, immediate medical treatment may be necessary and may include antibiotics and nasal decongestants. Oral or intravenous steroids can reduce swelling, but they have not shown any benefit for long-term problems such as Optic neuropathy.
Urgent interventions such as:
- Displacement of portions of the upper jaw to keep the airway open: removal of maxillary inclusions can be performed manually or with large forceps.
- Orbital injuries that threaten the integrity of the eye muscles or the optic nerve.
When the patient becomes neurologically and clinically stable, he is transferred to the surgical department, where the surgical repair of facial fractures includes the following:
- Restoration of affected facial protuberances and sinus cavities.
- Restoring the integrity of the nose and orbit.
- Open reduction surgery with internal fixation (ORIF) This process includes two stages: open reduction, which rearranges the broken bone to its normal position, and internal fixation, which is intended to surgically fix the fractures of the upper jaw in place until they heal properly and is performed in advanced cases of bone fractures , such as a crumbling bone, a bone protruding from the skin, or a dislocated joint.
The process of treating facial fractures is performed by an orthopedic surgeon, who begins by numbing the patient to relieve pain, and then the procedure is carried out in two stages:
The first stage: It involves putting the broken bones back in place to restore normal alignment, while ensuring that the bones are placed in the fewest possible number of gaps or bends.
The second stage: It is the internal fixation based on fixing the broken bones together through the use of different types of devices, such as: metal nails, solid bars, screws, and plates permanently or temporarily, and they are usually made of strong metal materials, such as titanium or stainless steel , with the aim of providing support and stability to the bones during the treatment of facial fractures.
Complications of surgery to treat facial fractures
Previous surgical procedure to treat facial fractures carries several risks:
- nerve damage;
- Some changes in blood circulation.
- Malfunction of the masticatory mechanism (including temporomandibular joint).
- Healing of the bone outside the correct alignment.
- Vision complications: ocular complications include decreased visual acuity, extraocular muscle dysfunction, neurogenic keratitis and problems in the lacrimal system including lacrimation.
- Malocclusion with instability in the upper jaw, which may occur as a result of insufficient bone to fill the space or as a result of poor or improper fixation, which may appear after 4 weeks of fixation.
- Injury to the infraorbital or supraorbital nerve accompanied by persistent hypertension, as the doctor must be careful to locate and preserve the nerve roots during surgery to treat facial fractures.
- Lymphadenitis, arthritis, abscesses and infections of the connective tissue andSinusitis.
- Some complications may appear in the respiratory system (which is often the cause of death for these patients), then hormone therapy is provided by a specialist in treating fractures of the face.
- Ectropion of the lower eyelid, where the lower eyelid hangs away from the eye and turns outward. It is not usually dangerous, but it can be uncomfortable and can occur in one or both eyes.
Postoperative instructions for treating facial fractures
- Maintain oral hygiene through periodic dental cleaning.
- Limit food to pureed and liquid foods.
- Take medications and anti-inflammatories regularly as prescribed by the specialist doctor, with periodic review of the doctor.
- Follow up with your eye doctor in order to note any changes in your vision, such as double vision.