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Explain management
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Reading File
This is from an oral surgery textbook (Section 3, page 411) covering the management of Le Fort II (Pyramidal) Fractures. Here is a detailed explanation of each management step:
Management of Pyramidal (Le Fort II) Fractures
1. Treatment Goal
Treatment is directed at two main objectives:
- Reducing the downward displacement of the maxilla (the typical displacement pattern in this fracture)
- Reducing concomitant nasal fractures that frequently accompany this injury
2. Intermaxillary Fixation (IMF)
Intermaxillary wires or arch bars are placed as the foundation of fixation. This brings the upper and lower teeth into their correct occlusal relationship (the bite), which serves as the reference point for proper reduction.
3. Traction to Reduce the Fracture
Manual or elastic traction is applied to reduce the fracture. The goal is to move the displaced maxillary segment back into its correct anatomical position. Once achieved, intermaxillary immobilization locks the jaws together to maintain the reduction.
4. Severely Displaced Fractures
When the pyramidal portion is severely displaced backward (posteriorly), simple traction is not enough. The steps are:
- Manual separation of the lateral portions to disimpact (free) the central pyramidal bone segment
- Specially designed forceps (e.g., Rowe's disimpaction forceps) are used to bring the segment forward
- Craniomaxillary fixation is then applied to hold the reduced position
5. Extraoral Upward Traction (Delayed Cases)
In delayed presentations (where swelling, organization, or early healing has occurred):
- A head bandage or headcap may be used to provide extraoral upward traction, counteracting the downward pull on the maxilla
- This is done before intermaxillary immobilization is possible
- However, internal wiring is preferred and used more often in modern practice
6. Suspension Wiring
The principle here is to use intact bone above the fracture line as an anchor for suspension wires to hold the reduced maxilla in place. Sites used include:
| Suspension Point | Notes |
|---|---|
| Infraorbital rim (lateral portion) | Used on one side |
| Supraorbital rim (lateral margin) | Can be used on one or both sides |
| Circumzygomatic wiring | Used occasionally; important to note the zygomatic complex itself may be fractured in this injury |
7. Management of Associated Nasal Fractures
- Nasal fractures are managed by the otolaryngologist or plastic surgeon
- Reduced by manipulation and shaping, then supported (splint/pack)
- Two timing approaches exist:
- Delayed reduction - wait until the maxillary fracture heals, then perform a submucous resection to reshape the nose
- Immediate reduction - reduce nasal fractures right after the maxillary fractures are reduced (this approach is done more frequently today)
8. Hemorrhage Control
- This procedure involves significant hemorrhage
- Must be managed carefully especially since the jaws are wired shut (IMF), making airway management and suction more challenging
- Effective hemostasis and anesthetic support are required
Summary Flow
Arch bars/IMF placed
↓
Manual/elastic traction → reduce fracture
↓
If severely displaced → disimpact + Rowe's forceps → bring forward
↓
Craniomaxillary fixation (suspension wiring from intact bone above)
↓
Nasal fractures reduced (immediately or delayed)
↓
Hemorrhage managed throughout
This management protocol reflects the classic approach to Le Fort II fractures, balancing reduction, stabilization, and associated injury care.
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