CASE REPORT

Journal of Dentomaxillofacial Science (J Dentomaxillofac Sci ) August 2017, Volume 2, Number 2: 143-146
P-ISSN.2503-0817, E-ISSN.2503-0825

Management of Le Fort II fracture accompanied

with blowout fracture of orbital base (case report)
CrossMark
Seto Adiantoro,1* Alwin Kasim,2 Faturrahman3

Abstract

Objective: To present a casereport of a 20 years old male with Le Fort the orbital base fracture fragments to achieve normal position and
II fracture accompanied with blowout fracture and its management. movement of the eyeball.
Methods: A 20 years old male patient with chief complaint of Results: One month post-surgery follow-up showed the face was
maxillary fracture and inability to chew food, also felt limitation symmetrical and the enophthalmos was corrected. A good occlusion
of right eye movement and double vision was then diagnosed with was reached.
Le Fort II fracture accompanied with blowout fracture of the right Conclusion: Proper management of Le Fort II fracture accompanied
orbital base. The patient was rehabilitated using open reduction with orbital base blowout fracture can restore the function of the
internal fixation of the maxilla to achieve good occlusion continue eye, mastication and occlusion. Symmetrical and proportional facial
with immobilization. The orbital base fracture was rehabilitated esthetics are among the indicators of a successful holistic maxillofacial
by orbital mesh placement and release of tissue trapped inside trauma management.

Keywords: Open Reduction, Le Fort II, Blow out

Cite this Article: Adiantoro S, Kasim A, Faturrahman. 2017. Management of le fort ii fracture accompanied with blowout fracture of orbital
base (case report). Journal of Dentomaxillofacial Science 2(2): 143-146. DOI: 10.15562/jdmfs.v2i2.534

1
Department of Oral and Introduction fracture causedby motorbike accident 7 days in
Maxillofacial Surgery, Dr. Hasan prior. He was previously treated at Garut Hospital
Sadikin General Hospital, Bandung, In everyday practice maxillofacial surgeons often then was referred to Dr. Hasan Sadikin General
Indonesia encounter a wide range of midfacial fractures. Le Fort Hospital. The patient was unable to chew his food
2
Department of Oral and fractures, which account for 10–20% of facial frac-
Maxillofacial Surgery, Faculty of properly and felt pain at his cheek and under his
Dentistry, Padjadjaran University, tures, are often associated with other serious injuries. eyes. He also felt double vision and his right eyeball
Bandung, Indonesia Nasal, orbitozygomatic, frontal, temporal, maxilla and was unable to move normally.
3
Department of Orthopedic and mandibula are bones composing the facial structure; On physical examination it was found that the
Traumatology, Faculty of Medicine, thus, fractures of those bones can cause facial patient was fully conscious and the vital sign was
Padjadjaran University/Dr. Hasan abnormality causing poor esthetic and disturbance of
Sadikin General Hospital, Bandung, normal. On doing head examination a slight bilat-
Indonesia sense of smell, respiration, digestion, and eyes. The eral periorbital edema and bilateral zygoma was
face is also important for the esthetics and self-image. found due to post-trauma inflammation, and it had
1,2

The etiology of maxillofacial fracture are traffic already subsided. Eye examination found medial
accident, occupational accident, sport injury, war subconjunctival hemorrhage of right eye, enoph-
injury, and injury caused by violent acts. The most thalmos of right eye, and dystopia and diplopia at
frequent cause is traffic accident of two-wheeled upper right direction figure 1. The patient was also
motor vehicle.Most of the jaw fracture occurs in unable to move his eyeball to the right, upper right,
young male aged 16–40 years old, and dominantly and lower right direction. An intraoral palpation
in age 21 and 25 years old.1–3 was found floating of nasofrontal suture to maxilla
Facial trauma commonly involves hard and soft and malocclusion with anterior open bite.
tissue, such as in Le Fort II fracture and blowout To support the diagnosis, postero–anterior
fracture of the orbital base. Those trauma cause the (PA) and lateral Caldwell radiograph, Water’s view
disturbance of the function of the eyes, mastication, radiograph, panoramic radiograph, axial, coronal,
and occlusion. This case report will describe the basic and 3D CT-scan was taken.
*
Corresponding Author: principles of the management of Le Fort II fracture The Water’s view radiograph showed radiolucent
[email protected] accompanied with blowout fracture of the orbital base. at fracture site at bilateral zygoma and nasofrontal
figure 2A, while Coronal CT-scan showed fracture
fragment at right orbital base figure 2B. This was
Received 26 March 2017 Case Report
supported by the result of 3D CT-scan imaging that
Revised 29 April 2017
Accepted 21 June 2017 A 20 years old male patient came to the Department showed fracture line at bilateral zygoma and naso
Available online 01 August 2017 of Oral Surgery with chief complaint of maxillary frontal figure 3. The patient was diagnosed with Le

 © 2017 JDMFS. Published by Faculty of Dentistry, Hasanuddin University. All rights reserved. 143
CASE REPORT

A fixation was done with internal fixation method

using mini plates and screw to achieve osteosynthe-
sis directly at the fracture site. An immobilization
was planned for 3–4 weeks using intermaxillary
fixation (IMF) technique. This technique was done
by immobilizing maxilla locked at the mandibular
direction to achieve and maintain proper occlusion.
The management of orbital base fracture was
done by trans conjunctival incision approach in
the right eye. The trapped periorbital fat tissue was
released from the fracture fragment. Reposition
of orbital base fracture was done by placing mesh
and fixing it to the infraorbital rim. A duction test
was done to assess the eye movement to the normal
limit.
The patient was followed-up until one-month
post-surgery. The facial examination showed
symmetrical face and no deformity. The right eye
was able to move normally and the enophthal-
mos and diplopia was corrected figure 4A. Good
occlusion and mastication function was achieved
figure 4B. The wound healing was good and there
was no sign of infection.
Figure 1 Facial profile. (There was enophthal-
mos of right eye) Discussion
Clinically, Le Fort II fracture commonly has the
following clinical signs; edema of the upper third
of the face, which is also known as ballooning or
moon face, bilateral circumorbital edema, and
ecchymosis (black eyes and a bilateral subcon-
junctival hemorrhage of the medial side of the
eyes), flat and depressed nose, bilateral epistaxis,
elongation of the face and premature occlusion
contact of the posterior teeth which causes anterior
open bite, mastication and speech disturbances,
airway obstruction caused by posterior and inferior
displacement causing dorsal tongue obstruction,
emphysema that occurs due to air released from
paranasal sinus caused by the fracture, leakage
ofcerebrospinal fluid, and anesthesia or paresthesia
of both cheeks caused by orbital foramen injury.2,4
The main principles of Le Fort II fracture
management are infection control, fracture frag-
ment reduction, fixation, and immobilization.
The management of fracture has to eliminate the
movement of fracture fragments, because excessive
Figure 2 A. Fracture line at bilateral zygoma was seen in water’s
fracture movement can inhibit new bone formation
radiograph.
and predisposes it to infection. Proper prophylaxis
B. Coronal section of the CT scan showed fracture fragment at the
antibiotic is sometime needed for good wound
orbital base
Fort II fracture accompanied with blowout fracture closure.6
of orbital base. Reduction has to be done immediately and
The management of this patient was done by accurately to restore the function and esthetics. To
open reduction internal fixation (ORIF) for the Le achieve a good reduction, occlusion has to be used
Fort II fracture with general anesthesia. An incision as guidance, so when the occlusion is achieved, the
was done intraorally at maxillary vestibulum. A mastication function also works properly. Delay of
reduction was done with right occlusion direction. reduction will affect the function and esthetics and

144 Journal of Dentomaxillofacial Science (J Dentomaxillofac Sci ) August 2017; 2(2): 143-146 | doi: 10.15562/jdmfs.v2i2.534
 CASE REPORT

inferior oblique muscle disturbance. The diplopia

is a symptom that frequently develops early. This
is because of the edema and hemorrhagic effusion
inside and around the extra ocular muscles. The
diplopia is usually temporary. The diplopia can also
be caused by enophthalmos and ptosis is caused
by eyeball shift which is caused by the trauma. An
orbital base trauma can also cause enophthalmos
if the orbital fat gets inside the maxillary sinus.
This type of diplopia needs special care because a
repair is impossible unless the orbital base fracture
is reduced.2
An eyeball movement examination of patient
in this case report showed inability to move right
eyeball towards right, lower right, and upper right
direction. The eyeball had to be assessed by eval-
Figure 3 Fracture of bilateral zygoma and fracture line at nasofrontal suture
uation of cardinal eyeball movement. A forced
was seen in 3D CT-scan imaging
duction test was done because it was suspected
that there was eye muscle trapped inside the
fracture fragment. The movement limitation
could also be caused by post-trauma edema and
orbital body prolapse. It could also be a sign of the
presence of scar tissue and contracture. An infra-
orbital nerve damage is also possible in orbital
base blowout fracture. If there is paresthesia at
the distribution of infraorbital nerve with limita-
tion of eyeball movement, suspicion of blow-
out fracture needs to be considered. An orbital
exploration is done if the diagnosis is confirmed
supported by the result of the CT scan as a gold
standard. Besides, careful examination showed
limited extra ocular muscle function, orbital tissue
herniation, enophthalmos, dystopia, and diplopia
which does not improve in 7–14 days, and positive
forced duction test. Based on these indications,
we planned orbital exploration for this patient.
Figure 4 A. Onemonth post-surgery followup. Access to orbital base is made by making subcil-
The face was symmetrical and the iary and trans conjunctival incision. The orbital
enophthalmos was corrected, B. A good base exploration is done by peripheral fat release
occlusion was reached and orbital bone reduction. Basic reconstruction
of orbital base is completed with reduction and
become difficult due to its delay. The reduction will stabilization of orbital rim. In large defect, the
be more difficult if it is delayed more than 10 days orbital base defect can be reconstructed by auto
in mandibula and 3 weeks in maxilla.6 graft, allograft, or prosthetic implant. Sources for
Movement of fracture line after reduction and auto graft are calvaria, iliac crest, or nasal septum
fixation will interfere the bone healing process. This cartilage. Sources for allograft are lyophilized dura
can cause deformity. An immobilization has to be and cartilage. Alloplastic material such as titanium
done until the bone healing process is completed. mesh has durable characteristic and can be accu-
The immobilization is done for 4–6 weeks for rately adjusted to the range of orbital base defect.
mandible and 3–4 weeks for maxilla. One of the Porous polyethylene implants and polydioxanone
management plans for maxillary or mandibular resorbable sheet have also been used for orbital
fracture is by IMF immobilization. This technique base reconstruction. Apart from the technique,
is done by immobilizing the mandible locked in restoration of orbital anatomy and volume is
the maxillar direction. This is done to achieve good needed to prevent post-surgical enophthalmos.
occlusion.6,7 A forced duction test has to be done before and
The orbital base blowout fracture can cause after the exploration of orbital base and after the
eyeball disturbance due to the inferior rectus and reconstruction.6–8

Journal of Dentomaxillofacial Science (J Dentomaxillofac Sci ) August 2017; 2(2): 143-146 | doi: 10.15562/jdmfs.v2i2.534 145
CASE REPORT

Conclusion 3. Ebenezer V, Balakrishnan R, Padmanabhan A.

Management of Le fort fractures. Biomed Pharmacology J
Proper management of Le Fort II fracture is accom- 2014;7: 179–182.
4. Holton J. Trauma surgery. J Oral Maxillofac Surg
panied with orbital base blowout fracture can 2012;11: e162–e203
restore the function of the eye, mastication and 5. Shetawi AHA. Initial evaluation and management of max-
occlusion. Symmetrical and proportional facial illofacial injuries.
6. Anand L, Sealey C. Orbital fractures treated in Auckland
esthetics are among the indicators of a successful from 2010–2015: review of patient outcomes. N Z Med J
holistic maxillofacial trauma management. 2017;130: 21–26.
7. Malik AH, Shah AA, Ahmad I. Ocular Injuries in patients
of zygomatico-complex (ZMC) fractures. J Maxillofac Oral
Conflict of Interest Surg 2017;16: 243–247.
8. Amrith S, Saw SM, Lim TC. Ophthalmic involvement in
The authors report no conflict of interest. cranio-facial trauma. J Craniomaxillofac Surg 2000;28:
140–147.

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146 Journal of Dentomaxillofacial Science (J Dentomaxillofac Sci ) August 2017; 2(2): 143-146 | doi: 10.15562/jdmfs.v2i2.534