0:01

We're going to return to this case and evaluate it from

0:04

the standpoint of the René Le Fort fractures.

0:08

So on the axial scans,

0:10

we can see that there are bilateral fractures involving

0:14

the orbital rims as well as the orbital floors.

0:17

And we also see on the axial scans that there is

0:21

discontinuity and displacement inward

0:24

of the medial orbital walls bilaterally.

0:28

So with those findings,

0:30

we are concerned about the possibility of a fracture

0:33

whose planes are going through the maxilla,

0:36

the orbital floor and bilateral medial orbital wall.

0:40

So we might say, oh, well, maybe this could be a Le Fort fracture.

0:43

What should we do? Well,

0:44

first thing we should do in evaluating the patient is

0:47

to see whether the pterygoid plates are fractured,

0:50

because the sine qua non of Le Fort fractures

0:53

is involvement of the pterygoid plates.

0:55

So the pterygoid plates are these structures down here,

0:58

and we can see that the left pterygoid plate is comminuted

1:03

and dislocated from the back of the maxilla.

1:06

You see the back of the maxilla has a fracture, as well.

1:10

Here on the right side,

1:13

we see that the lateral pterygoid plates has been

1:16

displaced lateral to the main pterygoid process.

1:21

And there also is some comminution.

1:24

And we also see that the medial pterygoid plate

1:28

here is also looking a little bit irregular.

1:31

So we have the combination of findings of a Le Forte fracture.

1:38

Frankly,

1:38

the Le Forte fractures are best evaluated in the coronal plane.

1:42

So let's shift to this coronal image that was done at the same

1:46

time. What we see is a fracture which goes across the maxilla.

1:51

Here you can see a little bit of the

1:53

comminuted fracture of the maxilla.

1:55

And this represents the Le Forte I fracture in which there's a

2:01

fragment that is involving the maxilla and potentially causing

2:06

malocclusion. In this case, when we look at the teeth,

2:09

there is a little bit of offset here and here.

2:13

So there could be an element of malocclusion.

2:16

Here you can see it looks a little bit better

2:18

further posteriorly. However,

2:21

we also see the orbital floor fractures which are seen here.

2:26

This is orbital rim and anterior orbital floor.

2:29

Here we have the orbital rim and anterior orbital floor

2:32

with the depression of the portion of the orbital floor.

2:36

And here we can see the previously described

2:39

fractures going across the medial orbital wall.

2:42

Here's the defect in the lamina papyracea on the right side.

2:46

And a little bit further anteriorly,

2:49

we saw the fracture involving the medial orbital

2:53

wall a little bit more inferiorly located.

2:56

So we have a fracture going from maxilla to orbital floor

3:00

across the medial orbital wall,

3:01

through the contralateral orbital floor,

3:04

and then across the maxilla.

3:06

This is representation of a Le Fort II fracture.

3:10

Finally, we want to look at the lateral orbital walls.

3:14

And we've seen before this normal suture here,

3:16

and that looks fine. It's not diastatic.

3:19

And we don't see any involvement of the lateral orbital wall.

3:22

You can see here orbital roof fracture

3:24

and comminuted fracture.

3:25

This is the patient who had the Naso-orbito-ethmoidal fracture.

3:29

So, just to be sure, we go back to the pterygoid plates.

3:32

And here you can see the gross fracture and displacement

3:36

of the pterygoid plates in this individual.

3:38

So, in summary, bilateral Le Forte I,

3:43

bilateral Le Forte II fractures, no Le Forte III fracture.