Maxillary and Le Fort Fractures Treatment & Management
- Author: Kris S Moe, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS more...
Stabilize the patient and treat serious insults to the airway, neurologic system, cervical spine, chest, and abdomen prior to definitive treatment of the maxillofacial bones.
Address emergencies related to maxillofacial trauma prior to definitive treatment. These include airway compromise and excessive bleeding. If the airway is compromised and orotracheal intubation cannot be established, the midface complex may be impacted posteroinferiorly, causing obstruction. Disimpaction may be attempted manually or with large disimpaction forceps around the alveolar arch and premaxilla. If the segments do not move readily and the airway is obstructed, an emergent tracheotomy or cricothyrotomy may be necessary. Severe bleeding may occur from soft tissue lacerations or intranasal structures. A combination of pressure, packing, cauterization, and suturing may be useful in such situations.
Fixation of unstable fracture segments to stable structures is the objective of definitive surgical treatment of maxillary fractures. This principle, while seemingly simple, becomes more complex in patients with extensive or panfacial fractures. In isolated maxillary fractures, the stable cranium above and occlusal plate below provide sources of stable fixation. One goal of treatment is to restore proper anatomic relationships. In particular, attempt to normalize the integrity of the support bolsters of the facial skeleton, the midfacial height and projection, and dental occlusion and masticatory function.
After all other more critical medical problems have been stabilized, the patient may be considered for repair of maxillofacial injuries. Have adequate plain film and CT imaging available in the operating room for intraoperative guidance. A complete maxillofacial plating set must be available.
Prior to surgery, inform the patient of the implications of the anticipated procedures. Counsel the patient regarding the limitations and duration of maxillomandibular fixation (MMF). Additionally, the patient must understand the risks and possible complications of the procedure, including temporary or permanent paresthesia, cerebrospinal fluid leak, meningitis, sinus infection or mucocele, anosmia, malocclusion, infection of implants, osteomyelitis, malunion or nonunion, external deformity, plate exposure, tooth injury, and the possible need for additional surgery.
Perform repair of any significant maxillary fracture requiring reduction and fixation in the operating room with the patient under general anesthesia. Because of the need for MMF, intubate the patient with a nasotracheal tube.
In general, attempt to complete restoration of dental occlusion with MMF prior to reduction and fixation of other segments of the maxilla. MMF accurately restores the position of the base of the maxilla, allowing for correct reconstruction from inferior to superior. If the mandible is also fractured, reduction and fixation of the mandible must be completed first, followed by MMF, and then definitive repair of maxillary fractures. Disimpaction of the free maxillary segments can be performed manually or with disimpaction forceps. Perform this procedure carefully because injury to the nasolacrimal duct, inferior orbital nerve, and extraocular muscles may be involved in middle and high maxillary fractures.
In patients with Le Fort III fractures, exclude the presence of bony segments in the optic canal prior to aggressive attempts at disimpaction. MMF is typically performed with arch bars and stainless steel 25- or 26-gauge interdental wires. For edentulous patients, surgical splints or dentures secured to the underlying bone with screws or with circummandibular and circumzygomatic wiring may serve as the basis of stabilization.
Once the proper occlusal plane is restored, definitive reduction and fixation of the maxillary fractures may be undertaken. Suspension and intraosseous wires have largely been abandoned more because of suboptimal immobilization than other reasons. Both miniplates and external fixation have been applied successfully to the treatment of midface fractures.
Le Fort I fractures
For stable, nondisplaced Le Fort I fractures, MMF alone may suffice to provide stable restoration of bony support. Partial or segmental alveolar ridge fractures can likewise be treated with MMF alone after proper reduction. However, unstable fractures require an additional means of fixation. Some surgeons prefer to place additional fixation even to nondisplaced fractures, with the goal of allowing earlier removal of MMF and return to mastication.
The method of choice for fixation is through miniplates placed via an open approach. Make gingivolabial incisions through mucosa 5-10 mm labial to the apex of the sulcus to preserve a cuff of untethered mucosa for closure. Carry the incision down to alveolar bone from one molar region to the other. Elevate the periosteum superiorly to expose the fracture lines. Take care to not injure the infraorbital neurovascular bundle. Expose the nasomaxillary and zygomaticomaxillary buttresses, piriform aperture, and premaxilla and nasal spine. Then, contour vertically oriented miniplates using a malleable template to span the fracture line. For true Le Fort I fractures, one plate across the nasomaxillary or zygomaticomaxillary buttress on each side is usually adequate for stable fixation. The most common method is low-profile titanium plates secured with monocortical self-tapping screws.
See the image below.
An alternative method of fixation uses suspension wiring. In this method, a 25- or 26-gauge wire is looped around the temporal aspect of the zygomatic arch, retrieved intraorally, and tightened to an intermediate wire loop connected to the arch bar.
The wire may be passed using a specialized awl with a hole at the tip. Insert the awl into the skin at the superior aspect of the junction of the body and arch of the zygoma. Pass it medially to the arch, and direct it toward the first molar or second premolar. The awl then pierces the mucosa, and a strand of wire is twisted securely around the hole in the awl tip. Withdraw the awl tip to a point just above the zygomatic arch, and then direct it downward, but lateral, to the arch. Once inferior to the arch, direct the awl toward the original tract to the same mucosal opening created by the first pass. Untwist the wire from the awl, remove the awl, and secure the 2 free ends of wire, tightening them to the arch bar using an intermediate wire loop. This method is useful for edentulous patients, in which case the free ends of wire are secured to an intermediate wire loop that passes through holes drilled through the patient's dentures (which are used as the basis for MMF).
Take care to not overtighten suspension wires because the zygomatic arch resides somewhat posterior to the true vertical plane of the maxilla. Overaggressive pulling may result in superoposterior displacement of the inferior fracture segment.
Le Fort II fractures
Just as for Le Fort I fractures, disimpaction, MMF, and sublabial incisions and exposure of maxillary bone and fracture lines are performed. Additional exposure is often necessary superiorly for adequate exploration of the orbital rim. This may be achieved through subciliary or transconjunctival incisions. More extensive degloving of the soft tissue envelope through exposure of the piriform aperture and frontomaxillary region may be facilitated by columellar-septal transfixion incisions.
In general, the pyramidal free maxillary segment is stabilized to the intact zygoma. Because rigid fixation is a traumatic procedure, do not perform it until reduction is optimized. Fixation may be completed directly using noncompression miniplates that span the break in the region of the zygomaticomaxillary buttresses. If instability persists, additional plates may be placed in the nasomaxillary buttresses or inferior orbital rim. Any plating must be placed in areas of adequately robust bone (ie, buttresses). Accurate contouring of the plates using malleable templates is important for precise reduction and fixation. Monocortical, self-tapping screws are ideal. Place plates so that at least 2 screws holes are on each side of the fracture. Thus, if needed, additional screws can be placed for more support.
An alternative to miniplates is interosseous wiring. In this method, place small holes into the appropriate bony segments on either side of the fracture line with a minidriver. Then, pass 28-gauge steel wire through the hole on one side of the fracture and retrieve it outward from the gap between the bony segments. Pull the free end of the wire through the opposite drill hole with a loop of 30-gauge wire. Tighten the 2 free ends of wire. In general, place wires from stable to unstable segments. Because this method is less stable than miniplating, perform several areas of fixation (eg, nasomaxillary, zygomaticomaxillary, inferior orbital rim buttresses). If this method is used, implement a longer duration of MMF than with plating.
Circumzygomatic suspension wiring of Le Fort II fractures has been described. While this method may be effective for clean, true Le Fort II fractures, it is discouraged for 3 main reasons. First, these injuries often have multiple segments, in which case comminution and compression of the maxilla may follow efforts to pull the maxilla en bloc. Second, reduction depends on a vector force that is imperfect. In most patients, the vector from the classic fracture line of Le Fort II fractures to the zygomatic arch is at least 15° askew from the ideal axis for fracture reduction. Finally, other methods have the advantage of more precise application of fixation forces immediately at the site of fracture, minimizing micromotion, maximizing bone healing, and allowing for earlier return to mastication.
Le Fort III fractures
In repairing Le Fort III fractures, stabilize the mobile segments of bone to the stable mandible below and cranium above. Initially, the maxilla must be disimpacted and MMF implemented. Soft tissue incisions may be made in the same locations as for Le Fort II fractures. Lateral brow incisions, glabellar fold incisions, or bicoronal scalp flaps can be used for additional exposure to the frontozygomatic buttress.
The bicoronal flaps may be extended to achieve access to the zygomatic arches. The bicoronal flap must be designed cautiously to avoid injury to the frontal branch of the facial nerve. The plane of dissection is between the galea and pericranium. Once the soft tissue flap is rolled over the superior orbital rims, the pericranium may be incised just above the rims to preserve the supraorbital and supratrochlear vascular supply to the flap.
Laterally, perform dissection just superficial to the temporalis fascia. In approaching the zygomatic arch, incise the temporalis fascia well above it. Develop a plane deep to the fascia down to the fractured zygomatic arch. The fracture can then be levered into reduction with a rigid elevator. If impacted or comminuted, direct fixation may be required. Do not use the bicoronal flap in situations in which soft tissue flaps based on the superficial temporal arteries are needed. A receding hairline also may prompt the surgeon to use other incisions.
Prior to fixation of the involved maxillary fractures, reduce and stabilize any mandibular and cranial fractures. Once this is performed and the fractured maxillary segments are exposed, fixation may be undertaken.
Miniplate fixation is currently the most reliable and rigid method. Use malleable templates; accurate contouring of plates; and monocortical, self-tapping screws. Use plates that span the involved major buttresses. For true Le Fort III fractures, bilateral zygomaticofrontal fixation may suffice. However, more commonly, additional points of fixation are needed (eg, nasomaxillary, nasofrontal, inferior orbital rim, zygomatic arch). Use as few plates as possible to achieve fixation; excessive plating is not necessary.
Interosseous wiring and suspension wiring have been described for Le Fort III fractures but are less reliable than miniplate fixation because vectors of forces to maintain reduction are less accurate and micromotion is increased.
Extraskeletal fixation is not usually necessary for simple Le Fort fractures. In patients with more extensive panfacial fractures, external fixation may be the only means of stabilization. If possible, avoid this method because it can place excessive or misdirected force onto the fracture segments and therefore cause shortening or further deformity of the mid face.
For all maxillary fractures, suspension of the soft tissue of the mid face should be performed prior to closing the intraoral incisions with 3-0 chromic suture and closing the skin incisions with absorbable subcutaneous sutures and permanent skin sutures. Bicoronal flaps may be closed with skin staples.
To minimize postoperative edema, a light pressure dressing consisting of gauze and a head wrap may be placed over the operated areas. If the dressing remains dry, it may be removed after 2-5 days.
Surgeons' opinions are divided regarding the need for postoperative antibiotics. If the original fracture sites were open to the external environment or in communication with intraoral or intranasal spaces, implement prophylactic antibiotics covering gram-positive and anaerobic organisms for 5-10 days.
After surgery, observe patients overnight for bleeding, airway problems, and vomiting. If wire fixation was used for MMF, place wire cutters near the patient at all times in the early postoperative period to allow the patient to expel vomited material. Remove wires or rubber bands if the patient begins to feel nauseated.
Prior to discharge, instruct patients on how to remove the MMF in case of vomiting. Also, counsel patients regarding limiting their diet to pureed or liquid intake.
Perform a follow-up evaluation at 5-7 days (skin sutures may be removed at this time), 2-4 weeks, and then at 3-8 weeks for removal of the MMF. Longer-term follow-up care may be needed to monitor postoperative complications or deformity.
The most important goal during the early postoperative period is maintaining a state of immobilization. Depending on the age and general health of the patient, the extensiveness and displacement of the fractures, and the repair technique used, this period may range from 4-8 weeks. This requires that MMF be maintained during this period. During this period, emphasize to the patient to maintain oral hygiene with diligent teeth and arch bar brushing and oral rinses with saline or antiseptic mouthwash each morning and evening and after each meal.
Throughout the postoperative course, the stability of the facial skeleton may be tested by palpating the patient's maxillary teeth during clenching and relaxing of the muscles of mastication. Minimal conducted motion is acceptable, but excessive mobility may indicate poor healing. Postoperative films (ie, mandible series, Panorex dental views, facial series, CT scan) may be helpful in patients in whom malunion is suggested.
Once the facial skeleton is deemed to be well healed and normal occlusion is present, the MMF may be removed. Minimal vertical mobility of the mid face likely resolves with time. Excessive motion indicates that it is too early for the arch bars to be removed or that a problem exists with union. In general, the MMF is removed earlier for fractures repaired with miniplate fixation and later for those repaired with interosseous or suspension wires.
Soft tissue complications result from technical pitfalls or problems with wound healing. In general, unfavorable scarring may be avoided by closing facial incisions in a 2-layered fashion, with deeper subcutaneous absorbable sutures placed to remove tension from the skin closure. Skin closure should be performed with nontraumatic handling of wound edges and should result in the wound edges being slightly everted.
Intraoral incisions may dehisce partially or completely because of inadequate closure during surgery, poor oral hygiene, local trauma, or excessive motion. When designing the gingivolabial incisions, a cuff of mucosa should be maintained on the gingiva to allow for adequate soft tissue upon which to suture. This may be accomplished by placing the incision slightly labial to the deepest part of the gingivolabial sulcus. If dehiscence occurs, maintaining local hygiene alone allows for eventual healing.
Lower lid ectropion may follow a subciliary approach to the maxilla. This complication may be avoided by performing meticulous dissection between the orbital septum and orbicularis oculi muscle and, for patients in whom laxity is present, superolateral suspension of the muscle to the periosteum of the lateral orbital wall. If severe ectropion occurs, breaking up the scar with Z-plasty or skin grafting from the opposite lid skin may be necessary. Lower lid transconjunctival incisions decrease the likelihood of ectropion and should be considered in high-risk patients.
Nerve injury may have occurred prior to surgery from the initial traumatic insult. Therefore, the status of the main sensory and motor nerves of the face and forehead must be documented prior to surgery. Care should be taken to identify and preserve the supraorbital and infraorbital neurovascular pedicles while the soft tissue flaps are raised. More commonly, supraorbital nerve injury results from nerve stretching in retracting the soft tissue and orbital tissues to gain access to the superior and medial orbital rims. The frontal branch of the facial nerve may be injured from excess traction on the forehead flap.
Anatomic disruption of the nerve may occur if the improper plane is used to access the zygomatic arch. The nerve is known to cross the arch superficially to the superficial layer of the deep temporalis fascia. Therefore, dissection should be performed deep into this layer. The appropriate plane is accessed by incising the temporalis fascia well above the arch and dissecting deeply to fascia down to the fractured arch. Nerve injury is often incomplete and temporary.
Injury to tooth roots from misplaced screw holes may result in nonviable teeth. If fracture lines are low and do not allow an area adequate to avoid teeth when placing plates, suspension or interosseous wire fixation may be considered.
Postoperative infections are more apt to occur in the setting of extensive soft tissue injury, contaminated wounds, open fractures, fractures communicating with intranasal or intraoral spaces, or nonevacuated sinus blood. If empiric antibiotic therapy does not clear the infection, debridement and drainage may be required. Cultures should be obtained if purulent material is encountered, and specific antibiotic treatment should be instituted. Long-term unchecked infection may cause osteomyelitis around the sites of the screws or wires. Removal of these implants and debridement of bone may be necessary if antibiotics are unsuccessful. Sinusitis may occur if fracture lines involve the sinus drainage ostia. In such instances, decongestants and antibiotics should be started; intranasal surgical drainage should be performed for nonresolving cases.
Malunion and resultant malocclusion and deformity occur if reduction is not precise or if loosening of fixation occurs during the postoperative period. This can be avoided with meticulous surgical technique and adequate fixation, preferably with carefully placed miniplates. Patient noncompliance with MMF and early mastication may result in micromotion, which leads to poor bone healing. If malunion is discovered early, attempts to optimize reduction may be made by loosening the MMF tension and adjusting the wire closure forces or elastics in order to normalize occlusion. If this fails, rigid fixation (wires or plates) must be removed and replaced for better stabilization.
For delayed presentations in which the bones have healed into malposition, osteotomies must be performed through or near the original fracture sites and the bones must be repositioned with rigid fixation. In rare instances, bone resorbs as a result of malunion and motion, and osseous interposition grafts or overlay grafts may be required. Split calvarial grafts are well suited for midface work, but rib grafts may be used as an alternative.
Total nonunion is less common than malunion. In most cases, maintaining an extended period of fixation and immobility results in eventual healing. For persistent nonunion, fracture sites must be reexplored, freshened, and refixated. Again, areas of gaps may need to be addressed with osseous grafts.
Outcome and Prognosis
A lack of prospective studies on trauma patients makes assessment of outcome measures for patients treated for maxillary fractures difficult. Repair of simple maxillary fractures typically restores bony aesthetic contour and function; however, complex fractures often leave the patient with some long-term cosmetic and functional deficits. Early and meticulous surgery is most likely to produce results that restore the patient to the pretrauma state.
Future and Controversies
The continuing trend in facial fracture repair is toward rigid osteosynthesis with miniplates and screws. The advantage of this technique is that a higher degree of stability is gained, allowing for earlier removal of MMF and return to mastication.
Opponents of this technique who favor suspension techniques cite the disadvantage that anatomic realignment must be perfect at the time of surgery. Whereas suspension techniques allow postoperative adjustment of segments by changing the MMF to compensate for slight deviations from perfect reduction, rigid techniques are much less forgiving. Unrecognized displacement of midface or mandibular segments results in inevitable malunion. Also cited are the higher cost of the materials, the difficulty in contouring plates to the surface of the bone, and increased surgical time. Despite these disadvantages, rigid techniques are gaining in popularity. As long as surgical technique is proficient, rigid osteosynthesis is generally believed to lead to better long-term results and faster recovery.
Absorbable plating systems composed of polylactic acids have recently become available and are gaining popularity for maxillofacial repair. These systems have the advantage of providing rigid osseous fixation without permanent foreign body implantation. This theoretically reduces the risk of infection and plate exposure. The other main advantage of these systems is the ability to contour plates with thermal manipulation (hot saline sponge or specialized heated instruments) even after the plates have been positioned in situ. This facilitates contouring plates to a precise and appropriate shape across fracture lines.
The use of endoscopically-assisted techniques allows for limited incisions for the reduction of facial fractures. These techniques have been pioneered for use in the reduction of condylar and orbital fractures but have recently been applied to more extensive procedures.[13, 14, 15] The use of endoscopic techniques allows for limited incisions, faster recovery periods, and shorter hospital stays.[14, 15] Despite the advantages afforded with these techniques, the indications for open procedures have not been drastically altered. Facial trauma that involves severely dislocated or comminuted fractures of the facial skeleton and major reconstruction of the facial support structures still requires the use of open techniques and direct visualization.
Reconstruction of the facial skeleton involves the reestablishment of the original contours of the face with the precise alignment of fractures. The advancement of image guidance systems has assisted the surgeon in preoperative evaluation and surgical planning, but its recent introduction into the operative arena allows real-time localization of displaced facial skeletal segments during reduction and internal fixation. The use of this technology can help the surgeon obtain a postoperative result that most closely approximates the pre-trauma skeletal structure. This may be most useful in cases where the adjacent bony anatomic landmarks are also displaced or altered and the continuing incorporation of computer-aided guidance of reduction of facial fractures will help to optimize surgical results.
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