Surgical Case of Comminuted Bilateral Maxillary Le Fort 1 Fracture with Mid-Palatal Split

Introduction

This report documents the surgical case of an 18-year-old male patient who presented at our medical facility following a high-energy motor vehicle accident. The patient suffered from extensive comminuted facial fractures as a result of the collision. The fractures involved various regions of the face, including a pure Le Fort I fracture, piriform aperture fracture, frontozygomatic fracture, fracture of the lateral wall of the left orbit, bilateral dentoalveolar fracture, medial maxillary arch fracture, bilateral fractures extending through the maxillary sinuses, and anterior maxillary fractures.

Background

The Le Fort I fracture is characterized by a low transverse fracture that traverses the floor of the nose, pyriform aperture, canine fossa, and lateral wall of the maxilla. This type of fracture results in the separation of the palate from the maxilla and is frequently associated with malocclusion and dental fractures. Maxillary fractures are often displaced posteriorly, leading to premature contact of posterior teeth and an anterior open-bite. Facial trauma is often associated with severe morbidity with respect to loss of function and disfigurement. The maxilla is undoubtedly the most anatomically complex structure of the face, and blunt trauma from falls, gunshot wounds, industrial accidents, car accidents, and interpersonal aggression all contribute to the aetiology of maxillary fractures. Due to the broad diversity of fracture patterns, difficult diagnostic issues, and difficult treatment options, fractures in the midface are frequently difficult for maxillofacial surgeons. The fundamental principle in treating these fractures is to rebuild the midface's vertical and horizontal buttresses in order to restore both structure and function.

In this case, there was dentoalveolar fracture of the anterior centrals and laterals with canines avulsed but attached to the periosteum that we tried to save. 

Surgical Anatomy/Osteology

The middle third of the facial skeleton is made up of the following bones:

Trauma directed at the cranium from the anterior or anterolateral direction can be cushioned by the relative brittleness of the midface skeleton. This well-known illustration, where the jaw resembles a hockey stick, the midface resembles a matchbox (the "crumble zone"), and the skull resembles a helmet, can be used to identify the facial skeleton. Assaults and car accidents are the most frequent causes of face fractures in adults. 

Le Fort I

The fracture line extends backwards from the lateral margin of the anterior nasal aperture below the zygomatic buttress to cross the lower third of the pterygoid laminae. The fracture also passes along the lateral wall of the nose and the lower third of the septum to join the lateral fracture behind the tuberosity.

Some features of the Le Forte 1 fracture are as follows:

Intraoral

·   Floating Maxilla

·   Telescopic fracture

·   Anterior open bite

·   Deranged occlusion

·   Guerin’s sign

·   Palatal fracture in some cases

Extraoral features

·   Swelling and edema of the midface and upper lip

·   Epistaxis

·   In this case there was peri-orbital edema present

Radiographic Examination

CT Scan of the case is shown below.

The CT Scan shows avulsed anterior maxillary segment along the nasal septum. Fracture can be seen on the left maxillary buttress area, medial wall of the left orbital cavity and fracture of the left orbital floor can also be seen. Bilateral zygomatic bones look intact and so does the frontal bone and mandibular structures. 

Treatment Goals

The primary treatment goals for addressing the fracture were focused on restoring the correct anatomical position and relationship of the fractured dental segments to the cranial base, midface structures, and mandibular dentition. Successful reconstruction was aimed at preservation of bone, restore facial contour, recover continuity of alveolar height, and reconstitute the width, projection, and dental arch of the maxilla.

Surgical Approach

Patient was given general anesthesia under nasal intubation. 

The standard approach for reduction and fixation of Le Fort I fractures involved an upper circumvestibular incision positioned above the attached gingiva to expose maxillary fractures. This incision is made in the mobile mucosa, located 5-10 mm above the attached gingiva, extending from the first molar to the other first molar. This exposed the fractures, zygomaticomaxillary buttress area, piriform aperture bilaterally. Right lateral brow incision was also given to expose zygomaticofrontal fracture.  Prior to making the incision, local anaesthesia with epinephrine is infiltrated to provide adequate pain control and minimize bleeding.

Access to the lower midface can be achieved intraorally. Through this incision, thnentire midface can be exposed. Further exposure is possible by converting this into a “midface degloving incision” 

Internal Fixation and Rigid Fixation

The surgical approach involved the use of mini plates and screws made of titanium to provide internal fixation for the fractured segments. Internal fixation refers to the stabilization of fractured bones using implants like plates and screws, thereby facilitating the healing process by holding the bone fragments in proper alignment. In this case, mini plates and screws were utilized due to their strength and compatibility with the facial bones.

Bridal Wiring

Bridal wiring was employed across the mobile teeth to enhance stability during the surgical procedure. This technique involves using wires to interconnect the teeth and fixate them in their proper positions. Bridal wiring is particularly useful when dealing with dental avulsion and missing teeth, ensuring that adjacent teeth remain in the correct alignment while promoting healing and preventing further displacement.

Open Bite Correction and Occlusion Maintenance

The surgical approach also addressed the open bite resulting from the fractures. By precisely aligning and stabilizing the fractured segments, the open bite was corrected, and the occlusion was maintained to restore proper function and aesthetic appearance.

Maxillomandibular Fixation (MMF)

Arch bars were placed bilaterally across the fractured maxillary segments to achieve MMF. MMF involves wiring the upper and lower jaws together, immobilizing the jaw and preventing movement during the healing process. This fixation method allows the fractured segments to heal without being subjected to forces that could disrupt the alignment and hinder proper bone union.

Plates were placed bilaterally under the piriform aperture and bilaterally at zygomaticomaxillary buttress area.

Frontozygomatic Fracture Reduction and Fixation

The frontozygomatic fracture, which involved the frontal bone and the zygomatic bone, was also addressed during the surgical procedure. Reduction (realignment) of the fracture was performed, and 5 hole mini plates and screws were used to stabilize the fractured segments, promoting proper healing and maintaining facial symmetry.

Frontozygomatic (FZ) Access

Incision marked in a suitable skin crease. The mobile skin allows surprisingly

extensive access through a small incision. The periosteum is incised and elevated. The fracture is reduced and plated.

Sutures Placement

At the completion of the surgical procedure, sutures were placed along the incision lines to close the surgical wounds. Proper wound closure is essential for minimizing the risk of infection, promoting healing, and optimizing aesthetic outcomes.

Conclusion

The surgical approach utilized in this case involved the reduction and stabilization of the extensive comminuted facial fractures using mini plates and screws for internal fixation. Bridal wiring was employed to stabilize the mobile teeth, and MMF was achieved with the use of arch bars. The frontozygomatic fracture was also addressed with mini plates and screws. The surgical technique allowed for wide subperiosteal exposure of all fracture lines and enabled precise alignment and application of osteosynthesis hardware. The successful implementation of this surgical approach aimed to restore facial function, correct the open bite, and ensure proper occlusion while promoting optimal healing and aesthetic results for the patient.

Patient is now on full fluid diet and got discharged after five days.

This case was done by Dr. Waqar Ali at Farooq Hospital, Westwood Branch, Lahore. Radiographic interpretations by Dr. Anas Nasir.