CC

A 26-year-old male presents to the emergency department (ED) with the chief complaint of, “They hit my face with a brick and got my wallet. My face hurts. . . . I was bleeding from my nose, but it has stopped.”

HPI

You are called by the ED team to evaluate the patient. He reports being struck in the face at the level of his upper lip and teeth just below the nose by an unknown male who was walking the opposite way on the sidewalk. (The vast majority of Le Fort I injuries are from blunt, as opposed to penetrating, trauma.) He explains that he was hit once in the face with a brick and subsequently fell to his knees, without any loss of consciousness (lower likelihood for intracranial injury in the absence of loss of consciousness).

PMHX/PDHX/medications/allergies/SH/FH

The patient smokes one pack of cigarettes daily and drinks alcohol regularly. (Both of these factors contribute to an increased relative risk of postoperative infections. A history of alcohol abuse is more frequently encountered in the trauma population.) The remainder of his medical history is noncontributory.

Examination

The initial evaluation of a trauma patient should follow the Advanced Trauma Life Support protocol.

Primary survey

The patient’s primary survey is intact. (Control of the airway and hemorrhage are both part of the primary survey. Compromised airway and life-threatening hemorrhage are unlikely with isolated Le Fort I injuries; however, they can be seen with more complex facial fractures; that is, those with higher Facial Injury Severity Scale [FISS] scores).

Secondary survey

General. The patient is a well-developed and well-nourished male in no apparent distress who is holding a blood-soaked cloth under his nose.

Vital signs. His blood pressure is 115/64 mm Hg, heart rate is 115 bpm, respirations are 12 breaths per minute, and temperature is 37.6°C. (Mild tachycardia can be caused by a compensatory response to volume loss from prolonged oropharyngeal bleeding or from the sympathetic response associated with pain and anxiety.)

Eyes. Pupillary response, visual acuity, visual fields, and extraocular movements are all within normal limits. (A complete eye examination is mandatory in all patients with midface fractures.) There is no evidence of subconjunctival hemorrhage or hyphema (blood in the anterior chamber of the eye).

Maxillofacial. The patient has moderate bilateral midface edema with left facial abrasions extending over the lip region. There is mild hypoesthesia of the bilateral infraorbital nerve distributions (cranial nerve V2). The maxilla is mobile, with no simultaneous movement of the nasal bones on palpation (as would be seen in Le Fort II and III injuries). Examination of the teeth reveals premature posterior occlusal contacts and a 5-mm anterior open bite ( Fig. 56.1 ). There is no evidence of mobile dentoalveolar segments. The remaining facial skeleton, including the nasal bones, is intact and stable on palpation. Nasal speculum examination reveals a deviated nasal septum to the right, with no evidence of a septal hematoma. (A septal hematoma needs to be drained to prevent subsequent necrosis of the quadrangular cartilage and possible saddle-nose deformity.)

Posttraumatic anterior open bite and malocclusion.

Imaging

The imaging modality of choice for the diagnosis and evaluation of suspected maxillary Le Fort I fractures is a noncontrast maxillofacial computed tomography (CT) scan with thin cuts (axial views with coronal reconstructions). Direct coronal imaging or coronal reconstructions are helpful (patients with suspected cervical spine injuries should not hyperextend the neck for direct coronal imaging). Three-dimensional reconstructed CT can be useful to demonstrate the fracture anatomy ( Fig. 56.2 ).

Preoperative three-dimensional lateral view of a different patient showing maxillary impaction anteriorly with resultant anterior open bite.

For the current patient, a facial helical CT scan without contrast was obtained after the primary and secondary surveys were completed. Axial bony window cuts showed bilateral pterygoid plate, anterior and lateral maxillary wall, and posterior nasal septal fractures, with opacification of the maxillary antrum ( Fig. 56.3 A). A moderate amount of soft tissue edema and subcutaneous emphysema was noted. Coronal reconstruction views showed bilateral fractures through the lateral walls of the maxillary sinuses ( Fig. 56.3 B). A three-dimensional reconstruction view allowed clear visualization of the lines of fracture at the Le Fort I level ( Fig. 56.3 C).

A, Preoperative axial bony computed tomography (CT) window showing fractures of the pterygoid plates, anterior maxillary walls, and subcutaneous emphysema and opacification of the maxillary sinuses. B, Preoperative coronal bony CT window through the anterior maxilla and nasal vault showing fracture at the Le Fort I level. C, Preoperative anterior three-dimensional reconstruction showing a horizontal fracture of the maxilla at the Le Fort I level.

Labs

For the current patient, a complete trauma panel was obtained. The results were remarkable for an elevated white blood cell (WBC) count of 16,900 cells/μL. (Increased WBCs or leukocytosis in the acute setting is most likely secondary to physiologic stress because of catecholamine-induced demargination of WBCs.)

Assessment

Isolated Le Fort I maxillary fracture; FISS score of 2.

Treatment

The goal of treatment of Le Fort I injuries is to reduce the displaced maxillary bone with its dentition to allow for uneventful healing, reestablishment of the patient’s preexisting occlusal function, and esthetics. Treatment of a particular fracture needs to be individualized and includes several options, mainly either open reduction with internal fixation (ORIF) or closed reduction with maxillomandibular fixation (MMF). The use of surgical splints should be considered, especially with segmental maxillary fractures. The degree of comminution at the anterior and lateral maxillary walls needs to be assessed for possible reconstructive measures.

Currently, most surgeons consider ORIF the gold standard. As a general principle, early reduction and fixation is preferable. After a 7- to 10-day period, some difficulty may be encountered in mobilizing the maxilla to achieve appropriate reduction, especially if the fracture is associated with significant impaction. Consideration should also be given to completing osteotomy of the maxilla at the Le Fort I level (as in an orthognathic Le Fort osteotomy) if the fracture is incomplete or significant time has elapsed since the original insult. Attempting to mobilize the incompletely fractured maxilla can result in unfavorable fractures, often distant from the site of injury. After MMF has been established, it is critical to establish passive reduction of the maxilla (maxillomandibular complex) with the condyles seated in a correct position; otherwise, an anterior open bite will reemerge after rigid fixation has been applied and the intermaxillary fixation is released. If adequate bone contact is available, a plating system applied bilaterally at the piriform rims and zygomatic buttress areas is usually sufficient for stabilization. However, if more comminution is present and less bone contact is available, immediate bone grafting or secondary bone grafting reconstructive procedures should be considered.

The presence of palatal fractures complicates the treatment of Le Fort I fractures and deserves special attention. If there is a palatal fracture but no concurrent mandibular fractures, the mandibular arch is used to guide the width of the maxilla with arch bars and MMF. With concurrent mandibular fractures, two options exist: (1) the mandible can be reconstructed first anatomically, followed by the maxilla, or (2) alginate impressions can be obtained and model surgery carried out with the use of an intraoperative maxillary splint to reestablish the occlusion.

In the current patient, maxillomandibular arch bars were placed. An intraoral circumvestibular maxillary incision was made to gain access to the fractured segments. After appropriate mobilization of the maxilla, the patient was placed in MMF. The maxillomandibular complex was guided passively, using the arc of rotation of the condyle, into proper anatomic reduction while the patient was paralyzed to ensure that the condyles were appropriately positioned. (Failure to seat the condyles may result in postoperative anterior open bite.) The deviated septum was reduced onto the nasal crest of the maxilla and sutured to a hole drilled through the anterior nasal spine. Subsequently, the maxilla was stabilized with fixation at the piriform rim and zygomaticomaxillary buttress regions bilaterally (four plates). MMF was then released, and the occlusion was found to be intact and reproducible.

Complications

Complications of Le Fort I injuries are related to the severity of the initial injury and to host-related factors but can be categorized into intraoperative, early, and late complications.

Intraoperative

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  Bleeding can occur as a result of damage to any number of the vessels in the vicinity, especially when significant disimpaction or an osteotomy is required for reduction of the segment. Potential sources of bleeding include the anterior and posterior superior alveolar, nasopalatine, and descending palatine arteries and, uncommonly, the internal maxillary artery. Packing, cauterization, and ligation are usually sufficient in controlling most situations. When hemorrhage cannot be controlled, external carotid artery ligation can be performed. Arterial angiography with embolization should also be considered.

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  Maxillary hypoperfusion is uncommon but can occur, especially when the maxilla is fractured in multiple pieces or when surgical splints are used. Early reduction and stabilization with rigid internal fixation may help improve the outcome. In addition, consideration should be given to positioning the maxilla back into the preoperative position (in trauma situations). Postoperative use of hyperbaric oxygen has been suggested, but its benefits remain unclear. If prefabricated occlusal splints are used, they should be checked to prevent impingement on the soft tissues (and possibly the blood supply) of the palate.

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  Malpositioning of the maxilla can occur when the bony interferences are not appropriately evaluated and the maxillomandibular complex is not seated passively with the condyles in the correct position; this results in a postoperative anterior open bite. Palatal fractures that are not reduced also result in improper maxillary segment positioning.

Early

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  Control of nasal bleeding can be obtained in the immediate postoperative period using a variety of techniques for nasal packing. A speculum and a good light source are essential for detecting an anterior versus a posterior origin. If adequate control is not achieved, exploration in the operating room or interventional radiology for angiographic evaluation may be necessary.

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  Malocclusion can result from improper intraoperative maxillary positioning, early hardware failure, or undiagnosed mandibular or maxillary segmental fractures. Careful examination and appropriate imaging modalities help discern the etiology of malocclusion for surgical repositioning and refixation.

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  Infraorbital nerve paresthesia can be the result of nerve injury at the initial trauma, especially when fracture patterns extend through the infraorbital foramen, or from intraoperative traction or manipulation for adequate reduction. Nasal septal deviation can result from improper repositioning of the nasal septum onto the nasal crest of the maxilla, undiagnosed nasal septal injuries, or preoperative septal deformities. This can result in increased airway resistance, nasolacrimal obstruction, and aesthetic complaints by the patient.

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  Loss of vision can result from an unfavorable fracture pattern of the maxilla or from the initial trauma, compounded by surgical manipulation of the segment during repositioning. The orbital process of the palatine bone makes up a portion of the bony orbit and has been hypothesized as a possible cause. (This is very rare for Le Fort I fractures but more common with Le Fort III injuries.)

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  Early postoperative infection can result from foreign bodies, necrotic teeth, or bony segments but is also related to host factors (malnutrition, immunocompromised state, chronic alcohol use). Management should be directed at appropriate antibiotic selection, incision and drainage, and removal of any possible source.

Late

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  Malocclusion, if not addressed early, typically presents with an anterior open bite, posterior premature contacts, and an overall Class III skeletal appearance. After union has developed, small discrepancies can be treated with orthodontics; larger ones need to be addressed through orthognathic surgery.

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  Late postoperative bleeding (especially with an intermittent pattern) should be taken seriously. Pseudoaneurysm formation should be high on the differential diagnosis list and can be evaluated by angiography.

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  Epiphora (excessive tearing) can result from damage or obstruction of the nasolacrimal duct. (The nasolacrimal duct drains beneath the inferior turbinate 11–17 mm above the nasal floor and 11–14 mm posterior to the piriform aperture.) Epiphora can be managed by a dacryocystorhinostomy procedure.

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  Nonunion or fibrous union causes the maxilla to demonstrate mobility, which can often be subtle. Management should be directed at refixation of the maxilla with rigid internal fixation, bone grafting, extraskeletal fixation, or MMF.

Discussion

Maxillary fractures most frequently occur as a result of blunt trauma from assault, sporting injuries, and motor vehicle accidents. They are frequently seen in conjunction with other facial and systemic injuries. The Le Fort classification is frequently used to describe midface fracture patterns. In 1901, Rene Le Fort published the results of his experiments based on 35 cadavers whose heads were subjected to different forms of force. Based on these findings, he concluded that the midface commonly fractures in three predictable patterns. A Le Fort level I fracture involves the anterior and lateral walls of the maxillary sinus, lateral nasal walls, pterygoid plates, and nasal septum (see Fig. 56.3 ). It should be noted that isolated Le Fort fractures are relatively uncommon and that fractures occur in a variety of combinations of Le Fort I, II, or III types, with unilateral (hemi–Le Fort) and bilateral fractures. The “pure” Le Fort I fracture is typically bilateral and is composed of the maxilla with associated alveolar bone and part of the palatine bone posteriorly. Unilateral fractures are seen with an additional fracture between the midpalatal suture.

The blood supply to the maxilla is from the descending palatine artery, which contributes to the greater and lesser palatine arteries and the terminal branch of the nasopalatine artery, and from the anterior, middle, and posterior superior alveolar arteries. Extensive research has been done with regard to the blood supply of the fractured maxilla, mostly in association with orthognathic maxillary procedures. In experiments done by Bell and later by Bays and by Dodson and colleagues, it has been shown that the maxilla (along with its associated dentition and periodontium) maintains an adequate blood supply even after complete downfracture and ligation of the descending palatine artery. The maxilla remains pedicled to the palate, receiving contributions from the ascending pharyngeal artery (a branch of the external carotid artery) and the ascending palatine artery (a branch of the facial artery), which in turn anastomose with the greater and lesser palatine arteries.

Patients suspected of having maxillary fractures should be evaluated according to the ATLS protocol. Because other bodily injuries may be present, the initial evaluation and stabilization of the patient are best performed by a trauma team experienced in the management of the multisystem trauma. Proper diagnosis should begin with a careful history and physical examination. The mechanism of injury should be considered. Symptoms associated with a Le Fort I fracture may include facial pain, infraorbital hypoesthesia, malocclusion, or epistaxis. Clinical signs suggestive of a Le Fort I fracture include facial edema, ecchymosis, abrasions, lacerations, active epistaxis, palpable crepitus, mobile maxilla, and step deformities. Intraoral examination could identify fractured teeth, vestibular ecchymosis, mucosal lacerations, palatal edema or ecchymosis (especially with fractures associated with midpalatal suture), and malocclusion (typically, an anterior open bite with posterior occlusal premature contacts secondary to the vector of impact and the pull of lateral and medial pterygoid muscles).