Authors of section

Authors

Carl-Peter Cornelius, Nils Gellrich, Søren Hillerup, Kenji Kusumoto, Warren Schubert

Executive Editors

Edward Ellis III, Kazuo Shimozato

General Editor

Daniel Buchbinder

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Open reduction internal fixation

1. Principles

Edentulous Le Fort I fractures are rare. If they occur, the fracture is usually linear.

It is not possible to establish a definite occlusal relationship.

These fractures are usually treated by using bone plates after osseous reduction.

More information regarding choice of implants can be found here.

Le Fort I

Teaching video

AO Teaching video on fixation of a complex midface fracture

2. Approach

For this procedure, standard approaches to the maxilla are used. However, if present, lacerations can be used to directly access fracture site for fracture managment.

Principles

3. Reduction

Fracture reduction

In case of a displaced maxillary complex, the fracture must be reduced first. This can be done manually or by use of reduction forceps.

Reduction instruments

Rowe disimpaction forceps

The Rowe disimpaction forces are side specific. They allow the application of great amounts of force to disimpact and reposition the maxilla and midface.

Note: Special attention has to be given to the patient individual fracture pattern so that the use of these instruments does not result in significant shearing at the skull base or orbit. Otherwise, severe complications such as blindness can occur.

Le Fort I

Special attention has to be paid regarding the correct placement of the Rowe disimpaction forceps so that the upper anterior dentition is not harmed.

The maxillary fracture is completely mobilized and an attempt should be made to make the fragment as passive as possible. This may require an up-down and side-to-side movement of the forceps.

Le Fort I

Bone hooks

According to regional preferences and various schools of teaching, different bone hooks are used for fracture reduction.

  • Reduction hook (Stromeyer hook)

The Stromeyer hook (Georg Friederich Louis Stromeyer, Hannover, Germany, 1804-1876) is very versatile for transoral reduction of Le Fort fractures.

In selected cases the Stromeyer hook can also be used for manipulating the Le Fort complex by hooking the tip of the instrument inside the piriform aperture and pulling downwards and anteriorly. This technique is called downfracture procedure in Le Fort osteotomies.

Le Fort I

Confirm proper reduction

Confirm proper reduction by assessing bone alignment at the piriform aperture (nasomaxillary buttress) and the zygomaticomaxillary buttress.

4. Fixation

Plating

A minimum of two plates are necessary. Four L-plates are shown in the illustration.

Le Fort I

Posttraumatic care

Hardware removal may be required in the future to facilitate the wearing of a denture or placement of dental implants.

5. Aftercare following open reduction and internal fixation of Le Fort I and palatoalveolar fractures

Postoperative positioning

Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain.

orbital reconstruction

Medication

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

  • No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days
  • Analgesia as necessary
  • Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
  • Nasal decongestant may be helpful for symptomatic improvement in some patients.
  • Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
  • Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.
  • Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.

Ophthalmological examination

Postoperative examination by an ophthalmologist may be requested. The following signs and symptoms are usually evaluated:

  • Vision (except for alveolar ridge fracture, palatal fracture)
  • Extraocular motion (motility) (except alveolar ridge fracture, palatal fracture)
  • Diplopia (except Le Fort I, alveolar ridge fracture, palatal fracture)
  • Globe position (except Le Fort I, alveolar ridge fracture, palatal fracture)
  • Perimetric examination (except Le Fort I, alveolar ridge fracture, palatal fracture)
  • Lid position
  • If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked.

Note: In case of postoperative double vision, ophthalmological assessment has to clarify the cause. Use of prism foils on existing glasses may be helpful as an early aid.

Postoperative imaging

Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging.
Especially in fractures involving the alveolar area, orthopantomograms (OPG) are helpful.

Wound care

Remove sutures from skin after approximately 5 days if nonresorbable sutures have been used.
Apply ice packs (may be effective in a short term to minimize edema).
Avoid sun exposure and tanning to skin incisions for several months.

Diet

Diet depends on the fracture pattern.
Soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision.
Intranasal feeding may be considered in cases with oral bone exposure and soft-tissue defects.
Patients in MMF will remain on a liquid diet until such time the MMF is released.

Clinical follow-up

Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems.

With patients having fracture patterns including periorbital trauma, issues to consider are the following:

  • Globe position
  • Double vision
  • Other vision problems

Other issues to consider are:

  • Facial deformity (incl. asymmetry)
  • Sensory nerve compromise
  • Problems of scar formation

Issues to consider with Le Fort fractures, palatal fractures and alveolar ridge fractures include:

  • Problems of dentition and dental sensation
  • Problems of occlusion
  • Problems of the temporomandibular joint (TMJ), (lack of range of motion, pain)

Implant removal

Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or visible. In some countries it will be more commonly requested. There have been cases where patients have complained of cold sensitivity in areas of plate placement. It is controversial whether this cold sensitivity is a result of the plate, a result of nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of cold sensitivity generally improve or resolve with time without removal of the hardware.

Generally, orbital implant removal is not necessary except in the event of infection or exposure. Readmission might be indicated if long term stability of the orbital volume has not been maintained.

MMF

The duration and/or use of MMF is controversial and highly dependent on the particular patient and complexity of the trauma. In some cases where long-term MMF may be recommended, the surgeon may choose to leave the patient out of MMF immediately postoperatively because of concerns of edema, postoperative sedation, and airway. In these cases the surgeon may choose to place the patient in MMF after these concerns have been resolved.

The need and duration of MMF is very much dependent on:

  • Fracture morphology
  • Type and stability of fixation (including palatal splints)
  • Dentition
  • Coexistence of mandibular fractures
  • Premorbid occlusion

Oral hygiene

Patients with arch bars and/or intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch bars or elastics makes this a more difficult procedure. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the surfaces of the teeth and arch bars. Elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth.
For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.