Considerations related to dental occlusion render nasotracheal intubation necessary. If that is not feasible, primary submental/submandibular intubation should be considered. Depending on the patient’s general condition, a tracheostomy might also be considered.
The aim of successful reconstruction of midface fractures is reestablishing the midfacial vertical buttresses. These pillars can serve an even more important role in patients who lack dentition (partial or completely edentulous patients).
A principle in all Le Fort fractures is to reestablish the premorbid dental occlusion. Portions of the pterygoid plates and associated musculature are still attached to the posterior portion of the maxilla, so passive mobilization of the fracture can be difficult. Without passive mobilization, Class III tendency often occurs in the postoperative period. The reason for this is that when patients are placed into MMF during surgery, soft-tissue tension from the attached musculature distalizes the mandibular condyles in the glenoid fossae. When the MMF is removed, the condyles re-seat themselves into their normal position, bringing the mandibular dentition forward, creating a Class III malocclusion. In order to properly achieve a passive position of the maxilla, the maxilla requires strong mobilization forces using varied instrumentation: Rowe’s disimpaction forceps, “Stromeyer” hook, Tessier retromaxillary mobilizers, etc.
The goal is to achieve an anatomical correct repositioning by means of 3-D reconstruction. If available, dental cast, stereolithographic models, and/or premorbid photographs may be useful guides for treatment.
As a general principle, all facial fractures should be exposed and reduced before plating.