Considerations related to dental occlusion render nasotracheal intubation necessary. If it is not feasible change of intubation or primary submental/submandibular intubation should be considered. Depending on the patient’s general condition, a tracheostomy might be the appropriate choice.
The aim of successful reconstruction of midface fractures is reestablishing the midfacial 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 occurs often in the postoperative period. The reason for this is that when patients are placed into MMF during the surgery, the soft-tissue tension from the attached musculature distalizers 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 various 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 fractures should be exposed and reduced before plating.