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Management of Le Fort I fracture

Among the classification of maxillary fracture, the Le Fort classification is the best-known categorization. Le Fort (1901) completed experiments that determined the maxilla areas of structural weakness which he designated as the “lines of weakness”. According to these results, there are three basic fracture line patterns (transverse, pyramidal and craniofacial disjunction). A transverse fracture is a Le Fort I fracture that is above the level of the apices of the maxillary teeth section, including the entire alveolar process of the maxilla, vault of the palate and inferior ends of the pterygoid processes in a single block from the upper craniofacial skeleton. Le Fort fractures result in both a cosmetic and a functional deficit if treated inappropriately. In this article, authors review the management of a Le Fort I fracture with a case-based discussion.


INTRODUCTION
Rene Le Fort's seminal classification system for maxillary fractures has been the standard for over 100 years. This system was developed through direct observation, and incorporates what Le Fort described as "great weak lines" in the craniofacial skeleton [1].
Le Fort found three basic patterns of maxillary fracture lines: transverse, pyramidal and craniofacial disjunction (Fig. 1). The transverse fracture is the Le Fort I fracture through the maxilla, cephalic to the maxillary dentition.
The symptoms of a Le Fort I fracture include swelling of the midface, a profuse nasopharyngeal bleeding, pain, malocclusion, and intraoral laceration. Fcacial elongation and facial retrusion can occur if the patient is not placed in intermaxillary fixation (IMF) and the midface is allowed to displace. The maxillary alveolus is usually retruded, and tilts with premature contact with the mandible in the molar occlusion [2]. In this review, authors provide the case of management of a Le Fort I fracture.

Management of Le Fort I fracture
Among the classification of maxillary fracture, the Le Fort classification is the best-known categorization. Le Fort (1901) completed experiments that determined the maxilla areas of structural weakness which he designated as the "lines of weakness". According to these results, there are three basic fracture line patterns (transverse, pyramidal and craniofacial disjunction). A transverse fracture is a Le Fort I fracture that is above the level of the apices of the maxillary teeth section, including the entire alveolar process of the maxilla, vault of the palate and inferior ends of the pterygoid processes in a single block from the upper craniofacial skeleton. Le Fort fractures result in both a cosmetic and a functional deficit if treated inappropriately. In this article, authors review the management of a Le Fort I fracture with a case-based discussion.

TREATMENT
The goals of the treatment of Le Fort I fractures are to restore midfacial height and projection and to reestablish pre-traumatic occlusal relationships. The structural support between the areas of the buttress and maxillary alveolus must also be restored to provide for proper soft tissue contour [5].
Le Fort I fractures may be accessed by a gingivobuccal sulcus incision, and fixed by reestablishing the midfacial buttresses using 1.5 to 2.0 mm L and J plates. To prevent the forces of mastication from disrupting the repair, emphasis must be put on placing the plates in the same direction as the forces of mastication [6]. The most common disturbance in a treated Le Fort injury is reduced midfacial height and projection rather than the facial elongation and retrusion seen in an untreated Le Fort fracture. It becomes important, therefore, to restore the facial height and projection by anatomic reconstruction of the buttresses of the maxilla. Anteriorly, nasomaxillary and zygomaticomaxillary buttresses are reconstructed after alignment, providing bone grafts and rigid fixation for stability. The fracture is usually worse on one side. The more intact side is often the best key to the correct facial height. Correction of the posterior facial height does not involve accurate reconstruction of the pterygoid buttresses, but is achieved by IMF [5]. Computed tomography (CT) showed the fracture of both zygomaticomaxillary buttresses, the inferior portion of the piriform apertures, the lower nasal septum, the posterior maxillary walls, and both pterygoid plates, which indicates a Le Fort I fracture ( Fig.   2A, B). Prophylactic systemic antibiotics were administered to reduce the chances of cheek cellulitis. Open reduction and internal fixation, with mini-plates and screws, were performed eight days after injury. Simultaneously, the IMF was performed using dual-top screws. The plates and screws fixed both the zygomaticomaxillary buttress and piriform aperture. A postoperative CT was taken several months after the surgery and demonstrated adequate reduction of the displaced maxilla with neutrocclusion (Fig. 2C).
The total hospital stay was 13 days. There is tendency in Le Fort fractures for the maxilla to be anteriorly displaced and impacted. When anteriorly displaced and impacted or when partially healed, maxillary fractures placed in IMF, without a complete mobilization and repositioning of the maxilla, allow the mandibular condyle to easily move anteriorly into the glenoid fossa to permit occlusal contact of the mandible with an impacted, malpositioned maxilla. When the IMF is released, the mandible moves posteriorly to re-set itself in its normal glenoid fossa position; however, the maxilla remains displaced, producing a class II occlusion and an anterior open bite [7].

CONCLUSION
Among the several kinds of classifications of maxillary fractures, the Le Fort classification system is widely known, and provides a method for concise communication of fracture patterns between clinicians and radiologists. A thorough understanding of the facial skeleton is essential for proper diagnosis and treatment of Le Fort fractures, to prevent cosmetic and functional deformities.