Maxillary and midface fractures

Maxillary and midface fractures are complex injuries that involve the intricate anatomy of the midfacial region, which includes the maxilla, zygoma, and the bones of the orbital, nasal, and ethmoidal areas. These fractures are often challenging to manage due to the numerous articulations with surrounding bones and the importance of preserving form, function, and aesthetics.

Mechanisms of Injury

Maxillary and midface fractures commonly result from motor vehicle accidents, falls, sports injuries, and interpersonal violence. Understanding the mechanism of injury can help predict the pattern and severity of fractures and guide the appropriate management plan.

Classification Systems

Le Fort Classification for Maxillary Fractures

The Le Fort classification system, named after French surgeon René Le Fort, describes three primary patterns of maxillary fractures:

1. Le Fort I (horizontal fracture): This fracture extends through the maxillary alveolar process above the apices of the teeth, typically below the nasal floor. The fracture line passes through the pterygoid plates, creating a separation of the lower part of the maxilla. The hard palate and alveolar process are mobile, while the rest of the midface remains stable.

2. Le Fort II (pyramidal fracture): The fracture line extends from the nasal bones to the lacrimal bone, through the infraorbital rim, across the anterior wall of the maxillary sinus, and posteriorly through the pterygoid plates. This type of fracture results in the mobility of the entire midface, including the maxilla, nasal bones, and the orbital rim.

3. Le Fort III (craniofacial disjunction): This fracture, also known as a "transverse facial" fracture, involves the separation of the entire facial skeleton from the cranial base. The fracture line extends through the nasofrontal suture, medial and lateral orbital walls, zygomatic arches, and the pterygoid plates. Both the midface and the orbital rims are mobile.

It is important to note that these classifications describe the most common patterns of maxillary fractures, but actual fractures can be a combination or a variation of these patterns.

Zygomatic Fractures

Zygomatic fractures involve the zygomatic arch, zygomaticofrontal suture, zygomaticomaxillary suture, and the zygomaticotemporal suture. The classification of zygomatic fractures is based on the displacement of the zygomatic complex:

1. Non-displaced fracture: The zygomatic complex is not displaced from its anatomical position.

2. Displaced fracture: The zygomatic complex is displaced from its anatomical position and may require reduction and fixation.

3. Comminuted fracture: The zygomatic complex is fractured into multiple fragments, which may require open reduction and internal fixation with plates and screws.

Orbital Fractures

Orbital fractures are classified based on the location and involvement of the orbital walls:

1. Orbital rim fracture: Involves the bony rim of the orbit (superior, lateral, or inferior).

2. Orbital floor fracture ("blowout fracture"): Involves the floor of the orbit, often caused by direct trauma to the orbital rim or indirectly by an increase in intraorbital pressure.

3. Medial orbital wall fracture: Involves the ethmoid bone, which forms the medial wall of the orbit.

4. Roof fracture: Involves the frontal bone that forms the superior aspect of the orbit.

Clinical Assessment

Perform a thorough head and neck examination, evaluating for facial asymmetry, tenderness, lacerations, occlusal discrepancies, trismus, and cranial nerve deficits. Be aware of the potential for associated injuries, such as skull fractures, cervical spine injuries, and traumatic brain injury.

Imaging

Radiographic studies are crucial in the evaluation of maxillary and midface fractures. Obtain a panoramic radiograph, facial series X-rays, and computed tomography (CT) scans, which are commonly used to visualize the extent of the fractures and plan surgical interventions.

Treatment Principles

The primary goal of managing maxillary and midface fractures is to restore form, function, and aesthetics. Treatment options depend on the type, location, and stability of the fractures and may include:

Conservative management: For non-displaced or minimally displaced fractures

Closed reduction: For stable fractures that can be realigned without the need for surgical exposure

Open reduction and internal fixation (ORIF): For unstable, displaced, or comminuted fractures that require surgical intervention

Timing of Surgery

Early surgical intervention is generally preferred for maxillary and midface fractures, typically within 1-2 weeks after the injury. However, the timing may vary depending on the patient's medical condition, the complexity of the fractures, and the presence of other injuries or comorbidities.

Postoperative Care

Monitor the patient for complications such as infection, malocclusion, nonunion, or hardware failure. Encourage the patient to maintain good oral hygiene and follow a soft diet during the healing period. Regular follow-up visits are essential to assess the healing process and address any complications.

Multidisciplinary Approach

It may be a good idea to collaborate with other specialties (e.g., neurosurgery, ophthalmology, plastic surgery, otolaryngology) when managing complex maxillary and midface fractures or associated injuries to other body regions.

Communication and Documentation

Clearly document your assessment, management plan, and any procedures performed. Maintain clear communication with patients, their families, and your colleagues to ensure a well-coordinated care plan.