When maxillary fractures were placed into IMF late, the maxilla, at its third (pterygoid) buttress, descended inferiorly and posteriorly. Lack of cuspid contact and incisor separation are the first signs of an open bite. The majority of highly comminuted fractures treated with immediate release of IMF (62%) had to be managed with traction elastics or a reinstitution of IMF. Commonly, patients released from IMF early and patients having late fracture reduction (where IMF was placed late after the initial injury) would be observed to have a small anterior open bite after the release of IMF. Review of preoperative and postoperative CT scans and clinical examinations demonstrates the most common errors with regard to midface fracture treatment. Clinical signs and symptoms demonstrated painful upper lip and cheek swelling, subcutaneous emphysema, epistaxis, chin abrasion, oral mucosal laceration and malocclusion.Ĭomputed 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. A 53-year-old man presented to our clinic with an injury from falling down from a height of 3 m. Īuthor present the case who diagnosed Le Fort I fracture. Correction of the posterior facial height does not involve accurate reconstruction of the pterygoid buttresses, but is achieved by IMF. The more intact side is often the best key to the correct facial height. The fracture is usually worse on one side. Anteriorly, nasomaxillary and zygomaticomaxillary buttresses are reconstructed after alignment, providing bone grafts and rigid fixation for stability. It becomes important, therefore, to restore the facial height and projection by anatomic reconstruction of the buttresses of the maxilla. 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. 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. 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. The structural support between the areas of the buttress and maxillary alveolus must also be restored to provide for proper soft tissue contour. The goals of the treatment of Le Fort I fractures are to restore midfacial height and projection and to reestablish pre-traumatic occlusal relationships. Therefore, the absence of a lateral pyriform fracture rules out a Le Fort I fracture. Īmong Le Fort fractures, only the Le Fort I fracture involves the lateral aspect of the pyriform aperture. These findings indicate that approximately one third of pterygoid plate fractures do not result from Le Fort pattern injuries and that the craniofacial surgeon should have a broad differential for causes of pterygoid plate fractures when reviewing trauma imaging. Common causes included sphenotemporal buttress fractures in 26 patients (33.3%), temporal bone fractures in 18 patients (23.1%), zygomaticomaxillary complex fractures in 17 patients (21.8%), and displaced mandible fractures in 14 patients (17.9%). Pterygoid plate fractures in 78 patients (37.3%) were unrelated to Le Fort fractures. A retrospective review of CT scans obtained on craniofacial trauma patients over a 5-year period revealed 209 patients with pterygoid plate fractures. However, the fracture of the pterygoid plate is not limited to Le Fort fractures. Conversely, if the CT scan does not reveal pterygoid fractures, the Le Fort fractures can be excluded. If a computed tomography (CT) reveals bilateral pterygoid fractures, a Le Fort fracture should be suspected. Pterygoid fractures are found in all three classes of Le Fort fractures, and are the key to establishing the diagnosis. The most consistent and uniting feature of a Le Fort fracture is the presence of bilateral pterygoid fractures. Bones fractured in a Le Fort I fracture include the lower nasal septum, the inferior portion of the pyriform apertures, the canine fossae, both zygomaticomaxillary buttresses, the posterior maxillary walls, and the pterygoid plates.
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