Management of Le Fort I Fractures

Abstract

Study Design: A retrospective study. Objective: This retrospective study aims to analyze the results of Le Fort I fracture treatment, with a focus on addressing malocclusion related to the fractures. Methods: The study included 43 patients diagnosed with Le Fort I fractures who underwent open reduction and internal fixation. Demographic data, causes of trauma, accompanying facial bone fractures, treatment methods, and complications were analyzed. Fisher’s exact test was employed to assess the association between fractures and malocclusion. Results: Postoperative complications included occlusal disorder (6 cases), sensory disturbance (4 cases), and facial deformation (6 cases). Condylar fractures showed a statistically significant association with occlusal disorders (P = 0.044). Surgeon variability did not significantly impact occlusal outcomes (P = 0.25). Conclusions: Proper management of Le Fort I fractures requires a thorough understanding of surgical principles and consideration of concomitant fractures. Achieving anatomical reduction based on occlusion is crucial for successful outcomes, and additional Le Fort I osteotomy may be considered in challenging cases.

Introduction

In facial fractures, a Le Fort I fracture is a horizontal fracture of the maxillary bone that makes a single block including the entire upper alveolar process, palatal vault, and inferior portion of the pterygoid processes. The symptoms of a Le Fort I fracture include midface swelling and pain, an epistaxis, and malocclusion. Recently, Le Fort I fractures can occur almost equally in low-velocity trauma as well as high-velocity trauma.[1] The facial bones are more complex than those in the axial skeleton. As a result, various fracture patterns occur, which makes treatment more difficult.

The goal of treatments is to restore the anatomical reduction and function of the facial bone, especially occlusal recovery has a significant importance on the prognosis. During surgery, occlusion is confirmed by fixing the maxillary bone based on the mandible. Maxillomandibular fixation (MMF) can provide the proper occlusion. However, due to the complex anatomical structures and the location of various adjacent facial bones, it may be difficult to check the occlusion due to restricted maxillary movement.[2] In addition, if there is difficulty in confirming the existing occlusion associated with a loss of teeth or if there is a limit to rejoining the mandible due to a condylar fracture, malocclusion may occur. If this is the situation, the malocclusion may recur when the intermaxillary fixation is released after the fracture reduction.[3]

To restore the pretrauma occlusion, mobilization of the fractured maxilla is mandatory. In case of incomplete Le Fort fracture which has the malocclusion, mobilization of the fractured segment is not always easy. Even when the fractured segment appears to be well mobilized and MMF may look correct during surgery, there may still be malocclusion after MMF release. If adequate mobilization could not be achieved than additional treatments such as Le Fort I osteotomy may be considered.[4] In this study, the results of the treatment of Le Fort I fractures were analyzed retrospectively, especially the results of the treatment for malocclusion related to the fractures.

Materials & Methods

Patients diagnosed with a Le Fort I fracture at the oral and maxillofacial surgery department of Gachon University Gil Medical Center and with surgery performed due to post-traumatic malocclusion between January 2012 and March 2018 were investigated. The study was limited to Le Fort I fracture cases in which surgery was performed within 2 weeks of injury. The presence or absence of occlusal abnormalities was evaluated through the patient’s own occlusion guidance. Meanwhile, cases where the presence or absence of occlusion abnormalities, such as unconscious mental status or edentulism, could not be clearly identified were excluded. This study excluded cases where the follow-up period was less than 2 months. This study followed the medical protocols and ethics guidelines outlined in the Declaration of Helsinki. Informed consent was waived for this study and the study was approved by the regional ethical review board (GAIRB2020-101). For the analysis, demographic data, causes of trauma, accompanying facial bone fractures (especially mandible or palatal fractures that affect the occlusion), treatment methods, and complications were investigated. Subject patients were divided into four groups according to the presence of palate or mandibular fractures, and the association between fractures and malocclusion was evaluated using Fisher’s exact test.

Results

A total of 43 patients (mean age: 41.3, range: 15-76) diagnosed with a Le Fort I fracture and treated by open reduction and internal fixation were enrolled. There was no statistically significant difference in age. Trauma occurred at a higher rate in males (males:females = 38:5). Traffic accidents were the highest cause of trauma (48.8%), followed by industrial accidents, sports trauma, assaults, and falls (

Table 1. Mechanisms of the Injury.

). Of the total patients, 42 patients developed accompanying fractures in a total of 101 areas (

Table 2. Sites of the Concomitant Fractures.

). Among them, 18 patients had mandible fractures with accompanying fractures in 22 areas, followed by symphysis (36.4%), body (27.3%), and condyle (22.7%) (Table 2). Postoperative complications included occlusal disorder (6 cases,

Table 3. List of Patients Who Had Malocclusion.

), sensory disturbance (4 cases), and facial deformation (6 cases), among which surgery, prosthetics, or corrective treatments were added to solve the problem of malocclusion. The fracture patterns of the patients with an occlusal disorder showed a distribution of palatal fractures (n = 2), mandibular fractures (n = 2), and palatal and mandibular fractures (n = 2) (

Table 4. Fracture Type Associated With Malocclusion.

and

Table 5. Type of Mandibular Fracture Associated With Malocclusion.

). There was no statistical significance between the presence or absence of a mandibular fracture and occlusal disorder (P = 0.536) (

Table 6. Statistical Analysis Between the Fracture Types and Malocclusion.

). There was a statistically significant difference in the relationship with the occlusal disorder when accompanied by mandibular condylar fractures (P = 0.044) (

Table 7. Statistical Analysis Between the Accompanied Condylar Fracture and Malocclusion.

). The patients surveyed in this study underwent surgery by three surgeons, and the relationship with the occurrence of an occlusal disorder, according to the surgeon, was not statistically significant (P = 0.25).

Discussion

This study analyzed the factors that affect malocclusion after Le Fort I fracture management. It is crucial to adhere to surgical principles to achieve proper occlusion recovery after trauma. In addition to considering the anatomical shape, reduction of the fractured maxillary segment should be based on the correctly positioned mandible such as a bimaxillary orthognathic surgery. Stable internal fixation should also be achieved. In cases involving multiple facial bone fractures, including Le Fort type fractures, the surgical sequence should be considered. Traditionally, the “top-to-bottom” and “bottom-to-top” approaches have been used as the reduction sequence of multiple facial fractures. However, the “bottom-up and outside-in” sequence is now widely preferred.[5,6] Numerous studies have reported that the lower facial skeleton can be prepared by initially reconstructing the occlusal area, then facilitating the three-dimensional reconstruction of the mid-face fracture fragments based on the established occlusion and mandible.[5,7,8,9,10] Consequently, the surgeon must accurately assess the degree of displacement of the fractured fragments and the pattern of the comminuted fractures to select the appropriate surgical procedure,[11,12] ensuring internal fixation while considering the positional relationship and occlusion with the adjacent fragments.

If the reduction of the mandibular condylar fracture is difficult or the landmark for the reduction is lost due to the comminuted fracture, there may be limitations to the reduction of Le Fort I fractures. Approximately 80% of multiple facial bone fractures involve condylar and intraarticular fractures, often accompanied by a comminuted pattern or fracture fragment dislocation.[10] In such cases, treating condylar fractures is challenging and may result in subsequent malocclusion. In this study, postoperative malocclusion was observed in three out of the five cases of untreated condylar head fractures, showing a statistically significant outcome. It was determined that the malocclusions in these three cases were primarily caused by the condylar fracture rather than the concomitant fractures, including a Le Fort I fracture. Therefore, inadequately treated condylar fractures are considered a contributing factor to postoperative malocclusion, irrespective of the concomitant fractures.

Previous study report that routine application of arch bars and use of occlusal wafer as well as radical disimpaction and mobilization of the fractured maxilla permits restoration of a good occlusion.[13] However, due to the complex three-dimensional structure of the midfacial bone, there are instances where achieving sufficient mobilization of the fracture fragment is challenging, necessitating measures such as downfracturing. However, downfracturing is a difficult procedure and carries a risk of severe complications in patients with fractures.[14] In 1983, Vaughan et al[2] first reported on irreducible maxillary fractures in four patients, highlighting the need for an additional Le Fort I osteotomy on the unaffected side to establish an accurate positional relationship with the mandible. Romano et al[15] found immobile fractures in approximately 9% of 217 patients with Le Fort type I fractures. They suggest the application of an additional osteotomy to the maxilla to passively reposition the maxillary and mandibular complex, ensuring proper occlusion. In this study, two patients underwent an additional Le Fort I osteotomy to restore pre-traumatic occlusion (Figure 1). The additional osteotomy made the repositioning of the maxilla in a tension-free manner, achieving restoration of the occlusion and yielding satisfactory surgical results.

Research is scarce on occlusal abnormalities as complications resulting from Le Fort fractures. This study is based on a retrospective cohort with a small number of subjects. Within the limitations of this study, it was assumed that favorable outcomes could be achieved through proper reduction and fixation based on the occlusion for both Le Fort I fractures and concomitant fractures. Conducting a study with a larger sample size would allow for the analysis of various variables that could impact postoperative occlusal abnormalities.

In summary, restoring function is a fundamental requirement in fracture management. In the case of Le Fort type I fractures, achieving proper occlusal restoration is a crucial aspect of the treatment, as in mandibular fractures. To accomplish this, it is vital to adhere to surgical principles and develop an appropriate treatment plan based on the fracture pattern.