What is the management of maxillary fractures?

Management of Maxillary Fractures

Maxillary fracture management requires immediate CT imaging for diagnosis followed by surgical reduction and fixation to restore both function and cosmesis, with airway management being the first priority in severe cases.

Initial Assessment and Airway Management

Maxillofacial trauma can lead to life-threatening airway compromise, making airway management the first priority in severe cases 1, 2:

• Assess for signs of airway obstruction: hemorrhage, soft-tissue edema, and loss of facial architecture
• In severe cases requiring intubation, consider:
  • Nasal intubation with direct visualization (most common approach - 57% of cases)
  • Fiberoptic bronchoscopic nasal intubation (preferred over tracheostomy)
  • Tracheostomy only in cases where other methods are impossible

Diagnostic Imaging

Accurate diagnosis through imaging is essential 3:

• Multidetector CT (MDCT) of the maxillofacial region is the gold standard for diagnosis
• CT provides superior delineation of osseous and soft-tissue structures
• Head CT may be indicated if concomitant intracranial injury is suspected (68% of facial fractures have associated head injuries)
• Avoid plain radiographs as they provide insufficient detail for surgical planning

Classification of Maxillary Fractures

Maxillary fractures are typically classified using the Le Fort system 3:

1. Le Fort I: Transverse fracture separating the maxillary alveolar process from the rest of the maxilla

   • Involves all maxillary sinus walls
   • Results in a mobile hard palate

2. Le Fort II: Pyramidal fracture

   • Involves posterior alveolar ridge, nasal bones, inferior orbital rims, and lateral walls of maxillary sinus
   • Results in a mobile hard palate and nose

3. Le Fort III: Complete craniofacial separation

   • Involves zygoma, medial and lateral orbital walls, and nasal bridge
   • Potential involvement of orbital apex and carotid canal

4. Midfacial smash: Most complex fracture with severe comminution of the anterior midface

Surgical Management

The goal of treatment is to restore both function and cosmesis 3, 4:

1. Exposure and Assessment:

   • Complete exposure of injured buttresses to assess exact fracture pattern
   • Identify comminuted or missing segments

2. Reduction and Fixation:

   • Direct fixation of medial and lateral maxillary buttresses on each side
   • Immediate bone-graft reinforcement or replacement of comminuted/missing buttresses
   • Rigid internal fixation using plates and screws

3. Fixation Materials:

   • Traditional metallic plates and screws are standard
   • Resorbable polymers (poly L-lactic acid and polyglycolic acid) can be used for isolated, non-comminuted Le Fort I fractures 5

4. Special Considerations:

   • Medial maxillary fractures (involving piriform aperture, maxillary frontal process, and infraorbital rim) may require specific approaches 6
   • Associated mandibular fractures should be managed simultaneously with rigid internal fixation

Post-Surgical Care

• Monitor for signs of infection
• Assess occlusion (bite alignment)
• Evaluate for nerve damage (particularly infraorbital nerve)
• Follow up for possible periodontal and pulpal pathology in involved teeth 3

Pitfalls and Caveats

1. Airway Management: Failure to secure the airway early can lead to mortality. Consider alternatives to tracheostomy when possible 2.

2. Missed Injuries: Complex maxillofacial trauma often involves multiple fractures. Complete imaging and thorough assessment are essential to avoid missing injuries.

3. Dental Considerations: Assess for dental trauma, as maxillary fractures often involve the alveolar process. Dental injuries may require specific management 3.

4. Associated Injuries: Be vigilant for concomitant injuries to the brain, cervical spine, and cerebrovascular structures 3.

5. Delayed Treatment: While airway management is the immediate priority, definitive surgical repair should not be unnecessarily delayed to prevent malunion and subsequent deformities.