It is similarly important that the foot of the L-plate is placed along the alveolar bone in a manner that the screws are not placed into the dental roots. It is important that the leg of the L-plate be placed on the most lateral portion of the zygomaticomaxillary buttress, where the bone is fairly thick. The first hole is drilled (a drill bit with a stop can be used) next to the fracture line in the zygomatic complex and a screw is inserted.Ī larger L-shaped plate is ideal for the fixation of this fracture. The plate is positioned with appropriate instruments (eg, forceps, plate holders, gauze packer). This is the most difficult plate to properly adapt. According to the particular fracture morphology, a plate of appropriate profile, shape, and length is selected and contoured using bending pliers. In the case shown, the first plate is applied to the left zygomaticomaxillary buttress. This has a further impact in deciding whether a larger or smaller plate is adequate.Ĭlick here for a description of implant options. Finally, in many cases of Le Fort II fractures with other panfacial trauma, many surgeons may choose to leave the patient in MMF for a period of time postoperatively. Furthermore, the majority of Le Fort II fractures are associated with a multitude of other midface fractures which influence the size and strength of the plate that must be used. There is considerable variation as to how unstable or comminuted the fractures may be. In many cases with adequate fixation at one or both of the other two sites, plate placement at the zygomaticofrontal area may not be necessary. If a plate is used at the nasofrontal area, there are several options, including one or two straight plates, or various configurations of Y or X plates.The forces in this area are smaller, and patients may complain of being able to palpate the implant if a larger plate is placed. If a plate is used along the infraorbital rim, it must be a low-profile plate.Depending on the fracture pattern a L-plate or a straight plate can be considered. The highest forces of mastication are in this area. The plate placed for the fixation of the fracture at the zygomaticomaxillary buttress is generally a larger plate.It is difficult to have absolute guidelines as to the strength of the plates that would be used at the three key points of fixation for a Le Fort II fracture: If available, dental cast, stereolithographic models, and/or premorbid photographs may be useful guides for treatment.Īs a general principle, all fractures should be exposed and reduced before plating. The goal is to achieve an anatomical correct repositioning by means of 3-D reconstruction. In order to properly achieve a passive position of the maxilla, the maxilla requires strong mobilization forces using various instrumentation: Rowe’s disimpaction forceps, “Stromeyer” hook, Tessier retromaxillary mobilizers, etc. When the MMF is removed, the condyles re-seat themselves into their normal position, bringing the mandibular dentition forward, creating a Class III malocclusion. The reason for this is that when patients are placed into MMF during the surgery, the soft-tissue tension from the attached musculature distalizers the mandibular condyles in the glenoid fossae. Without passive mobilization, Class III tendency occurs often in the postoperative period. Portions of the pterygoid plates and associated musculature are still attached to the posterior portion of the maxilla, so passive mobilization of the fracture can be difficult. These pillars can serve an even more important role in patients who lack dentition (partial or completely edentulous patients).Ī principle in all Le Fort fractures is to reestablish the premorbid dental occlusion. The aim of successful reconstruction of midface fractures is reestablishing the midfacial buttresses. Depending on the patient’s general condition, a tracheostomy might be the appropriate choice. If it is not feasible change of intubation or primary submental/submandibular intubation should be considered. Considerations related to dental occlusion render nasotracheal intubation necessary.
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