Midface mobility and malocclusion after a high-speed collision

§Chief complaint

Face feels loose, teeth do not meet after a car crash

§Medical & dental history

• 01Polytrauma patient, GCS 15 after resuscitation
• 02Intact dentition pre-injury

§Clinical examination

• 01Mobility of the whole midface on grasping the maxillary alveolus, with movement at the nasofrontal region
• 02Bilateral periorbital ecchymosis (raccoon eyes) and CSF rhinorrhoea
• 03Anterior open bite with a retruded, lengthened midface
• 04Battle sign absent; cervical collar in situ

§ figuresFigures (4)

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§Differential diagnosis

§Final diagnosis

Le Fort III craniofacial disjunction with an associated Le Fort I segment and CSF leak

Grasping the maxilla and observing where movement occurs localises the level: nasofrontal and zygomatic arch movement means Le Fort III. Le Fort patterns are often mixed and asymmetric — describe each side.

§Investigations

• 01ATLS primary survey with cervical spine and airway priority
• 02CT head, face and cervical spine with 3D reconstruction
• 03Beta-2 transferrin on nasal fluid to confirm CSF
• 04Ophthalmology and neurosurgery review

§Treatment plan

• 01Stabilise the patient before the face — airway, haemorrhage, C-spine, head injury
• 02Conservative management of the CSF leak with head elevation and avoidance of nose-blowing
• 03Definitive ORIF once neurologically stable, typically within 7-10 days
• 04Restore facial height, projection and occlusion from stable to unstable

§Surgical procedure

• 01Intermaxillary fixation to re-establish occlusion
• 02Coronal flap for nasofrontal and zygomatic arch exposure
• 03Fixation at frontozygomatic sutures, infraorbital rims, nasofrontal region and maxillary buttresses
• 04Bone grafting of comminuted buttresses

§Follow-up & outcome

• 01CSF leak stopped by day 5 without lumbar drainage
• 02Occlusion restored, elastics for 3 weeks
• 03Facial projection acceptable at 6 months; residual infraorbital numbness

§Clinical pearls / learning points

• 01Le Fort fractures are rarely pure or symmetrical — classify each side separately.
• 02CSF rhinorrhoea is a marker of anterior skull base injury; avoid nasal tubes and nasal packing.
• 03Reconstruct in the order outer facial frame, then buttresses, then occlusion.

§References

• Ehrenfeld M, Manson P, Prein J. AO Principles of Internal Fixation of the CMF Skeleton.

§Related diseases

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