Mid-face mobility and anterior open bite after a road traffic collision

§Chief complaint

Facial injury with bleeding, teeth not meeting and a long face after a car crash

§Medical & dental history

• 01Polytrauma: cervical spine cleared, GCS 15, no intracranial injury on CT head
• 02Full dentition, previously class I occlusion

§Clinical examination

• 01Elongated mid-face with bilateral periorbital ecchymosis and epistaxis
• 02Mobile maxilla on grasping the anterior alveolus, nasal complex moving with the maxilla on the right
• 03Anterior open bite with premature posterior contact
• 04Infraorbital paraesthesia bilaterally; no CSF rhinorrhoea
• 05Airway patent, no active haemorrhage after nasal packing

§ figuresFigures (4)

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§Differential diagnosis

§Final diagnosis

Right Le Fort II and left Le Fort I mid-face fractures with a sagittal palatal split

The mid-face is mobile at different levels on each side, which is common; CT defines the true fracture pattern and the palatal split that must be stabilised before vertical buttress fixation.

§Investigations

• 01Primary survey with cervical spine precautions and airway assessment
• 02CT head, cervical spine and facial bones with 3D reconstruction
• 03Ophthalmic review; test nasal discharge for beta-2 transferrin if CSF leak suspected
• 04Dental impressions or scans for occlusal reference

§Radiology

• 01CT — pyramidal fracture through the right nasofrontal region, infraorbital rim and pterygoid plates; horizontal left maxillary fracture above the apices
• 02Sagittal split of the palate between 11 and 21
• 03Bilateral haemosinus; no intracranial injury

§Treatment plan

• 01Stabilise the patient per ATLS priorities
• 02Restore occlusion with intermaxillary fixation, then open reduction and internal fixation of the vertical and horizontal buttresses
• 03Palatal split fixation first, then nasomaxillary and zygomaticomaxillary buttresses
• 04Soft diet, elastics and physiotherapy post-operatively

§Surgical procedure

• 01Arch bars applied and occlusion re-established in intermaxillary fixation
• 02Palatal split reduced and plated at the piriform aperture
• 03Maxillary vestibular degloving with 2.0 mm plates at the nasomaxillary and zygomaticomaxillary buttresses bilaterally; infraorbital rim plated via a transconjunctival approach
• 04Intermaxillary fixation released intraoperatively to confirm a stable, reproducible occlusion

§Follow-up & outcome

• 01Week 1 — occlusion stable, guiding elastics only
• 02Week 6 — plates stable, occlusion class I, mouth opening 42 mm
• 036 months — mid-face projection restored, paraesthesia improving

Outcome: Anatomical mid-face reduction with a stable pre-injury occlusion at 6 months.

§Discussion

• 01Pterygoid plate involvement is the radiological constant of all Le Fort patterns.
• 02Occlusion is the reference standard for mid-face reduction — buttress plating follows the occlusion, never the other way round.
• 03Palatal splits must be reduced before transverse width is locked in, or a crossbite results.

§Clinical pearls / learning points

• 01Check for CSF rhinorrhoea in Le Fort II and III patterns.
• 02Restore the vertical buttresses to regain facial height and projection.

§Viva questions

§MCQs

§Related diseases

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