The treatment of the fractured edentulous maxilla
Mostafa Farmand, Arnulf Baumann
Dept. of Oral and Maxillofacial Surgery (Head." Prof. Dr Dr E. W. Steinhiiuser, DDS, AID),
University of Erlangen-Nuremberg, Erlangen, Germany.
SUMMARY. The results of a follow-up of 13 out of 21 patients treated for fractures of the edentulous maxilla are
presented. They were treated alternatively with craniofacial suspension wiring and with miniplate osteosynthesis.
Better results are achieved by miniplate osteosynthesis. Depending on the general condition of the patient, a
treatment scheme can be recommended.
KEY W O R D S :
Edentulous midface fractures-Craniofacial suspension- Miniplate osteosynthesis
INTRODUCTION
Fractures of the edentulous maxilla are seen less
frequently than those of the mandible. In a series of 66
edentulous patients with midface fractures, only 6 %
( = 4 patients) occurred at the Le Fort I / I I / I I I levels
(Zachariades et al., 1984). But in elderly patients over
65 years of age, fractures in the maxilla and mandible
seem to be equally common (Falcone et al., 1990).
There is little literature available concerning the
treatment of fractures of the edentulous maxilla.
Furthermore, the treatment of these fractures has
changed during the past 30 years. In the past, most
fractures were treated conservatively with external
means of stabilization which was then replaced by
cranial suspension wires. Nowadays, an exact ana-
tomical reconstruction of the midface is possible in
most cases by using miniplate osteosynthesis. This is
to be applauded considering the increased life ex-
pectancy of elderly patients.
Fractures occurring in the edentulous maxilla occur
less frequently due to the absence of teeth through
which the fracturing forces are usually directly
transmitted to the maxilla. In addition, dentures
provide some protection against fracture by absorbing
part of the traumatic forces (Ailing and Osbon, 1988;
Mason, 1990). On the other hand, the midfacial bones
of elderly patients are brittle and less resistant to
fracture due to atrophy. These bones break into more
fragments than those of younger people (Schwenzer,
1970). So far, there are two reasons against extensive
surgical procedures of maxillary fractures in eden-
tulous patients : impaired general condition, as well as
the extensively fragmented facial bones.
Failure to treat often results in a disturbed
intermaxillary relationship with retromaxillism and a
potential short face. This has a negative impact on
both the stability of the denture and the masticatory
function, as well as on the appearance.
341
In our study, we aimed to examine the results of the
different methods of treatment and to record a
treatment scheme based on these results.
MATERIAL AND M E T H O D S
In the period between 1979 and 1989 we had 21 cases
of totally or almost edentulous maxilla with central
and centrolateral midfacial fractures (Le Fort I / I I /
III). An isolated fracture of the Le Fort III type did not
occur. There were 5 Le Fort I, 10 Le Fort II and 6 Le
Fort II/III type fractures. In 2 cases, it was associated
with mandibular fractures.
When the accidents happened, the patients had an
average age of 61 years, ranging from 32 to 84 years.
Seven out of 21 patients were female. The main cause
of the fracture was a road accident (48 %). 20 % of the
fractures resulted from syncope or circulatory trouble.
The remainder of the patients were injured in assaults
under the influence of alcohol or during timber felling.
The type of fractures and their treatment is shown
in Table 1. 11 patients were treated by miniplate
osteosynthesis, most of them with the Steinhiiuser
system (Steinhiiuser, 1982) and a few with the 3-D-
plating system (Farmand, 1991), and 8 by craniofacial
suspension wiring. Two patients were not treated at
all.
Not all patients could be followed-up. Five patients
had died in the meantime, 3 could not be contacted.
The other 13 patients (Table 2) appeared for investi-
Table 1 - Types of fracture and their treatment in all patients
Craniofacial No
Miniplate suspension treatment
Le Fort I 2 2 1
Le Fort II 6 3 1
Le Fort II/III 3 3 0
342 Journal of Cranio-Maxillo-Facial Surgery

Table 2 - Types of fracture and their treatment in the patients

followed-up

Craniofacial No
Miniplate suspension treatment
Le Fort I 2 2 0
Le Fort II 6 1 1
Le Fort II/III 1 0 0

gation. The average age of these patients was 58 years,

ranging from 32 to 84 years. In addition to the clinical
examination, we took x-rays of the face in the Water's
projection, as well as lateral views. The average period
between treatment and the follow-up was 2.25 years.

RESULTS

All patients followed-up were quite satisfied with the

results of the treatment. All patients had a maxillary
denture without irritation of the mucous membrane.
Fig. 3 - Pre- and postoperative lateral cephalometric X-ray of a
patient with a Le Fort-I fracture treated with miniplate
osteosynthesis, Note the position of the maxilla after the
operation.

Fig. 1 - Le Fort II- fracture treated with craniofacial suspension

wiring. Water's projection.

Fig. 4 - Water's projection of the same patient after repositioning

and fixationof the maxillawith 3-D-plates.

Four patients had a retromaxillism. Three of these

patients had previously been treated only by stabiliz-
ing the denture to the maxilla with zygomatic arch
suspension (monomaxillary fixation) and an infra-
orbital rim revision (Figs 1 and 2). One patient could
not be treated due to his poor general condition. In
this case the retromaxillism was compensated by the
denture.
Nine maxillary fractures, which were reduced and
fixed by using miniplates, showed a clinically correct
position of the upper jaw with a good intermaxillary
relationship in the lateral cephalogram (Figs 3 and 4).

DISCUSSION

Little literature is available concerning the results of

Fig. 2 - Lateral cephalometric X-ray showing retromaxillism in a treatment of edentulous midfacial fractures compared
patient treated by craniofacial suspension. with fractures occurring in the edentulous mandible.

Table 3 - Treatment scheme for fractures of the edentulous
maxilla
1. No displacement Soft diet for 2-3 weeks
incorporation of dentures
2. Displacement of the
maxilla patient in poor
general condition
Le Fort I- level No active therapy
later: Le Fort-I
osteotomy
Le Fort II/III level Minimal therapy,
repositioning of nose
and orbital rim, later:
Le Fort-l-osteotomy
Displacement of the Miniplate osteosynthesis
maxilla patient in good in younger patients
general condition Le eventually with
Fort I/II/III level simultaneous
preprosthetic surgery
Midfacial fractures in elderly persons are caused
mainly by road accidents, while mandibular fractures
are due to a fall or assault. If the maxilla is not
displaced, there is no need for stabilization, because
there will be no facial elongation (Joy et al., 1969).
Displaced midfacial fractures, which are not treat-
ed, will usually result in retromaxillism (as could be
seen in our patients), or in severe cases in a dishface
deformity. As a consequence there will be some
problems in providing a new denture. In addition to
the functional disadvantage there are also aesthetic
problems to be considered. In these cases a Le Fort-I-
osteotomy is the method of choice for the correction
of the malocclusion caused by a retrodisplaced maxilla
(Obwegeser, 1969; Kennett and Kernahan, 1970).
The follow-up of patients who were treated only
by zygomatic wire suspension showed less positive
results compared with patients treated with miniplate
osteosynthesis. Similar results were shown by Zisser
and Eskici (1973). Their 3 cases which were treated by
intraskeletal suspension of the maxilla and inter-
maxillary fixation also showed retromaxillism. Later
on the occlusion was prosthodontically compensated.
Advantages of craniofacial suspension wiring are
its rapid application and easy handling. The traction
forces of fronto-maxillary and zygomatic-maxillary
suspension wires, however, pull the maxilla caudally,
even if beforehand it was placed in the correct
position (Austermann and Meisel, 1975). If inter-
maxillary fixation with the application of splints is
used, pressure ulcers can occur, which make early
opening of the fixation necessary.
The repositioned maxilla can easily be kept in place
by means of miniplates. This prevents the midface
from being displaced and shortened. This can be seen
in our 9 patients who were treated by miniplate
osteosynthesis. A wire osteosynthesis might be poss-
ible in some cases, but stabilization with miniplates is
much easier and more effective. In addition, it is
possible to reconstruct the midfacial buttresses sim-
ultaneously by open reduction.
If an improvement of the situation for incor-
poration of the prosthesis is necessary, there are two
The treatment of the fractured edentulous maxilla 343
possibilities. In cases with soft tissue problems a
modified submucous vestibuloplasty with so-called
high retention sutures can be undertaken at the end of
the operation (Farmand, 1986). The incision for the
open reduction should therefore be made on the
alveolar crest; thus interference with the vestibul-
oplasty can be avoided. If retromaxillism already
exists before the accident, the fractured maxilla can be
brought forward and fixed in a better relation to the
mandible by means of miniplates. According to
Freihofer (1989) the advanced edentulous maxilla is
better stabilized by miniplates than by wire fixation.
Also the relapse rate was lower with miniplate
osteosynthesis. With the thin plates there is even the
possibility of leaving the osteosynthesis material in
situ without impairing denture function.
According to our study, and the general condition
of the patient and the severity of the midfacial
fracture, the following procedures that should be
carried out gradually, can be recommended (Table 3):
1. If the fractured maxilla is not displaced, in our
opinion no operation is needed. Soft diet is to be
prescribed for a period of 2-3 weeks and the dentures
are to be worn.
2. If the maxilla is displaced at the Le Fort I level,
the patient may be left untreated, if he is in a poor
general condition or the bones are extremely frag-
mented. At a later date a conventional Le Fort-I-
osteotomy might be necessary to improve the inter-
maxillary relationship.
The same procedure is also possible in a Le Fort
II/III fracture, when the patient's condition only
allows minimal therapy. Then the nose and the orbital
rim will be reduced, and a separate Le Fort-I
osteotomy can be performed later. A discrepancy in
the maxillary-mandibular relationship after minimal
revision can of course also be compensated with
dentures. But this can result in an increased resorption
of the alveolar bone, so that a later maxillary
osteotomy as a preposthetic procedure, is only
delayed.
3. The miniplate osteosynthesis with thin plates is
an alternative for all patients who can be operated on
without risk. If necessary, in younger patients pre-
prosthetic surgical procedures can be performed sim-
ultaneously, for instance a vestibuloplasty or an
advancement of the maxilla.
CONCLUSION
The treatment of fractures of the edentulous maxilla
with craniofacial suspension wiring does not prevent
retromaxillism.
If fractures of the edentulous maxilla occur and the
condition of the patient is satisfactory, operative
treatment with miniplate osteosynthesis should be
performed in order to prevent further deterioration of
the intermaxillary relationship. Intermaxillary fixation
is not necessary. This treatment will guarantee a good
functional and aesthetic result in most cases. If the
patient's condition contraindicates any operation, a
344 Journal of Cranio-Maxillo-Facial Surgery
Le Fort-I osteotomy to achieve a good position of the
maxilla can be recommended at a later date.
The results of this publication have been presented
at the 10th congress of the European Association of
Cranio-Maxillo-Facial Surgery, Brussels, 1990.
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Priv. Doz. Dr Dr M. Farmand
Department of Oral and Maxillofacial Surgery
University Erlangen- Nuremberg
Glfickstr. I 1
D-8520 Erlangen
Paper received 27 March 1992
Accepted 26 April 1992