The following case report describes a simple technique for closed reduction of a severely comminuted maxillary fracture with

shattering of the dentoalveolar process. Combination of a rigid external distractor halo frame on a skull, a kirschner wire through the maxilla, and an intermaxillary wire fixation resulted in stable vertical and sagittal correction of the fragmented maxilla.

Keywords : Kirschner wire, Le fort I fracture, RED halo frame

The growth in popularity of bicycling in recent years is reflected in the number of cyclingrelated oral and maxillofscial injuries. The treatment of choice for Le Fort I fracture is open reduction and internal fixation with miniplate.

Our patient to be difficult and complex due to the unstable, polyfragmented character of the fracture with shattering over the dentoalveolar process of the maxilla.

Option to treat the patient head frame and kirschner wire.

A 61y.o man (GCS 15/15) Bicycle fall with impact of the face on pavement No significant past medical history Loss of consciousness with amnesia (+) Cognition (N) No airway obstruction Pain (+) : neck, chest, face

Upper-lip laceration Multiple facial fractures Dental trauma Injury of cervical vertebrae Multiple bruises on the face Epistaxis (+) Laceration on the left side mucosa labial -> sutured (+)

CT scan Cervical spine -> fracture without displacement lateral mass C2 -> Fracture proc. Spinosus C4-C5 -> Teardrop fracture C7 Thoracic -> Fracture anterior border of first rib -> Lung contusion

Maxillofacial -> Frac. Comminuted Le Fort I -> Frac. Nose

3D

Axial view

Coronal view

ICU ( 4 days ) -> Neurosurgical - Hard neck collar (Conservative) -> Thorax-Cardiovaskuler - Conservative

-> Plastic surgical (2 days after) - GA - Nasoendotracheal tube -> endoscope

1. Intermaxillary fixation -> Ehrich bars + wires 2. Rigid external distractor (RED) + K-wire

K-wire placed transcutaneously thick anterior portion of palatal bone 3 mm from incisive foramen

RED II distractor Martin -> fixed 3 screw on each side to the skull and stabilized with K-wire to the vertikal rod of the RED frame

Panoramic radiograph Anterior + Lateral cephalometric Ro CT maxillofacial

Followed postoperative every week

After 6 weeks -> intermaxillary fixation + collar neck removed 1 year after post op -> oral opening (N) + occlusion (N)

30% of all maxillofacial and skull base fracture related to sports injuries (Elhammali et al) Concomitant injuries associated with maxillary fracture were laceration + abrasion (Haug et al, 1990) In isolated craniomaxillary fracture -> cervical spine injury 4.9-8.0 %(Mulligan)

3.6% patient with craniomaxillofacial fracture showed a concomitant cervical spine injury (Elahi et al, 2008)

The majority of injuries to the cervical spine caused motor vehicle accident, alcohol use.
Cervical spinal injuries most commonly occurred at C1-C2 + C6-C7

Comminuted maxillary fracture using bone graft reconstruction Use head frame in fracture - rare in modern practice - cumbersome - disliked - compensate bone loss - to stabilize unstable fracture - rehabilitate occlusion + vertical height

In this case use a head frame combination with a K-wire to obtain stabilization of the comminuted fracture.

For a experience surgeon only 15 minutes to total operative time Intermaxillary fixation time in this case was 6 weeks

Traumatic dental, maxillofacial and cervical injuries common in bicyclist The treatment of choice in comminuted maxillary fracture is internal fixation + miniplate + bone graft reconstruction -> difficult and complex Alternative treatment Kirschner wire + head frame -> minimal invasive + good result

THANKS