Guerin (Maxillary) Fractures

Dara Liotta, MD

Article by
New York Facial Plastic Surgeon

Synonyms
Le Fort I fracture, horizontal fracture, maxillary fracture

Definition

In 1901, Rene Le Fort categorized fracture patterns of the Maxilla resulting from a single blow to cadevaric skulls. The fracture lines, or “linea minoros resistentiae”, described by Le Fort in 1901 are the basis for the modern Le Fort classification. The midface is attached to the cranium by three vertical buttresses that help distribute masticatory forces and stabilize the midface: the medial buttress (frontomaxillary buttress) and lateral buttress (zygomatico-maxillary buttress) anteriorly, and the pterygomaxillary buttress posteriorly.  The fractures described by Le Fort disrupt these buttresses.  A Guerin fracture is equivalent to a Le Fort I fracture (also known as a horizontal fracture), and is a single horizontal fracture through the maxilla that passes through the septum medially, extending laterally through the pyriform rims, passing below the zygomatico-maxillary suture line, and transecting the pterygomaxillary junction to interrupt the pterygoid plates. Guerin fractures result in a mobile hard palate. It is important to realize that pure Guerin fractures are uncommon in clinical practice, and most midfacial fractures are an amalgam of various types of midfacial fractures. 

Figure 1 (Guerin fractures_fig1.tif): Anteroposterior view of the vertical buttresses of the facial skeleton
Figure 2 (Guerin fractures_fig2.tif): Lateral view of the vertical buttresses of the facial skeleton
Figure 3 (Guerin fractures_fig3.tif): Anteroposterior view of a Guerin fracture (Le Fort I fracture, or horizontal fracture).  The shaded area represents the resultant mobile bone fragment.
Figure 4 (Geurin fractures_fig4.tif): Lateral view of a Geurin fracture. The shaded area represents the resultant mobile bone fragment.

Etiology

Guerin fractures are generally the result of blunt-force trauma to the midface.  More specifically, Guerin fractures are most likely to occur after a blow to the inferior aspect of the maxilla, the maxillary alveolar ridge, directed downward. Common causes include motor vehicle accidents, interpersonal altercations, assaults, falls, and sports-related injuries.


Clinical PresentationIn the case of isolated Geurin fracture, overt clinical signs can be minimal.  Intraoral ecchymosis, lacerations or palpable step-offs may be appreciated.  The mobile bone fragment resulting from a Guerin fracture tends to be driven posteroinferiorly along the slope of the skull base, resulting in malocclusion and an anterior open bite with posterior molars contacting before incisors.  There may be crepitus at the gingival buccal sulcus from subcutaneous emphysema.  Mobility of the hard palate at the pyriform rims can generally be appreciated.  Palatal fractures and fractures of the dentoalveolar ridge may also occur.  Significant facial edema is common with midfacial fractures, and it is important to keep in mind that presence of a Guerin fracture does not rule out presence of additional maxillofacial injuries.

Diagnostics

Maxillary fractures often occur as the result of significant trauma and evaluation should begin with airway control and hemodynamic stabilization.  Serious intracranial injury may be seen in up to 38% of patients with midfacial fractures; serious ophthalmologic injury may be seen in up to 28% of patients.  Spinal cord injury should be ruled out, and any overt globe injury should be evaluated. A thorough history and physical, including a complete head and neck exam, may then be performed. With any midfacial fracture, suspicion for CSF rhinorrhea and/or otorrhea should be high. Examination of dental occlusion is important.  Maxillofacial CT scan is considered the modality of choice for diagnosis of Guerin fractures.                 


Differential DiagnosisLe Fort II fracture, Le Fort III fracture, naso-orbital-ethmoid fracture, zygomatico-maxillary complex fracture, palatal fracture

Prophylaxis

The use of restraints, seat belts, and protective headgear can help prevent maxillary fractures.

Therapy
Treatment of ocular and CNS injuries should precede treatment of Le Fort fracture in the presence of a stable airway.  Proper repair of complex midfacial fractures may require a surgical airway. When palatal fractures are present, the repair generally requires a custom-made reducing splint adapted to the palatal fragments and wired to the maxillary teeth.  Palatal fractures should be reduced before plating of other maxillary fractures to ensure that proper dental occlusion is ultimately restored.  Proper plating of Guerin fractures first requires mobilization of the resultant bone fragment and application of intermaxillary fixation. Reconstruction and plating of disrupted facial buttresses is an important part of restoring normal occlusion and vertical height of the midface and stabilizing the midfacial skeleton against masticatory forces.  Peri-operative antibiotics should be considered in patients with facial fractures.

Prognosis

Long-term prognosis after repair of Guerin fractures is excellent.  Post-operative infection rates are low and generally resolve with oral antibiotics.

Epidemiology
Maxillary (Guerin) fractures are most common in men age 21-40.

References

1. Cummings, C (2005) Otolaryngology, Head & Neck Surgery, 4th edn. Mosby, Pennsylvania, pp 602-636.
2. Papel, ID (2002) Facial Plastic and Reconstructive Surgery, 2nd edn.  Thieme, New York, pp759-767.
3. Stewart, M (2005) Head, Face and Neck Trauma, Comprehensive Management.  Thieme, New York, pp39-5177-85.