Authors of section

Authors

Nicolas Homsi, Paulo Rodrigues, Gregorio Sánchez Aniceto, Beat Hammer, Scott Bartlett

Executive Editors

Edward Ellis III, Eduardo Rodriguez

General Editor

Daniel Buchbinder

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Revision - Closed treatment

1. Introduction

When malocclusion is detected early after non-operative treatment, immediate intervention should be performed in order to re-establish the correct occlusion before osseous union makes adequate reduction impossible.

A proper reduction and stable MMF for 4-6 weeks should be sufficient to achieve a successful outcome.

Malreduction of the mandible - Revision surgery - Closed reduction and MMF

2. Closed reduction and MMF

The original MMF is removed.

Malreduction of the mandible - Revision surgery - Closed reduction and MMF

The occlusion is re-established and the patient replaced into MMF. In case the proper reduction cannot be achieved, open reduction with internal fixation should be considered.

For step-by-step description of how to establish MMF, follow this link.

Malreduction of the mandible - Revision surgery - Closed reduction and MMF

3. Aftercare following closed treatment of the mandible

Patients with infected fractures may be kept in the hospital allowing daily examinations and administration of intravenous antibiotics until the signs and symptoms of infection resolves.

The patient should be instructed how to release the MMF in case of emergency. Some surgeons prefer to provide wire cutters to the patient for the period of MMF. During this period, wire fatigue and loosening can occur. The patient should report any loosening of the MMF to the surgeon immediately.

Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken prior to releasing the MMF.

It will be necessary to see the patient approximately 1 week postoperatively to assess the stability of the occlusion. The intermaxillary fixation wires or elastics must be assessed and proven to hold the patient tightly in occlusion. Patients also have to be periodically re-examined to rule out signs of infection. At each visit, the surgeon must evaluate patient ability to perform adequate oral cleaning. It may be necessary to provide additional instruction to assure appropriate hygiene and wound care.

Adequate dental care is required in most patients having suffered a mandibular fracture.

There should be no malocclusion detected as occlusion is determined and secured previously. A slight malocclusion can be corrected by by orthodontics or dental adjustments with the help of a dentist.

On releasing the MMF, physiotherapy can be prescribed. The mandible will be hypomobile after the period of MMF, and the muscles will be atrophic and “tight.” Opening and excursive exercises should be demonstrated and implemented. Goals should be set, and typically, 40 mm of maximum interincisal mouth opening should be attained by 4 weeks postoperatively. If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite or tongue-blade training, or with the help of a physiotherapist.

MMF renders eating, speaking and oral hygiene more difficult. Patients will therefore have to follow three basic instructions:

1. Diet
The diet has to be in a liquid or semi-liquid form. For patients with a full complement of teeth, the diet must be more liquefied than when there are gaps with teeth missing. Because the diet will be no-chew, more fluids are required to assist in swallowing the food. A blender, or preferably, a juicer is useful. Anything can be made into a liquid or semi-liquid form with these tools. Liquid dietary supplements from the grocery store help maintain caloric intake. The patient should monitor their body weight on a weekly basis during the period of MMF to evaluate any dramatic changes. The assistance of a nutritionist may be helpful.

2. Oral hygiene
Patients must be instructed in oral hygiene procedures. The presence of the arch-bars and MMF wires makes this a much more difficult procedure, and the inside of the teeth cannot be reached with a toothbrush. A soft toothbrush (dipping in warm water makes softer) should be used to clean the buccal/labial surfaces of the teeth, arch-bars and wires. Chlorhexidine oral rinses should be prescribed and used at least 3 times each day to help sanitize the mouth. The tongue can be used to swipe the lingual surfaces of the teeth. With larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® or similar device is a very useful tool to help remove debris from the wires. The assistance of a dental hygienist may be helpful.

3. Speech
Patients are told to speak as freely as possible. Over the course of 1–2 weeks, patients can usually speak quite intelligibly, although voice projection remains difficult during the period of MMF.