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 - ORIF

1. Introduction

The surgical treatment of an early detected mal reduction consists of removal of plates and screws, proper reduction of the fracture with MMF and, reapplication of osteosynthesis material.

In case the proper fixation hardware was already chosen for the first surgery, slight modifications in the plate and/or the screw locations should be made to prevent mal reduction.

In case improper fixation hardware was applied during the first surgery, this is the time for selecting the appropriate device.

Further information: 

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

2. Approach

Ideally, for the secondary correction, the same approach is used as in the initial surgery.

When the original approach does not provide ideal exposure of the fracture site, the below approaches can be used.


Symphyseal and parasymphyseal area

For symphyseal and parasymphyseal fractures the trans oral approach usually offers sufficient access.

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

However, if this is not the case, a transcutaneous approach such as the submental approach may be selected.

revision orif

Mandibular body and angle

For most body and angle fractures a transoral approach usually offers sufficient access.

revision orif

However, if this is not the case, the submandibular approach may be selected.

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

Ramus and lower condylar neck

For the ramus and the lower part of the condylar neck, the retromandibular approach or...

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

...the submandibular approach may be selected.

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

Condylar head and superior condylar neck

For the condylar head and the superior part of the condylar neck, the preauricular approach may be selected.

For condylar neck and head fractures, a transoral approach with endoscopic assistance may be selected. However this requires formal training of the surgical team and specialized equipment.

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

3. Hardware removal

All of the previously installed internal fixation material is removed before the fracture is anatomically reduced and internal fixation reapplied.

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

4. Reduction and fixation

For further details on reduction and the fixation please refer to the trauma section.

To avoid mal reduction, care should be taken to obtain an anatomic reduction and make necessary modifications in the plate and/or the screw locations.

If the plate from the first surgical procedure is reused, further bending could result in metal fatigue (weakening of the plate), and the use of a new plate, or a second plate should be considered.

Malreduction of the mandible - Revision surgery - Open reduction and internal fixation

5. Aftercare following revision ORIF of the mandibular symphysis, body, angle and ramus

If arch bars or MMF screws are used intraoperatively, they are usually removed at the conclusion of surgery if proper fracture reduction and fixation have been achieved. Arch bars may be maintained postoperatively if functional therapy is required or if required as part of the fixation.

Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken after 4–6 weeks.

The patient is examined approximately 1 week postoperatively and periodically thereafter to assess the stability of the occlusion and to check for infection of the surgical site. During each visit, the surgeon must evaluate the patient's ability to perform adequate oral hygiene and wound care, and provide additional instructions if necessary.

The treatment of infected nonunions normally involves longer than the typical hospital stay, allowing daily examinations and intravenous antibiotics until the signs and symptoms of infection resolve.

Adequate dental care is required in most patients having undergone mandibular surgery.

If a malocclusion persists, the surgeon must ascertain its etiology (with appropriate imaging technique). If the malocclusion is secondary to surgical edema or muscle splinting, training elastics may be beneficial. The lightest elastics as possible are used for guidance, because active motion of the mandible is desirable. Patients should be shown how to place and remove the elastics using a hand mirror.

If the malocclusion is secondary to a bony problem due to malreduction or hardware failure or displacement, elastic training will be of no benefit. The patient must return to the operating room for revision surgery. A slight malocclusion can be corrected by by orthodontics or dental adjustments with the help of a dentist.

Follow-up appointments are at the discretion of the surgeon, and depend on the stability of the occlusion on the first visit. If a malocclusion is noted and treatable with training elastics, weekly appointments are recommended.

Postoperatively, patients will have to follow three basic instructions:

1. Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the discretion of the surgeon. Any elastics are removed during eating.

2. Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule. Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars and any elastics makes this a more difficult procedure than normal. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. For 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. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence. The assistance of a dental hygienist may be helpful.

3. Physiotherapy
Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw 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, as well as assistance from a physiotherapist if required.