Closed treatment

Fractures with minor malocclusions readily correctable with maxillary disimpaction, completion of the fracture and manipulation, and those stable after repositioning may be treated closed.

Patients with malocclusion who cannot have general anesthesia can be treated by applying arch bars and elastic traction until the maxillary dentition reaches the desired occlusion. The occlusion is then stabilized with MMF until healing occurs.

A closed reduction of the midface may be part of an emergency treatment to stop bleeding. Other options to control bleeding may include nasal packing or placement of a nasal balloon, and anterior and/or posterior packing. If these methods fail, embolization via interventional radiology may be required.

Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly reduce periorbital edema and pain.

The following medications may be used:

• Analgesia as necessary (no aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for seven days)
• In case of an open wound or exposed bone antibiotic coverage is indicated
• Regular perioral and oral wound care should include disinfectant mouth rinse, lip care, etc.

Postoperative imaging should be performed within the first days after surgery. 3D imaging (CT, cone beam) is recommended to assess complex fracture reductions.

In fractures involving the alveolar area, orthopantomograms (OPG) are helpful.

Diet depends on the fracture pattern.

A soft (non-chew) diet can be taken as tolerated until there has been adequate healing (usually 4–6 weeks).

Patients in MMF will remain on a liquid diet until the MMF is released.

Clinical follow-up depends on the complexity of the surgery and whether the patient has any postoperative problems.

Issues to consider with palatal fractures and alveolar ridge fractures include:

• Problems with dentition and dental sensation
• Problems with occlusion
• Problems with the temporomandibular joint (TMJ), such as reduced range of motion and pain

The need for and duration of MMF are very much dependent on:

• Fracture morphology
• Type and stability of fixation (including palatal splints)
• Dentition
• Coexistence of mandibular fractures
• Premorbid occlusion

Patients with arch bars, intraoral incisions, or wounds must be instructed about appropriate oral hygiene procedures. The presence of arch bars or elastics makes oral hygiene more complicated. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the teeth and arch bars. Elastics are removed during oral hygiene procedures. Disinfectant mouth rinses (Chlorhexidine) should be prescribed and used at least three times a day to help sanitize the mouth.

For larger debris, a 1:1 mixture of hydrogen peroxide/Chlorhexidine can be used. The effervescent action of the hydrogen peroxide helps remove debris. A jet irrigator, (eg, Waterpik) is a handy tool to help remove debris from the wires. If used, care should be taken not to directly point the jet stream over intraoral incisions, which may lead to wound dehiscence.