Closed treatment may be considered in a patient where on CT a fracture line with no splaying is visible, but there is possible instability of the fracture. In some cases, the surgeon may want to consider taking dental impressions, making dental models, and from these models making a palatal splint. The palatal splint is then wired to the dentition possibly also using arch bars. The patient is commonly left in MMF until adequate healing of the palatal fracture has occurred.
In the photographs, dental impressions have been taken, models have been made, …
… and a clear plastic palatal splint has been made.
In this photograph, the palatal splint has been inserted. Holes have been drilled through the palatal splint. These holes have been used to fix the wires to the arch bar.
Note: The focus has to be on reestablishing occlusion and the transverse bony dimension.
If there are dental models from previous treatments available, this may be helpful.
Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain.
The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.
Postoperative examination by an ophthalmologist may be requested. The following signs and symptoms are usually evaluated:
Note: In case of postoperative double vision, ophthalmological assessment has to clarify the cause. Use of prism foils on existing glasses may be helpful as an early aid.
Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging.
Especially in fractures involving the alveolar area, orthopantomograms (OPG) are helpful.
Diet depends on the fracture pattern.
Soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision.
Intranasal feeding may be considered in cases with oral bone exposure and soft-tissue defects.
Patients in MMF will remain on a liquid diet until such time the MMF is released.
Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems.
With patients having fracture patterns including periorbital trauma, issues to consider are the following:
Other issues to consider are:
Issues to consider with Le Fort fractures, palatal fractures and alveolar ridge fractures include:
The duration and/or use of MMF is controversial and highly dependent on the particular patient and complexity of the trauma. In some cases where long-term MMF may be recommended, the surgeon may choose to leave the patient out of MMF immediately postoperatively because of concerns of edema, postoperative sedation, and airway. In these cases the surgeon may choose to place the patient in MMF after these concerns have been resolved.
The need and duration of MMF is very much dependent on:
Patients with arch bars and/or intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch bars or elastics makes this a more difficult procedure. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the surfaces of the teeth and arch bars. Elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least 3 times a 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® 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.