Aftercare following open reduction and internal fixation of Le Fort I and palatoalveolar fractures
Postoperative positioning
Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain.
Medication
The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.
- No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days
- Analgesia as necessary
- Antibiotics (many surgeons use perioperative antibiotics. There is no clear
advantage of any one antibiotic, and the recommended duration of treatment is
debatable.)
- Nasal decongestant may be helpful for symptomatic improvement in some
patients.
- Steroids, in cases of severe orbital trauma, may help with postoperative
edema. Some surgeons have noted increased complications with perioperative
steroids.
- Ophthalmic ointment should follow local and approved protocol. This is not
generally required in case of periorbital edema. Some surgeons prefer it. Some
ointments have been found to cause significant conjunctival irritation.
- Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.
Ophthalmological examination
Postoperative examination by an ophthalmologist may be requested. The following signs and symptoms are usually evaluated:
- Vision (except for alveolar ridge fracture, palatal fracture)
- Extraocular motion (motility) (except alveolar ridge fracture, palatal
fracture)
- Diplopia (except Le Fort I, alveolar ridge fracture, palatal
fracture)
- Globe position (except Le Fort I, alveolar ridge fracture, palatal
fracture)
- Perimetric examination (except Le Fort I, alveolar ridge fracture, palatal
fracture)
- Lid position
- If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked.
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
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.
Wound care
Remove sutures from skin after approximately 5 days if nonresorbable sutures have been used.
Apply ice packs (may be effective in a short term to minimize edema).
Avoid sun exposure and tanning to skin incisions for several months.
Diet
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
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:
- Globe position
- Double vision
- Other vision problems
Other issues to consider are:
- Facial deformity (incl. asymmetry)
- Sensory nerve compromise
- Problems of scar formation
Issues to consider with Le Fort fractures, palatal fractures and alveolar
ridge fractures include:
- Problems of dentition and dental sensation
- Problems of occlusion
- Problems of the temporomandibular joint (TMJ), (lack of range of motion, pain)
Implant removal
Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or visible. In some countries it will be more commonly requested. There have been cases where patients have complained of cold sensitivity in areas of plate placement. It is controversial whether this cold sensitivity is a result of the plate, a result of nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of cold sensitivity generally improve or resolve with time without removal of the hardware.
Generally, orbital implant removal is not necessary except in the event of infection or exposure. Readmission might be indicated if long term stability of the orbital volume has not been maintained.
MMF
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:
- Fracture morphology
- Type and stability of fixation (including palatal splints)
- Dentition
- Coexistence of mandibular fractures
- Premorbid occlusion
Oral hygiene
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.