Aftercare following closed treatment of Le Fort II and Le Fort III fractures
Evaluation of the patients vision is performed as soon as they are awakened
from anesthesia and then at regular intervals until they are discharged from
A swinging flashlight test may serve in the unconscious and/or noncooperative patient; alternatively electrophysiological examination has to be performed but is dependent on the appropriate equipment (VEP).
Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain.
To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following orbital fracture repair.
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
- Nasal decongestant may be helpful for symptomatic improvement in some
- Steroids, in cases of severe orbital trauma, may help with postoperative
edema. Some surgeons have noted increased complications with perioperative
- 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.
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
- Diplopia (except Le Fort I, alveolar ridge fracture, palatal
- Globe position (except Le Fort I, alveolar ridge fracture, palatal
- Perimetric examination (except Le Fort I, alveolar ridge fracture, palatal
- 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 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:
- 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)
Eye movement exercises
Following orbital fractures, eye movement exercises should be considered.
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)
- Coexistence of mandibular fractures
- Premorbid occlusion
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.
The patient needs to be examined and reassessed regularly and often. Additionally, ophthalmological, ENT, and neurological/neurosurgical examination may be necessary. If any clinical signs for meningitis or mental disturbances develop, professional help has to be sought. A regular follow-up CT scan is recommended 3-6 months after the trauma to assure proper pneumatization of the sinuses (particularly, mucocele formation has to be ruled out), sealing of the skull base and stability of fragment position.
Note: Posttrauma meningitis can occur even decades following trauma.
Special considerations for orbital fractures
Travel in commercial airlines is permitted following orbital fractures. Commercial airlines pressurize their cabins. Mild pain on descent may be noticed. However, flying in military aircraft should be avoided for a minimum of six weeks.
No scuba diving should be permitted for at least six weeks.