1 Principles top
Modalities of treatment for open reduction internal fixation (ORIF) are controversial. With most options for treatment, the surgeon should plan on placing arch bars and using MMF. Depending on the nature of the fracture, the surgeon may or may not choose to leave the patient in MMF for a period of time postoperatively.
The first option is to perform an ORIF of the palatal fracture with fixation of one or more plates on the palate through a palatal approach. If there has been significant splaying, palatal laceration in this area is common. Alternative to placing the plate submucosally in the palatal region, it could be placed on the surface of the mucosa and removed at a later point. Locking screw/plate systems allow epimucusal application of bone plates. A second plate is placed on the anterior alveolar segment, taking care not to injure the tooth roots.
A second option is to reduce the fracture and use a palatal splint.
A third option is a combination of the first two options where ORIF is performed and a palatal splint added for further stability.
If there is significant splaying of the fracture and instability of the palate, most surgeons opt for the first or third option. Some surgeons feel that the first option alone would provide adequate stability. Others feel that if the first option is not combined with a palatal splint, there is a risk of having some lingual splaying of the teeth when the patients are placed into MMF.
In the following explanation we will demonstrate the third option.
In a panfacial trauma, which is the common situation where we see a palatal fracture, high priority should be given to reestablishment of the maxillomandibular unit early in the case. In the illustrated case, reduction and fixation of the palatal fracture should be the first step in the procedure.
AO Teaching video on fixation of a complex midface fracture
2 Approach topenlarge
3 Reduction topenlarge
Perform the reduction by applying pressure laterally on the two maxillary halves to reduce the splayed fracture.
Depending on the stability of the reduction and the number of assistants in the operating room, the surgeon decides as to whether to begin with the arch bars or the plating.
Reduction might be facilitated by placing a transpalatal wire to span the molars and compress whereby the fracture is reduced.
Arch bars are applied and the occlusion is checked. The occlusion is then secured by mandibulomaxillary fixation (MMF). Click here for a detailed description of the MMF technique.
Pearl: securing the reduction
It can be beneficial to use forceps to maintain the reduction while securing the MMF.
4 Fixation topenlarge
Fixation should be considered in two planes. This includes placement of plates in the palate, and a plate in the anterior alveolar arch, taking care to avoid injury to the dental roots.
It may be desirable to first plate the palate while a perfect reduction of the previously splayed palate is visualized.
More information on CMF implants can be found here.
This illustration shows a straight plate placed on the bone or on the mucosa thus through transmucosal screws.
Alternatively, an X plate can be considered.
If the surgeon decides to also use a palatal splint to provide further stabilization of the palatal unit, the palatal laceration (if present) needs to be repaired, prior to application of the splint.
Note: An acrylic splint can help 3-D stabilization of the dental arch and protect the palatal tissues.
Placing the second plate
In placing the second plate on the anterior alveolar fracture, consider the position of additional plates to be placed for the fixation of the Le Fort I fracture.
Care must be taken to avoid the dental roots.
In this axial CT scan the surgeon has chosen an X-plate for fixation of the palatal fracture. Further stabilization has been accomplished with the use of the anterior alveolar plate.
This is an axial view of the same patient and better demonstrates the palatal reduction.
In some cases, the surgeon may consider taking dental impressions, making dental models, and from these models making a palatal splint. Such a splint will support soft-tissue healing in the palate. The palatal splint is then wired to the dentition also possibly using arch bars. Depending on the stability of the palatal unit, as well as other complicating issues regarding other midface fractures and postoperative airway, the surgeon may choose to leave the patient in postoperative MMF.
In cases where there has been splaying of the palate, cuts are made in the maxillary portion of the dental model, along the line of the palatal fracture, with repositioning of the maxillary model to determine the premorbid contour of the maxillary arch. This is accomplished using the mandibular impression. Once the maxillary model has been adjusted to its premorbid shape, the palatal splint is made with the use of this maxillary model.
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 and are used to fixate the wires to the arch bar.
Addressing the Le Fort I fracture
In the illustrated case, the Le Fort I fracture should be addressed after the palatal unit has been repaired. Please refer to the section on Le Fort fractures for further details.