The search for the ideal fixation of palatal fractures: innovative experience with a mini-locking plate

Hendrickson Class II Palatal Fracture Following a Road Trauma Accident in a Pediatric Patient

Pediatric palatal fractures are rare clinical presentations owing to the relative plasticity of their bones. We present a case of a 3-year-old pedestrian struck male patient presenting with a mid-sagittal palatal fracture which corresponds to a Hendrickson class II fracture. Diagnosis and treatment of these rare cases are very critical to ensuring proper manducatory functions and normal facial growth in these children.

Evaluation of Maxillary Protraction Using a Mini Screw-Retained Palatal C-Shaped Plate and Face Mask

Objective

To evaluate a newly designed minimally invasive palatal-plate face mask combination for the management of developing Class III malocclusion due to maxillary deficiency.

Methods

A sample of 16 Class III patients due to maxillary deficiency in the early mixed dentition (8 boys and 8 girls) aged between 7 and 9 years participated in this study and were treated with a combination of palatal plate face masks. Extra-oral elastics were attached between the intra-oral and extra-oral appliances; the elastics were set at 30° to the occlusal plane. The force magnitude was 250-300 g per quadrant. Cephalometric radiographs were taken before and immediately after maxillary protraction. In addition, skeletal measurements were measured, tabulated, and statistically analyzed. The pre- and post-protraction measurements were compared using the Student's t-test, and the significance level was set at a p-value <0.05.

Results

A statistically significant increase in SNA angle and maxillary length was observed by 3.13±1.52 degrees and 2.60±0.75 mm (p<0.05), respectively, indicating forward maxillary growth. The skeletal and soft tissue patterns were also improved, as evidenced by the statistically significant increase in the ANB angle, Wits appraisal, and H angle by 4.50±1.28 degrees, 5.30±1.86 mm, and 5.02±3.24 degrees (p<0.05), respectively. A favorable clockwise mandibular rotation was observed as evidenced by the increase in the SN/MP angle and the decrease in the SNB angle by 1.46±1.96 degrees and -1.38±1.86 degrees (p<0.05), respectively.

Conclusion

The palatal-plate facemask combination is an effective treatment alternative for Class III malocclusion due to maxillary deficiency with minimal pain and discomfort.

Off-Label Use of an External Hand Fixator for Craniomaxillofacial Fractures-An Anatomical Feasibility Study

BACKGROUND

The lack of resources limits the treatment of craniomaxillofacial fractures (CMF) in low-income countries (LIC). Therefore, Barton bandages and/or interdental wiring are considered in these regions. Fracture reduction is maintained by permanent occlusion for 6 weeks, which often leads to limited compliance and dissatisfying results. The aim of this cadaver-based study is to evaluate the feasibility of the use of an external face fixator (EFF) for the treatment of CMF, its biomechanical values and to define the optimal pin insertion points and angles.

MATERIALS AND METHODS

An AO hand fixator was used. CMF of types Le Fort 1-3 with split fractures of the hard palate were treated with EFF on 13 anatomical specimens. Fractures were created using a chisel, and pins were placed in specific anatomical regions. The maximal pull-out force [N] of pins was analysed by a tensile force gauge, and Fmax of the mandibular pins was evaluated. Computer tomography scans were performed on the healthy, fractured and EFF-treated skulls.

RESULTS

The pull-out forces for the single pins were mandibular pins (n = 15, median 488.0 N), supraorbital pins (n = 15, median 455.0 N), zygomatic pins (n = 14, median 269.1 N), medial hard palate pins (n = 12, median 208.4 N) and lateral hard palate pins (n = 8, median 49.6 N).

CONCLUSIONS

The results indicate that the operation technique is feasible, and the stability of the EFF is sufficient for maintaining the reduction. The required pins can safely be inserted into the described areas with good reduction results. Using EFF offers a feasible alternative to the non-surgical treatment of CMF in LIC.

Pediatric Palate Fractures: An Assessment of Patterns and Management at a Level 1 Trauma Center

Study Design

Literature discussing palate fractures in the pediatric population is limited. We performed a retrospective review of pediatric palatal fractures at our institution to better understand the impact of this fracture pattern in the pediatric patient.

Objectives

The goal of our study is to analyze our institutional experience with pediatric palate fractures, focusing on epidemiology, concomitant injuries, and fracture management.

Methods

Records were collected for all palatal fractures in pediatric patients diagnosed between 2000 and 2016 at an urban Level I trauma center. Patient imaging was reviewed. Demographic characteristics and inpatient clinical data were recorded.

Results

Nine pediatric patients were diagnosed with fracture of the bony palate. Average age was twelve with male predominance (66%). Pedestrian struck injuries (33%) and motor vehicle accidents (33%) were the most common etiologies. Five patients sustained skull fractures. Three patients were found to have intracranial hemorrhage, two required emergent bolt placement. Two patients sustained cervical spine injury. One patient had severe facial hemorrhage requiring embolization. According to the Hendrickson classification, there were three type I fractures, two type II fractures, one type III fracture, one type IV fracture, and one type V fracture. Lefort I and/or alveolar fracture was present in every patient. Four patients underwent surgical treatment with open reduction and restoration of facial height with maxillomandibular fixation. Three patients underwent concomitant mandible fracture repair.

Conclusions

Pediatric palatal fractures are rare and are usually accompanied by devastating concomitant injuries. Surgical repair of the palate in the pediatric patient is often necessary to restore facial height.

Open reduction and internal fixation of palatal fractures using three-dimensional plates

The maxilla is arguably the most anatomically intricate structure of the craniofacial skeleton, and the hard palate is an important bone that regulates the width and architecture of the face. The management of palatal fractures has long been a matter of debate, and varies with anatomical pattern and other injuries to the craniofacial skeleton. We have studied 18 palatal fractures during a five-year period that were treated using 3-dimensional rectangular plates placed across the palatal vault together with fixation of other fractures of the facial bones. Healing was satisfactory in all patients by 12weeks, with no complications. We think that open reduction and internal fixation of palatal fractures with 3-dimensional plates offers adequate stability with minimal complications.

Reduction of Palatal Midline and Para-Midline Fractures Using Intra-arch Wire Fixation Versus Transmucosal Miniplate Stabilization: Prospective Randomized Clinical Study to Evaluate Postoperative Occlusion

Purpose

The aim of the study is to compare the post reduction squealae of transmucosal miniplate fixation technique for stabilization of palatal fractures with intra-arch wiring technique.

Materials and Method

This study was prospectively undertaken on 16 patients, dividing them into two treatment arms based on random sampling methodology (Group A & B). For patients in Group A, intra-arch wire stabilization technique and in Group B trans-mucosal miniplate stabilization technique was used. The pre-operative and post-operative occlusion and time taken for stabilization in both the techniques was compared.

Results

The mean time taken for reduction and stabilization of palatal fracture in group A was 10.9 ± 2.21 min and in group B was 14.2 ± 1.13 min. Four out of eight study patients in group A required post reduction interception to stabilize occlusion postoperatively, whereas none of the patients in group B needed any post operative intervention.

Conclusion

The post operative occlusal stability was found better in study patients included in group B when compared to group A patients, although satisfactory post-operative occlusion was obtained even in group A with post-operative interception for occlusal stability.

3 Dimensional Plate in Management of Sagittal Palatal Fracture: A Novel Technique

The palatal fracture is rare. There are varieties of techniques mentioned in the literature for fixation of palatal fracture. The management with Kirschner wire fixation, maxillary arch stabilization with the arch bars, trans-palatal, intra osseous, inter-molar, figure of eight wiring were technique sensitive and having poor patient compliance. We recommended the use of isolated 3 dimensional plate for fixation of sagittal palatal fracture.

A Single-Center Review of Palatal Fractures: Etiology, Patterns, Concomitant Injuries, and Management

Introduction: Palatal fractures are frequently associated with facial trauma and Le Fort fractures. The complex anatomy of the midfacial skeleton makes diagnosing and treating these injuries a challenge. The goal of this study was to report our experience with the presentation, concomitant injuries, and management of palatal fractures at a level I trauma center in an urban environment. Methods: Data were collected for all palatal fractures diagnosed between January 2000 and December 2012 at the University Hospital in Newark, NJ. Data on patient demographics, Glasgow Coma Scale score on presentation, concomitant facial fractures, extrafacial injuries, and management strategies were collected from these records. Results: Of the 3147 facial fractures treated at our institution during this time period, 61 were associated with a palatal fracture following blunt trauma. There was a strong male predominance (87%) and a mean age of 35.6 years in this subset of patients. The most common causes of injury were assault and motor vehicle accident. The most common fracture patterns were alveolar, parasagittal, and para-alveolar, whereas sagittal and transverse fractures were rare. The most frequently encountered facial and extrafacial injuries were orbital fractures and intracranial hemorrhage, respectively. There was a significant association between type II sagittal fractures and traumatic brain injury (P < .05). Conclusions: Our study examines a single center's experience with palatal fractures in terms of presentation, concomitant injuries, and management strategies. Palatal fractures are most often associated with high-energy mechanisms, and the severity of injury appears to correlate with the type of palatal fracture.

Palate Fracture Repair With Light-Cured Resin Splint: Technical Note

Palate fractures are rare, and their treatment is a matter of debate. Although some investigators have favored rigid plate fixation, others have reported successful treatment without it. Sagittal split and comminuted fractures can require rigid fixation to reduce the maxillary width; however, additional stabilization is needed. Also, palate repair without a splint is complicated by prolonged intermaxillary fixation (IMF), causing stiffness to the temporomandibular joint. We introduce a technique using a rapid light-cured resin (TRIAD TranSheet) frequently used by orthodontists for making dental retainers. Its use is similar to the splints traditionally created preoperatively, but obviates the need for making impressions, a model, and a molded splint. A series of 13 patients treated with this technique during a 5-year period is presented. The average duration of IMF was 4.7 weeks (range 3 to 6). The average duration of the palate splint was 8.4 weeks (range 5 to 12). One patient had malocclusion, but none had malunion, infection, or oronasal fistula. Our series has demonstrated a simple, cost-effective, and successful technique. It can be used alone or combined with rigid fixation and allows for a shortened duration of maxillomandibular fixation.

The Comprehensive AOCMF Classification System: Midface Fractures - Level 3 Tutorial

This tutorial outlines the details of the AOCMF image-based classification system for fractures of the midface at the precision level 3. The topography of the different midface regions (central midface-upper central midface, intermediate central midface, lower central midface-incorporating the naso-orbito-ethmoid region; lateral midface-zygoma and zygomatic arch, palate) is subdivided in much greater detail than in level 2 going beyond the Le Fort fracture types and its analogs. The level 3 midface classification system is presented along with guidelines to precisely delineate the fracture patterns in these specific subregions. It is easy to plot common fracture entities, such as nasal and naso-orbito-ethmoid, and their variants due to the refined structural layout of the subregions. As a key attribute, this focused approach permits to document the occurrence of fragmentation (i.e., single vs. multiple fracture lines), displacement, and bone loss. Moreover, the preinjury dental state and the degree of alveolar atrophy in edentulous maxillary regions can be recorded. On the basis of these individual features, tooth injuries, periodontal trauma, and fracture involvement of the alveolar process can be assessed. Coding rules are given to set up a distinctive formula for typical midface fractures and their combinations. The instructions and illustrations are elucidated by a series of radiographic imaging examples. A critical appraisal of the design of this level 3 midface classification is made.

Transpalatal screw traction: a simple technique for the management of sagittal fractures of the maxilla and palate

Sagittal fractures of the maxilla and palate are uncommon in clinical practice. Current methods for the management of such fractures have advantages and limitations. The authors present the simple and practical technique of bilateral transpalatal screw traction to manage this fracture type.