A management strategy for palatal fractures: a 12-year review

Multidetector CT of Midfacial Fractures: Classification Systems, Principles of Reduction, and Common Complications

The advent of titanium hardware, which provides firm three-dimensional positional control, and the exquisite bone detail afforded by multidetector computed tomography (CT) have spurred the evolution of subunit-specific midfacial fracture management principles. The structural, diagnostic, and therapeutic complexity of the individual midfacial subunits, including the nose, the naso-orbito-ethmoidal region, the internal orbits, the zygomaticomaxillary complex, and the maxillary occlusion-bearing segment, are not adequately reflected in the Le Fort classification system, which provides only a general framework and has become less relevant in contemporary practice. The purpose of this article is to facilitate the involvement of radiologists in the delivery of individualized multidisciplinary care to adults who have sustained blunt trauma and have midfacial fractures by providing a clinically relevant review of the role of multidetector CT in the management of each midfacial subunit. Surgically relevant anatomic structures, search patterns, critical CT findings and their management implications, contemporary classification systems, and common posttraumatic and postoperative complications are emphasized. ^©RSNA, 2018.

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.

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.

Treatment of Palatal Fractures by Osteosynthesis with 2.0-mm Locking Plates as External Fixator

Treatment options for palatal fractures range from orthodontic braces, acrylic bars, and arch bars for maxillomandibular fixation to internal fixation, with plates and screws placed under the palate mucosa and periosteum, together with pyriform aperture or alveolar plating plus buttress reconstruction. Forty-five patients, ages 4 to 56, were treated using medium- or high-profile locking plates placed over the palatal mucosa as an external fixator for palatal fractures, together with treatment for other associated facial fractures. In open fractures, plates were placed after approximating the edges of the mucosal wounds. Plates and screws for palate fixation were removed at 12 weeks, when computed tomography scans provided evidence of fracture healing. All palatal fractures healed by 12 weeks, with no cases of mucosal necrosis, bone exposure, fistulae, or infections. This approach achieves adequate stability, reduces the risk of bone and mucosal necrosis, and promotes healing of mucosal wounds in case of open fractures.

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

Fractures of the palate have defied conventional management, such that malrotation and disinclination of the palatal shelves occur in a significant number of patients after repair. The fractured palatal shelves of eight patients were first prealigned. To do so, one or more 205-mm ratchet clamps and two intermaxillary fixation (IMF) posts were used. Rigid fixation was then achieved by applying a 2.0-mm mini-locking titanium plate (across the palatal vault) and by applying an adaptation miniplate across the fracture line as it exited the anterior surface of the maxilla. Screws were passed directly through the mucoperiosteum, to engage the palatal shelves and to lock the locking plate into position. Lacerations in the mucoperiosteum were neither used to aid fixation nor used as portals for dissection; incisions and mucoperiosteal flaps in the palatal vault were avoided. Adjuncts, such as intraoral splints, have not been used in cases to date, and early mobilization was allowed. Reconstitution of the craniomaxillofacial buttresses was added in patients with more extensive maxillary injury. The palatal appliance and screws remained rigidly in position in the roof of the mouth, much like an external fixator, until their removal 8 to 12 weeks after the repair. No patient suffered erosion of the mucoperiosteum or other major morbidity, other than a transient fistula of the soft palate. The palatoalveolar segments remained in proper realignment and inclination, and pretraumatic occlusal patterns and the width and depth of the lower face appear to have been restored with one exception. The latter suffered a subtle posterolateral open bite that was corrected orthodontically. Prealignment of fractured palatal shelves with one or more large ratchet clamps and two IMF posts provides several points of forced reduction of the palatal shelves, along the dental arch. In addition, stabilization with mini-locking plate(s) in the palatal vault and an adaptation plate across the fracture line, as it exits the maxilla, appear to have merit, based on this preliminary report (n = 8). Outcomes seen on computed tomography and clinical examination during this 3-year experience have been favorable.

A 162-case review of palatal fracture: management strategy from a 10-year experience

BACKGROUND

Palatal fractures are frequently associated with Le Fort maxillary fractures in midfacial trauma. They may present diagnostic and therapeutic challenges and result in malunion and occlusion problems if not treated properly.

METHODS

In a retrospective study of 349 Le Fort maxillary fractures over 10 years, 162 patients were diagnosed with palatal fractures. The classification of fractures was based on the patterns observed on computed tomographic scans and treatment plan including type I, sagittal; type II, transverse; and type III, comminuted. Transverse palatal fractures were stabilized by standard Le Fort I buttresses and alveolar ridge fixation. Additional intermolar wiring fixation was applied for sagittal palatal fractures, and prolonged intermaxillary fixation with dental splinting was applied for comminuted palatal fractures.

RESULTS

Palatal fractures accounted for 46.4 percent of Le Fort maxillary fractures in this study. Motorcycle accident (69.5 percent) was the most common trauma mechanism. In the type I group, all patients achieved satisfactory results except one patient who needed orthognathic surgery because of malocclusion. Thirteen patients required orthodontic treatment without additional surgical intervention. There were three fistula formations in the type III group that required palatal flaps for closure.

CONCLUSIONS

The high incidence of concomitant palatal fractures in midfacial trauma suggests the importance of accurate diagnosis followed by appropriate management. Results of this study show that intermolar wiring fixation is a much less time-consuming and more cost-effective method for satisfactory treatment of sagittal fractures of the palate. Simultaneously, a palatal flap for closure of a palatal defect is the key to avoiding fistula formation.

Orthodontic management of a Le Fort II and midline palatal fracture

An unusual presentation of palatal fracture is described. Reduction and fixation with an orthodontic appliance proved to be an efficient and novel method in the treatment of this fracture.

A new classification of palatal fracture and an algorithm to establish a treatment plan

Palatal fractures have previously been classified according to the anatomic location of the fracture line, which is helpful for understanding the types of palatal fracture, but which is insufficient for helping the surgeon to decide which fracture to open and how to do so. The purpose of this study was to aid in the establishment of a precise treatment plan by determining the surgical approach and the types of stabilization that should be used for different types of palatal fracture. In a retrospective review of 136 consecutive Le Fort maxillary fractures over 6 years, 18 patients (13.2 percent) with palatal fractures were analyzed. The principle of open reduction and internal fixation was applied to all the patients. In six patients (33 percent), exploration and fixation was done in the palatal surface. Eight patients (44 percent) needed an extended period of immobilization (4 to 6 weeks). No major complications were observed during the follow-up period. An algorithm was devised to help establish a proper treatment plan, and palatal fractures were classified into four types: closed reduction, anterior treatment, anterior and palatal treatment, and combined. The key elements considered in deciding the treatment principle and the classification of a palatal fracture were the possibility of closed reduction, surgical exposure, site of rigid fixation, and stability of fractured segments after rigid fixation. The outcome of reconstruction and the postoperative course differed depending on the type of palatal fracture. This classification scheme provided an easy and simple way to establish a treatment plan and was helpful in learning the treatment principles of palatal fracture.