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General Considerations

This is a rare isolated fracture pattern. It mostly occurs in combination with other midfacial or panfacial fractures. Left untreated can lead to malocclusions and widened maxilla.

Observation - Main Indication

Non- or minimally displaced fractures in a compliant patient with good occlusion.

Note: This situation is fairly uncommon.

Closed Treatment - Main Indication

Non- or minimally displaced fractures in a compliant patient amenable to MMF.

Open Reduction Internal Fixation - Main Indication

When MMF alone is unable to prevent splaying of the segments and a palatal splint is not available.

General Considerations

In patients with comminution of the palatal segments, an open reduction is generally not the procedure of choice. Exposure of these fractures often reveals small fragments that are difficult or impossible to fix adequately. Therefore observation or closed reduction is usually the preferred modality of treatment for complex (comminuted) palatal fractures. It is common for these patients to present with palatal splaying and significant malocclusion.

Observation - Main Indication-Rarely indicated in complex injuries.

It is unlikely that a complex palatal fracture presents without displacement, and with stability and normal occlusion. There is a significant risk of fistula formation. For this reason observation alone is unlikely to be a good choice.

Closed Treatment - Main Indication

Severely comminuted fractures difficult to fix adequately with plates and screws without compromising the blood supply to the comminuted segments.

Open Reduction Internal Fixation - Main Indication

When MMF alone is unable to prevent splaying of the segments and a palatal splint is not readily available.

Large fragment accessible, reducible and possible to fix without disturbing the blood supply.
Treatment of complex maxillary fractures via open reduction internal fixation (ORIF) is controversial.
The surgeon should try to maintain the blood supply to the comminuted fragments to ensure goodhealing.

General Considerations

This is a very rare isolated fracture pattern, mostly occurring in edentulous patients wearing dentures during trauma. More often it occurs in combination with other midface fractures (Le Fort II and Le Fort III).

Observation

Non- or minimally mobile Le Fort I fractures with unaffected occlusion in compliant patients with good dentition.

Closed Treatment

Non- or minimally displaced fractures in a compliant patient amenable to MMF.

Fractures with minor malocclusion readily correctable with maxillary manipulation, and not grossly mobile after repositioning may be treated closed. However, closed reduction is more commonly used in conjunction with other stabilization techniques (skeletal suspension, external fixators, etc.).

Further Indications

Premorbid or unstable medical condition preventing general anesthetic.
Conditions making open reduction and internal fixation difficult.
Patient refusal of operative treatment (eg, for religious/cultural or financial reasons).
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

Open Reduction Internal Fixation

Mobile maxillae with resulting malocclusion in cases where vertical restoration of one or more of the buttresses are indicated.

Usually, open reduction and internal fixation is the method of choice for mobile maxillae with malocclusion.

A minimum of two plates are used to provide stability along the buttresses. Additional plates may support the fragments.

Closed Treatment

Unilateral fractures in patients with minor malocclusion correctable with maxillary disimpaction in compliant patients amenable to MMF. Basic surgical experience, no specialized skills.

Fractures with minor malocclusion readily correctable with maxillary manipulation, and not grossly mobile after repositioning may be treated closed.

However, closed reduction is more commonly used in conjunction with other stabilization techniques (skeletal suspension, external fixators, etc.).

Further Indications

Premorbid or unstable medical condition preventing general anesthetic.
Conditions making open reduction and internal fixation difficult.
Patient refusal of operative treatment (eg, for religious/cultural or financial reasons).
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

Open Reduction Internal Fixation

Unilateral comminuted fractures where vertical restoration of the buttress is required.

Open reduction internal fixation is usually the method of choice for mobile Le Fort I fractures with unilateral comminution and malocclusion. Bone contact on the noncomminuted side allows the reestablishment of appropriate facial height and maxillary position.

If there are large pieces in the comminuted area that can be attached to the plate, these are left in place and fixed to the plate by screws.

General Considerations

This is a very rare isolated fracture pattern. More often it occurs in combination with other midface fractures (Le Fort I and Le Fort III).

Observation - Main Indication

Non- or minimally mobile Le Fort II fractures with unaffected occlusion in compliant patients with good dentition.

Further Indications

Nondisplaced stable fractures with premorbid occlusion in compliant patients.
Edentulous patient with minimal fracture displacement.
General condition of the patient not allowing for surgical intervention.

Closed Treatment - Main Indication

Non- or minimally displaced fractures in a compliant patient amenable to MMF.

Fractures with minor malocclusion readily correctable with maxillary manipulation, and not grossly mobile after repositioning may be treated closed. However, closed reduction is more commonly used in conjunction with other stabilization techniques (skeletal suspension, external fixators, etc.).

Further Indications

Premorbid or unstable medical condition preventing general anesthetic.
Conditions making open reduction and internal fixation difficult.
Patient refusal of operative treatment (eg, for religious/cultural or financial reasons).
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

Open Reduction Internal Fixation - Main Indication

Displaced Le Fort II fractures resulting in malocclusion or facial deformity.

Ideally, any displaced Le Fort II fracture should be treated by open reduction internal fixation. The number of approaches depends on the extent of dislocation and comminution, and the degree of stability following reduction.

Observation - Main Indication

Non- or minimally mobile Le Fort III fractures with unaffected occlusion in compliant patients with good dentition.

Further Indications

Edentulous patient with minimal fracture displacement.
General condition of the patient not allowing for surgical intervention.

Closed Treatment - Main Indication

Non- or minimally displaced fractures in a compliant patient amenable to MMF.

Fractures with minor malocclusion readily correctable with maxillary manipulation, and not grossly mobile after repositioning may be treated closed. However, closed reduction is more commonly used in conjunction with other stabilization techniques (skeletal suspension, external fixators, etc.).

Further Indications

Premorbid or unstable medical condition preventing general anesthetic.
Conditions making open reduction and internal fixation difficult.
Patient refusal of operative treatment (eg, for religious/cultural or financial reasons).
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

Open Reduction Internal Fixation - Main Indication

Displaced Le Fort III fractures resulting in malocclusion or facial deformity.

Ideally, any displaced Le Fort III fracture should be treated by open reduction internal fixation. The number of approaches depends on the extent of dislocation and comminution, and the degree of stability following reduction.

General Considerations

Open reduction internal fixation (ORIF) is the recommended method for complex symphyseal fractures to assure adequate stability in the fracture site, thus preventing complications.
It is especially recommended in noncompliant patients.

Closed Treatment - Main Indication

Non- or minimally displaced complex fractures in compliant patients with good dentition amenable to MMF.

Further Indications

Premorbid or unstable medical condition preventing general anesthetic
Conditions making open reduction and internal fixation difficult
Patient refusal of operative treatment
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

ORIF, Two Plates (basal triangle) - Main Indication

If control of the top of the basal triangle is required, the use of two plates provides this control.
Advantage

When application of two plates is simpler than a single load bearing reconstruction plate.

ORIF, Reconstruction Plate (basal triangle) - Main Indication

Maximum stability under load bearing conditions.

The reconstruction plate is considered the most predictable method of treatment.

ORIF, Reconstruction Plate (comminuted fracture) - Main Indication

Standard method of treatment of a comminuted fracture.

External Fixator - Main Indication

Temporary stabilization of complex fractures simultaneously affecting several anatomic mandibular subunits.
Advantages

Maintain fragment position without disrupting the blood supply
Rapid application

General Considerations

Open reduction internal fixation (ORIF) is usually the method of choice for simple symphyseal fractures in order to avoid the drawbacks and inconveniences of MMF in the majority of patients.

It is recommended in all unstable fractures and noncompliant patients. Closed treatment of simple fractures is still well accepted as an alternative to open treatment.

Closed Treatment (MMF) - Main Indication

Non- or minimally displaced simple fractures in compliant patients with good dentition amenable to MMF.

Further Indications

Premorbid or unstable medical condition preventing general anesthetic
Conditions making open reduction and internal fixation difficult
Patient refusal of operative treatment
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

ORIF, Two Lag Screw Fixation - Main Indication

Oblique or sagittal fractures where two lag screws can be placed from the buccal or lingual cortices.
Advantages

Rapid application with a high level of stability
Perfect bony reduction after interfragmentary compression
Lower cost compared to plate and screw fixation
Intraosseous location avoiding palpability.

Disadvantages

Technically demanding
Difficult implant removal (if needed).

ORIF, Lag Screw And Plate - Main Indication

Oblique or sagittal fractures where only one lag screw is possible. The plate is used to supplement the fixation.

This technique is a backup procedure for two lag screw procedure where only one lag screw could be inserted due to anatomical or technical reasons.

Note: these fractures could also be treated with two miniplates.

ORIF, One Plate And Arch Bar - Main Indication

Simple fractures when used in combination with a stable arch bar.
Further Indication

Anatomical and technical limitation for the placement of two plates

Advantage

Easy to place and less expensive relative to two plates

ORIF, Two Plates - Main Indication

Cases where an arch bar is not possible because of missing teeth, loose teeth, or the objection to using an arch bar, or distal trailing fractures not amenable to the other treatments.

Advantages

Easy to contour and to secure to the mandible using monocortical screws
Rapidly applied and provide stable fixation
Readily available in most operating rooms.

General Considerations

Open reduction internal fixation (ORIF) is the recommended method for complex body fractures to assure adequate stability in the fracture site, thus preventing complications. It is especially recommended in noncompliant patients.

Closed Treatment - Main Indication

In rare cases, in compliant patients with good dentition and non- or minimally displaced fractures.

Further Indications

Premorbid or unstable medical condition preventing general anesthetic
Conditions making open reduction and internal fixation difficult
Patient refusal of operative treatment
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

ORIF, Two Plates (basal triangle) - Main Indication

Basal triangle fracture.

ORIF, Reconstruction Plate - Main Indication

Standard method of treatment of a comminuted fracture.

External Fixator - Main Indication

Temporary stabilization of complex fractures simultaneously affecting several anatomic mandibular subunits.

Advantages

Maintain fragment position without disrupting the blood supply
Rapid application.

General Considerations

Open reduction internal fixation (ORIF) is usually the method of choice for complete simple body fractures to avoid the drawbacks and inconveniences of MMF in the majority of patients. It is recommended in all displaced fractures and noncompliant patients.

Observation - Main Indication

Seldom indicated for non-mobile non-displaced fractures with undisturbed occlusion.
Further Indication

When fracture topography and muscular forces (favorable fracture) allow a stable environment of undisturbed healing.

Requirements

Fully compliant individual who is willing to adhere to a non- chew diet and avoid physical exercise and sports for a period of 6 weeks.
Patient must be advised that additional treatment may be required if complications arise during the observation period.

Closed Treatment - Main Indication

Non- or minimally displaced simple fractures in compliant patients with good dentition amenable to MMF.

Further Indications

Premorbid or unstable medical condition preventing general anesthetic
Conditions making open reduction and internal fixation difficult
Patient refusal of operative treatment
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

ORIF, Lag Screws - Main Indication

Sagittal/oblique fractures

Advantages Of The Lag Screws Over Plate Fixations Are

Rapid application with a high level of stability
Ideal fracture alignment and interfragmentary buttressing
Intraosseous location avoiding palpability
Less fixation hardware resulting in lower cost.

Disadvantages

Technically demanding
Difficult implant removal (if needed)

Lag screws can hardly be used in transverse fractures of the body.

ORIF, One Miniplate - Main Indication

Simple fractures in compliant patients with good dentition and buttressing of the segments after reduction.

ORIF, Two Plates - Main Indication

Simple fractures in transitional areas of the mandibular body.

ORIF, One Large Plate - Main Indication

Reduced bone buttressing requiring load bearing fixation.

Further Indications

Delayed fracture treatment
Infection
Pseudarthrosis
Nonunion
If more stability is required.

General Considerations

Open reduction internal fixation (ORIF) is the recommended method for complex angle fractures to assure adequate stability in the fracture site, thus preventing complications. Angular fractures are more likely to result in postoperative complications such as infection.

Closed treatment - Main Indication

Non- or minimally displaced favorable fractures of the angle in compliant patients with good dentition amenable to MMF.

Further Indications

Premorbid or unstable medical condition preventing general anesthetic
Conditions making open reduction and internal fixation difficult
Patient refusal of operative treatment
Unavailability of plates and screws

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

ORIF, Two Plates (basal triangle) - Main Indication

If control of the top of the basal triangle is required, the use of two plates provides this control.

Advantage

When application of two plates is simpler than a single load bearing reconstruction plate (when a transoral approach is selected).

ORIF, Reconstruction Plate (basal triangle) - Main Indication

Maximum stability under load bearing conditions. The reconstruction plate is considered the most predictable method of treatment.

ORIF, Reconstruction Plate (comminuted fracture) - Main Indication

Standard method of treatment for comminuted fractures requiring load-bearing fixation.

External Fixator - Main Indication

Temporary stabilization of complex fractures simultaneously affecting several anatomic mandibular subunits.

Advantages

Maintain fragment position without disrupting the blood supply.
Rapid application.

General Considerations

Treatment of angle fractures remains controversial. Open reduction internal fixation (ORIF) is usually the method of choice for unfavorable simple angle fractures to avoid postreduction displacement of the fragments and inconvenience of MMF.

Observation - Main Indication

Seldom indicated for non-displaced non-mobile fractures in a compliant patient with normal occlusion.
Further Indication

When fracture topography and muscular forces (favorable fracture) allow a stable environment of undisturbed healing.

Requirements

Fully compliant individual who is willing to adhere to a non-chew diet and avoid physical exercise and sports for a period of 6 weeks.
Patient must be advised that additional treatment may be required if complications arise during the observation period.

Closed Treatment - Main Indication

Non- or minimally displaced favorable fractures of the angle in compliant patients with good dentition amenable to MMF.

Further Indications

Full Facial 3D
Premorbid or unstable medical condition preventing general anesthetic
Conditions making open reduction and internal fixation difficult
Patient refusal of operative treatment
Unavailability of plates and screws.

Special Consideration

MMF may be contraindicated in patients with psychiatric disorders, seizure disorders, and alcoholics.

ORIF, Wire - Main Indications

In unfavorable fractures when plate/screw fixation is not available.

Note: Intraosseous wire fixation of angle fractures is a nonrigid technique that requires 5-6 weeks of postoperative MMF.

ORIF, Miniplate Fixation To The Oblique Ridge - Main Indications

Standard method of treatment of isolated simple mandibular angle fractures.

ORIF, Two Miniplates - Main Indications

Conditions when use of a secondary plate improves bone buttressing and fracture alignment.

ORIF, Reconstruction Plate - Main Indications

Reduced bone buttressing requiring load bearing fixation.

Further Indications

Delayed fracture treatment
Infection
Pseudarthrosis
Nonunion
If more stability is required.

Note: To consider when tooth removal in the line of fracture leads to decreased bone buttressing.

General considerations

The indications for condylar process fracture treatment are controversial, even among expert surgeons. At this point in time, consensus has not been reached. The surgeon must take into account the following considerations:

Location of the fracture
Amount of vertical reduction in height of the ramus
Degree of angulation
Degree of luxation of the condylar head out of the glenoid fossa
Fragmentation pattern (simple versus complex)
Association with other mandibular injuries
Dental occlusion/status of dentition
Association with other facial bone injuries
Association with systemic injuries
Association with the condition of the patient (comorbidity factors)
Foreign body in temporomandibular joint (TMJ).

Observation - Main Indication

Non- or minimally displaced fractures in compliant patient.

Requirements

Minimally or nondisplaced fracture
Dentate patients should have a stable occlusion over time
Acceptable level of pain
Patient compliance

Patient must be advised that additional treatment may be required if complications arise during the observation period.

Closed Treatment - Main Indication

Standard method of treatment for non-dislocated or minimally displaced fractures in compliant patients with good dentition and amenable for MMF.

Closed reduction is a misnomer. Often there is no anatomic reduction of the fracture. Closed treatment results in a functional adaptation by the patient to achieve a repeatable occlusion.

Advantages

Minimally invasive technique.
Can be performed under local anesthesia at the surgeon’s practice.
Many patients favor nonoperative techniques for management of their fractures where possible.

ORIF, One/Two Plate(s) - Extraoral Approach - Main Indication

Displaced fractures resulting in shortening of the ramus height or when the fracture segment interferes with normal mandibular function.

The main advantage of an extraoral approach is the direct access and improved visualization of the fracture for reduction and fixation.

ORIF, One/Two Plate(s) - Intraoral Approach - Main Indication

Low condylar process fractures.

Advantages

Avoidance of injury to the facial nerve.
No need for cutaneous access with the consequent scar.

It is more difficult to treat higher condylar process fractures using this surgical approach.
Note: Intraoral approaches require formal specialist training and specialized equipment.

ORIF, One/Two Plate(s) - Endoscopically Assisted - Main Indication

Higher condylar process fractures amenable to an intraoral approach with endoscopic assistance.

Note: Intraoral approaches and endoscopic assistance require formal training of the surgical team and specialized equipment. Endoscopic equipment can be very expensive and difficult to maintain.

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