The Search for the Ideal Fixation of Palatal Fractures: Innovative Experience with a Mini-Locking Plate

Abstract

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 ¼ 8). Outcomes seen on computed tomography and clinical examination during this 3-year experience have been favorable. KEYWORDS: Palatal fractures, fixation, mini-locking plate (s) Fractures that sagittally divide the palate and the maxillary alveoli are a notable challenge at surgery, largely because of splaying of the split palate, buccal version of the palatoalveolar segments, and instability of the lower third of the face. Soft tissue injury (most often of the upper lip) and dental trauma often herald the

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

“…Fractures of the palatal shelves are not classified in the common Le Fort fracture categories, though René Le Fort plainly reported them in some of his experimental settings. [18][19][20] A critical review of the numerous classification proposals [59][60][61][62][63][64] suggests to keep fractures confined to the palatal shelves apart from block fractures of the alveolar process. The horizontal fracture line of alveolar process fractures can travel with a medial offset from the very base of the process into the palatal shelf, which is why these socalled para-or palatoalveolar fractures have been inexpediently subsumed under palatal fractures.…”

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

“…Over-lapping of the loose fragments of palate or inadequate reduction is possible and therefore to prevent this transmucosal miniplate fixation is advocated by some authors. It has been observed that transpalatal plate fixation increases stability after reduction, restores width and depth of palatal platform, and limits the rotation and disinclination of palatoalveolar segments [2].…”

“…In a study undertaken by Pollock RA, on miniplate fixation in sagittal type of palatal fracture and removal after 8-12 weeks of repair, it was concluded that there was adequate healing with satisfactory post-operative occlusion [2].…”

“…With the conventional non-rigid modalities of fixation, mal-rotation and disinclination of palatal shelves is not uncommon post reduction. Fractures that sagittally divide the palate present a challenge for reduction and stabilization due to the splaying of the split palate and buccal version of the palatoalveolar segments [2]. Reduction of the posterior palatal splaying as seen in Hendrickson's Type II and Type III fractures presenting as buccal version of the palate-alveolar selves require a reliable fixation modality during the phases of healing to maintain functional occlusion.…”

A Review of Hard Palate Fracture Repair Techniques

“…In light of the dominance of this fracture type, it is understandable why other authors have proposed more intricate classification schemes9 . Nonetheless, because the fracture types encompassed by the Type I designation are treated similarly, several authors have adopted the simplified classification scheme implemented in this review7,14 . Overall, malocclusion was reported in 21/236 cases (8.9%) and other complications were reported in 13/299 cases (4.3%).The Rimell study 6 exemplifies the difficulty of craniofacial wiring and why these techniques have been largely abandoned in favor of plating techniques.…”