Post-traumatic malocclusion may significantly impair speech articulation. Alterations in the structural and functional relationships among the maxilla, mandible, and dentition can result from improperly treated fractures or postoperative complications. ^, According to Bode and colleagues in a narrative review, severe handicapping malocclusion results in an increased prevalence of speech distortions by as high as 25 times when compared to Class I occlusion groups. An observational study by Leavy and colleagues reports that the anterior open bite degree was significant in those with speech production errors, particularly for/s/and/t/sounds. An anterior open bite resulting from bilateral condylar process fractures have been documented in the literature. Furthermore, Class II and III malocclusions are associated with distortional and spectral changes in consonants. Such malocclusion classes may result from facial trauma due to malunion and ankylosis. Practitioners must consider the effect of facial trauma on speech as a result of potentially disrupted or improperly managed occlusion and provide adequate treatment to prevent such outcomes.

The effects of malocclusion on a patient’s ability to breathe normally have been described in both children and adults. While studies specifically investigating breathing problems due to post-traumatic malocclusion are limited, the risk of certain malocclusions from trauma, such as an anterior open bite, poses a threat to breathing. A study by Lyra and colleagues found that anterior open bite and posterior crossbite occlusal patterns were significantly associated with sleep-disordered breathing among children. The authors emphasized the importance of intervention to prevent and minimize these adverse breathing effects. The association of malocclusion and breathing difficulties could be explained through changes in pharyngeal airway dimensions. The authors stated that due to the proximity and association of the mandible with the nearby muscles, palate, hyoid, and tongue, any movement in the mandible could affect the area of the airway. Further studies exploring post-traumatic malocclusion and its effects on breathing ease should be conducted. Providers should be vigilant to avoid long-term breathing difficulties in patients with post-traumatic malocclusion.

The association between malocclusion and dental caries remains inconclusive in the literature. A study by Feldens and colleagues found that handicapping malocclusion, maxillary irregularities, and atypical posterior tooth relationships were associated with dental caries. This association may be mediated by impaired oral hygiene care due to tooth position irregularity or food and plaque accumulation. In contrast, a 2020 systematic review found insufficient evidence to draw definitive conclusions regarding the direct impact of malocclusion on oral health outcomes. Conversely, a more recent systematic review by Göranson and colleagues concluded that there is moderate evidence suggesting malocclusion in adolescents negatively affects oral health–related quality of life. The discrepancy among these findings may be attributable to variability in study design and the influence of confounding factors, including oral hygiene practices, socioeconomic status, and fluoride exposure. Consequently, further well-controlled studies are needed to isolate the independent effect of malocclusion on caries risk and related oral health outcomes.

Malocclusion also impairs proper masticatory function. ^, This impairment is due to reduced occlusal contacts on involved teeth, which decreases the maximum bite force that can be produced. Reduced bite force, in turn, compromises the ability to effectively break down and chew food. Anterior open bite and posterior crossbite—malocclusion patterns reported in patients with inadequately treated facial trauma—have been associated with significantly lower maximum bite force, reduced occlusal contact area, and diminished overall masticatory efficiency. ^,, Therefore, providers must consider masticatory dysfunction as a complication from post-traumatic malocclusion, and thus, potentially preventable in cases if occlusion is properly managed.

MMF is a management technique in facial trauma used to reduce fractured fragments and is achieved through securing the relationship of the occlusal surfaces of teeth, often through a metallic framework. Uncomplicated fractures, where consistent occlusion is present, can often be treated through closed reduction with MMF using the patient’s teeth or prosthesis. Techniques to perform MMF have evolved over the years and consist of traditional Erich arch bars (EABs), screw-based fixation, embrasure wires, dental occlusion ties (DOTs), or Risdon cables. EABs are wired together in a semirigid bar scaffold and secured to stable fractures to secure the occlusal plane and relationships of dentition of the mandible and maxilla. However, reported disadvantages of EABs include operating time, decreased oral hygiene maintenance, and periodontal damage. Furthermore, EABs are to be avoided in cases of pediatric or edentulous fractures and when an anterior open bite is present. Therefore, providers may instead use screw-based fixation methods to perform MMF, where the screw heads operate as anchor points to tighten wires or bands, precisely adjust occlusal relationships, and improve structural reduction. However, providers must be cautious of damage to tooth roots when placing screws, and fixation may be lost due to any screw loosening. Another method of MMF is embrasure wires, which involves a wire being moved through the maxillary contact and looped below the mandibular contact, bringing the teeth into occlusion by twisting the wire down to the teeth. Disadvantages of this method include its limitations in patients with periodontal disease, inadequate interproximal contacts, or dental instability, as well as that it cannot connect occlusion discrepancies postoperatively with elastic traction. Similarly to embrasure wires, DOTs are passed through embrasure spaces of each arch, but then passed through a unidirectional clasp that prevents releasing or slipping following tightening. Though DOTs have improved speed of procedure, access, and reduced periodontal and operator sharps injury, their use is limited in patients with missing teeth, compromised interproximal contacts, comminuted fractures, gum disease, or those in need of postoperative elastic therapies. ^, Lastly, Risdon cables are an effective wire-based technique to achieve MMF in primary or early mixed dentition populations, making it especially useful in pediatric maxillofacial trauma. This technique involves the twisting of a wire around the last molar of the mandible, then twisting the wire ends in line with the contour of the jaw and cervical margins of the dentition. The wire can extend from one side of the dental arch to the other, or if done on the arch bilaterally with 2 twisted wire ends, they can be twisted together in the mandibular symphyseal region. ^, The cable then acts similarly to an arch bar, allows circumdental ligature wires to secure the teeth, and establishes MMF following similar proceedings on the maxilla. More advanced displaced facial fractures will often require a combination of MMF and ORIF, or ORIF alone, to properly restore occlusion and function in patients.

ORIF is a surgical technique designed to achieve accurate anatomic reduction of displaced fracture segments. This approach involves surgical exposure and direct visualization of fracture sites to enhance reduction accuracy, followed by stabilization using internal fixation hardware such as plates and screws. Restoration of the occlusal relationship is achieved intraoperatively through precise 3-dimensional realignment of the fractured segments. Recent advancements in digital workflows, including patient-specific surgical guides and custom fixation plates, have demonstrated favorable occlusal outcomes following ORIF. The benefits of ORIF are further supported by a systematic review and meta-analysis by Jazayeri and colleagues, which demonstrated significant improvements in occlusion, jaw symmetry, and functional outcomes compared with closed reduction in the management of condylar fractures. ORIF is often combined with MMF intraoperatively to maintain occlusion until reduction and fixation of fractures have been accomplished. Interestingly, studies have supported that immediate release of maxillomandibular reduction (MMR) following ORIF procedure completion, in comparison to prolonged MMR postoperatively, presents similar occlusal and patient outcomes. ^, Thus, due to ORIF reproducing favorable outcomes on reduction and occlusal re-establishment, providers should continually consider its use in facial trauma treatment.

Occlusal splinting is another occlusion-restoring technique in facial trauma that can be combined with ORIF or MMF. ^, An occlusal splint is an acrylic plate that fits on the patient’s teeth to restore pretraumatic occlusion and aid in the alignment and reduction of fractures. They may be used as firm bases to establish MMF in facial fractures. In both simple and complex fractures, the use of occlusal splints has demonstrated favorable outcomes to prevent occlusal disharmony. ^, Computer-assisted designed occlusal splints have demonstrated excellent outcomes in patients with comminuted fractures, reproducing a stable occlusal relationship. Therefore, occlusal splints offer a valuable and versatile means to restore and manage occlusion in facial trauma.

Orthognathic surgery is an established procedure to provide definitive correction of post-traumatic malocclusion following initial fracture management. By repositioning the maxilla and mandible, orthognathic procedures restore functional occlusal relationships and facial harmony. Ramus osteotomies and Le Fort I osteotomies, in particular, have demonstrated predictable and favorable outcomes in the correction of post-traumatic malocclusion. Additionally, orthognathic surgery has shown to provide long-term dental stability and relationships. Due to these favorable and effective results, providers may consider orthognathic surgery to correct any existing post-traumatic malocclusion that was inadequately addressed during primary facial trauma treatment.

Postoperative care of facial trauma may consist of elastic occlusal guidance or jaw range physiotherapy to maintain proper occlusion and jaw position as fractured segments heal. Elastics accomplish this by controlling the range of motion and guiding occlusion. The use of elastics precedes jaw physiotherapy, which restores jaw movement, decreases pain, and improves oral health. ^, A study by Feng and colleagues found significant improvement in mouth opening and chewing ability using sequential functional exercise routines in the postsurgical period, while avoiding dysocclusion. Because of the postoperative and occlusion-restoring benefits, providers should actively encourage adherence and completion of elastic occlusal guidance and jaw physiotherapy to improve patient outcomes following facial trauma.