■ Part 2. Operative Technique and Exemplary Repair
The repair of palatal fractures is today quite different than that chosen several decades ago.1 , 2 , 19 During World Wars I and II, for example, the fractured dentoalveolar segment in the presence of palatal or midfacial comminution was deemed to be irreparably damaged and inherently unstable; the severely comminuted segment was thus summarily dissected out and discarded.20
After the wars, attempts to harness palatal instability after fracture were made. Intraoral splints, arch bars, Kirschner wires, a palatal bar, or transpalatal wires were used with some success ( Figs. 4.23A,B and 4.24A,B ).19 , 21 – 26 Improved fixation followed the use of small, straight or “boutique X, Y, or box” plates, placed by way of incisions or lacerations in the roof of the mouth4 , 27 – 29 and elevation of the mucoperiosteum ( Fig. 4.25 ). Denny deemed it proper to undertake extensive mucoperiosteal elevation and a U-shaped flap to expose the palatal fracture.30
Results were mixed using these earlier techniques, because postoperatively they do not provide very rigid fixation and allow malrotation and disinclination of the palatoalveolar segments. The use of straight and boutique designer plates allow a similar fate, and a large number of cases suffer malocclusion after surgery, including crossbite.27 , 31 Although the resulting malocclusion often responds to orthodontic adjustment, surgeons have sought to achieve better outcomes.2
Preoperative Assessment and Indications for Repair
Injuries of the upper or lower lip, or in some cases both lips, may herald the presence of dental trauma (such as subluxation or luxation of an incisor) or an alveolar or palatal fracture. The laceration(s) often “mark” the location of the exit of the palatal fracture through the anterior face of the maxilla ( Fig. 4.26A ).
A lip-dental-maxillary-palatal cascade of injury is created by the impact ( Fig. 4.26B ).
Fractures that sagittally divide the palate, the maxillary alveoli, and the midfacial buttresses are a notable challenge to the surgeon because the palatal shelves are free to rotate outwardly and upwardly when the palate is split and the midfacial buttresses are fragmented. Splaying of the palate, buccal version (outward rotation) of the palatoalveolar segments, and instability of the lower third of the face create a common clinical triad in patients with fractures of the palate.2 , 4 , 27
Fractures of the palate are often part of a more extensive midfacial comminution12 , 32 , 33 and notably characteristic of pancraniomaxillofacial fractures (see Chapter 9). Occlusal abberations, such as crossbite and underjet, are common ( Fig. 4.27 ).
Bruising in the gingivobuccal sulcus (upper vestibule) may be noted, and tenderness in the sulcus and in the roof of the mouth is elicited with palpation. Midfacial instability is typically evident upon examination.
When the fracture of the buttresses is immedially superior to the palatal platform, the dental arch is mobile but the nose and periorbit are not. As fracture lines occur at increasingly higher levels, greater mobility of the upper face is noted with bimanual examination. This “ bimanual maneuver” is elicited by grasping the upper, anterior dental arch with one hand and palpating the midface with the other ( Fig. 4.28 ).
Radiographic studies, notably HRCT scans with three-dimensional reformatting, have provoked several classifications of fractures of the palate in past decades.27 – 29 , 32 A simplification of the classification suggested by Hendrickson and colleagues27 is an effective aid to understanding the patterns of fracture, the categories of the injury, and plans for operative intervention2 ( Fig. 4.29A–C ):
Parasagittal, para-alveolar (anterior, anterolateral, posterolateral)
Transverse (or oblique)
HRCT, particularly three-dimensional reformats, readily reveals the four anterior craniomaxillofacial buttresses. Most studies also reveal injuries of the three posterior midfacial buttresses, and radiographic reports tend to emphasize the deviations of the vomer and disruption of the laminations of the pterygoid plates when present.
Studies by Le Fort12 at the turn of the 20th century using cadavers recognized three tiers of comminution:
Le Fort I, II, and III. Several levels of comminution may coexist. Clearly, the greater the extent of injury, the greater the torsion, distortion, and skeletal instability. The higher the Le Fort level of comminution, the greater the chance of bilateral periorbital ecchymosis ( Fig. 4.30A–D ).
Operative Repair of the Palate and Lower Midfacial Buttresses
Algorithm of Palatal Repair
The tendency toward rotation and disinclination (splaying) of fractured palatal shelves is controlled by prealignment and the extreme rigidity provided by transpalatal, mini-locking plates and screws. The screws are inserted directly by way of the oral cavity. The restored width and depth of the palatal platform allows the surgeon to avoid the potential bias of intraoral splints,31 transpalatal wires, and non-locking plates and screws.2 The palate is considered the first site of repair in most pancraniofacial cases (see Chapter 9). If there is no palatal fracture, the mandible is repaired, then other craniofacial structures ( Fig. 4.31 ).
The goal of repair is to restore the palatal shelves as a major load-bearing platform. Stress of mastication may then be distributed to the midface and more distant regions of the craniomaxillofacial skeleton and cervical spine.