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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 13-17

A review of rare palatal fractures and their management


Department Plastic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission12-Feb-2021
Date of Acceptance19-Jun-2021
Date of Web Publication04-Aug-2021

Correspondence Address:
Umesh Kumar
25, Brij Enclave Extension – 1, P.O. – Bazardiha, Varanasi - 221 109, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_35_21

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  Abstract 


Objective: The objective of this study was to diagnose rare palatal fractures and to subcategories them to formulate a definitive treatment plan depending upon the fracture lines.
Materials and Methods: All patients presenting in triage with palatal fractures were classified after computed tomography scan. Thirteen patients diagnosed with complex and transverse palatal fractures were included in the study. Complex fracture was further subdivided into five groups: (a) comminuted, (b) oblique, (c) S shaped, (d) C shaped, and (e) T shaped. The patients were divided into two groups. In Group A, six patients were managed without palatal vault plating, and in Group B, seven patients were managed with palatal vault plating along with anterior alveolar and anterior maxillary buttress plating.
Results: Twelve patients presented with complex fracture and one patient presented with transverse fracture. The male-to-female ratio and age range of the study were 5.5:1 and 15–55 years, respectively.Le Fort I and II fracture was present in five patients, isolated Le Fort II fracture in four patients, Le Fort I was present in two, and Le Fort I, II and III fractures was present in two patients.
Conclusion: Complex palatal fractures can be subcategorized which simplifies the management and documentation of the fracture. Palatal vault plating should be attempted in cases where there are two large fracture segments to achieve the better stability of fracture and reduce the duration of maxillomandibular fixation in postoperative period.

Keywords: Classification palatal fracture, complex palatal fracture, palatal vault plating, rare palatal fractures, transverse palatal fracture


How to cite this article:
Kumar U, Jain P. A review of rare palatal fractures and their management. J Med Soc 2021;35:13-7

How to cite this URL:
Kumar U, Jain P. A review of rare palatal fractures and their management. J Med Soc [serial online] 2021 [cited 2021 Oct 22];35:13-7. Available from: https://www.jmedsoc.org/text.asp?2021/35/1/13/323161




  Introduction Top


Palatal fractures are traditionally subclassified with Le Fort I fractures of maxilla.[1] Better roads and average increase in speed are resulting in high-velocity impact during road traffic accidents. These vehicular impacts result in multiple facial fractures, and the rare fractures are being more frequently diagnosed in triage of any trauma center. The incidence of palatal fractures is on the rise and may be as high as 46.4% as reported by Chen et al.[2] However, the majority of studies report its incidence varying from 8% to 13.2%.[3]

Palatal fractures have been classified by many authors, and the most acceptable classification was described by Hendrickson who classified palatal fractures on the basis of location and anatomical characteristics of injury into six subtypes.[4] In our study, we have diagnosed palatal fractures clinically and confirmed it radiologically. Patients presenting with rare palatal fractures were identified, and management was individualized to achieve optimal occlusion, width, height, and projection of midfacial region.


  Materials and Methods Top


This study was conducted in the department of plastic surgery from 2016 to 2020. In this study, patients were evaluated for airway, head, cervical, chest, and abdominal injuries, followed by thorough evaluation of face for lacerations, vision, facial asymmetry, abnormal occlusion, mouth opening, tenderness, crepitation, foreign body, fractured teeth, tongue laceration, loose dentures, ecchymosis of palate, or laceration in palate or floor of mouth. Computed tomography was advised with three-dimensional reconstructions of facial bones. Patients presenting with palatal fracture which were comminuted, oblique, S shaped, C shaped, T shaped, and transversely placed were included in the study. All patients were operated with nasal or submental intubation and divided into two groups. In Group A patients who had comminuted (multiple fragments), S-shaped, or C-shaped fracture of palate, Erich arch bar was applied followed by palatal mucosa suturing if laceration was present in hard and soft palate. Anterior alveolar or pyriform ridge plating was done when fracture was present in the anterior alveolar arch. Maxilla fracture was managed with anterior maxillary buttress plating. To achieve stabilization, patients were kept on maxillomandibular fixation for 4–6 weeks. In Group B patients in whom the palatal fracture line was oblique or comminuted (three fragments), Erich arch bar was applied following which the fracture line in the palatal vault was exposed through preexisting laceration, or if required, the incision was given in the middle one-third of the palatal vault after infiltrating the palatal mucosa with 1:100,000 dilution of lignocaine with adrenaline. Mucoperiosteal flaps were dissected in the area where plating was planned. Three- or four-hole plate with gap was used along with 4-mm long and 2-mm diameter screws. Plating was done in the posterior half of the hard palate to achieve maximum stabilization of palatal arch. Anterior alveolar or pyriform ridge plating was done next with anterior maxillary buttress stabilization. Patients were kept on maxillomandibular fixation for 2–4 weeks in patients who had oblique fracture and for 4–6 weeks in patients who had comminuted fracture. They were advised liquid diet for 6 weeks. Patients were followed in outdoor facility on a weekly basis for initial 6 weeks followed by fortnightly follow-up for further 6 weeks.


  Results Top


Thirteen patients presenting with rare palatal fractures were included in the study [Table 1]. The male-to-female ratio in our study was 5.5:1. The age range of our patients was 15–55 years and the average age was 26 years. Twelve patients were diagnosed as complex fracture of palate and one presented with transverse fracture. Complex fractures were subdivided into five subtypes in our study: (a) comminuted (4), (b) oblique (5), (c) S shaped (1), (d) C shaped (1), and (e) T shaped (1). Le Fort I and II fracture was present in five patients, isolated Le Fort II fracture in four patients, Le Fort I was present in two, and Le Fort I, II and III fractures was present in two patients. The most common mode of injury was road traffic accident in 11 patients, sports injury in 1 patient, and mobile battery blast injury in 1 patient.
Table 1: Details of patients with type of palatal fracture, associated fracture, treatment, mode of injury, and complications

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Six patients of Group A were managed with palatal suturing and anterior alveolar and anterior maxillary buttress stabilization. These patients were kept on maxillomandibular fixation for 4–6 weeks. Seven patients of Group B were managed with palatal vault plating in addition to the abovementioned procedures. We encountered two complications during the study such as palatal fistula and lower eyelid ectropion in one patient each. The mandible (10), zygoma (8), and nasoethmoid fracture (7) were the common fractures associated with palate fracture.


  Discussion Top


Palatal fractures should always be looked for in a patient presenting in triage with facial injuries. Diagnosis can be made with proper clinical examination, but to formulate a definitive treatment plan, computed tomography with complete three-dimensional reconstructions of facial bones is very important. Hendrickson et al. in their study classified palatal fractures into six subtypes.[4] They are (A) Type I alveolar (anterior and posterolateral), (B) Type II sagittal, (C) Type III parasagittal, (D) Type IV para-alveolar, (E) Type V complex, and (F) Type VI transverse fractures. Chen et al. simplified the classification which included anatomical description clubbed with optimal treatment of the fracture.[2] They described three fracture subtypes which were sagittal (Type I), transverse (Type II), and comminuted (Type III) fractures. Park and Ock in their study classified palatal fractures based on the method of treatment into four groups.[5]

Transverse fracture and complex fractures are relatively rare and their incidence in various studies is negligible. In our study, we encountered 12 patients who had complex palatal fractures and 1 had transverse fracture. Palatal fracture lines which are oblique or comminuted are classified as complex fractures. In general, any fracture which results in fracture of the bone into more than two fragments is called a comminuted fracture. In our study, we subdivided complex fracture into five subtypes depending upon the fracture line as it helped in formulating treatment plan and having a better understanding for documentation and future reference. The subcategories were (a) comminuted, (b) oblique, (c) S shaped, (d) C shaped, and (e) T shaped [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e. Using English alphabets helped in describing the fracture line in better way (COS “C” T). In most of the articles, we find that the authors have laid very little emphasis in elaborating complex fractures and all the miscellaneous fractures which do not fit in any category are included into it.[4]
Figure 1: (a) Comminuted palate fracture. (b) Oblique palate fracture. (c) S-shaped palate fracture. (d) C-shaped palate fracture. (e) T-shaped palate fracture

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Palatal fractures are managed by multiple methods which range from simpler methods such as acrylic palatal splints, k-wire fixation,[6] circummolar wires,[7] circumdental wiring,[8] transpalatal wires,[6] figure-of-eight wiring, and interfragment wiring. While the abovementioned methods are less time-consuming, they are less accurate in achieving stability of the fracture segments and wires passing through the arch may be very distressing to a patient who is having sutured lacerations over the palate and tongue. The other major issue is maintaining oral hygiene as poor care of oral cavity may increase the rate of postinjury complications. These wires are maintained for 6–8 weeks, thus further aggravating the distress of patients.

To achieve better reduction and stabilization of fracture segments, open reduction and internal fixation of the palatal vault has been advocated. Plating of palatal vault is possible in cases where the fracture line is passing in the median or paramedian region of the vault and is required in patients where there is instability in fracture segments. Park and Ock in their study have suggested a treatment algorithm for management of palatal fractures and have emphasized that all palatal fractures do not require palatal vault plating and a good number of cases can be managed without it and achieved optimal stability of fracture segments.[5] When we manage complex fracture of palate, we should individualize our treatment and do palatal plating only in those patients where there are two large fracture segments and plating of these segments would provide stability to the vault and help in achieving optimal palatal width. Plating of palatal bones is done after raising the mucoperiosteal flaps and their liberal elevation can result in devascularization of the palatal fracture segments in comminuted fracture and can lead to bone necrosis and oroantral fistula.

Palatal vault plating is done with a 2-mm thick three- or four-hole plate, though 1.5-mm, three-dimensional plates or locking plates have been used for management each having their own advantages and disadvantages [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. Thin plates fail to provide strength to the fracture segments and three-dimensional plates may provide better strength and stability to the fracture segments. Applying long three-dimensional rectangular plates in oblique or comminuted fracture may be technically demanding and require dissection of mucoperiosteum in a large area of palate though it may be useful in certain palatal fractures.[9] Locking plates can be used as an external fixator for stabilization of fracture without dissection of mucoperiosteum.[10] The disadvantages of this method are difficulty in maintaining oral hygiene and requirement of a second surgery for removal of the external plate after achieving complete healing.
Figure 2: (a) Comminuted palate fracture with two large segments ideal for palatal vault plating. (b) Comminuted palate fracture with gap in two large bony segments. (c) Plating with 2-mm three-hole plate with gap. (d) Postoperative photograph after suturing of mucoperiosteal flap

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  Conclusion Top


Complex palatal fracture lines may clinically present in various forms. Individualization of treatment should be done in each case to achieve optimal outcome. Palatal vault plating should be considered in cases where the fracture is unstable and there are sufficient large bony segments for open reduction and internal fixation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Manson PN. Some thoughts on the classification and treatment of Le Fort fractures. Ann Plast Surg 1986;17:356-63.  Back to cited text no. 1
    
2.
Chen CH, Wang TY, Tsay PK, Lai JB, Chen CT, Liao HT, et al. A 162-case review of palatal fracture: Management strategy from a 10-year experience. Plast Reconstr Surg 2008;121:2065-73.  Back to cited text no. 2
    
3.
Manson PN, Clark N, Robertson B, Bradley MD, Slezak S, Wheatly M, et al. Subunit principles in midface fracture: The importance of sagittal buttress soft tissue reductions and sequencing treatment of segmental fractures. Plast Reconstr Surg 1999;103:1287-306.  Back to cited text no. 3
    
4.
Hendrickson M, Clark N, Manson PN, Yaremchuk M, Robertson B, Slezak S, et al. Palatal fracture: Classification, pattern and treatment with rigid internal fixation. Plast Reconstr Surg 1999;103:1287-307.  Back to cited text no. 4
    
5.
Park S, Ock JJ. A new classification of palatal fractures and an algorithm to establish a treatment plan. Plast Reconstr Surg 2001;107:1669-76.  Back to cited text no. 5
    
6.
Davis DG, Constant E. Transverse palatal wire for the treatment of vertical maxillary fractures. Plast Reconstr Surg 1971;48:191-3.  Back to cited text no. 6
    
7.
Williams JL, Rowe N. Fracture of Facial Skeleton. 2nd ed. London: Churchill Livingston; 1994.  Back to cited text no. 7
    
8.
Irby WB. Facial trauma and concomitant problems. St Louis: Mosby; 1974. p. 250.  Back to cited text no. 8
    
9.
Karthik R, Cynthia S, Vivek N, Prashanthi G, Saravana Kumar S, Rajyalakshmi V. Open reduction and internal fixation of palatal fractures using three-dimensional plates. Br J Oral Maxillofac Surg 2018;56:411-5.  Back to cited text no. 9
    
10.
Cienfuegos R, Sierra E, Ortiz B, Fernández G. Treatment of palatal fractures by osteosynthesis with 2.0-mm locking plates as external fixator. Craniomaxillofac Trauma Reconstr 2010;3:223-30.  Back to cited text no. 10
    


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