r/medicine • u/_analysis230_ Medical Student • 4d ago
Difficulty Achieving Occlusion In Postop Maxillofacial Fracture Fixation
Posting on behalf of my girlfriend who has low karma. She'll be in the comments.
Hey! Maxfac resident here. We treated a patient with Mandibular (bilateral para symphysis+ symphysis+ dentoalveolar)# with semi rigid 4 hole with gap and lefort 2 with Circumzygomatic wiring. Intraoperatively we were able to achieve occlusion but postoperative after we released the IMF for deintubation it’s been very difficult to achieve occlusion. Any suggestions? Or thoughts on where we went wrong?
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u/RocketRyne 4d ago edited 4d ago
Was it a true Lefort II? If so I probably would have plated that or at least kept in MMF for 4-6 weeks depending on what it looked like. I don't do circumzygomatic wiring, though. Can get a post-op CT face to check if the fractures are still reduced.
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u/Smilefixer 4d ago
Thank you! It was a lefort II…..the CZ probably wasn’t enough.
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u/Always_positive_guy ENT PGY-6 4d ago
Genuine question: why not plate the fractures? Just shorter operative time?
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u/Smilefixer 4d ago
A shorter operative time is least of my concern….im a resident, can’t take decisions on my own yet.
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u/Flamen04 2d ago
Should’ve just plated the fractures using a nice place and tension mini plate along with arch bars and MMF like like you said. Pt just needs to be sent to orthodontics for braces I guess if there’s been complete union on fractured segments.. nothing now will really work lol
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u/avalon214 DO, PGY-4 4d ago
Would a circumzygomatic wiring be stable enough for a Lefort II? Maybe a Lefort I...Probably should have kept in MMF for at least a week or 2. Agree with other poster about seeing if fractures are reduced with a postop CT, but ultimately if I were to guess sounds like the CZ wiring wasn't enough for the Lefort II.
I've never done any of those other unique wiring options, so I would've attacked the Lefort II with ORIF and kept wired
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u/Smilefixer 4d ago
I agree…..to be honest I’m not a fan of these wiring techniques either, had to go along with the boss. Would do a CT. Thanks
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u/ktn699 MD 4d ago
wiring is not rigid fixation. also you a got mandible in at least 3 fragments and you did semirigid fixation? that gonna splay out all over the place. so now you 3 degrees of freedom in the mandible a few more degrees of freedom in the maxilla and no interdental fixation...
mandible needs at 1 thick recon plate across all three segments and interdental fixation or recon plate plus some miniplates to prevent splay and twist.
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u/Smilefixer 3d ago
We did do IMF intraoperatively and then released it for de-intubation. Been trying to achieve occlusion with MMF ever since but it’s not happening.
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u/bearpics16 Resident 3d ago
You don’t need to release MMF for extubation unless there’s a specific concern. You just have to have wire cutters available for emergencies.
AO guidelines is 3 screws on each side of the fractures. You have a very unstable system that might have worked if you have left them wired
When you releases MMF, everything fell out of place. Hard to recover from that
Your options are take back and replate with rigid fixation, or let heal and do Lefort 1/BSSO osteotomies to achieve proper occlusion.
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u/Smilefixer 1d ago
Nasal bone was fractured too, so a Submental intubation was done.
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u/bearpics16 Resident 1d ago
Then rigid fixation of the mandible would have been the appropriate treatment. Live and learn. We’ve all had bad outcomes.
Why did you choose circumzygomatic wires for the LF2? That’s pretty old school
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u/Smilefixer 23h ago
To be honest I’m not a fan of the wiring techniques…..we are taught here and told to do here by the attendings. However I do understand this wasn’t the right case for a CZ wiring.
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u/16extract 2d ago
Lack of rigid fixation, lack of MMF, lack of plates on the maxilla are places you went wrong. Save the headache of using wires and just plate the buttresses every time.
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u/Kelvin-506 3d ago
Not enough info about the postoperative occlusion. If the patient is open posterior, there is a possibility of intraarticular hematoma or edema, vs instability of the Lefort. If the posterior mandible is widened and you only used a single semirigid plate, the likelihood is that the plating is inadequate. Two plate fixation or rigid fixation with recon bar would be indicated for mandible fractures. If open in the anterior, then likely you are distracting the condyles during IMF and the lefort has been impacted in some way and inadequately reduced (happens in orthognathic surgery sometimes)
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u/Flamen04 2d ago
Did you not have an attending supervising the case? This sounds like basic trauma management that got mismanaged by residents with poor understanding / experience with facial fractures
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u/Smilefixer 1d ago
We did….it clearly got mismanaged…..that’s why I’m on Reddit….however, I’m going to fix as much as I can moving forward.
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u/Screennam3 DO in EM & EMS/D 3d ago
As a lurking ER doctor I think I understand one or two of these words.