What are the indications for closed reduction versus open reduction internal fixation (ORIF) in the management of maxillofacial injuries?

Closed vs Open Reduction in Maxillofacial Injuries

Closed reduction is appropriate for minimally displaced fractures with stable occlusal relationships, while open reduction and internal fixation (ORIF) is indicated for severely displaced fractures, edentulous patients lacking stable occlusion, and cases requiring the mandible as a guide for midface repositioning. 1

Indications for Closed Reduction

Closed reduction with maxillomandibular fixation should be used for:

• Non-displaced or minimally displaced fractures that can be adequately aligned without surgical exposure 1, 2
• Fractures with intact occlusal relationships where dental guidance provides adequate reduction 1
• Pediatric maxillofacial fractures, which can be managed conservatively in the majority of cases (46.15% observation, 15.38% closed reduction) 2
• Settings where surgical expertise in rigid internal fixation is unavailable or equipment is lacking—in these situations, simple closed reduction is far superior to poorly executed ORIF 1

The evidence strongly supports conservative management when anatomic alignment can be achieved without surgery. In pediatric populations specifically, only 12.30% required ORIF, with most fractures managed through observation or closed techniques 2.

Indications for Open Reduction and Internal Fixation (ORIF)

ORIF is mandated in the following clinical scenarios:

• Severe injuries with significant displacement requiring restoration of pretraumatic anatomic relationships 1
• Edentulous and semi-dentate patients who lack stable occlusal relationships to guide closed reduction 1
• Multiple midface fractures where the mandible must serve as the foundational guide for repositioning midfacial bones 1
• Comminuted fractures with inadequate soft tissue or dental support for maxillomandibular fixation, particularly gunshot wounds requiring external pin fixation 1
• Grossly displaced fractures from high-velocity injuries, though this represents a small subset of pediatric cases 2

Technical Considerations for ORIF

When ORIF is indicated, specific technical principles must be followed:

• Load-bearing osteosynthesis with 2.7-mm reconstruction plates is the preferred method for comminuted fractures, as compression osteosynthesis is contraindicated when small fragments cannot share loads 1
• Multiple rigid fixations using refined titanium plates and screws through standard surgical approaches achieve good to excellent outcomes with low complication rates (14.8% functional problems, 13.0% cosmetic deformities, 16.7% reoperation rate) 3
• External pin fixation should be reserved for extreme comminution with soft tissue disruption when inadequate teeth exist for maxillomandibular fixation 1

Critical Decision-Making Algorithm

The treatment selection follows this hierarchy:

1. Assess fracture displacement: Non-displaced or minimally displaced → closed reduction 1, 2
2. Evaluate occlusal stability: Stable occlusion present → closed reduction; absent in edentulous patients → ORIF 1
3. Determine injury severity: Severe displacement or multiple midface fractures → ORIF 1
4. Consider surgical resources: If ORIF expertise/equipment unavailable for indicated cases → transfer to capable facility rather than attempt inadequate ORIF 1

Evolving Treatment Patterns

The surgical approach has shifted over time from predominantly closed reduction (59.52% of cases) toward combined approaches, with open reduction techniques now being applied more frequently instead of closed reduction alone for mandibular fractures 4. This reflects improved outcomes with modern rigid fixation techniques, which have revolutionized complex facial fracture management 3.

Common Pitfalls to Avoid

• Never attempt ORIF without proper expertise or equipment—closed reduction is safer than poorly executed open surgery 1
• Do not use compression osteosynthesis for comminuted fractures—small fragments cannot be compressed and require load-bearing fixation 1
• Ensure cervical spine clearance before any manipulation, as 11% of mandibular fracture patients have concomitant cervical spine injury 5, 6
• Obtain mandatory ophthalmology consultation for orbital fractures to assess visual acuity and extraocular movements, as 37% develop postoperative diplopia 5