Facial Fracture ORIF Operative Note (Mandible/Midface)

Date of Surgery: [Date]

Patient: [Patient full name and MRN]

Facility: [Facility name]

Service: [Oral & Maxillofacial Surgery / Otolaryngology–Head & Neck Surgery / Plastic Surgery]

Preoperative Diagnosis

[Fracture diagnosis list] (For each fracture, specify bone/region, anatomic subsite, laterality, and notable characteristics such as displacement or comminution. Note tooth in fracture line or relevant dentition status when applicable.)

Postoperative Diagnosis

[Diagnosis] (Typically same as preoperative. If intraoperative findings changed the diagnosis, state what changed and why.)

Procedure(s) Performed

• [Procedure 1] (List each procedure in order performed with fracture site and laterality)
• [Procedure 2] (Include ancillary procedures such as arch bar application, tooth extraction, laceration repair)

Surgical Team

Surgeon: [Name, credentials]

Assistant(s): [Name(s), credentials]

Anesthesia: [Name(s), credentials]

Anesthesia and Airway

Anesthesia: [general / regional / local with sedation]

Airway route: [nasotracheal / orotracheal / submental / tracheostomy] (Critical to document as this affects intraoperative occlusion assessment and exposure.)

Indications

[Indication statement] (1–3 sentences covering mechanism if pertinent, clinical indication for surgery, imaging basis, and functional goals. Document that informed consent was obtained.)

Operative Findings

• Fracture patterns: [By region/site, document displacement, comminution, segment mobility]
• Dentition and occlusion: [Pre-injury occlusion status and source of information; note explicitly if pre-injury occlusion cannot be reliably determined]
• Soft tissue: [Lacerations, mucosal injuries, open fracture status]
• Nerve status: [Mental nerve / Infraorbital nerve status if assessed]

Operative Course

Preparation

[Patient positioning]. [Prep and drape]. [Local anesthetic infiltration if used: agent, concentration, volume, locations].

Occlusion Management and MMF

(Include this subsection only if occlusion work was performed.)

• Method: [arch bars / IMF screws / interdental wiring / elastics / splints]
• Occlusion setting: [Pre-injury occlusion / best achievable occlusion] (State basis for occlusal target.)
• Duration: [Intraoperative only / Left postoperatively] (If postoperative, specify wires vs elastics and planned timeline.)
• Final occlusion check: [MMF released and final occlusion verified prior to closure / Patient intentionally left in MMF due to (reason)]

Surgical Approaches

(For each fracture site, document approach and key structures identified or protected.)

• [Fracture site 1]: [intraoral vestibular / transbuccal trocar / submandibular / preauricular / transconjunctival / coronal / other approach]; [structures protected]
• [Fracture site 2]: [Approach]; [structures protected]

Reduction and Fixation

(For each fracture, describe reduction method, confirmation of reduction, and fixation details.)

• [Fracture site and laterality]:
  • Reduction: [manual / bone clamp / temporary fixation]
  • Confirmation: [direct visualization / palpation / occlusion check / intraoperative imaging]
  • Fixation: [Plate type and location]; [number of holes]; [screw count, diameter, monocortical vs bicortical, locking vs nonlocking]
• [Additional fracture site]: [Repeat as above]

Closure

[Irrigation and hemostasis]. [Closure by incision: layers and suture types]. [Dressings, splints, nasal packing, or guiding elastics if applied].

Hardware

(Omit section if no implants placed.)

• [Implant 1]: [Manufacturer/system]; [plate type and location]; [screw specifications]; [lot/UDI if tracked]
• [Implant 2]: [Details as above]

Specimens

(Omit section if none sent.)

• [Specimen description] – [pathology / microbiology]

Drains

(Omit section if none placed.)

• [Type and size] – [Location] – [Management plan]

Estimated Blood Loss

[EBL in mL]

Complications

[None / Description of complication, intervention performed, and patient status]

Disposition

[Patient condition]; [extubated in OR / transferred intubated]; [PACU / ICU]. (If patient left in MMF, document wire cutter availability per unit protocol.)

Postoperative Plan

• Diet: [Non-chew/soft diet duration and advancement plan / Liquid diet while in MMF]
• Activity: [No chewing; avoid trauma; contact sports restriction duration] (For midface: add sinus precautions—no nose blowing ~10 days, sneeze with mouth open, avoid straws, avoid pressure changes.)
• Oral Hygiene: [Chlorhexidine rinse schedule]; [brushing instructions]; [irrigation syringe if applicable]
• Medications: [Antibiotic agent and duration]; [pain management]; [NSAID restrictions if applicable]
• Imaging: [Postoperative imaging modality and timing, if indicated]
• Follow-up: [Clinic follow-up timeframe]; [hardware management timeline]

(Omit sections that do not apply. When information is unknown or cannot be verified, document this explicitly rather than inferring.)