Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible

Fibula Jaw-during-Admission

BACKGROUND

Fibula Jaw-in-a-Day (JIAD) is considered the most advanced approach for segmental mandibular defect reconstruction and dental rehabilitation. However, it has limitations and challenges for further pursuit. We propose Fibula Jaw-during-Admission (JDA) as a solution.

MATERIALS AND METHODS

From 2019 to 2021, six patients received fibula "Jaw-during-Admission." Segmental mandibulectomy, fibula transfer, and immediate dental implantation were performed simultaneously during a single surgery. Intraoral scans were used to fabricate temporary light occlusion contact dental prostheses while on the ward prior to discharge during the first and second week post operation. The prostheses were installed before discharge and changed to permanent ones with normal occlusal contact in the clinic at about six months after X-ray confirmation of bone healing.

RESULTS

All six surgeries succeeded. Four patients received palatal muco-periosteal graft after debridement of peri-implant overgrown granulation tissue. Follow-up ranged from 12 to 34 months (average 21.2 months) and revealed good function and appearance in all patients.

CONCLUSION

Fibula JDA is superior to the Fibula JIAD approach for simultaneous mandibular reconstruction with fibula and dental rehabilitation. There is no need for postoperative intermaxillary fixation. The surgery can be performed more reliably with less stress. It provides an additional opportunity for dental rehabilitation if initial dental prosthesis installation during JIAD fails. Postreconstruction intraoral scans provide greater precision and more flexibility in milling dental prosthesis which are mapped to the reconstructed mandible during the postoperative period.

The Role of Imaging in Mandibular Reconstruction with Microvascular Surgery

Imaging plays a critical role in the diagnosis, staging, and management of segmental mandibular defects. Imaging allows mandibular defects to be classified which aids in microvascular free flap reconstruction. This review serves to complement the surgeon's clinical experience with image-based examples of mandibular pathology, defect classification systems, reconstruction options, treatment complications, and Virtual Surgical Planning.

Self-inflicted craniomaxillofacial gunshot wounds: management, reconstruction, and outcomes

Suicide by firearm remains one of the leading causes of violence-related injury death in the United States each year. The mortality rate from these injuries is high, resulting in a paucity of outcome data in the literature regarding injuries to the maxillofacial region. This has largely been attributed to a lack of funding for research in this area compared to other leading causes of mortality in the United States. The aim of this study was to detail the authors' experience and approach to complex maxillofacial reconstruction using both local reconstructive methods and microvascular free tissue transfer. A retrospective cohort study was designed, including patients who sustained self-inflicted gunshot wounds to the maxillofacial region between January 1, 2012 and May 1, 2020. Forty-one patients met the inclusion criteria. The majority of the patients were male (87.8%). Mean patient age was 44.2 ± 16.6 years. Alcohol or drugs, and a psychiatric history were present in a majority of the cases. The most involved anatomical region was the midface (75.6% of cases). Seven patients required free tissue transfer for reconstruction, with many needing multiple flaps. Self-inflicted gunshot wounds represent challenging reconstruction scenarios, often in the setting of severe psychological trauma, and require a multidisciplinary team to ensure the optimal outcome.

Correction of Traumatic Transverse Mandibular Widening With Interdental Wiring

ABSTRACT

Mandibular symphysis fractures pose several technical challenges for the craniomaxillofacial surgeon. One classic challenge is restoration of the transverse dimension when the mandible is widened secondary to splaying of the lingual cortex. Failure to diagnose or correct this problem can result in widening of the lower facial third, inadequate fracture reduction, and/or a malocclusion. Surgeons have traditionally utilized techniques such as manual pressure to the rami or lingual splint application to address transverse defects intraoperatively. However, these methods may be inadequate in situations with significant widening, such as in the case of concomitant subcondylar fractures. More recently, virtual surgical planning and custom hardware have been utilized to address mandibular widening, though this method also has various shortcomings. In this technical note, the authors present a simple technique using interdental wiring to precisely control mandibular width intraoperatively. The technique is cost effective, does not require an assistant, and can be used in conjunction with any of the above methods. The authors also present a case of secondary reconstruction in which use of this technique was necessary given a large degree of mandibular widening not amenable to reduction and fixation with manual pressure alone.