Technological advances in the treatment of facial trauma

Utilization of Computer-Assisted Navigation Technology Within Craniomaxillofacial Fracture Surgery: A Systematic Review

BACKGROUND

Use of intraoperative computer-assisted navigation (iCAN) has been well-established in otolaryngology and neurosurgery; however, its use in surgical management of facial fractures is yet to be reported on a large scale. This study aimed to review the existing literature to determine the outcomes, limitations, risks, and benefits of iCAN use in facial fracture management.

METHODS

A systematic review of iCAN use in craniomaxillofacial fracture surgery was performed by 2 authors in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted on 3 databases, PubMed, Cochrane Library, and Embase, using the search terms "navigation," "intraoperative," and "brain lab" in combination with "facial fractures" or "facial reconstruction." Study type, demographics, fracture characteristics, surgery characteristics, iCAN devices, intraoperative fracture fixation accuracy, postoperative outcomes, complications, navigation limitations, and risks and benefits were analyzed.

RESULTS

There were 909 studies identified in the initial search, of which 42 were chosen for final use. iCAN use was most commonly reported in unilateral (57.1%) and complex (50%) facial fracture cases. Surgical accuracy ranged from 0.7 to 4 mm and postoperative discrepancy ranged from 0.05 to 8 mm. Benefits included improved intraoperative surgical accuracy (95.2%), improved postoperative surgical discrepancy (52.4%), and decreased total surgical time (35.7%). Limitations reported with iCAN device use included operative technical difficulties (23.8%) and persistent systematic errors during device registration (21.4%). None of the studies discussed cost analysis or risks compared to conventional fixation methods.

CONCLUSIONS

Advancements in and increasing familiarity with iCAN technology have preliminarily shown favorable surgical outcomes in facial fracture fixation, which include improved operative accuracy and discrepancy and decreased surgical time.

A "Custom" Plate in a Day-Accurate Predictive Hole Fabrication Using Point-of-Care 3-Dimensional Printing

PURPOSE

In computer surgical planned (CSP) fibular reconstructions of the mandible, custom plates facilitate accurate and efficient transfer of the digital plan intraoperatively by a way of predrilled fixation holes. Stock plates are more easily accessible and are more economical but typically preclude the utilization of these predictive holes. The purpose of this article is to describe an accurate and economical alternative to custom plates, while still having the ability to create predictive holes for plate alignment and execution of a digital surgical plan.

METHODS

An in vitro accuracy study was performed on a point-of-care resin-printed predictive hole guide termed "prebent plate analog" (PPA). Twenty stock 2.0 reconstruction plates prebent against a 3-dimensional printed mandibular model reconstructed with a 2-piece fibula were used to fabricate 20 PPAs. The proximal and distal 4 holes of each prebent plate and corresponding PPA were assessed using a heat map overlay, measuring difference in millimeters between matching points of the predictive hole segments. The median distance from the points of reference in the PPA versus the prebent plate was calculated for each predictive hole position in addition to the average error of the PPA to the stock plate.

RESULTS

Eighteen PPAs were used for statistical analysis; 2 were damaged in transport. The mean error between the body (-0.265) and condylar segments (-0.116 mm) and mean difference in error between the proximal predictive holes (-0.124 mm) and distal predictive holes (-0.215 mm) on the PPA were not statistically different (P = .061, P = .314 general estimating equation regression, respectively). The mean error across the PPA predictive holes and corresponding holes of the prebent plates was -0.194 mm (P < .001, general estimating equation regression).

CONCLUSIONS

The PPA is a precise and accurate analog that faithfully replicates the position of proximal and distal components of a prebent stock plate, thereby allowing for predictive hole placement in lieu of a custom plate in fibula mandibular reconstruction cases.

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

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

Risk Factors for Postoperative Inflammatory Complications After Maxillofacial Reconstruction Using Polyether-Ether-Ketone Implants

PURPOSE

Polyether-ether-ketone (PEEK) implants are increasingly used for the reconstruction of craniomaxillofacial deformities, but limited data exist on their limitations or risk factors for complications associated with their use. The purpose of the present study was to identify risk factors for postoperative inflammatory complications (POICs) after the use of PEEK implants in craniomaxillofacial reconstruction.

METHODS

A retrospective cohort study was conducted, incorporating all patients treated with patient-specific PEEK implants at the authors' institution from August 1, 2012 to June 30, 2019. The outcome variable was the presence of POICs. The potential predictor variables were demographic, medical, anatomic, and treatment related. Statistical analysis was performed using Fisher exact tests, t tests, and multivariable logistic regression analysis where appropriate.

RESULTS

The 32 patients included in the study were composed of 68.8% men; mean age was 40.6 years. The PEEK implant was placed adjacent to the paranasal sinuses in 56.3% of patients. The indication for use was malar depression in 50.0%, orbital dystopia in 46.9%, forehead or skull defects in 21.9%, and mandibular contour deformities in 6.2%; 8 patients had more than 1 indication. The overall rate of POICs was 28.1%. Of the POICs, 66.7% were managed with incision and drainage, revision surgery, or removal and 33.3% were managed with outpatient wound care or antibiotics. Tobacco use, the presence of an intraoral incision, and the presence of multiple incisions were all associated with POICs. On multivariable analysis, tobacco use approached significance (odds ratio, 17.3 [95% confidence interval, 0.98 to 306.7]) and multiple incisions (odds ratio, 6.9 [95% confidence interval, 1.5 to 32.3]) had a statistically significant association with the occurrence of complications.

CONCLUSIONS

The present study identified several variables potentially associated with complications after the use of PEEK implants in maxillofacial reconstruction. Consideration should be given in the preoperative evaluation when a smoker is identified and when multiple incisions are planned.

Zygomaticomaxillary buttress and its dilemma

Zygomatic fractures are the second most common fractures of the facial skeleton, after nasal bone fractures. Due to its uniqueness, the malar bone plays a very important role in maintaining appropriate facial contours. Zygomatic fractures can cause ocular and mandibular functional impairment, along with cosmetic defects. With the help of advanced imaging techniques and various treatment options, the management of zygomatic fractures has become more sophisticated and less invasive. This article discusses zygomatic fractures in detail: their clinical and radiographic features, and the various treatment options available.

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

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

Reconstruction of hard and soft tissue maxillofacial defects

Reconstruction of maxillofacial composite defects is a technically demanding and time-demanding process. It also requires a prolonged treatment course, a team approach, and meticulous planning that is prosthetic and esthetically driven. The use of vascularized flap reconstruction, dental implants, and computer-aided technology and advances in maxillofacial prosthetics has contributed immensely toward the goal of fully reconstructing victims of large avulsive wounds. Further advances in technology, surgical training, and maxillofacial prosthodontics will undoubtedly aid in minimizing the number of surgical interventions and maximize the final functional and esthetic results of these patients.