Endoscopic approach to maxillofacial trauma

Feasibility of a craniometry in a comminuted zygomaticomaxillary complex fracture

Few studies have reported on using craniometry for comminuted zygomaticomaxillary complex (ZMC) fracture management. We present our experiences with this procedure and a review of the related literature.From September 2011 to October 2018, 43 patients with comminuted ZMC fracture receiving open reduction internal fixation under coronal incision were enrolled. Data on gender, age, operation time, hospital stay, duration of follow-up, vertical/horizontal differences, and complications were collected. Between-group differences (C-arm imaging vs craniometry) were evaluated using nonparametric Mann-Whitney test for continuous data and chi-square test for categorical data.No significant difference were found between the groups regarding gender, age, hospital duration, follow-up duration, and postoperative complications, except for operation time. The averaged operation time was significantly shorter in the C-arm imaging group (4.217 h) than in the craniometry group (6.193 h). The C-arm imaging group had two cases with horizontal differences >3 mm and one case with vertical differences >3 mm. The craniometry group had four cases with horizontal differences >3 mm and four cases with vertical differences >3 mm. There were no significant differences between the two groups in horizontal differences and vertical differences.Craniometry may achieve the same outcomes as C-arm imaging in comminuted ZMC fracture management; however, the former requires more time than the latter.

Complications of the retromandibular transparotid approach for low condylar neck and subcondylar fractures: a retrospective study

Objectives

The goal of this study was to evaluate the rates of complications, morbidity, and safety with the transparotid approach.

Materials and Methods

A retrospective study was conducted and consisted of 53 surgically treated patients in the past five years for low condylar neck and subcondylar fractures. Only patients with malocclusion and who underwent open reduction with internal fixation with the retromandibular transparotid approach were included. The examined parameters were postoperative suboptimal occlusion, deflection, saliva fistula, and facial nerve weakness.

Results

Fifty-three patients had an open reduction with internal fixation on 55 sides (41 males, 77.4%; mean age, 42 years [range, 18-72 years]). Four patients (7.5%) experienced transient facial nerve weakness of the marginal mandibular branch, but none was permanent. Four patients had a salivary fistula, and 5 patients showed postoperative malocclusion, where one needed repeat surgery after one year. One patient showed long-term deflection. No other complications were observed.

Conclusion

The retromandibular transparotid approach is a safe procedure for open reduction and internal fixation of low condylar neck and subcondylar fractures, and it has minimal complications.

Evaluation of a Minimally Disruptive Treatment Protocol for Frontal Sinus Fractures

Importance

Despite common goals of frontal sinus fracture treatment (restoring forehead contour and creating a safe sinus), there remains significant variability in evaluation and treatment.

Objective

To describe our experience with a minimally disruptive treatment protocol for the treatment of frontal sinus fractures.

Design, Setting, and Participants

Analysis of prospectively collected data from 2010 through 2015 at a level 1 trauma center. All patients with frontal sinus fractures treated with our protocol from January 2010 to December 2015. Patients with poor follow-up and/or incomplete medical records were excluded from analysis.

Main Outcomes and Measures

Presence of an aerated frontal sinus and aesthetically acceptable forehead contour. Secondary outcome measures were complications related to frontal sinus fractures.

Results

A total of 39 patients were treated under our minimally disruptive protocol, and 25 patients were included in the study; 18 (72%) were male and 7 (28%) were female. Their ages ranged from 6 to 62 years. After review, 22 patients had both clinical and radiographic follow-up. No patients underwent immediate frontal sinus repair. Five of 22 patients underwent surgery for indications other than their frontal sinus fracture: 1 of 5 patients underwent immediate surgical repair due to bilateral LeFort fractures, and 4 of 5 underwent delayed surgery due to nasal polyps (1 patient), scar revision (1 patient), and concomitant LeFort fractures (2 patients). Two of 22 patients (9%) underwent frontal sinus repair after outpatient surveillance due to persistent cerebrospinal fluid leak (1 patient) and orbital roof fracture (1 patient). The remaining 20 patients were treated nonoperatively, and 19 of 20 (95%) had spontaneous improvement in opacification and/or contour deformity. Twelve of 20 patients (60%) had improvement or resolution in both. One patient had ongoing partial opacification and deformity at the 3-month follow-up but was asymptomatic and had bony contour that was aesthetically acceptable to the patient. There were no complications. The median of all follow-up was 3 months.

Conclusions and Relevance

Frontal sinus fractures treated nonoperatively had a high rate of spontaneous ventilation and bony autoreduction with aesthetically acceptable frontal bone remodeling. There were no complications in the nonoperative group. The initial results of this study support further study of the safety and efficacy of a minimally disruptive protocol for frontal sinus fractures.

Level of Evidence

4.

Analysis of Fractured Mandible Over Two Decades

Mandible fractures have a special place within the injuries of the other bones of the maxillofacial system. In their management, cosmetic issues and functional aspects such as chewing, speaking, and swallowing become very important.In this study, a retrospective analysis of 419 mandible fractures in 283 patients was performed in relation to epidemiologic factors, treatment strategies, and complications. The average age was 32.14 years (4-69 years). The male/female ratio was 4/1. The most frequent etiologic factor was interpersonal violence (104 patients, 36.7%). The parasymphysis region was the mostly affected site (28.4%). A total of 157 patients (55.5%) were presented with single fracture and the rest with 2, 3, or 4 fracture lines on the mandible. The most common fracture combination was angulus-parasymphysis fracture combination (24.6%). Open reduction and fixation with mini plates and screws was the most preferred treatment strategy (48.2%). Transient short arch bars were not used intraoperatively for any of the patients. There was not any difference in terms of complications between the patients treated with plating systems and plating systems plus intermaxillary fixation.In conclusion, proper treatment of mandible fractures is critical. Except certain fracture types, the usage of intermaxillary fixation as an adjunct to fixation with plating systems is not necessary.

Reconstruction of orbital floor defects assisted by transantral endoscopy

PURPOSE

The goal of orbital reconstruction is to restore anatomy, volume, and function. In extensive orbital floor defects, the visualization of the posterior area is limited through inferior eyelid incisions. The use of endoscope may improve the treatment; however, it is a high-sensitivity technique. The aim of this case series is to describe the combination of inferior eyelid incision with transantral endoscopy for treatment of extensive orbital floor defects.

METHODS

Three patients were submitted to orbital reconstruction, and the postoperative CT scans were evaluated to analyze the orbital volume and anteroposterior globe position. Surgical treatment was performed using subciliary inferior palpebral approach to explore the orbital floor and placement of the titanium mesh and an intraoral antrostomy for endoscopy to magnification of the surgical field and adaptation of the mesh.

RESULTS

Postoperative CT scan analysis shows that all treatments restored orbital volume and globe position without compression or damage of the optical nerve.

CONCLUSION

The use of endoscope allowed the precise visualization of the posterior region of the orbit and adaptation of the titanium mesh.

Endoscopically-Assisted Zygomatic Implant Placement: A Novel Approach

BACKGROUND

Zygomatic implants (ZIs) have been proposed as a valid alternative to advance bone-grafting procedures in the rehabilitation of the severe atrophied upper maxilla, with a reported overall success rate of more than 95 %. Otherwise, the use of the endoscope has been described for the treatment of maxillofacial trauma, orthognatic surgical procedures, sinonasal pathology, salivary gland disease, and TMJ internal derangement. A careful identification of anatomical landmarks is of utmost importance while trying to avoid potential complications during the insertion of ZIs. Several approaches for ZI insertion have been reported, such as the classical approach; the sinus slot technique; and the exteriorized approach.

MATERIALS AND METHODS

The authors first introduce in the literature the endoscopically-assisted approach for the insertion of ZIs in the extremely severe atrophic maxilla.

RESULTS

Optimal results in terms of ZIs positioning with no damage to surrounding structures were obtained.

CONCLUSIONS

By means of this new technique the surgeon may minimize the risk of complications related to the damage of neighbouring anatomic structures, such as orbital disruption or infraorbitary nerve damage, while ensuring an adequate drill positioning and angulation for the placement of one or two implants into the zygomatic bone.

Endoscopic-Assisted Intraoral Three-Dimensional Reduction Mandibuloplasty

BACKGROUND

Oriental people have a square face with a prominent mandibular angle, which means masculine and coarse and is considered to be an unappealing feature. Reduction mandibuloplasty has become popular in the orient in the past 2 decades, and the operation was frequently performed through the intraoral approach. But an invisible mandibular angle forces the surgeon to perform blind ostectomy which leads to difficulty in performing an accurate ostectomy as planned, leaving unnatural mandibular contours and severe complications.

METHODS

From January 2010 to January 2013, a total of 112 patients with prominent mandibular angles underwent one-stage long-curved ostectomy combined with splitting corticectomy through an intraoral approach with endoscopic assistance for reduction of the lower face. A retractor with an adjustable endoscope provides a clear operative field; the ostectomy line was marked. The one-stage long-curved ostectomy and corticectomy were performed following the marked ostectomy line using an oscillating saw with angles of various degrees and length under direct vision.

RESULTS

Mandibular contouring was 3-dimensionally refined; the width of the lower face was reduced in the frontal view and the mandibular angle appeared natural and inconspicuous in the lateral view. The majority of patients were satisfied with both their frontal and lateral appearances. The gonial angle and the mandibular plane angle were increased effectively. No major complications such as fracture or facial nerve injury occurred.

CONCLUSIONS

Intraoral approach of long-curved ostectomy combined with splitting corticectomy with endoscopic assistance allows surgeons to perform accurate, safe, and reproducible ostectomies and to recontour mandible 3-dimensionally, which can make the face look thinner from the frontal view and, in the lateral view, keeps it more natural looking with smooth ostectomized borders.

Update on approaches to the craniomaxillofacial skeleton

PURPOSE OF REVIEW

A myriad of surgical approaches to the craniomaxillofacial skeleton exist. Depending on the purpose of the procedure and the anatomic area to be addressed, classically used approaches include coronal approach, midfacial degloving, eyelid incisions, and other cutaneous incisions. Over the last decade, endoscopic approaches have become more popular. Whether external, transoral, or endoscopic, a detailed knowledge of the indications, anatomy, limitations, and potential complications is critical to the successful employment of these approaches. This article reviews the recent literature on classic as well as novel advancements to the craniofacial skeleton.

RECENT FINDINGS

Multiple studies in the last 5 years have investigated the approaches to the craniofacial skeleton. Most of these focus on trauma. Recent advances have concentrated on external versus endoscopic approaches to the mandibular condyle, an endoscopic approach to the midface and orbit, three-dimensional imaging of the facial skeleton, and improving upon the existing classic approaches and techniques.

SUMMARY

Approaches to the craniomaxillofacial skeleton continue to evolve with the refinement of classic approaches and advent of new technologies and approaches. This study reviews the recent literature and provides a comprehensive review of options for craniofacial exposure and the most up-to-date surgical options.

Reconstruction of the scalp, calvarium, and frontal sinus

Scalp and cranial deformities are common after trauma or ablative surgery. Local flaps and free flaps may be used in reconstruction of soft tissue defects, and autogenous bone or alloplastic bone substitutes may be used for cranioplasty procedures. Injuries to the frontal sinus, particularly when complicated by leak of cerebrospinal fluid or obstruction of the nasofrontal outflow tract, represent special challenges. Further studies are recommended to improve the multidisciplinary management of these complex, debilitating conditions, in anticipation of enhanced function and cosmesis, reduced donor site morbidity, and improved surgical outcomes.

Optimizing the surgical management of zygomaticomaxillary complex fractures

Zygomaticomaxillary complex (ZMC) fractures are a group of fractures that can significantly alter the structure, function, and appearance of the midface, including the globe. Like other facial fractures, the optimal management of operative ZMC fractures requires anatomic reduction of all fractures followed by rigid internal fixation. However, surgical treatment of these fractures can be quite challenging with the potential for high rates of complications. The goal of this article is to provide an overview of ZMC fractures and discuss treatment options, with an emphasis on providing surgical pearls to optimize outcomes.

Minimally invasive endoscopic osteosynthesis for frontozygomatic fracture: a new approach

Miniplate fixation on the lateral face of the orbital rim using existing endoscopic methods for frontozygomatic fracture still has some disadvantages, such as cosmetic disturbance from the lateral brow incision for the trocar, and abnormal palpability of the miniplate. We applied a new method of endoscopic osteosynthesis by access through temporal incisions alone and miniplate fixation on the lateral temporal face of the frontozygoma. Postoperative courses were uneventful in all four cases treated, and we achieved cosmetic improvement (minimizing incision and scars) as well as decreased palpability of the miniplate.